[From the U.S. Government Printing Office via GPO Access]
[DOCID: h3590pp.txt]
[Public Print]
December 24, 2009
Ordered to be printed as passed
In the Senate of the United States,
December 24, 2009.
Resolved, That the bill from the House of Representatives (H.R.
3590) entitled ``An Act to amend the Internal Revenue Code of 1986 to
modify the first-time homebuyers credit in the case of members of the
Armed Forces and certain other Federal employees, and for other
purposes.'', do pass with the following
AMENDMENTS:
Strike out all after the enacting clause and insert:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Patient Protection
and Affordable Care Act''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A--Immediate Improvements in Health Care Coverage for All
Americans
Sec. 1001. Amendments to the Public Health Service Act.
``PART A--Individual and Group Market Reforms
``subpart ii--improving coverage
``Sec. 2711. No lifetime or annual limits.
``Sec. 2712. Prohibition on rescissions.
``Sec. 2713. Coverage of preventive health services.
``Sec. 2714. Extension of dependent coverage.
``Sec. 2715. Development and utilization of uniform explanation
of coverage documents and standardized
definitions.
``Sec. 2716. Prohibition of discrimination based on salary.
``Sec. 2717. Ensuring the quality of care.
``Sec. 2718. Bringing down the cost of health care coverage.
``Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with
a preexisting condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify
affordable coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C--Quality Health Insurance Coverage for All Americans
PART I--Health Insurance Market Reforms
Sec. 1201. Amendment to the Public Health Service Act.
``subpart i--general reform
``Sec. 2704. Prohibition of preexisting condition exclusions or
other discrimination based on health
status.
``Sec. 2701. Fair health insurance premiums.
``Sec. 2702. Guaranteed availability of coverage.
``Sec. 2703. Guaranteed renewability of coverage.
``Sec. 2705. Prohibiting discrimination against individual
participants and beneficiaries based on
health status.
``Sec. 2706. Non-discrimination in health care.
``Sec. 2707. Comprehensive health insurance coverage.
``Sec. 2708. Prohibition on excessive waiting periods.
PART II--Other Provisions
Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance
issuers and group health plans.
Sec. 1253. Effective dates.
Subtitle D--Available Coverage Choices for All Americans
PART I--Establishment of Qualified Health Plans
Sec. 1301. Qualified health plan defined.
Sec. 1302. Essential health benefits requirements.
Sec. 1303. Special rules.
Sec. 1304. Related definitions.
PART II--Consumer Choices and Insurance Competition Through Health
Benefit Exchanges
Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.
PART III--State Flexibility Relating to Exchanges
Sec. 1321. State flexibility in operation and enforcement of Exchanges
and related requirements.
Sec. 1322. Federal program to assist establishment and operation of
nonprofit, member-run health insurance
issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.
PART IV--State Flexibility to Establish Alternative Programs
Sec. 1331. State flexibility to establish basic health programs for
low-income individuals not eligible for
Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one
State.
PART V--Reinsurance and Risk Adjustment
Sec. 1341. Transitional reinsurance program for individual and small
group markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and
small group markets.
Sec. 1343. Risk adjustment.
Subtitle E--Affordable Coverage Choices for All Americans
PART I--Premium Tax Credits and Cost-sharing Reductions
subpart a--premium tax credits and cost-sharing reductions
Sec. 1401. Refundable tax credit providing premium assistance for
coverage under a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified
health plans.
subpart b--eligibility determinations
Sec. 1411. Procedures for determining eligibility for Exchange
participation, premium tax credits and
reduced cost-sharing, and individual
responsibility exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and
cost-sharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an
exchange and State Medicaid, CHIP, and
health subsidy programs.
Sec. 1414. Disclosures to carry out eligibility requirements for
certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments
disregarded for Federal and Federally-
assisted programs.
PART II--Small Business Tax Credit
Sec. 1421. Credit for employee health insurance expenses of small
businesses.
Subtitle F--Shared Responsibility for Health Care
PART I--Individual Responsibility
Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.
PART II--Employer Responsibilities
Sec. 1511. Automatic enrollment for employees of large employers.
Sec. 1512. Employer requirement to inform employees of coverage
options.
Sec. 1513. Shared responsibility for employers.
Sec. 1514. Reporting of employer health insurance coverage.
Sec. 1515. Offering of Exchange-participating qualified health plans
through cafeteria plans.
Subtitle G--Miscellaneous Provisions
Sec. 1551. Definitions.
Sec. 1552. Transparency in government.
Sec. 1553. Prohibition against discrimination on assisted suicide.
Sec. 1554. Access to therapies.
Sec. 1555. Freedom not to participate in Federal health insurance
programs.
Sec. 1556. Equity for certain eligible survivors.
Sec. 1557. Nondiscrimination.
Sec. 1558. Protections for employees.
Sec. 1559. Oversight.
Sec. 1560. Rules of construction.
Sec. 1561. Health information technology enrollment standards and
protocols.
Sec. 1562. Conforming amendments.
Sec. 1563. Sense of the Senate promoting fiscal responsibility.
TITLE II--ROLE OF PUBLIC PROGRAMS
Subtitle A--Improved Access to Medicaid
Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified
gross income.
Sec. 2003. Requirement to offer premium assistance for employer-
sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
Sec. 2006. Special adjustment to FMAP determination for certain States
recovering from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.
Subtitle C--Medicaid and CHIP Enrollment Simplification
Sec. 2201. Enrollment Simplification and coordination with State Health
Insurance Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility
determinations for all Medicaid eligible
populations.
Subtitle D--Improvements to Medicaid Services
Sec. 2301. Coverage for freestanding birth center services.
Sec. 2302. Concurrent care for children.
Sec. 2303. State eligibility option for family planning services.
Sec. 2304. Clarification of definition of medical assistance.
Subtitle E--New Options for States to Provide Long-Term Services and
Supports
Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based
services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based
services against spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource
Centers.
Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle F--Medicaid Prescription Drug Coverage
Sec. 2501. Prescription drug rebates.
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.
Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 2551. Disproportionate share hospital payments.
Subtitle H--Improved Coordination for Dual Eligible Beneficiaries
Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual
eligible beneficiaries.
Subtitle I--Improving the Quality of Medicaid for Patients and
Providers
Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with
chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a
hospitalization.
Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration
Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.
Subtitle J--Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
Sec. 2801. MACPAC assessment of policies affecting all Medicaid
beneficiaries.
Subtitle K--Protections for American Indians and Alaska Natives
Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare
part B services furnished by certain indian
hospitals and clinics.
Subtitle L--Maternal and Child Health Services
Sec. 2951. Maternal, infant, and early childhood home visiting
programs.
Sec. 2952. Support, education, and research for postpartum depression.
Sec. 2953. Personal responsibility education.
Sec. 2954. Restoration of funding for abstinence education.
Sec. 2955. Inclusion of information about the importance of having a
health care power of attorney in transition
planning for children aging out of foster
care and independent living programs.
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A--Transforming the Health Care Delivery System
PART I--Linking Payment to Quality Outcomes Under the Medicare Program
Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient
rehabilitation hospitals, and hospice
programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled
nursing facilities and home health
agencies.
Sec. 3007. Value-based payment modifier under the physician fee
schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.
PART II--National Strategy to Improve Health Care Quality
Sec. 3011. National strategy.
Sec. 3012. Interagency Working Group on Health Care Quality.
Sec. 3013. Quality measure development.
Sec. 3014. Quality measurement.
Sec. 3015. Data collection; public reporting.
PART III--Encouraging Development of New Patient Care Models
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
Sec. 3024. Independence at home demonstration program.
Sec. 3025. Hospital readmissions reduction program.
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.
Subtitle B--Improving Medicare for Patients and Providers
PART I--Ensuring Beneficiary Access to Physician Care and Other
Services
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions
to the practice expense geographic
adjustment under the Medicare physician fee
schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain
physician pathology services.
Sec. 3105. Extension of ambulance add-ons.
Sec. 3106. Extension of certain payment rules for long-term care
hospital services and of moratorium on the
establishment of certain hospitals and
facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital
extended care services.
Sec. 3109. Exemption of certain pharmacies from accreditation
requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE
beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.
PART II--Rural Protections
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain
clinical diagnostic laboratory tests
furnished to hospital patients in certain
rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration
Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital
payment adjustment for low-volume
hospitals.
Sec. 3126. Improvements to the demonstration project on community
health integration models in certain rural
counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health
care providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital
services.
Sec. 3129. Extension of and revisions to Medicare rural hospital
flexibility program.
PART III--Improving Payment Accuracy
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital
(DSH) payments.
Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced
imaging services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the
calculation of the Medicare hospital wage
index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Sec. 3143. Protecting home health benefits.
Subtitle C--Provisions Relating to Part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment
transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs
individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.
Subtitle D--Medicare Part D Improvements for Prescription Drug Plans
and MA-PD Plans
Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income
benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals
under prescription drug plans and MA-PD
plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility
for low-income assistance.
Sec. 3305. Improved information for subsidy eligible individuals
reassigned to prescription drug plans and
MA-PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans
and MA-PD plans with respect to certain
categories or classes of drugs.
Sec. 3308. Reducing part D premium subsidy for high-income
beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible
individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription
drugs in long-term care facilities under
prescription drug plans and MA-PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan
complaint system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug
plans and MA-PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs
and Indian Health Service in providing
prescription drugs toward the annual out-
of-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.
Subtitle E--Ensuring Medicare Sustainability
Sec. 3401. Revision of certain market basket updates and incorporation
of productivity improvements into market
basket updates that do not already
incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.
Subtitle F--Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality improvement
technical assistance.
Sec. 3502. Establishing community health teams to support the patient-
centered medical home.
Sec. 3503. Medication management services in treatment of chronic
disease.
Sec. 3504. Design and implementation of regionalized systems for
emergency care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk
information.
Sec. 3508. Demonstration program to integrate quality improvement and
patient safety training into clinical
education of health professionals.
Sec. 3509. Improving women's health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.
Subtitle G--Protecting and Improving Guaranteed Medicare Benefits
Sec. 3601. Protecting and improving guaranteed Medicare benefits.
Sec. 3602. No cuts in guaranteed benefits.
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
Sec. 4001. National Prevention, Health Promotion and Public Health
Council.
Sec. 4002. Prevention and Public Health Fund.
Sec. 4003. Clinical and community preventive services.
Sec. 4004. Education and outreach campaign regarding preventive
benefits.
Subtitle B--Increasing Access to Clinical Preventive Services
Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
Sec. 4103. Medicare coverage of annual wellness visit providing a
personalized prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults
in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for
pregnant women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
Subtitle C--Creating Healthier Communities
Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based
prevention and wellness programs for
Medicare beneficiaries.
Sec. 4203. Removing barriers and improving access to wellness for
individuals with disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain
restaurants.
Sec. 4206. Demonstration project concerning individualized wellness
plan.
Sec. 4207. Reasonable break time for nursing mothers.
Subtitle D--Support for Prevention and Public Health Innovation
Sec. 4301. Research on optimizing the delivery of public health
services.
Sec. 4302. Understanding health disparities: data collection and
analysis.
Sec. 4303. CDC and employer-based wellness programs.
Sec. 4304. Epidemiology-Laboratory Capacity Grants.
Sec. 4305. Advancing research and treatment for pain care management.
Sec. 4306. Funding for Childhood Obesity Demonstration Project.
Subtitle E--Miscellaneous Provisions
Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.
TITLE V--HEALTH CARE WORKFORCE
Subtitle A--Purpose and Definitions
Sec. 5001. Purpose.
Sec. 5002. Definitions.
Subtitle B--Innovations in the Health Care Workforce
Sec. 5101. National health care workforce commission.
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.
Subtitle C--Increasing the Supply of the Health Care Workforce
Sec. 5201. Federally supported student loan funds.
Sec. 5202. Nursing student loan program.
Sec. 5203. Health care workforce loan repayment programs.
Sec. 5204. Public health workforce recruitment and retention programs.
Sec. 5205. Allied health workforce recruitment and retention programs.
Sec. 5206. Grants for State and local programs.
Sec. 5207. Funding for National Health Service Corps.
Sec. 5208. Nurse-managed health clinics.
Sec. 5209. Elimination of cap on commissioned corps.
Sec. 5210. Establishing a Ready Reserve Corps.
Subtitle D--Enhancing Health Care Workforce Education and Training
Sec. 5301. Training in family medicine, general internal medicine,
general pediatrics, and physician
assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration
project.
Sec. 5305. Geriatric education and training; career awards;
comprehensive geriatric education.
Sec. 5306. Mental and behavioral health education and training grants.
Sec. 5307. Cultural competency, prevention, and public health and
individuals with disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
Sec. 5312. Authorization of appropriations for parts B through D of
title VIII.
Sec. 5313. Grants to promote the community health workforce.
Sec. 5314. Fellowship training in public health.
Sec. 5315. United States Public Health Sciences Track.
Subtitle E--Supporting the Existing Health Care Workforce
Sec. 5401. Centers of excellence.
Sec. 5402. Health care professionals training for diversity.
Sec. 5403. Interdisciplinary, community-based linkages.
Sec. 5404. Workforce diversity grants.
Sec. 5405. Primary care extension program.
Subtitle F--Strengthening Primary Care and Other Workforce Improvements
Sec. 5501. Expanding access to primary care services and general
surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in nonprovider settings.
Sec. 5505. Rules for counting resident time for didactic and scholarly
activities and other activities.
Sec. 5506. Preservation of resident cap positions from closed
hospitals.
Sec. 5507. Demonstration projects To address health professions
workforce needs; extension of family-to-
family health information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.
Subtitle G--Improving Access to Health Care Services
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and
criteria for designating medically
underserved populations and health
professions shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services
for Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based
mental health settings.
Sec. 5605. Key National indicators.
Subtitle H--General Provisions
Sec. 5701. Reports.
TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A--Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on
certain physician referrals for hospitals.
Sec. 6002. Transparency reports and reporting of physician ownership or
investment interests.
Sec. 6003. Disclosure requirements for in-office ancillary services
exception to the prohibition on physician
self-referral for certain imaging services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.
Subtitle B--Nursing Home Transparency and Improvement
PART I--Improving Transparency of Information
Sec. 6101. Required disclosure of ownership and additional disclosable
parties information.
Sec. 6102. Accountability requirements for skilled nursing facilities
and nursing facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.
PART II--Targeting Enforcement
Sec. 6111. Civil money penalties.
Sec. 6112. National independent monitor demonstration project.
Sec. 6113. Notification of facility closure.
Sec. 6114. National demonstration projects on culture change and use of
information technology in nursing homes.
PART III--Improving Staff Training
Sec. 6121. Dementia and abuse prevention training.
Subtitle C--Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and
Providers
Sec. 6201. Nationwide program for National and State background checks
on direct patient access employees of long-
term care facilities and providers.
Subtitle D--Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness
research.
Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions
Sec. 6401. Provider screening and other enrollment requirements under
Medicare, Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National
Practitioner Data Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 6405. Physicians who order items or services required to be
Medicare enrolled physicians or eligible
professionals.
Sec. 6406. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste
and abuse.
Sec. 6407. Face to face encounter with patient required before
physicians may certify eligibility for home
health services or durable medical
equipment under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment,
prosthetics, orthotics, and supplies
competitive acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle F--Additional Medicaid Program Integrity Provisions
Sec. 6501. Termination of provider participation under Medicaid if
terminated under Medicare or other State
plan.
Sec. 6502. Medicaid exclusion from participation relating to certain
ownership, control, and management
affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located
outside of the United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.
Subtitle G--Additional Program Integrity Provisions
Sec. 6601. Prohibition on false statements and representations.
Sec. 6602. Clarifying definition.
Sec. 6603. Development of model uniform report form.
Sec. 6604. Applicability of State law to combat fraud and abuse.
Sec. 6605. Enabling the Department of Labor to issue administrative
summary cease and desist orders and summary
seizures orders against plans that are in
financially hazardous condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential
communications.
Subtitle H--Elder Justice Act
Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.
Subtitle I--Sense of the Senate Regarding Medical Malpractice
Sec. 6801. Sense of the Senate regarding medical malpractice.
TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
Subtitle A--Biologics Price Competition and Innovation
Sec. 7001. Short title.
Sec. 7002. Approval pathway for biosimilar biological products.
Sec. 7003. Savings.
Subtitle B--More Affordable Medicines for Children and Underserved
Communities
Sec. 7101. Expanded participation in 340B program.
Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B
program.
TITLE VIII--CLASS ACT
Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for
purchasing community living assistance
services and support.
TITLE IX--REVENUE PROVISIONS
Subtitle A--Revenue Offset Provisions
Sec. 9001. Excise tax on high cost employer-sponsored health coverage.
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on
W-2.
Sec. 9003. Distributions for medicine qualified only if for prescribed
drug or insulin.
Sec. 9004. Increase in additional tax on distributions from HSAs and
Archer MSAs not used for qualified medical
expenses.
Sec. 9005. Limitation on health flexible spending arrangements under
cafeteria plans.
Sec. 9006. Expansion of information reporting requirements.
Sec. 9007. Additional requirements for charitable hospitals.
Sec. 9008. Imposition of annual fee on branded prescription
pharmaceutical manufacturers and importers.
Sec. 9009. Imposition of annual fee on medical device manufacturers and
importers.
Sec. 9010. Imposition of annual fee on health insurance providers.
Sec. 9011. Study and report of effect on veterans health care.
Sec. 9012. Elimination of deduction for expenses allocable to Medicare
Part D subsidy.
Sec. 9013. Modification of itemized deduction for medical expenses.
Sec. 9014. Limitation on excessive remuneration paid by certain health
insurance providers.
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.
Sec. 9016. Modification of section 833 treatment of certain health
organizations.
Sec. 9017. Excise tax on elective cosmetic medical procedures.
Subtitle B--Other Provisions
Sec. 9021. Exclusion of health benefits provided by Indian tribal
governments.
Sec. 9022. Establishment of simple cafeteria plans for small
businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
Subtitle A--Provisions Relating to Title I
Sec. 10101. Amendments to subtitle A.
Sec. 10102. Amendments to subtitle B.
Sec. 10103. Amendments to subtitle C.
Sec. 10104. Amendments to subtitle D.
Sec. 10105. Amendments to subtitle E.
Sec. 10106. Amendments to subtitle F.
Sec. 10107. Amendments to subtitle G.
Sec. 10108. Free choice vouchers.
Sec. 10109. Development of standards for financial and administrative
transactions.
Subtitle B--Provisions Relating to Title II
PART I--Medicaid and CHIP
Sec. 10201. Amendments to the Social Security Act and title II of this
Act.
Sec. 10202. Incentives for States to offer home and community-based
services as a long-term care alternative to
nursing homes.
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and
other CHIP-related provisions.
PART II--Support for Pregnant and Parenting Teens and Women
Sec. 10211. Definitions.
Sec. 10212. Establishment of pregnancy assistance fund.
Sec. 10213. Permissible uses of Fund.
Sec. 10214. Appropriations.
PART III--Indian Health Care Improvement
Sec. 10221. Indian health care improvement.
Subtitle C--Provisions Relating to Title III
Sec. 10301. Plans for a Value-Based purchasing program for ambulatory
surgical centers.
Sec. 10302. Revision to national strategy for quality improvement in
health care.
Sec. 10303. Development of outcome measures.
Sec. 10304. Selection of efficiency measures.
Sec. 10305. Data collection; public reporting.
Sec. 10306. Improvements under the Center for Medicare and Medicaid
Innovation.
Sec. 10307. Improvements to the Medicare shared savings program.
Sec. 10308. Revisions to national pilot program on payment bundling.
Sec. 10309. Revisions to hospital readmissions reduction program.
Sec. 10310. Repeal of physician payment update.
Sec. 10311. Revisions to extension of ambulance add-ons.
Sec. 10312. Certain payment rules for long-term care hospital services
and moratorium on the establishment of
certain hospitals and facilities.
Sec. 10313. Revisions to the extension for the rural community hospital
demonstration program.
Sec. 10314. Adjustment to low-volume hospital provision.
Sec. 10315. Revisions to home health care provisions.
Sec. 10316. Medicare DSH.
Sec. 10317. Revisions to extension of section 508 hospital provisions.
Sec. 10318. Revisions to transitional extra benefits under Medicare
Advantage.
Sec. 10319. Revisions to market basket adjustments.
Sec. 10320. Expansion of the scope of, and additional improvements to,
the Independent Medicare Advisory Board.
Sec. 10321. Revision to community health teams.
Sec. 10322. Quality reporting for psychiatric hospitals.
Sec. 10323. Medicare coverage for individuals exposed to environmental
health hazards.
Sec. 10324. Protections for frontier States.
Sec. 10325. Revision to skilled nursing facility prospective payment
system.
Sec. 10326. Pilot testing pay-for-performance programs for certain
Medicare providers.
Sec. 10327. Improvements to the physician quality reporting system.
Sec. 10328. Improvement in part D medication therapy management (MTM)
programs.
Sec. 10329. Developing methodology to assess health plan value.
Sec. 10330. Modernizing computer and data systems of the Centers for
Medicare & Medicaid services to support
improvements in care delivery.
Sec. 10331. Public reporting of performance information.
Sec. 10332. Availability of medicare data for performance measurement.
Sec. 10333. Community-based collaborative care networks.
Sec. 10334. Minority health.
Sec. 10335. Technical correction to the hospital value-based purchasing
program.
Sec. 10336. GAO study and report on Medicare beneficiary access to
high-quality dialysis services.
Subtitle D--Provisions Relating to Title IV
Sec. 10401. Amendments to subtitle A.
Sec. 10402. Amendments to subtitle B.
Sec. 10403. Amendments to subtitle C.
Sec. 10404. Amendments to subtitle D.
Sec. 10405. Amendments to subtitle E.
Sec. 10406. Amendment relating to waiving coinsurance for preventive
services.
Sec. 10407. Better diabetes care.
Sec. 10408. Grants for small businesses to provide comprehensive
workplace wellness programs.
Sec. 10409. Cures Acceleration Network.
Sec. 10410. Centers of Excellence for Depression.
Sec. 10411. Programs relating to congenital heart disease.
Sec. 10412. Automated Defibrillation in Adam's Memory Act.
Sec. 10413. Young women's breast health awareness and support of young
women diagnosed with breast cancer.
Subtitle E--Provisions Relating to Title V
Sec. 10501. Amendments to the Public Health Service Act, the Social
Security Act, and title V of this Act.
Sec. 10502. Infrastructure to Expand Access to Care.
Sec. 10503. Community Health Centers and the National Health Service
Corps Fund.
Sec. 10504. Demonstration project to provide access to affordable care.
Subtitle F--Provisions Relating to Title VI
Sec. 10601. Revisions to limitation on medicare exception to the
prohibition on certain physician referrals
for hospitals.
Sec. 10602. Clarifications to patient-centered outcomes research.
Sec. 10603. Striking provisions relating to individual provider
application fees.
Sec. 10604. Technical correction to section 6405.
Sec. 10605. Certain other providers permitted to conduct face to face
encounter for home health services.
Sec. 10606. Health care fraud enforcement.
Sec. 10607. State demonstration programs to evaluate alternatives to
current medical tort litigation.
Sec. 10608. Extension of medical malpractice coverage to free clinics.
Sec. 10609. Labeling changes.
Subtitle G--Provisions Relating to Title VIII
Sec. 10801. Provisions relating to title VIII.
Subtitle H--Provisions Relating to Title IX
Sec. 10901. Modifications to excise tax on high cost employer-sponsored
health coverage.
Sec. 10902. Inflation adjustment of limitation on health flexible
spending arrangements under cafeteria
plans.
Sec. 10903. Modification of limitation on charges by charitable
hospitals.
Sec. 10904. Modification of annual fee on medical device manufacturers
and importers.
Sec. 10905. Modification of annual fee on health insurance providers.
Sec. 10906. Modifications to additional hospital insurance tax on high-
income taxpayers.
Sec. 10907. Excise tax on indoor tanning services in lieu of elective
cosmetic medical procedures.
Sec. 10908. Exclusion for assistance provided to participants in State
student loan repayment programs for certain
health professionals.
Sec. 10909. Expansion of adoption credit and adoption assistance
programs.
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A--Immediate Improvements in Health Care Coverage for All
Americans
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42 U.S.C.
300gg et seq.) is amended--
(1) by striking the part heading and inserting the
following:
``PART A--INDIVIDUAL AND GROUP MARKET REFORMS'';
(2) by redesignating sections 2704 through 2707 as sections
2725 through 2728, respectively;
(3) by redesignating sections 2711 through 2713 as sections
2731 through 2733, respectively;
(4) by redesignating sections 2721 through 2723 as sections
2735 through 2737, respectively; and
(5) by inserting after section 2702, the following:
``Subpart II--Improving Coverage
``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
``(a) In General.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage may not
establish--
``(1) lifetime limits on the dollar value of benefits for
any participant or beneficiary; or
``(2) unreasonable annual limits (within the meaning of
section 223 of the Internal Revenue Code of 1986) on the dollar
value of benefits for any participant or beneficiary.
``(b) Per Beneficiary Limits.--Subsection (a) shall not be
construed to prevent a group health plan or health insurance coverage
that is not required to provide essential health benefits under section
1302(b) of the Patient Protection and Affordable Care Act from placing
annual or lifetime per beneficiary limits on specific covered benefits
to the extent that such limits are otherwise permitted under Federal or
State law.
``SEC. 2712. PROHIBITION ON RESCISSIONS.
``A group health plan and a health insurance issuer offering group
or individual health insurance coverage shall not rescind such plan or
coverage with respect to an enrollee once the enrollee is covered under
such plan or coverage involved, except that this section shall not
apply to a covered individual who has performed an act or practice that
constitutes fraud or makes an intentional misrepresentation of material
fact as prohibited by the terms of the plan or coverage. Such plan or
coverage may not be cancelled except with prior notice to the enrollee,
and only as permitted under section 2702(c) or 2742(b).
``SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
``(a) In General.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage shall, at
a minimum provide coverage for and shall not impose any cost sharing
requirements for--
``(1) evidence-based items or services that have in effect
a rating of `A' or `B' in the current recommendations of the
United States Preventive Services Task Force;
``(2) immunizations that have in effect a recommendation
from the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention with respect to the
individual involved; and
``(3) with respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for
in the comprehensive guidelines supported by the Health
Resources and Services Administration.
``(4) with respect to women, such additional preventive
care and screenings not described in paragraph (1) as provided
for in comprehensive guidelines supported by the Health
Resources and Services Administration for purposes of this
paragraph.
``(5) for the purposes of this Act, and for the purposes of
any other provision of law, the current recommendations of the
United States Preventive Service Task Force regarding breast
cancer screening, mammography, and prevention shall be
considered the most current other than those issued in or
around November 2009.
Nothing in this subsection shall be construed to prohibit a plan or
issuer from providing coverage for services in addition to those
recommended by United States Preventive Services Task Force or to deny
coverage for services that are not recommended by such Task Force.
``(b) Interval.--
``(1) In general.--The Secretary shall establish a minimum
interval between the date on which a recommendation described
in subsection (a)(1) or (a)(2) or a guideline under subsection
(a)(3) is issued and the plan year with respect to which the
requirement described in subsection (a) is effective with
respect to the service described in such recommendation or
guideline.
``(2) Minimum.--The interval described in paragraph (1)
shall not be less than 1 year.
``(c) Value-based Insurance Design.--The Secretary may develop
guidelines to permit a group health plan and a health insurance issuer
offering group or individual health insurance coverage to utilize
value-based insurance designs.
``SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
``(a) In General.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage that
provides dependent coverage of children shall continue to make such
coverage available for an adult child (who is not married) until the
child turns 26 years of age. Nothing in this section shall require a
health plan or a health insurance issuer described in the preceding
sentence to make coverage available for a child of a child receiving
dependent coverage.
``(b) Regulations.--The Secretary shall promulgate regulations to
define the dependents to which coverage shall be made available under
subsection (a).
``(c) Rule of Construction.--Nothing in this section shall be
construed to modify the definition of `dependent' as used in the
Internal Revenue Code of 1986 with respect to the tax treatment of the
cost of coverage.
``SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF
COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS.
``(a) In General.--Not later than 12 months after the date of
enactment of the Patient Protection and Affordable Care Act, the
Secretary shall develop standards for use by a group health plan and a
health insurance issuer offering group or individual health insurance
coverage, in compiling and providing to enrollees a summary of benefits
and coverage explanation that accurately describes the benefits and
coverage under the applicable plan or coverage. In developing such
standards, the Secretary shall consult with the National Association of
Insurance Commissioners (referred to in this section as the `NAIC'), a
working group composed of representatives of health insurance-related
consumer advocacy organizations, health insurance issuers, health care
professionals, patient advocates including those representing
individuals with limited English proficiency, and other qualified
individuals.
``(b) Requirements.--The standards for the summary of benefits and
coverage developed under subsection (a) shall provide for the
following:
``(1) Appearance.--The standards shall ensure that the
summary of benefits and coverage is presented in a uniform
format that does not exceed 4 pages in length and does not
include print smaller than 12-point font.
``(2) Language.--The standards shall ensure that the
summary is presented in a culturally and linguistically
appropriate manner and utilizes terminology understandable by
the average plan enrollee.
``(3) Contents.--The standards shall ensure that the
summary of benefits and coverage includes--
``(A) uniform definitions of standard insurance
terms and medical terms (consistent with subsection
(g)) so that consumers may compare health insurance
coverage and understand the terms of coverage (or
exception to such coverage);
``(B) a description of the coverage, including cost
sharing for--
``(i) each of the categories of the
essential health benefits described in
subparagraphs (A) through (J) of section
1302(b)(1) of the Patient Protection and
Affordable Care Act; and
``(ii) other benefits, as identified by the
Secretary;
``(C) the exceptions, reductions, and limitations
on coverage;
``(D) the cost-sharing provisions, including
deductible, coinsurance, and co-payment obligations;
``(E) the renewability and continuation of coverage
provisions;
``(F) a coverage facts label that includes examples
to illustrate common benefits scenarios, including
pregnancy and serious or chronic medical conditions and
related cost sharing, such scenarios to be based on
recognized clinical practice guidelines;
``(G) a statement of whether the plan or coverage--
``(i) provides minimum essential coverage
(as defined under section 5000A(f) of the
Internal Revenue Code 1986); and
``(ii) ensures that the plan or coverage
share of the total allowed costs of benefits
provided under the plan or coverage is not less
than 60 percent of such costs;
``(H) a statement that the outline is a summary of
the policy or certificate and that the coverage
document itself should be consulted to determine the
governing contractual provisions; and
``(I) a contact number for the consumer to call
with additional questions and an Internet web address
where a copy of the actual individual coverage policy
or group certificate of coverage can be reviewed and
obtained.
``(c) Periodic Review and Updating.--The Secretary shall
periodically review and update, as appropriate, the standards developed
under this section.
``(d) Requirement To Provide.--
``(1) In general.--Not later than 24 months after the date
of enactment of the Patient Protection and Affordable Care Act,
each entity described in paragraph (3) shall provide, prior to
any enrollment restriction, a summary of benefits and coverage
explanation pursuant to the standards developed by the
Secretary under subsection (a) to--
``(A) an applicant at the time of application;
``(B) an enrollee prior to the time of enrollment
or reenrollment, as applicable; and
``(C) a policyholder or certificate holder at the
time of issuance of the policy or delivery of the
certificate.
``(2) Compliance.--An entity described in paragraph (3) is
deemed to be in compliance with this section if the summary of
benefits and coverage described in subsection (a) is provided
in paper or electronic form.
``(3) Entities in general.--An entity described in this
paragraph is--
``(A) a health insurance issuer (including a group
health plan that is not a self-insured plan) offering
health insurance coverage within the United States; or
``(B) in the case of a self-insured group health
plan, the plan sponsor or designated administrator of
the plan (as such terms are defined in section 3(16) of
the Employee Retirement Income Security Act of 1974).
``(4) Notice of modifications.--If a group health plan or
health insurance issuer makes any material modification in any
of the terms of the plan or coverage involved (as defined for
purposes of section 102 of the Employee Retirement Income
Security Act of 1974) that is not reflected in the most
recently provided summary of benefits and coverage, the plan or
issuer shall provide notice of such modification to enrollees
not later than 60 days prior to the date on which such
modification will become effective.
``(e) Preemption.--The standards developed under subsection (a)
shall preempt any related State standards that require a summary of
benefits and coverage that provides less information to consumers than
that required to be provided under this section, as determined by the
Secretary.
``(f) Failure To Provide.--An entity described in subsection (d)(3)
that willfully fails to provide the information required under this
section shall be subject to a fine of not more than $1,000 for each
such failure. Such failure with respect to each enrollee shall
constitute a separate offense for purposes of this subsection.
``(g) Development of Standard Definitions.--
``(1) In general.--The Secretary shall, by regulation,
provide for the development of standards for the definitions of
terms used in health insurance coverage, including the
insurance-related terms described in paragraph (2) and the
medical terms described in paragraph (3).
``(2) Insurance-related terms.--The insurance-related terms
described in this paragraph are premium, deductible, co-
insurance, co-payment, out-of-pocket limit, preferred provider,
non-preferred provider, out-of-network co-payments, UCR (usual,
customary and reasonable) fees, excluded services, grievance
and appeals, and such other terms as the Secretary determines
are important to define so that consumers may compare health
insurance coverage and understand the terms of their coverage.
``(3) Medical terms.--The medical terms described in this
paragraph are hospitalization, hospital outpatient care,
emergency room care, physician services, prescription drug
coverage, durable medical equipment, home health care, skilled
nursing care, rehabilitation services, hospice services,
emergency medical transportation, and such other terms as the
Secretary determines are important to define so that consumers
may compare the medical benefits offered by health insurance
and understand the extent of those medical benefits (or
exceptions to those benefits).
``SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.
``(a) In General.--The plan sponsor of a group health plan (other
than a self-insured plan) may not establish rules relating to the
health insurance coverage eligibility (including continued eligibility)
of any full-time employee under the terms of the plan that are based on
the total hourly or annual salary of the employee or otherwise
establish eligibility rules that have the effect of discriminating in
favor of higher wage employees.
``(b) Limitation.--Subsection (a) shall not be construed to
prohibit a plan sponsor from establishing contribution requirements for
enrollment in the plan or coverage that provide for the payment by
employees with lower hourly or annual compensation of a lower dollar or
percentage contribution than the payment required of similarly situated
employees with a higher hourly or annual compensation.
``SEC. 2717. ENSURING THE QUALITY OF CARE.
``(a) Quality Reporting.--
``(1) In general.--Not later than 2 years after the date of
enactment of the Patient Protection and Affordable Care Act,
the Secretary, in consultation with experts in health care
quality and stakeholders, shall develop reporting requirements
for use by a group health plan, and a health insurance issuer
offering group or individual health insurance coverage, with
respect to plan or coverage benefits and health care provider
reimbursement structures that--
``(A) improve health outcomes through the
implementation of activities such as quality reporting,
effective case management, care coordination, chronic
disease management, and medication and care compliance
initiatives, including through the use of the medical
homes model as defined for purposes of section 3602 of
the Patient Protection and Affordable Care Act, for
treatment or services under the plan or coverage;
``(B) implement activities to prevent hospital
readmissions through a comprehensive program for
hospital discharge that includes patient-centered
education and counseling, comprehensive discharge
planning, and post discharge reinforcement by an
appropriate health care professional;
``(C) implement activities to improve patient
safety and reduce medical errors through the
appropriate use of best clinical practices, evidence
based medicine, and health information technology under
the plan or coverage; and
``(D) implement wellness and health promotion
activities.
``(2) Reporting requirements.--
``(A) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall annually submit to the
Secretary, and to enrollees under the plan or coverage,
a report on whether the benefits under the plan or
coverage satisfy the elements described in
subparagraphs (A) through (D) of paragraph (1).
``(B) Timing of reports.--A report under
subparagraph (A) shall be made available to an enrollee
under the plan or coverage during each open enrollment
period.
``(C) Availability of reports.--The Secretary shall
make reports submitted under subparagraph (A) available
to the public through an Internet website.
``(D) Penalties.--In developing the reporting
requirements under paragraph (1), the Secretary may
develop and impose appropriate penalties for non-
compliance with such requirements.
``(E) Exceptions.--In developing the reporting
requirements under paragraph (1), the Secretary may
provide for exceptions to such requirements for group
health plans and health insurance issuers that
substantially meet the goals of this section.
``(b) Wellness and Prevention Programs.--For purposes of subsection
(a)(1)(D), wellness and health promotion activities may include
personalized wellness and prevention services, which are coordinated,
maintained or delivered by a health care provider, a wellness and
prevention plan manager, or a health, wellness or prevention services
organization that conducts health risk assessments or offers ongoing
face-to-face, telephonic or web-based intervention efforts for each of
the program's participants, and which may include the following
wellness and prevention efforts:
``(1) Smoking cessation.
``(2) Weight management.
``(3) Stress management.
``(4) Physical fitness.
``(5) Nutrition.
``(6) Heart disease prevention.
``(7) Healthy lifestyle support.
``(8) Diabetes prevention.
``(c) Regulations.--Not later than 2 years after the date of
enactment of the Patient Protection and Affordable Care Act, the
Secretary shall promulgate regulations that provide criteria for
determining whether a reimbursement structure is described in
subsection (a).
``(d) Study and Report.--Not later than 180 days after the date on
which regulations are promulgated under subsection (c), the Government
Accountability Office shall review such regulations and conduct a study
and submit to the Committee on Health, Education, Labor, and Pensions
of the Senate and the Committee on Energy and Commerce of the House of
Representatives a report regarding the impact the activities under this
section have had on the quality and cost of health care.
``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.
``(a) Clear Accounting for Costs.--A health insurance issuer
offering group or individual health insurance coverage shall, with
respect to each plan year, submit to the Secretary a report concerning
the percentage of total premium revenue that such coverage expends--
``(1) on reimbursement for clinical services provided to
enrollees under such coverage;
``(2) for activities that improve health care quality; and
``(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding State
taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section available
to the public on the Internet website of the Department of Health and
Human Services.
``(b) Ensuring That Consumers Receive Value for Their Premium
Payments.--
``(1) Requirement to provide value for premium payments.--A
health insurance issuer offering group or individual health
insurance coverage shall, with respect to each plan year,
provide an annual rebate to each enrollee under such coverage,
on a pro rata basis, in an amount that is equal to the amount
by which premium revenue expended by the issuer on activities
described in subsection (a)(3) exceeds--
``(A) with respect to a health insurance issuer
offering coverage in the group market, 20 percent, or
such lower percentage as a State may by regulation
determine; or
``(B) with respect to a health insurance issuer
offering coverage in the individual market, 25 percent,
or such lower percentage as a State may by regulation
determine, except that such percentage shall be
adjusted to the extent the Secretary determines that
the application of such percentage with a State may
destabilize the existing individual market in such
State.
``(2) Consideration in setting percentages.--In determining
the percentages under paragraph (1), a State shall seek to
ensure adequate participation by health insurance issuers,
competition in the health insurance market in the State, and
value for consumers so that premiums are used for clinical
services and quality improvements.
``(3) Termination.--The provisions of this subsection shall
have no force or effect after December 31, 2013.
``(c) Standard Hospital Charges.--Each hospital operating within
the United States shall for each year establish (and update) and make
public (in accordance with guidelines developed by the Secretary) a
list of the hospital's standard charges for items and services provided
by the hospital, including for diagnosis-related groups established
under section 1886(d)(4) of the Social Security Act.
``(d) Definitions.--The Secretary, in consultation with the
National Association of Insurance Commissions, shall establish uniform
definitions for the activities reported under subsection (a).
``SEC. 2719. APPEALS PROCESS.
``A group health plan and a health insurance issuer offering group
or individual health insurance coverage shall implement an effective
appeals process for appeals of coverage determinations and claims,
under which the plan or issuer shall, at a minimum--
``(1) have in effect an internal claims appeal process;
``(2) provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and
external appeals processes, and the availability of any
applicable office of health insurance consumer assistance or
ombudsman established under section 2793 to assist such
enrollees with the appeals processes;
``(3) allow an enrollee to review their file, to present
evidence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process; and
``(4) provide an external review process for such plans and
issuers that, at a minimum, includes the consumer protections
set forth in the Uniform External Review Model Act promulgated
by the National Association of Insurance Commissioners and is
binding on such plans.''.
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
Part C of title XXVII of the Public Health Service Act (42 U.S.C.
300gg-91 et seq.) is amended by adding at the end the following:
``SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
``(a) In General.--The Secretary shall award grants to States to
enable such States (or the Exchanges operating in such States) to
establish, expand, or provide support for--
``(1) offices of health insurance consumer assistance; or
``(2) health insurance ombudsman programs.
``(b) Eligibility.--
``(1) In general.--To be eligible to receive a grant, a
State shall designate an independent office of health insurance
consumer assistance, or an ombudsman, that, directly or in
coordination with State health insurance regulators and
consumer assistance organizations, receives and responds to
inquiries and complaints concerning health insurance coverage
with respect to Federal health insurance requirements and under
State law.
``(2) Criteria.--A State that receives a grant under this
section shall comply with criteria established by the Secretary
for carrying out activities under such grant.
``(c) Duties.--The office of health insurance consumer assistance
or health insurance ombudsman shall--
``(1) assist with the filing of complaints and appeals,
including filing appeals with the internal appeal or grievance
process of the group health plan or health insurance issuer
involved and providing information about the external appeal
process;
``(2) collect, track, and quantify problems and inquiries
encountered by consumers;
``(3) educate consumers on their rights and
responsibilities with respect to group health plans and health
insurance coverage;
``(4) assist consumers with enrollment in a group health
plan or health insurance coverage by providing information,
referral, and assistance; and
``(5) resolve problems with obtaining premium tax credits
under section 36B of the Internal Revenue Code of 1986.
``(d) Data Collection.--As a condition of receiving a grant under
subsection (a), an office of health insurance consumer assistance or
ombudsman program shall be required to collect and report data to the
Secretary on the types of problems and inquiries encountered by
consumers. The Secretary shall utilize such data to identify areas
where more enforcement action is necessary and shall share such
information with State insurance regulators, the Secretary of Labor,
and the Secretary of the Treasury for use in the enforcement activities
of such agencies.
``(e) Funding.--
``(1) Initial funding.--There is hereby appropriated to the
Secretary, out of any funds in the Treasury not otherwise
appropriated, $30,000,000 for the first fiscal year for which
this section applies to carry out this section. Such amount
shall remain available without fiscal year limitation.
``(2) Authorization for subsequent years.--There is
authorized to be appropriated to the Secretary for each fiscal
year following the fiscal year described in paragraph (1), such
sums as may be necessary to carry out this section.''.
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.
Part C of title XXVII of the Public Health Service Act (42 U.S.C.
300gg-91 et seq.), as amended by section 1002, is further amended by
adding at the end the following:
``SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.
``(a) Initial Premium Review Process.--
``(1) In general.--The Secretary, in conjunction with
States, shall establish a process for the annual review,
beginning with the 2010 plan year and subject to subsection
(b)(2)(A), of unreasonable increases in premiums for health
insurance coverage.
``(2) Justification and disclosure.--The process
established under paragraph (1) shall require health insurance
issuers to submit to the Secretary and the relevant State a
justification for an unreasonable premium increase prior to the
implementation of the increase. Such issuers shall prominently
post such information on their Internet websites. The Secretary
shall ensure the public disclosure of information on such
increases and justifications for all health insurance issuers.
``(b) Continuing Premium Review Process.--
``(1) Informing secretary of premium increase patterns.--As
a condition of receiving a grant under subsection (c)(1), a
State, through its Commissioner of Insurance, shall--
``(A) provide the Secretary with information about
trends in premium increases in health insurance
coverage in premium rating areas in the State; and
``(B) make recommendations, as appropriate, to the
State Exchange about whether particular health
insurance issuers should be excluded from participation
in the Exchange based on a pattern or practice of
excessive or unjustified premium increases.
``(2) Monitoring by secretary of premium increases.--
``(A) In general.--Beginning with plan years
beginning in 2014, the Secretary, in conjunction with
the States and consistent with the provisions of
subsection (a)(2), shall monitor premium increases of
health insurance coverage offered through an Exchange
and outside of an Exchange.
``(B) Consideration in opening exchange.--In
determining under section 1312(f)(2)(B) of the Patient
Protection and Affordable Care Act whether to offer
qualified health plans in the large group market
through an Exchange, the State shall take into account
any excess of premium growth outside of the Exchange as
compared to the rate of such growth inside the
Exchange.
``(c) Grants in Support of Process.--
``(1) Premium review grants during 2010 through 2014.--The
Secretary shall carry out a program to award grants to States
during the 5-year period beginning with fiscal year 2010 to
assist such States in carrying out subsection (a), including--
``(A) in reviewing and, if appropriate under State
law, approving premium increases for health insurance
coverage; and
``(B) in providing information and recommendations
to the Secretary under subsection (b)(1).
``(2) Funding.--
``(A) In general.--Out of all funds in the Treasury
not otherwise appropriated, there are appropriated to
the Secretary $250,000,000, to be available for
expenditure for grants under paragraph (1) and
subparagraph (B).
``(B) Further availability for insurance reform and
consumer protection.--If the amounts appropriated under
subparagraph (A) are not fully obligated under grants
under paragraph (1) by the end of fiscal year 2014, any
remaining funds shall remain available to the Secretary
for grants to States for planning and implementing the
insurance reforms and consumer protections under part
A.
``(C) Allocation.--The Secretary shall establish a
formula for determining the amount of any grant to a
State under this subsection. Under such formula--
``(i) the Secretary shall consider the
number of plans of health insurance coverage
offered in each State and the population of the
State; and
``(ii) no State qualifying for a grant
under paragraph (1) shall receive less than
$1,000,000, or more than $5,000,000 for a grant
year.''.
SEC. 1004. EFFECTIVE DATES.
(a) In General.--Except as provided for in subsection (b), this
subtitle (and the amendments made by this subtitle) shall become
effective for plan years beginning on or after the date that is 6
months after the date of enactment of this Act, except that the
amendments made by sections 1002 and 1003 shall become effective for
fiscal years beginning with fiscal year 2010.
(b) Special Rule.--The amendments made by sections 1002 and 1003
shall take effect on the date of enactment of this Act.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED INDIVIDUALS WITH
A PREEXISTING CONDITION.
(a) In General.--Not later than 90 days after the date of enactment
of this Act, the Secretary shall establish a temporary high risk health
insurance pool program to provide health insurance coverage for
eligible individuals during the period beginning on the date on which
such program is established and ending on January 1, 2014.
(b) Administration.--
(1) In general.--The Secretary may carry out the program
under this section directly or through contracts to eligible
entities.
(2) Eligible entities.--To be eligible for a contract under
paragraph (1), an entity shall--
(A) be a State or nonprofit private entity;
(B) submit to the Secretary an application at such
time, in such manner, and containing such information
as the Secretary may require; and
(C) agree to utilize contract funding to establish
and administer a qualified high risk pool for eligible
individuals.
(3) Maintenance of effort.--To be eligible to enter into a
contract with the Secretary under this subsection, a State
shall agree not to reduce the annual amount the State expended
for the operation of one or more State high risk pools during
the year preceding the year in which such contract is entered
into.
(c) Qualified High Risk Pool.--
(1) In general.--Amounts made available under this section
shall be used to establish a qualified high risk pool that
meets the requirements of paragraph (2).
(2) Requirements.--A qualified high risk pool meets the
requirements of this paragraph if such pool--
(A) provides to all eligible individuals health
insurance coverage that does not impose any preexisting
condition exclusion with respect to such coverage;
(B) provides health insurance coverage--
(i) in which the issuer's share of the
total allowed costs of benefits provided under
such coverage is not less than 65 percent of
such costs; and
(ii) that has an out of pocket limit not
greater than the applicable amount described in
section 223(c)(2) of the Internal Revenue Code
of 1986 for the year involved, except that the
Secretary may modify such limit if necessary to
ensure the pool meets the actuarial value limit
under clause (i);
(C) ensures that with respect to the premium rate
charged for health insurance coverage offered to
eligible individuals through the high risk pool, such
rate shall--
(i) except as provided in clause (ii), vary
only as provided for under section 2701 of the
Public Health Service Act (as amended by this
Act and notwithstanding the date on which such
amendments take effect);
(ii) vary on the basis of age by a factor
of not greater than 4 to 1; and
(iii) be established at a standard rate for
a standard population; and
(D) meets any other requirements determined
appropriate by the Secretary.
(d) Eligible Individual.--An individual shall be deemed to be an
eligible individual for purposes of this section if such individual--
(1) is a citizen or national of the United States or is
lawfully present in the United States (as determined in
accordance with section 1411);
(2) has not been covered under creditable coverage (as
defined in section 2701(c)(1) of the Public Health Service Act
as in effect on the date of enactment of this Act) during the
6-month period prior to the date on which such individual is
applying for coverage through the high risk pool; and
(3) has a pre-existing condition, as determined in a manner
consistent with guidance issued by the Secretary.
(e) Protection Against Dumping Risk by Insurers.--
(1) In general.--The Secretary shall establish criteria for
determining whether health insurance issuers and employment-
based health plans have discouraged an individual from
remaining enrolled in prior coverage based on that individual's
health status.
(2) Sanctions.--An issuer or employment-based health plan
shall be responsible for reimbursing the program under this
section for the medical expenses incurred by the program for an
individual who, based on criteria established by the Secretary,
the Secretary finds was encouraged by the issuer to disenroll
from health benefits coverage prior to enrolling in coverage
through the program. The criteria shall include at least the
following circumstances:
(A) In the case of prior coverage obtained through
an employer, the provision by the employer, group
health plan, or the issuer of money or other financial
consideration for disenrolling from the coverage.
(B) In the case of prior coverage obtained directly
from an issuer or under an employment-based health
plan--
(i) the provision by the issuer or plan of
money or other financial consideration for
disenrolling from the coverage; or
(ii) in the case of an individual whose
premium for the prior coverage exceeded the
premium required by the program (adjusted based
on the age factors applied to the prior
coverage)--
(I) the prior coverage is a policy
that is no longer being actively
marketed (as defined by the Secretary)
by the issuer; or
(II) the prior coverage is a policy
for which duration of coverage form
issue or health status are factors that
can be considered in determining
premiums at renewal.
(3) Construction.--Nothing in this subsection shall be
construed as constituting exclusive remedies for violations of
criteria established under paragraph (1) or as preventing
States from applying or enforcing such paragraph or other
provisions under law with respect to health insurance issuers.
(f) Oversight.--The Secretary shall establish--
(1) an appeals process to enable individuals to appeal a
determination under this section; and
(2) procedures to protect against waste, fraud, and abuse.
(g) Funding; Termination of Authority.--
(1) In general.--There is appropriated to the Secretary,
out of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to pay claims against (and the administrative
costs of) the high risk pool under this section that are in
excess of the amount of premiums collected from eligible
individuals enrolled in the high risk pool. Such funds shall be
available without fiscal year limitation.
(2) Insufficient funds.--If the Secretary estimates for any
fiscal year that the aggregate amounts available for the
payment of the expenses of the high risk pool will be less than
the actual amount of such expenses, the Secretary shall make
such adjustments as are necessary to eliminate such deficit.
(3) Termination of authority.--
(A) In general.--Except as provided in subparagraph
(B), coverage of eligible individuals under a high risk
pool in a State shall terminate on January 1, 2014.
(B) Transition to exchange.--The Secretary shall
develop procedures to provide for the transition of
eligible individuals enrolled in health insurance
coverage offered through a high risk pool established
under this section into qualified health plans offered
through an Exchange. Such procedures shall ensure that
there is no lapse in coverage with respect to the
individual and may extend coverage after the
termination of the risk pool involved, if the Secretary
determines necessary to avoid such a lapse.
(4) Limitations.--The Secretary has the authority to stop
taking applications for participation in the program under this
section to comply with the funding limitation provided for in
paragraph (1).
(5) Relation to state laws.--The standards established
under this section shall supersede any State law or regulation
(other than State licensing laws or State laws relating to plan
solvency) with respect to qualified high risk pools which are
established in accordance with this section.
SEC. 1102. REINSURANCE FOR EARLY RETIREES.
(a) Administration.--
(1) In general.--Not later than 90 days after the date of
enactment of this Act, the Secretary shall establish a
temporary reinsurance program to provide reimbursement to
participating employment-based plans for a portion of the cost
of providing health insurance coverage to early retirees (and
to the eligible spouses, surviving spouses, and dependents of
such retirees) during the period beginning on the date on which
such program is established and ending on January 1, 2014.
(2) Reference.--In this section:
(A) Health benefits.--The term ``health benefits''
means medical, surgical, hospital, prescription drug,
and such other benefits as shall be determined by the
Secretary, whether self-funded, or delivered through
the purchase of insurance or otherwise.
(B) Employment-based plan.--The term ``employment-
based plan'' means a group health benefits plan that--
(i) is--
(I) maintained by one or more
current or former employers (including
without limitation any State or local
government or political subdivision
thereof), employee organization, a
voluntary employees' beneficiary
association, or a committee or board of
individuals appointed to administer
such plan; or
(II) a multiemployer plan (as
defined in section 3(37) of the
Employee Retirement Income Security Act
of 1974); and
(ii) provides health benefits to early
retirees.
(C) Early retirees.--The term ``early retirees''
means individuals who are age 55 and older but are not
eligible for coverage under title XVIII of the Social
Security Act, and who are not active employees of an
employer maintaining, or currently contributing to, the
employment-based plan or of any employer that has made
substantial contributions to fund such plan.
(b) Participation.--
(1) Employment-based plan eligibility.--A participating
employment-based plan is an employment-based plan that--
(A) meets the requirements of paragraph (2) with
respect to health benefits provided under the plan; and
(B) submits to the Secretary an application for
participation in the program, at such time, in such
manner, and containing such information as the
Secretary shall require.
(2) Employment-based health benefits.--An employment-based
plan meets the requirements of this paragraph if the plan--
(A) implements programs and procedures to generate
cost-savings with respect to participants with chronic
and high-cost conditions;
(B) provides documentation of the actual cost of
medical claims involved; and
(C) is certified by the Secretary.
(c) Payments.--
(1) Submission of claims.--
(A) In general.--A participating employment-based
plan shall submit claims for reimbursement to the
Secretary which shall contain documentation of the
actual costs of the items and services for which each
claim is being submitted.
(B) Basis for claims.--Claims submitted under
subparagraph (A) shall be based on the actual amount
expended by the participating employment-based plan
involved within the plan year for the health benefits
provided to an early retiree or the spouse, surviving
spouse, or dependent of such retiree. In determining
the amount of a claim for purposes of this subsection,
the participating employment-based plan shall take into
account any negotiated price concessions (such as
discounts, direct or indirect subsidies, rebates, and
direct or indirect remunerations) obtained by such plan
with respect to such health benefit. For purposes of
determining the amount of any such claim, the costs
paid by the early retiree or the retiree's spouse,
surviving spouse, or dependent in the form of
deductibles, co-payments, or co-insurance shall be
included in the amounts paid by the participating
employment-based plan.
(2) Program payments.--If the Secretary determines that a
participating employment-based plan has submitted a valid claim
under paragraph (1), the Secretary shall reimburse such plan
for 80 percent of that portion of the costs attributable to
such claim that exceed $15,000, subject to the limits contained
in paragraph (3).
(3) Limit.--To be eligible for reimbursement under the
program, a claim submitted by a participating employment-based
plan shall not be less than $15,000 nor greater than $90,000.
Such amounts shall be adjusted each fiscal year based on the
percentage increase in the Medical Care Component of the
Consumer Price Index for all urban consumers (rounded to the
nearest multiple of $1,000) for the year involved.
(4) Use of payments.--Amounts paid to a participating
employment-based plan under this subsection shall be used to
lower costs for the plan. Such payments may be used to reduce
premium costs for an entity described in subsection
(a)(2)(B)(i) or to reduce premium contributions, co-payments,
deductibles, co-insurance, or other out-of-pocket costs for
plan participants. Such payments shall not be used as general
revenues for an entity described in subsection (a)(2)(B)(i).
The Secretary shall develop a mechanism to monitor the
appropriate use of such payments by such entities.
(5) Payments not treated as income.--Payments received
under this subsection shall not be included in determining the
gross income of an entity described in subsection (a)(2)(B)(i)
that is maintaining or currently contributing to a
participating employment-based plan.
(6) Appeals.--The Secretary shall establish--
(A) an appeals process to permit participating
employment-based plans to appeal a determination of the
Secretary with respect to claims submitted under this
section; and
(B) procedures to protect against fraud, waste, and
abuse under the program.
(d) Audits.--The Secretary shall conduct annual audits of claims
data submitted by participating employment-based plans under this
section to ensure that such plans are in compliance with the
requirements of this section.
(e) Funding.--There is appropriated to the Secretary, out of any
moneys in the Treasury not otherwise appropriated, $5,000,000,000 to
carry out the program under this section. Such funds shall be available
without fiscal year limitation.
(f) Limitation.--The Secretary has the authority to stop taking
applications for participation in the program based on the availability
of funding under subsection (e).
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO IDENTIFY
AFFORDABLE COVERAGE OPTIONS.
(a) Internet Portal to Affordable Coverage Options.--
(1) Immediate establishment.--Not later than July 1, 2010,
the Secretary, in consultation with the States, shall establish
a mechanism, including an Internet website, through which a
resident of any State may identify affordable health insurance
coverage options in that State.
(2) Connecting to affordable coverage.--An Internet website
established under paragraph (1) shall, to the extent
practicable, provide ways for residents of any State to receive
information on at least the following coverage options:
(A) Health insurance coverage offered by health
insurance issuers, other than coverage that provides
reimbursement only for the treatment or mitigation of--
(i) a single disease or condition; or
(ii) an unreasonably limited set of
diseases or conditions (as determined by the
Secretary);
(B) Medicaid coverage under title XIX of the Social
Security Act.
(C) Coverage under title XXI of the Social Security
Act.
(D) A State health benefits high risk pool, to the
extent that such high risk pool is offered in such
State; and
(E) Coverage under a high risk pool under section
1101.
(b) Enhancing Comparative Purchasing Options.--
(1) In general.--Not later than 60 days after the date of
enactment of this Act, the Secretary shall develop a
standardized format to be used for the presentation of
information relating to the coverage options described in
subsection (a)(2). Such format shall, at a minimum, require the
inclusion of information on the percentage of total premium
revenue expended on nonclinical costs (as reported under
section 2718(a) of the Public Health Service Act), eligibility,
availability, premium rates, and cost sharing with respect to
such coverage options and be consistent with the standards
adopted for the uniform explanation of coverage as provided for
in section 2715 of the Public Health Service Act.
(2) Use of format.--The Secretary shall utilize the format
developed under paragraph (1) in compiling information
concerning coverage options on the Internet website established
under subsection (a).
(c) Authority To Contract.--The Secretary may carry out this
section through contracts entered into with qualified entities.
SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.
(a) Purpose of Administrative Simplification.--Section 261 of the
Health Insurance Portability and Accountability Act of 1996 (42 U.S.C.
1320d note) is amended--
(1) by inserting ``uniform'' before ``standards''; and
(2) by inserting ``and to reduce the clerical burden on
patients, health care providers, and health plans'' before the
period at the end.
(b) Operating Rules for Health Information Transactions.--
(1) Definition of operating rules.--Section 1171 of the
Social Security Act (42 U.S.C. 1320d) is amended by adding at
the end the following:
``(9) Operating rules.--The term `operating rules' means
the necessary business rules and guidelines for the electronic
exchange of information that are not defined by a standard or
its implementation specifications as adopted for purposes of
this part.''.
(2) Transaction standards; operating rules and
compliance.--Section 1173 of the Social Security Act (42 U.S.C.
1320d-2) is amended--
(A) in subsection (a)(2), by adding at the end the
following new subparagraph:
``(J) Electronic funds transfers.'';
(B) in subsection (a), by adding at the end the
following new paragraph:
``(4) Requirements for financial and administrative
transactions.--
``(A) In general.--The standards and associated
operating rules adopted by the Secretary shall--
``(i) to the extent feasible and
appropriate, enable determination of an
individual's eligibility and financial
responsibility for specific services prior to
or at the point of care;
``(ii) be comprehensive, requiring minimal
augmentation by paper or other communications;
``(iii) provide for timely acknowledgment,
response, and status reporting that supports a
transparent claims and denial management
process (including adjudication and appeals);
and
``(iv) describe all data elements
(including reason and remark codes) in
unambiguous terms, require that such data
elements be required or conditioned upon set
values in other fields, and prohibit additional
conditions (except where necessary to implement
State or Federal law, or to protect against
fraud and abuse).
``(B) Reduction of clerical burden.--In adopting
standards and operating rules for the transactions
referred to under paragraph (1), the Secretary shall
seek to reduce the number and complexity of forms
(including paper and electronic forms) and data entry
required by patients and providers.''; and
(C) by adding at the end the following new
subsections:
``(g) Operating Rules.--
``(1) In general.--The Secretary shall adopt a single set
of operating rules for each transaction referred to under
subsection (a)(1) with the goal of creating as much uniformity
in the implementation of the electronic standards as possible.
Such operating rules shall be consensus-based and reflect the
necessary business rules affecting health plans and health care
providers and the manner in which they operate pursuant to
standards issued under Health Insurance Portability and
Accountability Act of 1996.
``(2) Operating rules development.--In adopting operating
rules under this subsection, the Secretary shall consider
recommendations for operating rules developed by a qualified
nonprofit entity that meets the following requirements:
``(A) The entity focuses its mission on
administrative simplification.
``(B) The entity demonstrates a multi-stakeholder
and consensus-based process for development of
operating rules, including representation by or
participation from health plans, health care providers,
vendors, relevant Federal agencies, and other standard
development organizations.
``(C) The entity has a public set of guiding
principles that ensure the operating rules and process
are open and transparent, and supports
nondiscrimination and conflict of interest policies
that demonstrate a commitment to open, fair, and
nondiscriminatory practices.
``(D) The entity builds on the transaction
standards issued under Health Insurance Portability and
Accountability Act of 1996.
``(E) The entity allows for public review and
updates of the operating rules.
``(3) Review and recommendations.--The National Committee
on Vital and Health Statistics shall--
``(A) advise the Secretary as to whether a
nonprofit entity meets the requirements under paragraph
(2);
``(B) review the operating rules developed and
recommended by such nonprofit entity;
``(C) determine whether such operating rules
represent a consensus view of the health care
stakeholders and are consistent with and do not
conflict with other existing standards;
``(D) evaluate whether such operating rules are
consistent with electronic standards adopted for health
information technology; and
``(E) submit to the Secretary a recommendation as
to whether the Secretary should adopt such operating
rules.
``(4) Implementation.--
``(A) In general.--The Secretary shall adopt
operating rules under this subsection, by regulation in
accordance with subparagraph (C), following
consideration of the operating rules developed by the
non-profit entity described in paragraph (2) and the
recommendation submitted by the National Committee on
Vital and Health Statistics under paragraph (3)(E) and
having ensured consultation with providers.
``(B) Adoption requirements; effective dates.--
``(i) Eligibility for a health plan and
health claim status.--The set of operating
rules for eligibility for a health plan and
health claim status transactions shall be
adopted not later than July 1, 2011, in a
manner ensuring that such operating rules are
effective not later than January 1, 2013, and
may allow for the use of a machine readable
identification card.
``(ii) Electronic funds transfers and
health care payment and remittance advice.--The
set of operating rules for electronic funds
transfers and health care payment and
remittance advice transactions shall--
``(I) allow for automated
reconciliation of the electronic
payment with the remittance advice; and
``(II) be adopted not later than
July 1, 2012, in a manner ensuring that
such operating rules are effective not
later than January 1, 2014.
``(iii) Health claims or equivalent
encounter information, enrollment and
disenrollment in a health plan, health plan
premium payments, referral certification and
authorization.--The set of operating rules for
health claims or equivalent encounter
information, enrollment and disenrollment in a
health plan, health plan premium payments, and
referral certification and authorization
transactions shall be adopted not later than
July 1, 2014, in a manner ensuring that such
operating rules are effective not later than
January 1, 2016.
``(C) Expedited rulemaking.--The Secretary shall
promulgate an interim final rule applying any standard
or operating rule recommended by the National Committee
on Vital and Health Statistics pursuant to paragraph
(3). The Secretary shall accept and consider public
comments on any interim final rule published under this
subparagraph for 60 days after the date of such
publication.
``(h) Compliance.--
``(1) Health plan certification.--
``(A) Eligibility for a health plan, health claim
status, electronic funds transfers, health care payment
and remittance advice.--Not later than December 31,
2013, a health plan shall file a statement with the
Secretary, in such form as the Secretary may require,
certifying that the data and information systems for
such plan are in compliance with any applicable
standards (as described under paragraph (7) of section
1171) and associated operating rules (as described
under paragraph (9) of such section) for electronic
funds transfers, eligibility for a health plan, health
claim status, and health care payment and remittance
advice, respectively.
``(B) Health claims or equivalent encounter
information, enrollment and disenrollment in a health
plan, health plan premium payments, health claims
attachments, referral certification and
authorization.--Not later than December 31, 2015, a
health plan shall file a statement with the Secretary,
in such form as the Secretary may require, certifying
that the data and information systems for such plan are
in compliance with any applicable standards and
associated operating rules for health claims or
equivalent encounter information, enrollment and
disenrollment in a health plan, health plan premium
payments, health claims attachments, and referral
certification and authorization, respectively. A health
plan shall provide the same level of documentation to
certify compliance with such transactions as is
required to certify compliance with the transactions
specified in subparagraph (A).
``(2) Documentation of compliance.--A health plan shall
provide the Secretary, in such form as the Secretary may
require, with adequate documentation of compliance with the
standards and operating rules described under paragraph (1). A
health plan shall not be considered to have provided adequate
documentation and shall not be certified as being in compliance
with such standards, unless the health plan--
``(A) demonstrates to the Secretary that the plan
conducts the electronic transactions specified in
paragraph (1) in a manner that fully complies with the
regulations of the Secretary; and
``(B) provides documentation showing that the plan
has completed end-to-end testing for such transactions
with their partners, such as hospitals and physicians.
``(3) Service contracts.--A health plan shall be required
to ensure that any entities that provide services pursuant to a
contract with such health plan shall comply with any applicable
certification and compliance requirements (and provide the
Secretary with adequate documentation of such compliance) under
this subsection.
``(4) Certification by outside entity.--The Secretary may
designate independent, outside entities to certify that a
health plan has complied with the requirements under this
subsection, provided that the certification standards employed
by such entities are in accordance with any standards or
operating rules issued by the Secretary.
``(5) Compliance with revised standards and operating
rules.--
``(A) In general.--A health plan (including
entities described under paragraph (3)) shall file a
statement with the Secretary, in such form as the
Secretary may require, certifying that the data and
information systems for such plan are in compliance
with any applicable revised standards and associated
operating rules under this subsection for any interim
final rule promulgated by the Secretary under
subsection (i) that--
``(i) amends any standard or operating rule
described under paragraph (1) of this
subsection; or
``(ii) establishes a standard (as described
under subsection (a)(1)(B)) or associated
operating rules (as described under subsection
(i)(5)) for any other financial and
administrative transactions.
``(B) Date of compliance.--A health plan shall
comply with such requirements not later than the
effective date of the applicable standard or operating
rule.
``(6) Audits of health plans.--The Secretary shall conduct
periodic audits to ensure that health plans (including entities
described under paragraph (3)) are in compliance with any
standards and operating rules that are described under
paragraph (1) or subsection (i)(5).
``(i) Review and Amendment of Standards and Operating Rules.--
``(1) Establishment.--Not later than January 1, 2014, the
Secretary shall establish a review committee (as described
under paragraph (4)).
``(2) Evaluations and reports.--
``(A) Hearings.--Not later than April 1, 2014, and
not less than biennially thereafter, the Secretary,
acting through the review committee, shall conduct
hearings to evaluate and review the adopted standards
and operating rules established under this section.
``(B) Report.--Not later than July 1, 2014, and not
less than biennially thereafter, the review committee
shall provide recommendations for updating and
improving such standards and operating rules. The
review committee shall recommend a single set of
operating rules per transaction standard and maintain
the goal of creating as much uniformity as possible in
the implementation of the electronic standards.
``(3) Interim final rulemaking.--
``(A) In general.--Any recommendations to amend
adopted standards and operating rules that have been
approved by the review committee and reported to the
Secretary under paragraph (2)(B) shall be adopted by
the Secretary through promulgation of an interim final
rule not later than 90 days after receipt of the
committee's report.
``(B) Public comment.--
``(i) Public comment period.--The Secretary
shall accept and consider public comments on
any interim final rule published under this
paragraph for 60 days after the date of such
publication.
``(ii) Effective date.--The effective date
of any amendment to existing standards or
operating rules that is adopted through an
interim final rule published under this
paragraph shall be 25 months following the
close of such public comment period.
``(4) Review committee.--
``(A) Definition.--For the purposes of this
subsection, the term `review committee' means a
committee chartered by or within the Department of
Health and Human services that has been designated by
the Secretary to carry out this subsection, including--
``(i) the National Committee on Vital and
Health Statistics; or
``(ii) any appropriate committee as
determined by the Secretary.
``(B) Coordination of hit standards.--In developing
recommendations under this subsection, the review
committee shall ensure coordination, as appropriate,
with the standards that support the certified
electronic health record technology approved by the
Office of the National Coordinator for Health
Information Technology.
``(5) Operating rules for other standards adopted by the
secretary.--The Secretary shall adopt a single set of operating
rules (pursuant to the process described under subsection (g))
for any transaction for which a standard had been adopted
pursuant to subsection (a)(1)(B).
``(j) Penalties.--
``(1) Penalty fee.--
``(A) In general.--Not later than April 1, 2014,
and annually thereafter, the Secretary shall assess a
penalty fee (as determined under subparagraph (B))
against a health plan that has failed to meet the
requirements under subsection (h) with respect to
certification and documentation of compliance with--
``(i) the standards and associated
operating rules described under paragraph (1)
of such subsection; and
``(ii) a standard (as described under
subsection (a)(1)(B)) and associated operating
rules (as described under subsection (i)(5))
for any other financial and administrative
transactions.
``(B) Fee amount.--Subject to subparagraphs (C),
(D), and (E), the Secretary shall assess a penalty fee
against a health plan in the amount of $1 per covered
life until certification is complete. The penalty shall
be assessed per person covered by the plan for which
its data systems for major medical policies are not in
compliance and shall be imposed against the health plan
for each day that the plan is not in compliance with
the requirements under subsection (h).
``(C) Additional penalty for misrepresentation.--A
health plan that knowingly provides inaccurate or
incomplete information in a statement of certification
or documentation of compliance under subsection (h)
shall be subject to a penalty fee that is double the
amount that would otherwise be imposed under this
subsection.
``(D) Annual fee increase.--The amount of the
penalty fee imposed under this subsection shall be
increased on an annual basis by the annual percentage
increase in total national health care expenditures, as
determined by the Secretary.
``(E) Penalty limit.--A penalty fee assessed
against a health plan under this subsection shall not
exceed, on an annual basis--
``(i) an amount equal to $20 per covered
life under such plan; or
``(ii) an amount equal to $40 per covered
life under the plan if such plan has knowingly
provided inaccurate or incomplete information
(as described under subparagraph (C)).
``(F) Determination of covered individuals.--The
Secretary shall determine the number of covered lives
under a health plan based upon the most recent
statements and filings that have been submitted by such
plan to the Securities and Exchange Commission.
``(2) Notice and dispute procedure.--The Secretary shall
establish a procedure for assessment of penalty fees under this
subsection that provides a health plan with reasonable notice
and a dispute resolution procedure prior to provision of a
notice of assessment by the Secretary of the Treasury (as
described under paragraph (4)(B)).
``(3) Penalty fee report.--Not later than May 1, 2014, and
annually thereafter, the Secretary shall provide the Secretary
of the Treasury with a report identifying those health plans
that have been assessed a penalty fee under this subsection.
``(4) Collection of penalty fee.--
``(A) In general.--The Secretary of the Treasury,
acting through the Financial Management Service, shall
administer the collection of penalty fees from health
plans that have been identified by the Secretary in the
penalty fee report provided under paragraph (3).
``(B) Notice.--Not later than August 1, 2014, and
annually thereafter, the Secretary of the Treasury
shall provide notice to each health plan that has been
assessed a penalty fee by the Secretary under this
subsection. Such notice shall include the amount of the
penalty fee assessed by the Secretary and the due date
for payment of such fee to the Secretary of the
Treasury (as described in subparagraph (C)).
``(C) Payment due date.--Payment by a health plan
for a penalty fee assessed under this subsection shall
be made to the Secretary of the Treasury not later than
November 1, 2014, and annually thereafter.
``(D) Unpaid penalty fees.--Any amount of a penalty
fee assessed against a health plan under this
subsection for which payment has not been made by the
due date provided under subparagraph (C) shall be--
``(i) increased by the interest accrued on
such amount, as determined pursuant to the
underpayment rate established under section
6621 of the Internal Revenue Code of 1986; and
``(ii) treated as a past-due, legally
enforceable debt owed to a Federal agency for
purposes of section 6402(d) of the Internal
Revenue Code of 1986.
``(E) Administrative fees.--Any fee charged or
allocated for collection activities conducted by the
Financial Management Service will be passed on to a
health plan on a pro-rata basis and added to any
penalty fee collected from the plan.''.
(c) Promulgation of Rules.--
(1) Unique health plan identifier.--The Secretary shall
promulgate a final rule to establish a unique health plan
identifier (as described in section 1173(b) of the Social
Security Act (42 U.S.C. 1320d-2(b))) based on the input of the
National Committee on Vital and Health Statistics. The
Secretary may do so on an interim final basis and such rule
shall be effective not later than October 1, 2012.
(2) Electronic funds transfer.--The Secretary shall
promulgate a final rule to establish a standard for electronic
funds transfers (as described in section 1173(a)(2)(J) of the
Social Security Act, as added by subsection (b)(2)(A)). The
Secretary may do so on an interim final basis and shall adopt
such standard not later than January 1, 2012, in a manner
ensuring that such standard is effective not later than January
1, 2014.
(3) Health claims attachments.--The Secretary shall
promulgate a final rule to establish a transaction standard and
a single set of associated operating rules for health claims
attachments (as described in section 1173(a)(2)(B) of the
Social Security Act (42 U.S.C. 1320d-2(a)(2)(B))) that is
consistent with the X12 Version 5010 transaction standards. The
Secretary may do so on an interim final basis and shall adopt a
transaction standard and a single set of associated operating
rules not later than January 1, 2014, in a manner ensuring that
such standard is effective not later than January 1, 2016.
(d) Expansion of Electronic Transactions in Medicare.--Section
1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended--
(1) in paragraph (23), by striking the ``or'' at the end;
(2) in paragraph (24), by striking the period and inserting
``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) not later than January 1, 2014, for which the
payment is other than by electronic funds transfer (EFT) or an
electronic remittance in a form as specified in ASC X12 835
Health Care Payment and Remittance Advice or subsequent
standard.''.
SEC. 1105. EFFECTIVE DATE.
This subtitle shall take effect on the date of enactment of this
Act.
Subtitle C--Quality Health Insurance Coverage for All Americans
PART I--HEALTH INSURANCE MARKET REFORMS
SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42 U.S.C.
300gg et seq.), as amended by section 1001, is further amended--
(1) by striking the heading for subpart 1 and inserting the
following:
``Subpart I--General Reform'';
(2)(A) in section 2701 (42 U.S.C. 300gg), by striking the
section heading and subsection (a) and inserting the following:
``SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER
DISCRIMINATION BASED ON HEALTH STATUS.
``(a) In General.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage may not
impose any preexisting condition exclusion with respect to such plan or
coverage.''; and
(B) by transferring such section (as amended by
subparagraph (A)) so as to appear after the section 2703 added
by paragraph (4);
(3)(A) in section 2702 (42 U.S.C. 300gg-1)--
(i) by striking the section heading and all that
follows through subsection (a);
(ii) in subsection (b)--
(I) by striking ``health insurance issuer
offering health insurance coverage in
connection with a group health plan'' each
place that such appears and inserting ``health
insurance issuer offering group or individual
health insurance coverage''; and
(II) in paragraph (2)(A)--
(aa) by inserting ``or individual''
after ``employer''; and
(bb) by inserting ``or individual
health coverage, as the case may be''
before the semicolon; and
(iii) in subsection (e)--
(I) by striking ``(a)(1)(F)'' and inserting
``(a)(6)'';
(II) by striking ``2701'' and inserting
``2704''; and
(III) by striking ``2721(a)'' and inserting
``2735(a)''; and
(B) by transferring such section (as amended by
subparagraph (A)) to appear after section 2705(a) as
added by paragraph (4); and
(4) by inserting after the subpart heading (as added by
paragraph (1)) the following:
``SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
``(a) Prohibiting Discriminatory Premium Rates.--
``(1) In general.--With respect to the premium rate charged
by a health insurance issuer for health insurance coverage
offered in the individual or small group market--
``(A) such rate shall vary with respect to the
particular plan or coverage involved only by--
``(i) whether such plan or coverage covers
an individual or family;
``(ii) rating area, as established in
accordance with paragraph (2);
``(iii) age, except that such rate shall
not vary by more than 3 to 1 for adults
(consistent with section 2707(c)); and
``(iv) tobacco use, except that such rate
shall not vary by more than 1.5 to 1; and
``(B) such rate shall not vary with respect to the
particular plan or coverage involved by any other
factor not described in subparagraph (A).
``(2) Rating area.--
``(A) In general.--Each State shall establish 1 or
more rating areas within that State for purposes of
applying the requirements of this title.
``(B) Secretarial review.--The Secretary shall
review the rating areas established by each State under
subparagraph (A) to ensure the adequacy of such areas
for purposes of carrying out the requirements of this
title. If the Secretary determines a State's rating
areas are not adequate, or that a State does not
establish such areas, the Secretary may establish
rating areas for that State.
``(3) Permissible age bands.--The Secretary, in
consultation with the National Association of Insurance
Commissioners, shall define the permissible age bands for
rating purposes under paragraph (1)(A)(iii).
``(4) Application of variations based on age or tobacco
use.--With respect to family coverage under a group health plan
or health insurance coverage, the rating variations permitted
under clauses (iii) and (iv) of paragraph (1)(A) shall be
applied based on the portion of the premium that is
attributable to each family member covered under the plan or
coverage.
``(5) Special rule for large group market.--If a State
permits health insurance issuers that offer coverage in the
large group market in the State to offer such coverage through
the State Exchange (as provided for under section 1312(f)(2)(B)
of the Patient Protection and Affordable Care Act), the
provisions of this subsection shall apply to all coverage
offered in such market in the State.
``SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.
``(a) Guaranteed Issuance of Coverage in the Individual and Group
Market.--Subject to subsections (b) through (e), each health insurance
issuer that offers health insurance coverage in the individual or group
market in a State must accept every employer and individual in the
State that applies for such coverage.
``(b) Enrollment.--
``(1) Restriction.--A health insurance issuer described in
subsection (a) may restrict enrollment in coverage described in
such subsection to open or special enrollment periods.
``(2) Establishment.--A health insurance issuer described
in subsection (a) shall, in accordance with the regulations
promulgated under paragraph (3), establish special enrollment
periods for qualifying events (under section 603 of the
Employee Retirement Income Security Act of 1974).
``(3) Regulations.--The Secretary shall promulgate
regulations with respect to enrollment periods under paragraphs
(1) and (2).
``SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.
``(a) In General.--Except as provided in this section, if a health
insurance issuer offers health insurance coverage in the individual or
group market, the issuer must renew or continue in force such coverage
at the option of the plan sponsor or the individual, as applicable.
``SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL PARTICIPANTS
AND BENEFICIARIES BASED ON HEALTH STATUS.
``(a) In General.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage may not
establish rules for eligibility (including continued eligibility) of
any individual to enroll under the terms of the plan or coverage based
on any of the following health status-related factors in relation to
the individual or a dependent of the individual:
``(1) Health status.
``(2) Medical condition (including both physical and mental
illnesses).
``(3) Claims experience.
``(4) Receipt of health care.
``(5) Medical history.
``(6) Genetic information.
``(7) Evidence of insurability (including conditions
arising out of acts of domestic violence).
``(8) Disability.
``(9) Any other health status-related factor determined
appropriate by the Secretary.
``(j) Programs of Health Promotion or Disease Prevention.--
``(1) General provisions.--
``(A) General rule.--For purposes of subsection
(b)(2)(B), a program of health promotion or disease
prevention (referred to in this subsection as a
`wellness program') shall be a program offered by an
employer that is designed to promote health or prevent
disease that meets the applicable requirements of this
subsection.
``(B) No conditions based on health status
factor.--If none of the conditions for obtaining a
premium discount or rebate or other reward for
participation in a wellness program is based on an
individual satisfying a standard that is related to a
health status factor, such wellness program shall not
violate this section if participation in the program is
made available to all similarly situated individuals
and the requirements of paragraph (2) are complied
with.
``(C) Conditions based on health status factor.--If
any of the conditions for obtaining a premium discount
or rebate or other reward for participation in a
wellness program is based on an individual satisfying a
standard that is related to a health status factor,
such wellness program shall not violate this section if
the requirements of paragraph (3) are complied with.
``(2) Wellness programs not subject to requirements.--If
none of the conditions for obtaining a premium discount or
rebate or other reward under a wellness program as described in
paragraph (1)(B) are based on an individual satisfying a
standard that is related to a health status factor (or if such
a wellness program does not provide such a reward), the
wellness program shall not violate this section if
participation in the program is made available to all similarly
situated individuals. The following programs shall not have to
comply with the requirements of paragraph (3) if participation
in the program is made available to all similarly situated
individuals:
``(A) A program that reimburses all or part of the
cost for memberships in a fitness center.
``(B) A diagnostic testing program that provides a
reward for participation and does not base any part of
the reward on outcomes.
``(C) A program that encourages preventive care
related to a health condition through the waiver of the
copayment or deductible requirement under group health
plan for the costs of certain items or services related
to a health condition (such as prenatal care or well-
baby visits).
``(D) A program that reimburses individuals for the
costs of smoking cessation programs without regard to
whether the individual quits smoking.
``(E) A program that provides a reward to
individuals for attending a periodic health education
seminar.
``(3) Wellness programs subject to requirements.--If any of
the conditions for obtaining a premium discount, rebate, or
reward under a wellness program as described in paragraph
(1)(C) is based on an individual satisfying a standard that is
related to a health status factor, the wellness program shall
not violate this section if the following requirements are
complied with:
``(A) The reward for the wellness program, together
with the reward for other wellness programs with
respect to the plan that requires satisfaction of a
standard related to a health status factor, shall not
exceed 30 percent of the cost of employee-only coverage
under the plan. If, in addition to employees or
individuals, any class of dependents (such as spouses
or spouses and dependent children) may participate
fully in the wellness program, such reward shall not
exceed 30 percent of the cost of the coverage in which
an employee or individual and any dependents are
enrolled. For purposes of this paragraph, the cost of
coverage shall be determined based on the total amount
of employer and employee contributions for the benefit
package under which the employee is (or the employee
and any dependents are) receiving coverage. A reward
may be in the form of a discount or rebate of a premium
or contribution, a waiver of all or part of a cost-
sharing mechanism (such as deductibles, copayments, or
coinsurance), the absence of a surcharge, or the value
of a benefit that would otherwise not be provided under
the plan. The Secretaries of Labor, Health and Human
Services, and the Treasury may increase the reward
available under this subparagraph to up to 50 percent
of the cost of coverage if the Secretaries determine
that such an increase is appropriate.
``(B) The wellness program shall be reasonably
designed to promote health or prevent disease. A
program complies with the preceding sentence if the
program has a reasonable chance of improving the health
of, or preventing disease in, participating individuals
and it is not overly burdensome, is not a subterfuge
for discriminating based on a health status factor, and
is not highly suspect in the method chosen to promote
health or prevent disease.
``(C) The plan shall give individuals eligible for
the program the opportunity to qualify for the reward
under the program at least once each year.
``(D) The full reward under the wellness program
shall be made available to all similarly situated
individuals. For such purpose, among other things:
``(i) The reward is not available to all
similarly situated individuals for a period
unless the wellness program allows--
``(I) for a reasonable alternative
standard (or waiver of the otherwise
applicable standard) for obtaining the
reward for any individual for whom, for
that period, it is unreasonably
difficult due to a medical condition to
satisfy the otherwise applicable
standard; and
``(II) for a reasonable alternative
standard (or waiver of the otherwise
applicable standard) for obtaining the
reward for any individual for whom, for
that period, it is medically
inadvisable to attempt to satisfy the
otherwise applicable standard.
``(ii) If reasonable under the
circumstances, the plan or issuer may seek
verification, such as a statement from an
individual's physician, that a health status
factor makes it unreasonably difficult or
medically inadvisable for the individual to
satisfy or attempt to satisfy the otherwise
applicable standard.
``(E) The plan or issuer involved shall disclose in
all plan materials describing the terms of the wellness
program the availability of a reasonable alternative
standard (or the possibility of waiver of the otherwise
applicable standard) required under subparagraph (D).
If plan materials disclose that such a program is
available, without describing its terms, the disclosure
under this subparagraph shall not be required.
``(k) Existing Programs.--Nothing in this section shall prohibit a
program of health promotion or disease prevention that was established
prior to the date of enactment of this section and applied with all
applicable regulations, and that is operating on such date, from
continuing to be carried out for as long as such regulations remain in
effect.
``(l) Wellness Program Demonstration Project.--
``(1) In general.--Not later than July 1, 2014, the
Secretary, in consultation with the Secretary of the Treasury
and the Secretary of Labor, shall establish a 10-State
demonstration project under which participating States shall
apply the provisions of subsection (j) to programs of health
promotion offered by a health insurance issuer that offers
health insurance coverage in the individual market in such
State.
``(2) Expansion of demonstration project.--If the
Secretary, in consultation with the Secretary of the Treasury
and the Secretary of Labor, determines that the demonstration
project described in paragraph (1) is effective, such
Secretaries may, beginning on July 1, 2017 expand such
demonstration project to include additional participating
States.
``(3) Requirements.--
``(A) Maintenance of coverage.--The Secretary, in
consultation with the Secretary of the Treasury and the
Secretary of Labor, shall not approve the participation
of a State in the demonstration project under this
section unless the Secretaries determine that the
State's project is designed in a manner that--
``(i) will not result in any decrease in
coverage; and
``(ii) will not increase the cost to the
Federal Government in providing credits under
section 36B of the Internal Revenue Code of
1986 or cost-sharing assistance under section
1402 of the Patient Protection and Affordable
Care Act.
``(B) Other requirements.--States that participate
in the demonstration project under this subsection--
``(i) may permit premium discounts or
rebates or the modification of otherwise
applicable copayments or deductibles for
adherence to, or participation in, a reasonably
designed program of health promotion and
disease prevention;
``(ii) shall ensure that requirements of
consumer protection are met in programs of
health promotion in the individual market;
``(iii) shall require verification from
health insurance issuers that offer health
insurance coverage in the individual market of
such State that premium discounts--
``(I) do not create undue burdens
for individuals insured in the
individual market;
``(II) do not lead to cost
shifting; and
``(III) are not a subterfuge for
discrimination;
``(iv) shall ensure that consumer data is
protected in accordance with the requirements
of section 264(c) of the Health Insurance
Portability and Accountability Act of 1996 (42
U.S.C. 1320d-2 note); and
``(v) shall ensure and demonstrate to the
satisfaction of the Secretary that the
discounts or other rewards provided under the
project reflect the expected level of
participation in the wellness program involved
and the anticipated effect the program will
have on utilization or medical claim costs.
``(m) Report.--
``(1) In general.--Not later than 3 years after the date of
enactment of the Patient Protection and Affordable Care Act,
the Secretary, in consultation with the Secretary of the
Treasury and the Secretary of Labor, shall submit a report to
the appropriate committees of Congress concerning--
``(A) the effectiveness of wellness programs (as
defined in subsection (j)) in promoting health and
preventing disease;
``(B) the impact of such wellness programs on the
access to care and affordability of coverage for
participants and non-participants of such programs;
``(C) the impact of premium-based and cost-sharing
incentives on participant behavior and the role of such
programs in changing behavior; and
``(D) the effectiveness of different types of
rewards.
``(2) Data collection.--In preparing the report described
in paragraph (1), the Secretaries shall gather relevant
information from employers who provide employees with access to
wellness programs, including State and Federal agencies.
``(n) Regulations.--Nothing in this section shall be construed as
prohibiting the Secretaries of Labor, Health and Human Services, or the
Treasury from promulgating regulations in connection with this section.
``SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.
``(a) Providers.--A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall not
discriminate with respect to participation under the plan or coverage
against any health care provider who is acting within the scope of that
provider's license or certification under applicable State law. This
section shall not require that a group health plan or health insurance
issuer contract with any health care provider willing to abide by the
terms and conditions for participation established by the plan or
issuer. Nothing in this section shall be construed as preventing a
group health plan, a health insurance issuer, or the Secretary from
establishing varying reimbursement rates based on quality or
performance measures.
``(b) Individuals.--The provisions of section 1558 of the Patient
Protection and Affordable Care Act (relating to non-discrimination)
shall apply with respect to a group health plan or health insurance
issuer offering group or individual health insurance coverage.
``SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COVERAGE.
``(a) Coverage for Essential Health Benefits Package.--A health
insurance issuer that offers health insurance coverage in the
individual or small group market shall ensure that such coverage
includes the essential health benefits package required under section
1302(a) of the Patient Protection and Affordable Care Act.
``(b) Cost-sharing Under Group Health Plans.--A group health plan
shall ensure that any annual cost-sharing imposed under the plan does
not exceed the limitations provided for under paragraphs (1) and (2) of
section 1302(c).
``(c) Child-only Plans.--If a health insurance issuer offers health
insurance coverage in any level of coverage specified under section
1302(d) of the Patient Protection and Affordable Care Act, the issuer
shall also offer such coverage in that level as a plan in which the
only enrollees are individuals who, as of the beginning of a plan year,
have not attained the age of 21.
``(d) Dental Only.--This section shall not apply to a plan
described in section 1302(d)(2)(B)(ii)(I).
``SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
``A group health plan and a health insurance issuer offering group
or individual health insurance coverage shall not apply any waiting
period (as defined in section 2704(b)(4)) that exceeds 90 days.''.
PART II--OTHER PROVISIONS
SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXISTING COVERAGE.
(a) No Changes to Existing Coverage.--
(1) In general.--Nothing in this Act (or an amendment made
by this Act) shall be construed to require that an individual
terminate coverage under a group health plan or health
insurance coverage in which such individual was enrolled on the
date of enactment of this Act.
(2) Continuation of coverage.--With respect to a group
health plan or health insurance coverage in which an individual
was enrolled on the date of enactment of this Act, this
subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply to such plan or coverage, regardless
of whether the individual renews such coverage after such date
of enactment.
(b) Allowance for Family Members To Join Current Coverage.--With
respect to a group health plan or health insurance coverage in which an
individual was enrolled on the date of enactment of this Act and which
is renewed after such date, family members of such individual shall be
permitted to enroll in such plan or coverage if such enrollment is
permitted under the terms of the plan in effect as of such date of
enactment.
(c) Allowance for New Employees To Join Current Plan.--A group
health plan that provides coverage on the date of enactment of this Act
may provide for the enrolling of new employees (and their families) in
such plan, and this subtitle and subtitle A (and the amendments made by
such subtitles) shall not apply with respect to such plan and such new
employees (and their families).
(d) Effect on Collective Bargaining Agreements.--In the case of
health insurance coverage maintained pursuant to one or more collective
bargaining agreements between employee representatives and one or more
employers that was ratified before the date of enactment of this Act,
the provisions of this subtitle and subtitle A (and the amendments made
by such subtitles) shall not apply until the date on which the last of
the collective bargaining agreements relating to the coverage
terminates. Any coverage amendment made pursuant to a collective
bargaining agreement relating to the coverage which amends the coverage
solely to conform to any requirement added by this subtitle or subtitle
A (or amendments) shall not be treated as a termination of such
collective bargaining agreement.
(e) Definition.--In this title, the term ``grandfathered health
plan'' means any group health plan or health insurance coverage to
which this section applies.
SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO ALL HEALTH INSURANCE
ISSUERS AND GROUP HEALTH PLANS.
Any standard or requirement adopted by a State pursuant to this
title, or any amendment made by this title, shall be applied uniformly
to all health plans in each insurance market to which the standard and
requirements apply. The preceding sentence shall also apply to a State
standard or requirement relating to the standard or requirement
required by this title (or any such amendment) that is not the same as
the standard or requirement but that is not preempted under section
1321(d).
SEC. 1253. EFFECTIVE DATES.
This subtitle (and the amendments made by this subtitle) shall
become effective for plan years beginning on or after January 1, 2014.
Subtitle D--Available Coverage Choices for All Americans
PART I--ESTABLISHMENT OF QUALIFIED HEALTH PLANS
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED.
(a) Qualified Health Plan.--In this title:
(1) In general.--The term ``qualified health plan'' means a
health plan that--
(A) has in effect a certification (which may
include a seal or other indication of approval) that
such plan meets the criteria for certification
described in section 1311(c) issued or recognized by
each Exchange through which such plan is offered;
(B) provides the essential health benefits package
described in section 1302(a); and
(C) is offered by a health insurance issuer that--
(i) is licensed and in good standing to
offer health insurance coverage in each State
in which such issuer offers health insurance
coverage under this title;
(ii) agrees to offer at least one qualified
health plan in the silver level and at least
one plan in the gold level in each such
Exchange;
(iii) agrees to charge the same premium
rate for each qualified health plan of the
issuer without regard to whether the plan is
offered through an Exchange or whether the plan
is offered directly from the issuer or through
an agent; and
(iv) complies with the regulations
developed by the Secretary under section
1311(d) and such other requirements as an
applicable Exchange may establish.
(2) Inclusion of co-op plans and community health insurance
option.--Any reference in this title to a qualified health plan
shall be deemed to include a qualified health plan offered
through the CO-OP program under section 1322 or a community
health insurance option under section 1323, unless specifically
provided for otherwise.
(b) Terms Relating to Health Plans.--In this title:
(1) Health plan.--
(A) In general.--The term ``health plan'' means
health insurance coverage and a group health plan.
(B) Exception for self-insured plans and mewas.--
Except to the extent specifically provided by this
title, the term ``health plan'' shall not include a
group health plan or multiple employer welfare
arrangement to the extent the plan or arrangement is
not subject to State insurance regulation under section
514 of the Employee Retirement Income Security Act of
1974.
(2) Health insurance coverage and issuer.--The terms
``health insurance coverage'' and ``health insurance issuer''
have the meanings given such terms by section 2791(b) of the
Public Health Service Act.
(3) Group health plan.--The term ``group health plan'' has
the meaning given such term by section 2791(a) of the Public
Health Service Act.
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) Essential Health Benefits Package.--In this title, the term
``essential health benefits package'' means, with respect to any health
plan, coverage that--
(1) provides for the essential health benefits defined by
the Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance
with subsection (c); and
(3) subject to subsection (e), provides either the bronze,
silver, gold, or platinum level of coverage described in
subsection (d).
(b) Essential Health Benefits.--
(1) In general.--Subject to paragraph (2), the Secretary
shall define the essential health benefits, except that such
benefits shall include at least the following general
categories and the items and services covered within the
categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder
services, including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and
devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic
disease management.
(J) Pediatric services, including oral and vision
care.
(2) Limitation.--
(A) In general.--The Secretary shall ensure that
the scope of the essential health benefits under
paragraph (1) is equal to the scope of benefits
provided under a typical employer plan, as determined
by the Secretary. To inform this determination, the
Secretary of Labor shall conduct a survey of employer-
sponsored coverage to determine the benefits typically
covered by employers, including multiemployer plans,
and provide a report on such survey to the Secretary.
(B) Certification.--In defining the essential
health benefits described in paragraph (1), and in
revising the benefits under paragraph (4)(H), the
Secretary shall submit a report to the appropriate
committees of Congress containing a certification from
the Chief Actuary of the Centers for Medicare &
Medicaid Services that such essential health benefits
meet the limitation described in paragraph (2).
(3) Notice and hearing.--In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall provide
notice and an opportunity for public comment.
(4) Required elements for consideration.--In defining the
essential health benefits under paragraph (1), the Secretary
shall--
(A) ensure that such essential health benefits
reflect an appropriate balance among the categories
described in such subsection, so that benefits are not
unduly weighted toward any category;
(B) not make coverage decisions, determine
reimbursement rates, establish incentive programs, or
design benefits in ways that discriminate against
individuals because of their age, disability, or
expected length of life;
(C) take into account the health care needs of
diverse segments of the population, including women,
children, persons with disabilities, and other groups;
(D) ensure that health benefits established as
essential not be subject to denial to individuals
against their wishes on the basis of the individuals'
age or expected length of life or of the individuals'
present or predicted disability, degree of medical
dependency, or quality of life;
(E) provide that a qualified health plan shall not
be treated as providing coverage for the essential
health benefits described in paragraph (1) unless the
plan provides that--
(i) coverage for emergency department
services will be provided without imposing any
requirement under the plan for prior
authorization of services or any limitation on
coverage where the provider of services does
not have a contractual relationship with the
plan for the providing of services that is more
restrictive than the requirements or
limitations that apply to emergency department
services received from providers who do have
such a contractual relationship with the plan;
and
(ii) if such services are provided out-of-
network, the cost-sharing requirement
(expressed as a copayment amount or coinsurance
rate) is the same requirement that would apply
if such services were provided in-network;
(F) provide that if a plan described in section
1311(b)(2)(B)(ii) (relating to stand-alone dental
benefits plans) is offered through an Exchange, another
health plan offered through such Exchange shall not
fail to be treated as a qualified health plan solely
because the plan does not offer coverage of benefits
offered through the stand-alone plan that are otherwise
required under paragraph (1)(J); and
(G) periodically review the essential health
benefits under paragraph (1), and provide a report to
Congress and the public that contains--
(i) an assessment of whether enrollees are
facing any difficulty accessing needed services
for reasons of coverage or cost;
(ii) an assessment of whether the essential
health benefits needs to be modified or updated
to account for changes in medical evidence or
scientific advancement;
(iii) information on how the essential
health benefits will be modified to address any
such gaps in access or changes in the evidence
base;
(iv) an assessment of the potential of
additional or expanded benefits to increase
costs and the interactions between the addition
or expansion of benefits and reductions in
existing benefits to meet actuarial limitations
described in paragraph (2); and
(H) periodically update the essential health
benefits under paragraph (1) to address any gaps in
access to coverage or changes in the evidence base the
Secretary identifies in the review conducted under
subparagraph (G).
(5) Rule of construction.--Nothing in this title shall be
construed to prohibit a health plan from providing benefits in
excess of the essential health benefits described in this
subsection.
(c) Requirements Relating to Cost-Sharing.--
(1) Annual limitation on cost-sharing.--
(A) 2014.--The cost-sharing incurred under a health
plan with respect to self-only coverage or coverage
other than self-only coverage for a plan year beginning
in 2014 shall not exceed the dollar amounts in effect
under section 223(c)(2)(A)(ii) of the Internal Revenue
Code of 1986 for self-only and family coverage,
respectively, for taxable years beginning in 2014.
(B) 2015 and later.--In the case of any plan year
beginning in a calendar year after 2014, the limitation
under this paragraph shall--
(i) in the case of self-only coverage, be
equal to the dollar amount under subparagraph
(A) for self-only coverage for plan years
beginning in 2014, increased by an amount equal
to the product of that amount and the premium
adjustment percentage under paragraph (4) for
the calendar year; and
(ii) in the case of other coverage, twice
the amount in effect under clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the
next lowest multiple of $50.
(2) Annual limitation on deductibles for employer-sponsored
plans.--
(A) In general.--In the case of a health plan
offered in the small group market, the deductible under
the plan shall not exceed--
(i) $2,000 in the case of a plan covering a
single individual; and
(ii) $4,000 in the case of any other plan.
The amounts under clauses (i) and (ii) may be increased
by the maximum amount of reimbursement which is
reasonably available to a participant under a flexible
spending arrangement described in section 106(c)(2) of
the Internal Revenue Code of 1986 (determined without
regard to any salary reduction arrangement).
(B) Indexing of limits.--In the case of any plan
year beginning in a calendar year after 2014--
(i) the dollar amount under subparagraph
(A)(i) shall be increased by an amount equal to
the product of that amount and the premium
adjustment percentage under paragraph (4) for
the calendar year; and
(ii) the dollar amount under subparagraph
(A)(ii) shall be increased to an amount equal
to twice the amount in effect under
subparagraph (A)(i) for plan years beginning in
the calendar year, determined after application
of clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the
next lowest multiple of $50.
(C) Actuarial value.--The limitation under this
paragraph shall be applied in such a manner so as to
not affect the actuarial value of any health plan,
including a plan in the bronze level.
(D) Coordination with preventive limits.--Nothing
in this paragraph shall be construed to allow a plan to
have a deductible under the plan apply to benefits
described in section 2713 of the Public Health Service
Act.
(3) Cost-sharing.--In this title--
(A) In general.--The term ``cost-sharing''
includes--
(i) deductibles, coinsurance, copayments,
or similar charges; and
(ii) any other expenditure required of an
insured individual which is a qualified medical
expense (within the meaning of section
223(d)(2) of the Internal Revenue Code of 1986)
with respect to essential health benefits
covered under the plan.
(B) Exceptions.--Such term does not include
premiums, balance billing amounts for non-network
providers, or spending for non-covered services.
(4) Premium adjustment percentage.--For purposes of
paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment
percentage for any calendar year is the percentage (if any) by
which the average per capita premium for health insurance
coverage in the United States for the preceding calendar year
(as estimated by the Secretary no later than October 1 of such
preceding calendar year) exceeds such average per capita
premium for 2013 (as determined by the Secretary).
(d) Levels of Coverage.--
(1) Levels of coverage defined.--The levels of coverage
described in this subsection are as follows:
(A) Bronze level.--A plan in the bronze level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 60 percent
of the full actuarial value of the benefits provided
under the plan.
(B) Silver level.--A plan in the silver level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 70 percent
of the full actuarial value of the benefits provided
under the plan.
(C) Gold level.--A plan in the gold level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 80 percent
of the full actuarial value of the benefits provided
under the plan.
(D) Platinum level.--A plan in the platinum level
shall provide a level of coverage that is designed to
provide benefits that are actuarially equivalent to 90
percent of the full actuarial value of the benefits
provided under the plan.
(2) Actuarial value.--
(A) In general.--Under regulations issued by the
Secretary, the level of coverage of a plan shall be
determined on the basis that the essential health
benefits described in subsection (b) shall be provided
to a standard population (and without regard to the
population the plan may actually provide benefits to).
(B) Employer contributions.--The Secretary may
issue regulations under which employer contributions to
a health savings account (within the meaning of section
223 of the Internal Revenue Code of 1986) may be taken
into account in determining the level of coverage for a
plan of the employer.
(C) Application.--In determining under this title,
the Public Health Service Act, or the Internal Revenue
Code of 1986 the percentage of the total allowed costs
of benefits provided under a group health plan or
health insurance coverage that are provided by such
plan or coverage, the rules contained in the
regulations under this paragraph shall apply.
(3) Allowable variance.--The Secretary shall develop
guidelines to provide for a de minimis variation in the
actuarial valuations used in determining the level of coverage
of a plan to account for differences in actuarial estimates.
(4) Plan reference.--In this title, any reference to a
bronze, silver, gold, or platinum plan shall be treated as a
reference to a qualified health plan providing a bronze,
silver, gold, or platinum level of coverage, as the case may
be.
(e) Catastrophic Plan.--
(1) In general.--A health plan not providing a bronze,
silver, gold, or platinum level of coverage shall be treated as
meeting the requirements of subsection (d) with respect to any
plan year if--
(A) the only individuals who are eligible to enroll
in the plan are individuals described in paragraph (2);
and
(B) the plan provides--
(i) except as provided in clause (ii), the
essential health benefits determined under
subsection (b), except that the plan provides
no benefits for any plan year until the
individual has incurred cost-sharing expenses
in an amount equal to the annual limitation in
effect under subsection (c)(1) for the plan
year (except as provided for in section 2713);
and
(ii) coverage for at least three primary
care visits.
(2) Individuals eligible for enrollment.--An individual is
described in this paragraph for any plan year if the
individual--
(A) has not attained the age of 30 before the
beginning of the plan year; or
(B) has a certification in effect for any plan year
under this title that the individual is exempt from the
requirement under section 5000A of the Internal Revenue
Code of 1986 by reason of--
(i) section 5000A(e)(1) of such Code
(relating to individuals without affordable
coverage); or
(ii) section 5000A(e)(5) of such Code
(relating to individuals with hardships).
(3) Restriction to individual market.--If a health
insurance issuer offers a health plan described in this
subsection, the issuer may only offer the plan in the
individual market.
(f) Child-only Plans.--If a qualified health plan is offered
through the Exchange in any level of coverage specified under
subsection (d), the issuer shall also offer that plan through the
Exchange in that level as a plan in which the only enrollees are
individuals who, as of the beginning of a plan year, have not attained
the age of 21, and such plan shall be treated as a qualified health
plan.
SEC. 1303. SPECIAL RULES.
(a) Special Rules Relating to Coverage of Abortion Services.--
(1) Voluntary choice of coverage of abortion services.--
(A) In general.--Notwithstanding any other
provision of this title (or any amendment made by this
title), and subject to subparagraphs (C) and (D)--
(i) nothing in this title (or any amendment
made by this title), shall be construed to
require a qualified health plan to provide
coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of its essential
health benefits for any plan year; and
(ii) the issuer of a qualified health plan
shall determine whether or not the plan
provides coverage of services described in
subparagraph (B)(i) or (B)(ii) as part of such
benefits for the plan year.
(B) Abortion services.--
(i) Abortions for which public funding is
prohibited.--The services described in this
clause are abortions for which the expenditure
of Federal funds appropriated for the
Department of Health and Human Services is not
permitted, based on the law as in effect as of
the date that is 6 months before the beginning
of the plan year involved.
(ii) Abortions for which public funding is
allowed.--The services described in this clause
are abortions for which the expenditure of
Federal funds appropriated for the Department
of Health and Human Services is permitted,
based on the law as in effect as of the date
that is 6 months before the beginning of the
plan year involved.
(C) Prohibition on federal funds for abortion
services in community health insurance option.--
(i) Determination by secretary.--The
Secretary may not determine, in accordance with
subparagraph (A)(ii), that the community health
insurance option established under section 1323
shall provide coverage of services described in
subparagraph (B)(i) as part of benefits for the
plan year unless the Secretary--
(I) assures compliance with the
requirements of paragraph (2);
(II) assures, in accordance with
applicable provisions of generally
accepted accounting requirements,
circulars on funds management of the
Office of Management and Budget, and
guidance on accounting of the
Government Accountability Office, that
no Federal funds are used for such
coverage; and
(III) notwithstanding section
1323(e)(1)(C) or any other provision of
this title, takes all necessary steps
to assure that the United States does
not bear the insurance risk for a
community health insurance option's
coverage of services described in
subparagraph (B)(i).
(ii) State requirement.--If a State
requires, in addition to the essential health
benefits required under section 1323(b)(3) (A),
coverage of services described in subparagraph
(B)(i) for enrollees of a community health
insurance option offered in such State, the
State shall assure that no funds flowing
through or from the community health insurance
option, and no other Federal funds, pay or
defray the cost of providing coverage of
services described in subparagraph (B)(i). The
United States shall not bear the insurance risk
for a State's required coverage of services
described in subparagraph (B)(i).
(iii) Exceptions.--Nothing in this
subparagraph shall apply to coverage of
services described in subparagraph (B)(ii) by
the community health insurance option. Services
described in subparagraph (B)(ii) shall be
covered to the same extent as such services are
covered under title XIX of the Social Security
Act.
(D) Assured availability of varied coverage through
exchanges.--
(i) In general.--The Secretary shall assure
that with respect to qualified health plans
offered in any Exchange established pursuant to
this title--
(I) there is at least one such plan
that provides coverage of services
described in clauses (i) and (ii) of
subparagraph (B); and
(II) there is at least one such
plan that does not provide coverage of
services described in subparagraph
(B)(i).
(ii) Special rules.--For purposes of clause
(i)--
(I) a plan shall be treated as
described in clause (i)(II) if the plan
does not provide coverage of services
described in either subparagraph (B)(i)
or (B)(ii); and
(II) if a State has one Exchange
covering more than 1 insurance market,
the Secretary shall meet the
requirements of clause (i) separately
with respect to each such market.
(2) Prohibition on the use of federal funds.--
(A) In general.--If a qualified health plan
provides coverage of services described in paragraph
(1)(B)(i), the issuer of the plan shall not use any
amount attributable to any of the following for
purposes of paying for such services:
(i) The credit under section 36B of the
Internal Revenue Code of 1986 (and the amount
(if any) of the advance payment of the credit
under section 1412 of the Patient Protection
and Affordable Care Act).
(ii) Any cost-sharing reduction under
section 1402 of thePatient Protection and
Affordable Care Act (and the amount (if any) of
the advance payment of the reduction under
section 1412 of the Patient Protection and
Affordable Care Act).
(B) Segregation of funds.--In the case of a plan to
which subparagraph (A) applies, the issuer of the plan
shall, out of amounts not described in subparagraph
(A), segregate an amount equal to the actuarial amounts
determined under subparagraph (C) for all enrollees
from the amounts described in subparagraph (A).
(C) Actuarial value of optional service coverage.--
(i) In general.--The Secretary shall
estimate the basic per enrollee, per month
cost, determined on an average actuarial basis,
for including coverage under a qualified health
plan of the services described in paragraph
(1)(B)(i).
(ii) Considerations.--In making such
estimate, the Secretary--
(I) may take into account the
impact on overall costs of the
inclusion of such coverage, but may not
take into account any cost reduction
estimated to result from such services,
including prenatal care, delivery, or
postnatal care;
(II) shall estimate such costs as
if such coverage were included for the
entire population covered; and
(III) may not estimate such a cost
at less than $1 per enrollee, per
month.
(3) Provider conscience protections.--No individual health
care provider or health care facility may be discriminated
against because of a willingness or an unwillingness, if doing
so is contrary to the religious or moral beliefs of the
provider or facility, to provide, pay for, provide coverage of,
or refer for abortions.
(b) Application of State and Federal Laws Regarding Abortion.--
(1) No preemption of state laws regarding abortion.--
Nothing in this Act shall be construed to preempt or otherwise
have any effect on State laws regarding the prohibition of (or
requirement of) coverage, funding, or procedural requirements
on abortions, including parental notification or consent for
the performance of an abortion on a minor.
(2) No effect on federal laws regarding abortion.--
(A) In general.--Nothing in this Act shall be
construed to have any effect on Federal laws
regarding--
(i) conscience protection;
(ii) willingness or refusal to provide
abortion; and
(iii) discrimination on the basis of the
willingness or refusal to provide, pay for,
cover, or refer for abortion or to provide or
participate in training to provide abortion.
(3) No effect on federal civil rights law.--Nothing in this
subsection shall alter the rights and obligations of employees
and employers under title VII of the Civil Rights Act of 1964.
(c) Application of Emergency Services Laws.--Nothing in this Act
shall be construed to relieve any health care provider from providing
emergency services as required by State or Federal law, including
section 1867 of the Social Security Act (popularly known as
``EMTALA'').
SEC. 1304. RELATED DEFINITIONS.
(a) Definitions Relating to Markets.--In this title:
(1) Group market.--The term ``group market'' means the
health insurance market under which individuals obtain health
insurance coverage (directly or through any arrangement) on
behalf of themselves (and their dependents) through a group
health plan maintained by an employer.
(2) Individual market.--The term ``individual market''
means the market for health insurance coverage offered to
individuals other than in connection with a group health plan.
(3) Large and small group markets.--The terms ``large group
market'' and ``small group market'' mean the health insurance
market under which individuals obtain health insurance coverage
(directly or through any arrangement) on behalf of themselves
(and their dependents) through a group health plan maintained
by a large employer (as defined in subsection (b)(1)) or by a
small employer (as defined in subsection (b)(2)), respectively.
(b) Employers.--In this title:
(1) Large employer.--The term ``large employer'' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 101 employees on business days during the preceding
calendar year and who employs at least 1 employee on the first
day of the plan year.
(2) Small employer.--The term ``small employer'' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 1 but not more than 100 employees on business days during
the preceding calendar year and who employs at least 1 employee
on the first day of the plan year.
(3) State option to treat 50 employees as small.--In the
case of plan years beginning before January 1, 2016, a State
may elect to apply this subsection by substituting ``51
employees'' for ``101 employees'' in paragraph (1) and by
substituting ``50 employees'' for ``100 employees'' in
paragraph (2).
(4) Rules for determining employer size.--For purposes of
this subsection--
(A) Application of aggregation rule for
employers.--All persons treated as a single employer
under subsection (b), (c), (m), or (o) of section 414
of the Internal Revenue Code of 1986 shall be treated
as 1 employer.
(B) Employers not in existence in preceding year.--
In the case of an employer which was not in existence
throughout the preceding calendar year, the
determination of whether such employer is a small or
large employer shall be based on the average number of
employees that it is reasonably expected such employer
will employ on business days in the current calendar
year.
(C) Predecessors.--Any reference in this subsection
to an employer shall include a reference to any
predecessor of such employer.
(D) Continuation of participation for growing small
employers.--If--
(i) a qualified employer that is a small
employer makes enrollment in qualified health
plans offered in the small group market
available to its employees through an Exchange;
and
(ii) the employer ceases to be a small
employer by reason of an increase in the number
of employees of such employer;
the employer shall continue to be treated as a small
employer for purposes of this subtitle for the period
beginning with the increase and ending with the first
day on which the employer does not make such enrollment
available to its employees.
(c) Secretary.--In this title, the term ``Secretary'' means the
Secretary of Health and Human Services.
(d) State.--In this title, the term ``State'' means each of the 50
States and the District of Columbia.
PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH
BENEFIT EXCHANGES
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
(a) Assistance to States to Establish American Health Benefit
Exchanges.--
(1) Planning and establishment grants.--There shall be
appropriated to the Secretary, out of any moneys in the
Treasury not otherwise appropriated, an amount necessary to
enable the Secretary to make awards, not later than 1 year
after the date of enactment of this Act, to States in the
amount specified in paragraph (2) for the uses described in
paragraph (3).
(2) Amount specified.--For each fiscal year, the Secretary
shall determine the total amount that the Secretary will make
available to each State for grants under this subsection.
(3) Use of funds.--A State shall use amounts awarded under
this subsection for activities (including planning activities)
related to establishing an American Health Benefit Exchange, as
described in subsection (b).
(4) Renewability of grant.--
(A) In general.--Subject to subsection (d)(4), the
Secretary may renew a grant awarded under paragraph (1)
if the State recipient of such grant--
(i) is making progress, as determined by
the Secretary, toward--
(I) establishing an Exchange; and
(II) implementing the reforms
described in subtitles A and C (and the
amendments made by such subtitles); and
(ii) is meeting such other benchmarks as
the Secretary may establish.
(B) Limitation.--No grant shall be awarded under
this subsection after January 1, 2015.
(5) Technical assistance to facilitate participation in
shop exchanges.--The Secretary shall provide technical
assistance to States to facilitate the participation of
qualified small businesses in such States in SHOP Exchanges.
(b) American Health Benefit Exchanges.--
(1) In general.--Each State shall, not later than January
1, 2014, establish an American Health Benefit Exchange
(referred to in this title as an ``Exchange'') for the State
that--
(A) facilitates the purchase of qualified health
plans;
(B) provides for the establishment of a Small
Business Health Options Program (in this title referred
to as a ``SHOP Exchange'') that is designed to assist
qualified employers in the State who are small
employers in facilitating the enrollment of their
employees in qualified health plans offered in the
small group market in the State; and
(C) meets the requirements of subsection (d).
(2) Merger of individual and shop exchanges.--A State may
elect to provide only one Exchange in the State for providing
both Exchange and SHOP Exchange services to both qualified
individuals and qualified small employers, but only if the
Exchange has adequate resources to assist such individuals and
employers.
(c) Responsibilities of the Secretary.--
(1) In general.--The Secretary shall, by regulation,
establish criteria for the certification of health plans as
qualified health plans. Such criteria shall require that, to be
certified, a plan shall, at a minimum--
(A) meet marketing requirements, and not employ
marketing practices or benefit designs that have the
effect of discouraging the enrollment in such plan by
individuals with significant health needs;
(B) ensure a sufficient choice of providers (in a
manner consistent with applicable network adequacy
provisions under section 2702(c) of the Public Health
Service Act), and provide information to enrollees and
prospective enrollees on the availability of in-network
and out-of-network providers;
(C) include within health insurance plan networks
those essential community providers, where available,
that serve predominately low-income, medically-
underserved individuals, such as health care providers
defined in section 340B(a)(4) of the Public Health
Service Act and providers described in section
1927(c)(1)(D)(i)(IV) of the Social Security Act as set
forth by section 221 of Public Law 111-8, except that
nothing in this subparagraph shall be construed to
require any health plan to provide coverage for any
specific medical procedure;
(D)(i) be accredited with respect to local
performance on clinical quality measures such as the
Healthcare Effectiveness Data and Information Set,
patient experience ratings on a standardized Consumer
Assessment of Healthcare Providers and Systems survey,
as well as consumer access, utilization management,
quality assurance, provider credentialing, complaints
and appeals, network adequacy and access, and patient
information programs by any entity recognized by the
Secretary for the accreditation of health insurance
issuers or plans (so long as any such entity has
transparent and rigorous methodological and scoring
criteria); or
(ii) receive such accreditation within a period
established by an Exchange for such accreditation that
is applicable to all qualified health plans;
(E) implement a quality improvement strategy
described in subsection (g)(1);
(F) utilize a uniform enrollment form that
qualified individuals and qualified employers may use
(either electronically or on paper) in enrolling in
qualified health plans offered through such Exchange,
and that takes into account criteria that the National
Association of Insurance Commissioners develops and
submits to the Secretary;
(G) utilize the standard format established for
presenting health benefits plan options; and
(H) provide information to enrollees and
prospective enrollees, and to each Exchange in which
the plan is offered, on any quality measures for health
plan performance endorsed under section 399JJ of the
Public Health Service Act, as applicable.
(2) Rule of construction.--Nothing in paragraph (1)(C)
shall be construed to require a qualified health plan to
contract with a provider described in such paragraph if such
provider refuses to accept the generally applicable payment
rates of such plan.
(3) Rating system.--The Secretary shall develop a rating
system that would rate qualified health plans offered through
an Exchange in each benefits level on the basis of the relative
quality and price. The Exchange shall include the quality
rating in the information provided to individuals and employers
through the Internet portal established under paragraph (4).
(4) Enrollee satisfaction system.--The Secretary shall
develop an enrollee satisfaction survey system that would
evaluate the level of enrollee satisfaction with qualified
health plans offered through an Exchange, for each such
qualified health plan that had more than 500 enrollees in the
previous year. The Exchange shall include enrollee satisfaction
information in the information provided to individuals and
employers through the Internet portal established under
paragraph (5) in a manner that allows individuals to easily
compare enrollee satisfaction levels between comparable plans.
(5) Internet portals.--The Secretary shall--
(A) continue to operate, maintain, and update the
Internet portal developed under section 1103(a) and to
assist States in developing and maintaining their own
such portal; and
(B) make available for use by Exchanges a model
template for an Internet portal that may be used to
direct qualified individuals and qualified employers to
qualified health plans, to assist such individuals and
employers in determining whether they are eligible to
participate in an Exchange or eligible for a premium
tax credit or cost-sharing reduction, and to present
standardized information (including quality ratings)
regarding qualified health plans offered through an
Exchange to assist consumers in making easy health
insurance choices.
Such template shall include, with respect to each qualified
health plan offered through the Exchange in each rating area,
access to the uniform outline of coverage the plan is required
to provide under section 2716 of the Public Health Service Act
and to a copy of the plan's written policy.
(6) Enrollment periods.--The Secretary shall require an
Exchange to provide for--
(A) an initial open enrollment, as determined by
the Secretary (such determination to be made not later
than July 1, 2012);
(B) annual open enrollment periods, as determined
by the Secretary for calendar years after the initial
enrollment period;
(C) special enrollment periods specified in section
9801 of the Internal Revenue Code of 1986 and other
special enrollment periods under circumstances similar
to such periods under part D of title XVIII of the
Social Security Act; and
(D) special monthly enrollment periods for Indians
(as defined in section 4 of the Indian Health Care
Improvement Act).
(d) Requirements.--
(1) In general.--An Exchange shall be a governmental agency
or nonprofit entity that is established by a State.
(2) Offering of coverage.--
(A) In general.--An Exchange shall make available
qualified health plans to qualified individuals and
qualified employers.
(B) Limitation.--
(i) In general.--An Exchange may not make
available any health plan that is not a
qualified health plan.
(ii) Offering of stand-alone dental
benefits.--Each Exchange within a State shall
allow an issuer of a plan that only provides
limited scope dental benefits meeting the
requirements of section 9832(c)(2)(A) of the
Internal Revenue Code of 1986 to offer the plan
through the Exchange (either separately or in
conjunction with a qualified health plan) if
the plan provides pediatric dental benefits
meeting the requirements of section
1302(b)(1)(J)).
(3) Rules relating to additional required benefits.--
(A) In general.--Except as provided in subparagraph
(B), an Exchange may make available a qualified health
plan notwithstanding any provision of law that may
require benefits other than the essential health
benefits specified under section 1302(b).
(B) States may require additional benefits.--
(i) In general.--Subject to the
requirements of clause (ii), a State may
require that a qualified health plan offered in
such State offer benefits in addition to the
essential health benefits specified under
section 1302(b).
(ii) State must assume cost.--A State shall
make payments to or on behalf of an individual
eligible for the premium tax credit under
section 36B of the Internal Revenue Code of
1986 and any cost-sharing reduction under
section 1402 to defray the cost to the
individual of any additional benefits described
in clause (i) which are not eligible for such
credit or reduction under section 36B(b)(3)(D)
of such Code and section 1402(c)(4).
(4) Functions.--An Exchange shall, at a minimum--
(A) implement procedures for the certification,
recertification, and decertification, consistent with
guidelines developed by the Secretary under subsection
(c), of health plans as qualified health plans;
(B) provide for the operation of a toll-free
telephone hotline to respond to requests for
assistance;
(C) maintain an Internet website through which
enrollees and prospective enrollees of qualified health
plans may obtain standardized comparative information
on such plans;
(D) assign a rating to each qualified health plan
offered through such Exchange in accordance with the
criteria developed by the Secretary under subsection
(c)(3);
(E) utilize a standardized format for presenting
health benefits plan options in the Exchange, including
the use of the uniform outline of coverage established
under section 2715 of the Public Health Service Act;
(F) in accordance with section 1413, inform
individuals of eligibility requirements for the
medicaid program under title XIX of the Social Security
Act, the CHIP program under title XXI of such Act, or
any applicable State or local public program and if
through screening of the application by the Exchange,
the Exchange determines that such individuals are
eligible for any such program, enroll such individuals
in such program;
(G) establish and make available by electronic
means a calculator to determine the actual cost of
coverage after the application of any premium tax
credit under section 36B of the Internal Revenue Code
of 1986 and any cost-sharing reduction under section
1402;
(H) subject to section 1411, grant a certification
attesting that, for purposes of the individual
responsibility penalty under section 5000A of the
Internal Revenue Code of 1986, an individual is exempt
from the individual requirement or from the penalty
imposed by such section because--
(i) there is no affordable qualified health
plan available through the Exchange, or the
individual's employer, covering the individual;
or
(ii) the individual meets the requirements
for any other such exemption from the
individual responsibility requirement or
penalty;
(I) transfer to the Secretary of the Treasury--
(i) a list of the individuals who are
issued a certification under subparagraph (H),
including the name and taxpayer identification
number of each individual;
(ii) the name and taxpayer identification
number of each individual who was an employee
of an employer but who was determined to be
eligible for the premium tax credit under
section 36B of the Internal Revenue Code of
1986 because--
(I) the employer did not provide
minimum essential coverage; or
(II) the employer provided such
minimum essential coverage but it was
determined under section 36B(c)(2)(C)
of such Code to either be unaffordable
to the employee or not provide the
required minimum actuarial value; and
(iii) the name and taxpayer identification
number of each individual who notifies the
Exchange under section 1411(b)(4) that they
have changed employers and of each individual
who ceases coverage under a qualified health
plan during a plan year (and the effective date
of such cessation);
(J) provide to each employer the name of each
employee of the employer described in subparagraph
(I)(ii) who ceases coverage under a qualified health
plan during a plan year (and the effective date of such
cessation); and
(K) establish the Navigator program described in
subsection (i).
(5) Funding limitations.--
(A) No federal funds for continued operations.--In
establishing an Exchange under this section, the State
shall ensure that such Exchange is self-sustaining
beginning on January 1, 2015, including allowing the
Exchange to charge assessments or user fees to
participating health insurance issuers, or to otherwise
generate funding, to support its operations.
(B) Prohibiting wasteful use of funds.--In carrying
out activities under this subsection, an Exchange shall
not utilize any funds intended for the administrative
and operational expenses of the Exchange for staff
retreats, promotional giveaways, excessive executive
compensation, or promotion of Federal or State
legislative and regulatory modifications.
(6) Consultation.--An Exchange shall consult with
stakeholders relevant to carrying out the activities under this
section, including--
(A) health care consumers who are enrollees in
qualified health plans;
(B) individuals and entities with experience in
facilitating enrollment in qualified health plans;
(C) representatives of small businesses and self-
employed individuals;
(D) State Medicaid offices; and
(E) advocates for enrolling hard to reach
populations.
(7) Publication of costs.--An Exchange shall publish the
average costs of licensing, regulatory fees, and any other
payments required by the Exchange, and the administrative costs
of such Exchange, on an Internet website to educate consumers
on such costs. Such information shall also include monies lost
to waste, fraud, and abuse.
(e) Certification.--
(1) In general.--An Exchange may certify a health plan as a
qualified health plan if--
(A) such health plan meets the requirements for
certification as promulgated by the Secretary under
subsection (c)(1); and
(B) the Exchange determines that making available
such health plan through such Exchange is in the
interests of qualified individuals and qualified
employers in the State or States in which such Exchange
operates, except that the Exchange may not exclude a
health plan--
(i) on the basis that such plan is a fee-
for-service plan;
(ii) through the imposition of premium
price controls; or
(iii) on the basis that the plan provides
treatments necessary to prevent patients'
deaths in circumstances the Exchange determines
are inappropriate or too costly.
(2) Premium considerations.--The Exchange shall require
health plans seeking certification as qualified health plans to
submit a justification for any premium increase prior to
implementation of the increase. Such plans shall prominently
post such information on their websites. The Exchange may take
this information, and the information and the recommendations
provided to the Exchange by the State under section 2794(b)(1)
of the Public Health Service Act (relating to patterns or
practices of excessive or unjustified premium increases), into
consideration when determining whether to make such health plan
available through the Exchange. The Exchange shall take into
account any excess of premium growth outside the Exchange as
compared to the rate of such growth inside the Exchange,
including information reported by the States.
(f) Flexibility.--
(1) Regional or other interstate exchanges.--An Exchange
may operate in more than one State if--
(A) each State in which such Exchange operates
permits such operation; and
(B) the Secretary approves such regional or
interstate Exchange.
(2) Subsidiary exchanges.--A State may establish one or
more subsidiary Exchanges if--
(A) each such Exchange serves a geographically
distinct area; and
(B) the area served by each such Exchange is at
least as large as a rating area described in section
2701(a) of the Public Health Service Act.
(3) Authority to contract.--
(A) In general.--A State may elect to authorize an
Exchange established by the State under this section to
enter into an agreement with an eligible entity to
carry out 1 or more responsibilities of the Exchange.
(B) Eligible entity.--In this paragraph, the term
``eligible entity'' means--
(i) a person--
(I) incorporated under, and subject
to the laws of, 1 or more States;
(II) that has demonstrated
experience on a State or regional basis
in the individual and small group
health insurance markets and in
benefits coverage; and
(III) that is not a health
insurance issuer or that is treated
under subsection (a) or (b) of section
52 of the Internal Revenue Code of 1986
as a member of the same controlled
group of corporations (or under common
control with) as a health insurance
issuer; or
(ii) the State medicaid agency under title
XIX of the Social Security Act.
(g) Rewarding Quality Through Market-Based Incentives.--
(1) Strategy described.--A strategy described in this
paragraph is a payment structure that provides increased
reimbursement or other incentives for--
(A) improving health outcomes through the
implementation of activities that shall include quality
reporting, effective case management, care
coordination, chronic disease management, medication
and care compliance initiatives, including through the
use of the medical home model, for treatment or
services under the plan or coverage;
(B) the implementation of activities to prevent
hospital readmissions through a comprehensive program
for hospital discharge that includes patient-centered
education and counseling, comprehensive discharge
planning, and post discharge reinforcement by an
appropriate health care professional;
(C) the implementation of activities to improve
patient safety and reduce medical errors through the
appropriate use of best clinical practices, evidence
based medicine, and health information technology under
the plan or coverage; and
(D) the implementation of wellness and health
promotion activities.
(2) Guidelines.--The Secretary, in consultation with
experts in health care quality and stakeholders, shall develop
guidelines concerning the matters described in paragraph (1).
(3) Requirements.--The guidelines developed under paragraph
(2) shall require the periodic reporting to the applicable
Exchange of the activities that a qualified health plan has
conducted to implement a strategy described in paragraph (1).
(h) Quality Improvement.--
(1) Enhancing patient safety.--Beginning on January 1,
2015, a qualified health plan may contract with--
(A) a hospital with greater than 50 beds only if
such hospital--
(i) utilizes a patient safety evaluation
system as described in part C of title IX of
the Public Health Service Act; and
(ii) implements a mechanism to ensure that
each patient receives a comprehensive program
for hospital discharge that includes patient-
centered education and counseling,
comprehensive discharge planning, and post
discharge reinforcement by an appropriate
health care professional; or
(B) a health care provider only if such provider
implements such mechanisms to improve health care
quality as the Secretary may by regulation require.
(2) Exceptions.--The Secretary may establish reasonable
exceptions to the requirements described in paragraph (1).
(3) Adjustment.--The Secretary may by regulation adjust the
number of beds described in paragraph (1)(A).
(i) Navigators.--
(1) In general.--An Exchange shall establish a program
under which it awards grants to entities described in paragraph
(2) to carry out the duties described in paragraph (3).
(2) Eligibility.--
(A) In general.--To be eligible to receive a grant
under paragraph (1), an entity shall demonstrate to the
Exchange involved that the entity has existing
relationships, or could readily establish
relationships, with employers and employees, consumers
(including uninsured and underinsured consumers), or
self-employed individuals likely to be qualified to
enroll in a qualified health plan.
(B) Types.--Entities described in subparagraph (A)
may include trade, industry, and professional
associations, commercial fishing industry
organizations, ranching and farming organizations,
community and consumer-focused nonprofit groups,
chambers of commerce, unions, small business
development centers, other licensed insurance agents
and brokers, and other entities that--
(i) are capable of carrying out the duties
described in paragraph (3);
(ii) meet the standards described in
paragraph (4); and
(iii) provide information consistent with
the standards developed under paragraph (5).
(3) Duties.--An entity that serves as a navigator under a
grant under this subsection shall--
(A) conduct public education activities to raise
awareness of the availability of qualified health
plans;
(B) distribute fair and impartial information
concerning enrollment in qualified health plans, and
the availability of premium tax credits under section
36B of the Internal Revenue Code of 1986 and cost-
sharing reductions under section 1402;
(C) facilitate enrollment in qualified health
plans;
(D) provide referrals to any applicable office of
health insurance consumer assistance or health
insurance ombudsman established under section 2793 of
the Public Health Service Act, or any other appropriate
State agency or agencies, for any enrollee with a
grievance, complaint, or question regarding their
health plan, coverage, or a determination under such
plan or coverage; and
(E) provide information in a manner that is
culturally and linguistically appropriate to the needs
of the population being served by the Exchange or
Exchanges.
(4) Standards.--
(A) In general.--The Secretary shall establish
standards for navigators under this subsection,
including provisions to ensure that any private or
public entity that is selected as a navigator is
qualified, and licensed if appropriate, to engage in
the navigator activities described in this subsection
and to avoid conflicts of interest. Under such
standards, a navigator shall not--
(i) be a health insurance issuer; or
(ii) receive any consideration directly or
indirectly from any health insurance issuer in
connection with the enrollment of any qualified
individuals or employees of a qualified
employer in a qualified health plan.
(5) Fair and impartial information and services.--The
Secretary, in collaboration with States, shall develop
standards to ensure that information made available by
navigators is fair, accurate, and impartial.
(6) Funding.--Grants under this subsection shall be made
from the operational funds of the Exchange and not Federal
funds received by the State to establish the Exchange.
(j) Applicability of Mental Health Parity.--Section 2726 of the
Public Health Service Act shall apply to qualified health plans in the
same manner and to the same extent as such section applies to health
insurance issuers and group health plans.
(k) Conflict.--An Exchange may not establish rules that conflict
with or prevent the application of regulations promulgated by the
Secretary under this subtitle.
SEC. 1312. CONSUMER CHOICE.
(a) Choice.--
(1) Qualified individuals.--A qualified individual may
enroll in any qualified health plan available to such
individual.
(2) Qualified employers.--
(A) Employer may specify level.--A qualified
employer may provide support for coverage of employees
under a qualified health plan by selecting any level of
coverage under section 1302(d) to be made available to
employees through an Exchange.
(B) Employee may choose plans within a level.--Each
employee of a qualified employer that elects a level of
coverage under subparagraph (A) may choose to enroll in
a qualified health plan that offers coverage at that
level.
(b) Payment of Premiums by Qualified Individuals.--A qualified
individual enrolled in any qualified health plan may pay any applicable
premium owed by such individual to the health insurance issuer issuing
such qualified health plan.
(c) Single Risk Pool.--
(1) Individual market.--A health insurance issuer shall
consider all enrollees in all health plans (other than
grandfathered health plans) offered by such issuer in the
individual market, including those enrollees who do not enroll
in such plans through the Exchange, to be members of a single
risk pool.
(2) Small group market.--A health insurance issuer shall
consider all enrollees in all health plans (other than
grandfathered health plans) offered by such issuer in the small
group market, including those enrollees who do not enroll in
such plans through the Exchange, to be members of a single risk
pool.
(3) Merger of markets.--A State may require the individual
and small group insurance markets within a State to be merged
if the State determines appropriate.
(4) State law.--A State law requiring grandfathered health
plans to be included in a pool described in paragraph (1) or
(2) shall not apply.
(d) Empowering Consumer Choice.--
(1) Continued operation of market outside exchanges.--
Nothing in this title shall be construed to prohibit--
(A) a health insurance issuer from offering outside
of an Exchange a health plan to a qualified individual
or qualified employer; and
(B) a qualified individual from enrolling in, or a
qualified employer from selecting for its employees, a
health plan offered outside of an Exchange.
(2) Continued operation of state benefit requirements.--
Nothing in this title shall be construed to terminate, abridge,
or limit the operation of any requirement under State law with
respect to any policy or plan that is offered outside of an
Exchange to offer benefits.
(3) Voluntary nature of an exchange.--
(A) Choice to enroll or not to enroll.--Nothing in
this title shall be construed to restrict the choice of
a qualified individual to enroll or not to enroll in a
qualified health plan or to participate in an Exchange.
(B) Prohibition against compelled enrollment.--
Nothing in this title shall be construed to compel an
individual to enroll in a qualified health plan or to
participate in an Exchange.
(C) Individuals allowed to enroll in any plan.--A
qualified individual may enroll in any qualified health
plan, except that in the case of a catastrophic plan
described in section 1302(e), a qualified individual
may enroll in the plan only if the individual is
eligible to enroll in the plan under section
1302(e)(2).
(D) Members of congress in the exchange.--
(i) Requirement.--Notwithstanding any other
provision of law, after the effective date of
this subtitle, the only health plans that the
Federal Government may make available to
Members of Congress and congressional staff
with respect to their service as a Member of
Congress or congressional staff shall be health
plans that are--
(I) created under this Act (or an
amendment made by this Act); or
(II) offered through an Exchange
established under this Act (or an
amendment made by this Act).
(ii) Definitions.--In this section:
(I) Member of congress.--The term
``Member of Congress'' means any member
of the House of Representatives or the
Senate.
(II) Congressional staff.--The term
``congressional staff'' means all full-
time and part-time employees employed
by the official office of a Member of
Congress, whether in Washington, DC or
outside of Washington, DC.
(4) No penalty for transferring to minimum essential
coverage outside exchange.--An Exchange, or a qualified health
plan offered through an Exchange, shall not impose any penalty
or other fee on an individual who cancels enrollment in a plan
because the individual becomes eligible for minimum essential
coverage (as defined in section 5000A(f) of the Internal
Revenue Code of 1986 without regard to paragraph (1)(C) or (D)
thereof) or such coverage becomes affordable (within the
meaning of section 36B(c)(2)(C) of such Code).
(e) Enrollment Through Agents or Brokers.--The Secretary shall
establish procedures under which a State may allow agents or brokers--
(1) to enroll individuals in any qualified health plans in
the individual or small group market as soon as the plan is
offered through an Exchange in the State; and
(2) to assist individuals in applying for premium tax
credits and cost-sharing reductions for plans sold through an
Exchange.
Such procedures may include the establishment of rate schedules for
broker commissions paid by health benefits plans offered through an
exchange.
(f) Qualified Individuals and Employers; Access Limited to Citizens
and Lawful Residents.--
(1) Qualified individuals.--In this title:
(A) In general.--The term ``qualified individual''
means, with respect to an Exchange, an individual who--
(i) is seeking to enroll in a qualified
health plan in the individual market offered
through the Exchange; and
(ii) resides in the State that established
the Exchange (except with respect to
territorial agreements under section 1312(f)).
(B) Incarcerated individuals excluded.--An
individual shall not be treated as a qualified
individual if, at the time of enrollment, the
individual is incarcerated, other than incarceration
pending the disposition of charges.
(2) Qualified employer.--In this title:
(A) In general.--The term ``qualified employer''
means a small employer that elects to make all full-
time employees of such employer eligible for 1 or more
qualified health plans offered in the small group
market through an Exchange that offers qualified health
plans.
(B) Extension to large groups.--
(i) In general.--Beginning in 2017, each
State may allow issuers of health insurance
coverage in the large group market in the State
to offer qualified health plans in such market
through an Exchange. Nothing in this
subparagraph shall be construed as requiring
the issuer to offer such plans through an
Exchange.
(ii) Large employers eligible.--If a State
under clause (i) allows issuers to offer
qualified health plans in the large group
market through an Exchange, the term
``qualified employer'' shall include a large
employer that elects to make all full-time
employees of such employer eligible for 1 or
more qualified health plans offered in the
large group market through the Exchange.
(3) Access limited to lawful residents.--If an individual
is not, or is not reasonably expected to be for the entire
period for which enrollment is sought, a citizen or national of
the United States or an alien lawfully present in the United
States, the individual shall not be treated as a qualified
individual and may not be covered under a qualified health plan
in the individual market that is offered through an Exchange.
SEC. 1313. FINANCIAL INTEGRITY.
(a) Accounting for Expenditures.--
(1) In general.--An Exchange shall keep an accurate
accounting of all activities, receipts, and expenditures and
shall annually submit to the Secretary a report concerning such
accountings.
(2) Investigations.--The Secretary, in coordination with
the Inspector General of the Department of Health and Human
Services, may investigate the affairs of an Exchange, may
examine the properties and records of an Exchange, and may
require periodic reports in relation to activities undertaken
by an Exchange. An Exchange shall fully cooperate in any
investigation conducted under this paragraph.
(3) Audits.--An Exchange shall be subject to annual audits
by the Secretary.
(4) Pattern of abuse.--If the Secretary determines that an
Exchange or a State has engaged in serious misconduct with
respect to compliance with the requirements of, or carrying out
of activities required under, this title, the Secretary may
rescind from payments otherwise due to such State involved
under this or any other Act administered by the Secretary an
amount not to exceed 1 percent of such payments per year until
corrective actions are taken by the State that are determined
to be adequate by the Secretary.
(5) Protections against fraud and abuse.--With respect to
activities carried out under this title, the Secretary shall
provide for the efficient and non-discriminatory administration
of Exchange activities and implement any measure or procedure
that--
(A) the Secretary determines is appropriate to
reduce fraud and abuse in the administration of this
title; and
(B) the Secretary has authority to implement under
this title or any other Act.
(6) Application of the false claims act.--
(A) In general.--Payments made by, through, or in
connection with an Exchange are subject to the False
Claims Act (31 U.S.C. 3729 et seq.) if those payments
include any Federal funds. Compliance with the
requirements of this Act concerning eligibility for a
health insurance issuer to participate in the Exchange
shall be a material condition of an issuer's
entitlement to receive payments, including payments of
premium tax credits and cost-sharing reductions,
through the Exchange.
(B) Damages.--Notwithstanding paragraph (1) of
section 3729(a) of title 31, United States Code, and
subject to paragraph (2) of such section, the civil
penalty assessed under the False Claims Act on any
person found liable under such Act as described in
subparagraph (A) shall be increased by not less than 3
times and not more than 6 times the amount of damages
which the Government sustains because of the act of
that person.
(b) GAO Oversight.--Not later than 5 years after the first date on
which Exchanges are required to be operational under this title, the
Comptroller General shall conduct an ongoing study of Exchange
activities and the enrollees in qualified health plans offered through
Exchanges. Such study shall review--
(1) the operations and administration of Exchanges,
including surveys and reports of qualified health plans offered
through Exchanges and on the experience of such plans
(including data on enrollees in Exchanges and individuals
purchasing health insurance coverage outside of Exchanges), the
expenses of Exchanges, claims statistics relating to qualified
health plans, complaints data relating to such plans, and the
manner in which Exchanges meet their goals;
(2) any significant observations regarding the utilization
and adoption of Exchanges;
(3) where appropriate, recommendations for improvements in
the operations or policies of Exchanges; and
(4) how many physicians, by area and specialty, are not
taking or accepting new patients enrolled in Federal Government
health care programs, and the adequacy of provider networks of
Federal Government health care programs.
PART III--STATE FLEXIBILITY RELATING TO EXCHANGES
SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF EXCHANGES
AND RELATED REQUIREMENTS.
(a) Establishment of Standards.--
(1) In general.--The Secretary shall, as soon as
practicable after the date of enactment of this Act, issue
regulations setting standards for meeting the requirements
under this title, and the amendments made by this title, with
respect to--
(A) the establishment and operation of Exchanges
(including SHOP Exchanges);
(B) the offering of qualified health plans through
such Exchanges;
(C) the establishment of the reinsurance and risk
adjustment programs under part V; and
(D) such other requirements as the Secretary
determines appropriate.
The preceding sentence shall not apply to standards for
requirements under subtitles A and C (and the amendments made
by such subtitles) for which the Secretary issues regulations
under the Public Health Service Act.
(2) Consultation.--In issuing the regulations under
paragraph (1), the Secretary shall consult with the National
Association of Insurance Commissioners and its members and with
health insurance issuers, consumer organizations, and such
other individuals as the Secretary selects in a manner designed
to ensure balanced representation among interested parties.
(b) State Action.--Each State that elects, at such time and in such
manner as the Secretary may prescribe, to apply the requirements
described in subsection (a) shall, not later than January 1, 2014,
adopt and have in effect--
(1) the Federal standards established under subsection (a);
or
(2) a State law or regulation that the Secretary determines
implements the standards within the State.
(c) Failure To Establish Exchange or Implement Requirements.--
(1) In general.--If--
(A) a State is not an electing State under
subsection (b); or
(B) the Secretary determines, on or before January
1, 2013, that an electing State--
(i) will not have any required Exchange
operational by January 1, 2014; or
(ii) has not taken the actions the
Secretary determines necessary to implement--
(I) the other requirements set
forth in the standards under subsection
(a); or
(II) the requirements set forth in
subtitles A and C and the amendments
made by such subtitles;
the Secretary shall (directly or through agreement with a not-
for-profit entity) establish and operate such Exchange within
the State and the Secretary shall take such actions as are
necessary to implement such other requirements.
(2) Enforcement authority.--The provisions of section
2736(b) of the Public Health Services Act shall apply to the
enforcement under paragraph (1) of requirements of subsection
(a)(1) (without regard to any limitation on the application of
those provisions to group health plans).
(d) No Interference With State Regulatory Authority.--Nothing in
this title shall be construed to preempt any State law that does not
prevent the application of the provisions of this title.
(e) Presumption for Certain State-Operated Exchanges.--
(1) In general.--In the case of a State operating an
Exchange before January 1, 2010, and which has insured a
percentage of its population not less than the percentage of
the population projected to be covered nationally after the
implementation of this Act, that seeks to operate an Exchange
under this section, the Secretary shall presume that such
Exchange meets the standards under this section unless the
Secretary determines, after completion of the process
established under paragraph (2), that the Exchange does not
comply with such standards.
(2) Process.--The Secretary shall establish a process to
work with a State described in paragraph (1) to provide
assistance necessary to assist the State's Exchange in coming
into compliance with the standards for approval under this
section.
SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND OPERATION OF
NONPROFIT, MEMBER-RUN HEALTH INSURANCE ISSUERS.
(a) Establishment of Program.--
(1) In general.--The Secretary shall establish a program to
carry out the purposes of this section to be known as the
Consumer Operated and Oriented Plan (CO-OP) program.
(2) Purpose.--It is the purpose of the CO-OP program to
foster the creation of qualified nonprofit health insurance
issuers to offer qualified health plans in the individual and
small group markets in the States in which the issuers are
licensed to offer such plans.
(b) Loans and Grants Under the CO-OP Program.--
(1) In general.--The Secretary shall provide through the
CO-OP program for the awarding to persons applying to become
qualified nonprofit health insurance issuers of--
(A) loans to provide assistance to such person in
meeting its start-up costs; and
(B) grants to provide assistance to such person in
meeting any solvency requirements of States in which
the person seeks to be licensed to issue qualified
health plans.
(2) Requirements for awarding loans and grants.--
(A) In general.--In awarding loans and grants under
the CO-OP program, the Secretary shall--
(i) take into account the recommendations
of the advisory board established under
paragraph (3);
(ii) give priority to applicants that will
offer qualified health plans on a Statewide
basis, will utilize integrated care models, and
have significant private support; and
(iii) ensure that there is sufficient
funding to establish at least 1 qualified
nonprofit health insurance issuer in each
State, except that nothing in this clause shall
prohibit the Secretary from funding the
establishment of multiple qualified nonprofit
health insurance issuers in any State if the
funding is sufficient to do so.
(B) States without issuers in program.--If no
health insurance issuer applies to be a qualified
nonprofit health insurance issuer within a State, the
Secretary may use amounts appropriated under this
section for the awarding of grants to encourage the
establishment of a qualified nonprofit health insurance
issuer within the State or the expansion of a qualified
nonprofit health insurance issuer from another State to
the State.
(C) Agreement.--
(i) In general.--The Secretary shall
require any person receiving a loan or grant
under the CO-OP program to enter into an
agreement with the Secretary which requires
such person to meet (and to continue to meet)--
(I) any requirement under this
section for such person to be treated
as a qualified nonprofit health
insurance issuer; and
(II) any requirements contained in
the agreement for such person to
receive such loan or grant.
(ii) Restrictions on use of federal
funds.--The agreement shall include a
requirement that no portion of the funds made
available by any loan or grant under this
section may be used--
(I) for carrying on propaganda, or
otherwise attempting, to influence
legislation; or
(II) for marketing.
Nothing in this clause shall be construed to
allow a person to take any action prohibited by
section 501(c)(29) of the Internal Revenue Code
of 1986.
(iii) Failure to meet requirements.--If the
Secretary determines that a person has failed
to meet any requirement described in clause (i)
or (ii) and has failed to correct such failure
within a reasonable period of time of when the
person first knows (or reasonably should have
known) of such failure, such person shall repay
to the Secretary an amount equal to the sum
of--
(I) 110 percent of the aggregate
amount of loans and grants received
under this section; plus
(II) interest on the aggregate
amount of loans and grants received
under this section for the period the
loans or grants were outstanding.
The Secretary shall notify the Secretary of the
Treasury of any determination under this
section of a failure that results in the
termination of an issuer's tax-exempt status
under section 501(c)(29) of such Code.
(D) Time for awarding loans and grants.--The
Secretary shall not later than July 1, 2013, award the
loans and grants under the CO-OP program and begin the
distribution of amounts awarded under such loans and
grants.
(3) Advisory board.--
(A) In general.--The advisory board under this
paragraph shall consist of 15 members appointed by the
Comptroller General of the United States from among
individuals with qualifications described in section
1805(c)(2) of the Social Security Act.
(B) Rules relating to appointments.--
(i) Standards.--Any individual appointed
under subparagraph (A) shall meet ethics and
conflict of interest standards protecting
against insurance industry involvement and
interference.
(ii) Original appointments.--The original
appointment of board members under subparagraph
(A)(ii) shall be made no later than 3 months
after the date of enactment of this Act.
(C) Vacancy.--Any vacancy on the advisory board
shall be filled in the same manner as the original
appointment.
(D) Pay and reimbursement.--
(i) No compensation for members of advisory
board.--Except as provided in clause (ii), a
member of the advisory board may not receive
pay, allowances, or benefits by reason of their
service on the board.
(ii) Travel expenses.--Each member shall
receive travel expenses, including per diem in
lieu of subsistence under subchapter I of
chapter 57 of title 5, United States Code.
(E) Application of faca.--The Federal Advisory
Committee Act (5 U.S.C. App.) shall apply to the
advisory board, except that section 14 of such Act
shall not apply.
(F) Termination.--The advisory board shall
terminate on the earlier of the date that it completes
its duties under this section or December 31, 2015.
(c) Qualified Nonprofit Health Insurance Issuer.--For purposes of
this section--
(1) In general.--The term ``qualified nonprofit health
insurance issuer'' means a health insurance issuer that is an
organization--
(A) that is organized under State law as a
nonprofit, member corporation;
(B) substantially all of the activities of which
consist of the issuance of qualified health plans in
the individual and small group markets in each State in
which it is licensed to issue such plans; and
(C) that meets the other requirements of this
subsection.
(2) Certain organizations prohibited.--An organization
shall not be treated as a qualified nonprofit health insurance
issuer if--
(A) the organization or a related entity (or any
predecessor of either) was a health insurance issuer on
July 16, 2009; or
(B) the organization is sponsored by a State or
local government, any political subdivision thereof, or
any instrumentality of such government or political
subdivision.
(3) Governance requirements.--An organization shall not be
treated as a qualified nonprofit health insurance issuer
unless--
(A) the governance of the organization is subject
to a majority vote of its members;
(B) its governing documents incorporate ethics and
conflict of interest standards protecting against
insurance industry involvement and interference; and
(C) as provided in regulations promulgated by the
Secretary, the organization is required to operate with
a strong consumer focus, including timeliness,
responsiveness, and accountability to members.
(4) Profits inure to benefit of members.--An organization
shall not be treated as a qualified nonprofit health insurance
issuer unless any profits made by the organization are required
to be used to lower premiums, to improve benefits, or for other
programs intended to improve the quality of health care
delivered to its members.
(5) Compliance with state insurance laws.--An organization
shall not be treated as a qualified nonprofit health insurance
issuer unless the organization meets all the requirements that
other issuers of qualified health plans are required to meet in
any State where the issuer offers a qualified health plan,
including solvency and licensure requirements, rules on
payments to providers, and compliance with network adequacy
rules, rate and form filing rules, any applicable State premium
assessments and any other State law described in section
1324(b).
(6) Coordination with state insurance reforms.--An
organization shall not be treated as a qualified nonprofit
health insurance issuer unless the organization does not offer
a health plan in a State until that State has in effect (or the
Secretary has implemented for the State) the market reforms
required by part A of title XXVII of the Public Health Service
Act (as amended by subtitles A and C of this Act).
(d) Establishment of Private Purchasing Council.--
(1) In general.--Qualified nonprofit health insurance
issuers participating in the CO-OP program under this section
may establish a private purchasing council to enter into
collective purchasing arrangements for items and services that
increase administrative and other cost efficiencies, including
claims administration, administrative services, health
information technology, and actuarial services.
(2) Council may not set payment rates.--The private
purchasing council established under paragraph (1) shall not
set payment rates for health care facilities or providers
participating in health insurance coverage provided by
qualified nonprofit health insurance issuers.
(3) Continued application of antitrust laws.--
(A) In general.--Nothing in this section shall be
construed to limit the application of the antitrust
laws to any private purchasing council (whether or not
established under this subsection) or to any qualified
nonprofit health insurance issuer participating in such
a council.
(B) Antitrust laws.--For purposes of this
subparagraph, the term ``antitrust laws'' has the
meaning given the term in subsection (a) of the first
section of the Clayton Act (15 U.S.C. 12(a)). Such term
also includes section 5 of the Federal Trade Commission
Act (15 U.S.C. 45) to the extent that such section 5
applies to unfair methods of competition.
(e) Limitation on Participation.--No representative of any Federal,
State, or local government (or of any political subdivision or
instrumentality thereof), and no representative of a person described
in subsection (c)(2)(A), may serve on the board of directors of a
qualified nonprofit health insurance issuer or with a private
purchasing council established under subsection (d).
(f) Limitations on Secretary.--
(1) In general.--The Secretary shall not--
(A) participate in any negotiations between 1 or
more qualified nonprofit health insurance issuers (or a
private purchasing council established under subsection
(d)) and any health care facilities or providers,
including any drug manufacturer, pharmacy, or hospital;
and
(B) establish or maintain a price structure for
reimbursement of any health benefits covered by such
issuers.
(2) Competition.--Nothing in this section shall be
construed as authorizing the Secretary to interfere with the
competitive nature of providing health benefits through
qualified nonprofit health insurance issuers.
(g) Appropriations.--There are hereby appropriated, out of any
funds in the Treasury not otherwise appropriated, $6,000,000,000 to
carry out this section.
(h) Tax Exemption for Qualified Nonprofit Health Insurance
Issuer.--
(1) In general.--Section 501(c) of the Internal Revenue
Code of 1986 (relating to list of exempt organizations) is
amended by adding at the end the following:
``(29) CO-OP health insurance issuers.--
``(A) In general.--A qualified nonprofit health
insurance issuer (within the meaning of section 1322 of
the Patient Protection and Affordable Care Act) which
has received a loan or grant under the CO-OP program
under such section, but only with respect to periods
for which the issuer is in compliance with the
requirements of such section and any agreement with
respect to the loan or grant.
``(B) Conditions for exemption.--Subparagraph (A)
shall apply to an organization only if--
``(i) the organization has given notice to
the Secretary, in such manner as the Secretary
may by regulations prescribe, that it is
applying for recognition of its status under
this paragraph,
``(ii) except as provided in section
1322(c)(4) of the Patient Protection and
Affordable Care Act, no part of the net
earnings of which inures to the benefit of any
private shareholder or individual,
``(iii) no substantial part of the
activities of which is carrying on propaganda,
or otherwise attempting, to influence
legislation, and
``(iv) the organization does not
participate in, or intervene in (including the
publishing or distributing of statements), any
political campaign on behalf of (or in
opposition to) any candidate for public
office.''.
(2) Additional reporting requirement.--Section 6033 of such
Code (relating to returns by exempt organizations) is amended
by redesignating subsection (m) as subsection (n) and by
inserting after subsection (l) the following:
``(m) Additional Information Required From CO-OP Insurers.--An
organization described in section 501(c)(29) shall include on the
return required under subsection (a) the following information:
``(1) The amount of the reserves required by each State in
which the organization is licensed to issue qualified health
plans.
``(2) The amount of reserves on hand.''.
(3) Application of tax on excess benefit transactions.--
Section 4958(e)(1) of such Code (defining applicable tax-exempt
organization) is amended by striking ``paragraph (3) or (4)''
and inserting ``paragraph (3), (4), or (29)''.
(i) GAO Study and Report.--
(1) Study.--The Comptroller General of the General
Accountability Office shall conduct an ongoing study on
competition and market concentration in the health insurance
market in the United States after the implementation of the
reforms in such market under the provisions of, and the
amendments made by, this Act. Such study shall include an
analysis of new issuers of health insurance in such market.
(2) Report.--The Comptroller General shall, not later than
December 31 of each even-numbered year (beginning with 2014),
report to the appropriate committees of the Congress the
results of the study conducted under paragraph (1), including
any recommendations for administrative or legislative changes
the Comptroller General determines necessary or appropriate to
increase competition in the health insurance market.
SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION.
(a) Voluntary Nature.--
(1) No requirement for health care providers to
participate.--Nothing in this section shall be construed to
require a health care provider to participate in a community
health insurance option, or to impose any penalty for non-
participation.
(2) No requirement for individuals to join.--Nothing in
this section shall be construed to require an individual to
participate in a community health insurance option, or to
impose any penalty for non-participation.
(3) State opt out.--
(A) In general.--A State may elect to prohibit
Exchanges in such State from offering a community
health insurance option if such State enacts a law to
provide for such prohibition.
(B) Termination of opt out.--A State may repeal a
law described in subparagraph (A) and provide for the
offering of such an option through the Exchange.
(b) Establishment of Community Health Insurance Option.--
(1) Establishment.--The Secretary shall establish a
community health insurance option to offer, through the
Exchanges established under this title (other than Exchanges in
States that elect to opt out as provided for in subsection
(a)(3)), health care coverage that provides value, choice,
competition, and stability of affordable, high quality coverage
throughout the United States.
(2) Community health insurance option.--In this section,
the term ``community health insurance option'' means health
insurance coverage that--
(A) except as specifically provided for in this
section, complies with the requirements for being a
qualified health plan;
(B) provides high value for the premium charged;
(C) reduces administrative costs and promotes
administrative simplification for beneficiaries;
(D) promotes high quality clinical care;
(E) provides high quality customer service to
beneficiaries;
(F) offers a sufficient choice of providers; and
(G) complies with State laws (if any), except as
otherwise provided for in this title, relating to the
laws described in section 1324(b).
(3) Essential health benefits.--
(A) General rule.--Except as provided in
subparagraph (B), a community health insurance option
offered under this section shall provide coverage only
for the essential health benefits described in section
1302(b).
(B) States may offer additional benefits.--Nothing
in this section shall preclude a State from requiring
that benefits in addition to the essential health
benefits required under subparagraph (A) be provided to
enrollees of a community health insurance option
offered in such State.
(C) Credits.--
(i) In general.--An individual enrolled in
a community health insurance option under this
section shall be eligible for credits under
section 36B of the Internal Revenue Code of
1986 in the same manner as an individual who is
enrolled in a qualified health plan.
(ii) No additional federal cost.--A
requirement by a State under subparagraph (B)
that benefits in addition to the essential
health benefits required under subparagraph (A)
be provided to enrollees of a community health
insurance option shall not affect the amount of
a premium tax credit provided under section 36B
of the Internal Revenue Code of 1986 with
respect to such plan.
(D) State must assume cost.--A State shall make
payments to or on behalf of an eligible individual to
defray the cost of any additional benefits described in
subparagraph (B).
(E) Ensuring access to all services.--Nothing in
this Act shall prohibit an individual enrolled in a
community health insurance option from paying out-of-
pocket the full cost of any item or service not
included as an essential health benefit or otherwise
covered as a benefit by a health plan. Nothing in
subparagraph (B) shall prohibit any type of medical
provider from accepting an out-of-pocket payment from
an individual enrolled in a community health insurance
option for a service otherwise not included as an
essential health benefit.
(F) Protecting access to end of life care.--A
community health insurance option offered under this
section shall be prohibited from limiting access to end
of life care.
(4) Cost sharing.--A community health insurance option
shall offer coverage at each of the levels of coverage
described in section 1302(d).
(5) Premiums.--
(A) Premiums sufficient to cover costs.--The
Secretary shall establish geographically adjusted
premium rates in an amount sufficient to cover expected
costs (including claims and administrative costs) using
methods in general use by qualified health plans.
(B) Applicable rules.--The provisions of title
XXVII of the Public Health Service Act relating to
premiums shall apply to community health insurance
options under this section, including modified
community rating provisions under section 2701 of such
Act.
(C) Collection of data.--The Secretary shall
collect data as necessary to set premium rates under
subparagraph (A).
(D) National pooling.--Notwithstanding any other
provision of law, the Secretary may treat all enrollees
in community health insurance options as members of a
single pool.
(E) Contingency margin.--In establishing premium
rates under subparagraph (A), the Secretary shall
include an appropriate amount for a contingency margin.
(6) Reimbursement rates.--
(A) Negotiated rates.--The Secretary shall
negotiate rates for the reimbursement of health care
providers for benefits covered under a community health
insurance option.
(B) Limitation.--The rates described in
subparagraph (A) shall not be higher, in aggregate,
than the average reimbursement rates paid by health
insurance issuers offering qualified health plans
through the Exchange.
(C) Innovation.--Subject to the limits contained in
subparagraph (A), a State Advisory Council established
or designated under subsection (d) may develop or
encourage the use of innovative payment policies that
promote quality, efficiency and savings to consumers.
(7) Solvency and consumer protection.--
(A) Solvency.--The Secretary shall establish a
Federal solvency standard to be applied with respect to
a community health insurance option. A community health
insurance option shall also be subject to the solvency
standard of each State in which such community health
insurance option is offered.
(B) Minimum required.--In establishing the standard
described under subparagraph (A), the Secretary shall
require a reserve fund that shall be equal to at least
the dollar value of the incurred but not reported
claims of a community health insurance option.
(C) Consumer protections.--The consumer protection
laws of a State shall apply to a community health
insurance option.
(8) Requirements established in partnership with insurance
commissioners.--
(A) In general.--The Secretary, in collaboration
with the National Association of Insurance
Commissioners (in this paragraph referred to as the
``NAIC''), may promulgate regulations to establish
additional requirements for a community health
insurance option.
(B) Applicability.--Any requirement promulgated
under subparagraph (A) shall be applicable to such
option beginning 90 days after the date on which the
regulation involved becomes final.
(c) Start-up Fund.--
(1) Establishment of fund.--
(A) In general.--There is established in the
Treasury of the United States a trust fund to be known
as the ``Health Benefit Plan Start-Up Fund'' (referred
to in this section as the ``Start-Up Fund''), that
shall consist of such amounts as may be appropriated or
credited to the Start-Up Fund as provided for in this
subsection to provide loans for the initial operations
of a community health insurance option. Such amounts
shall remain available until expended.
(B) Funding.--There is hereby appropriated to the
Start-Up Fund, out of any moneys in the Treasury not
otherwise appropriated an amount requested by the
Secretary of Health and Human Services as necessary
to--
(i) pay the start-up costs associated with
the initial operations of a community health
insurance option; and
(ii) pay the costs of making payments on
claims submitted during the period that is not
more than 90 days from the date on which such
option is offered.
(2) Use of start-up fund.--The Secretary shall use amounts
contained in the Start-Up Fund to make payments (subject to the
repayment requirements in paragraph (4)) for the purposes
described in paragraph (1)(B).
(3) Pass through of rebates.--The Secretary may establish
procedures for reducing the amount of payments to a contracting
administrator to take into account any rebates or price
concessions.
(4) Repayment.--
(A) In general.--A community health insurance
option shall be required to repay the Secretary of the
Treasury (on such terms as the Secretary may require)
for any payments made under paragraph (1)(B) by the
date that is not later than 9 years after the date on
which the payment is made. The Secretary may require
the payment of interest with respect to such repayments
at rates that do not exceed the market interest rate
(as determined by the Secretary).
(B) Sanctions in case of for-profit conversion.--In
any case in which the Secretary enters into a contract
with a qualified entity for the offering of a community
health insurance option and such entity is determined
to be a for-profit entity by the Secretary, such entity
shall be--
(i) immediately liable to the Secretary for
any payments received by such entity from the
Start-Up Fund; and
(ii) permanently ineligible to offer a
qualified health plan.
(d) State Advisory Council.--
(1) Establishment.--A State (other than a State that elects
to opt out as provided for in subsection (a)(3)) shall
establish or designate a public or non-profit private entity to
serve as the State Advisory Council to provide recommendations
to the Secretary on the operations and policies of a community
health insurance option in the State. Such Council shall
provide recommendations on at least the following:
(A) policies and procedures to integrate quality
improvement and cost containment mechanisms into the
health care delivery system;
(B) mechanisms to facilitate public awareness of
the availability of a community health insurance
option; and
(C) alternative payment structures under a
community health insurance option for health care
providers that encourage quality improvement and cost
control.
(2) Members.--The members of the State Advisory Council
shall be representatives of the public and shall include health
care consumers and providers.
(3) Applicability of recommendations.--The Secretary may
apply the recommendations of a State Advisory Council to a
community health insurance option in that State, in any other
State, or in all States.
(e) Authority To Contract; Terms of Contract.--
(1) Authority.--
(A) In general.--The Secretary may enter into a
contract or contracts with one or more qualified
entities for the purpose of performing administrative
functions (including functions described in subsection
(a)(4) of section 1874A of the Social Security Act)
with respect to a community health insurance option in
the same manner as the Secretary may enter into
contracts under subsection (a)(1) of such section. The
Secretary shall have the same authority with respect to
a community health insurance option under this section
as the Secretary has under subsections (a)(1) and (b)
of section 1874A of the Social Security Act with
respect to title XVIII of such Act.
(B) Requirements apply.--If the Secretary enters
into a contract with a qualified entity to offer a
community health insurance option, under such contract
such entity--
(i) shall meet the criteria established
under paragraph (2); and
(ii) shall receive an administrative fee
under paragraph (7).
(C) Limitation.--Contracts under this subsection
shall not involve the transfer of insurance risk to the
contracting administrator.
(D) Reference.--An entity with which the Secretary
has entered into a contract under this paragraph shall
be referred to as a ``contracting administrator''.
(2) Qualified entity.--To be qualified to be selected by
the Secretary to offer a community health insurance option, an
entity shall--
(A) meet the criteria established under section
1874A(a)(2) of the Social Security Act;
(B) be a nonprofit entity for purposes of offering
such option;
(C) meet the solvency standards applicable under
subsection (b)(7);
(D) be eligible to offer health insurance or health
benefits coverage;
(E) meet quality standards specified by the
Secretary;
(F) have in place effective procedures to control
fraud, abuse, and waste; and
(G) meet such other requirements as the Secretary
may impose.
Procedures described under subparagraph (F) shall include the
implementation of procedures to use beneficiary identifiers to
identify individuals entitled to benefits so that such an
individual's social security account number is not used, and
shall also include procedures for the use of technology
(including front-end, prepayment intelligent data-matching
technology similar to that used by hedge funds, investment
funds, and banks) to provide real-time data analysis of claims
for payment under this title to identify and investigate
unusual billing or order practices under this title that could
indicate fraud or abuse.
(3) Term.--A contract provided for under paragraph (1)
shall be for a term of at least 5 years but not more than 10
years, as determined by the Secretary. At the end of each such
term, the Secretary shall conduct a competitive bidding process
for the purposes of renewing existing contracts or selecting
new qualified entities with which to enter into contracts under
such paragraph.
(4) Limitation.--A contract may not be renewed under this
subsection unless the Secretary determines that the contracting
administrator has met performance requirements established by
the Secretary in the areas described in paragraph (7)(B).
(5) Audits.--The Inspector General shall conduct periodic
audits with respect to contracting administrators under this
subsection to ensure that the administrator involved is in
compliance with this section.
(6) Revocation.--A contract awarded under this subsection
shall be revoked by the Secretary, upon the recommendation of
the Inspector General, only after notice to the contracting
administrator involved and an opportunity for a hearing. The
Secretary may revoke such contract if the Secretary determines
that such administrator has engaged in fraud, deception, waste,
abuse of power, negligence, mismanagement of taxpayer dollars,
or gross mismanagement. An entity that has had a contract
revoked under this paragraph shall not be qualified to enter
into a subsequent contract under this subsection.
(7) Fee for administration.--
(A) In general.--The Secretary shall pay the
contracting administrator a fee for the management,
administration, and delivery of the benefits under this
section.
(B) Requirement for high quality administration.--
The Secretary may increase the fee described in
subparagraph (A) by not more than 10 percent, or reduce
the fee described in subparagraph (A) by not more than
50 percent, based on the extent to which the
contracting administrator, in the determination of the
Secretary, meets performance requirements established
by the Secretary, in at least the following areas:
(i) Maintaining low premium costs and low
cost sharing requirements, provided that such
requirements are consistent with section 1302.
(ii) Reducing administrative costs and
promoting administrative simplification for
beneficiaries.
(iii) Promoting high quality clinical care.
(iv) Providing high quality customer
service to beneficiaries.
(C) Non-renewal.--The Secretary may not renew a
contract to offer a community health insurance option
under this section with any contracting entity that has
been assessed more than one reduction under
subparagraph (B) during the contract period.
(8) Limitation.--Notwithstanding the terms of a contract
under this subsection, the Secretary shall negotiate the
reimbursement rates for purposes of subsection (b)(6).
(f) Report by HHS and Insolvency Warnings.--
(1) In general.--On an annual basis, the Secretary shall
conduct a study on the solvency of a community health insurance
option and submit to Congress a report describing the results
of such study.
(2) Result.--If, in any year, the result of the study under
paragraph (1) is that a community health insurance option is
insolvent, such result shall be treated as a community health
insurance option solvency warning.
(3) Submission of plan and procedure.--
(A) In general.--If there is a community health
insurance option solvency warning under paragraph (2)
made in a year, the President shall submit to Congress,
within the 15-day period beginning on the date of the
budget submission to Congress under section 1105(a) of
title 31, United States Code, for the succeeding year,
proposed legislation to respond to such warning.
(B) Procedure.--In the case of a legislative
proposal submitted by the President pursuant to
subparagraph (A), such proposal shall be considered by
Congress using the same procedures described under
sections 803 and 804 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 that shall
be used for a medicare funding warning.
(g) Marketing Parity.--In a facility controlled by the Federal
Government, or by a State, where marketing or promotional materials
related to a community health insurance option are made available to
the public, making available marketing or promotional materials
relating to private health insurance plans shall not be prohibited.
Such materials include informational pamphlets, guidebooks, enrollment
forms, or other materials determined reasonable for display.
(h) Authorization of Appropriations.--There is authorized to be
appropriated such sums as may be necessary to carry out this section.
SEC. 1324. LEVEL PLAYING FIELD.
(a) In General.--Notwithstanding any other provision of law, any
health insurance coverage offered by a private health insurance issuer
shall not be subject to any Federal or State law described in
subsection (b) if a qualified health plan offered under the Consumer
Operated and Oriented Plan program under section 1322, a community
health insurance option under section 1323, or a nationwide qualified
health plan under section 1333(b), is not subject to such law.
(b) Laws Described.--The Federal and State laws described in this
subsection are those Federal and State laws relating to--
(1) guaranteed renewal;
(2) rating;
(3) preexisting conditions;
(4) non-discrimination;
(5) quality improvement and reporting;
(6) fraud and abuse;
(7) solvency and financial requirements;
(8) market conduct;
(9) prompt payment;
(10) appeals and grievances;
(11) privacy and confidentiality;
(12) licensure; and
(13) benefit plan material or information.
PART IV--STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS
SEC. 1331. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH PROGRAMS FOR
LOW-INCOME INDIVIDUALS NOT ELIGIBLE FOR MEDICAID.
(a) Establishment of Program.--
(1) In general.--The Secretary shall establish a basic
health program meeting the requirements of this section under
which a State may enter into contracts to offer 1 or more
standard health plans providing at least the essential health
benefits described in section 1302(b) to eligible individuals
in lieu of offering such individuals coverage through an
Exchange.
(2) Certifications as to benefit coverage and costs.--Such
program shall provide that a State may not establish a basic
health program under this section unless the State establishes
to the satisfaction of the Secretary, and the Secretary
certifies, that--
(A) in the case of an eligible individual enrolled
in a standard health plan offered through the program,
the State provides--
(i) that the amount of the monthly premium
an eligible individual is required to pay for
coverage under the standard health plan for the
individual and the individual's dependents does
not exceed the amount of the monthly premium
that the eligible individual would have been
required to pay (in the rating area in which
the individual resides) if the individual had
enrolled in the applicable second lowest cost
silver plan (as defined in section 36B(b)(3)(B)
of the Internal Revenue Code of 1986) offered
to the individual through an Exchange; and
(ii) that the cost-sharing an eligible
individual is required to pay under the
standard health plan does not exceed--
(I) the cost-sharing required under
a platinum plan in the case of an
eligible individual with household
income not in excess of 150 percent of
the poverty line for the size of the
family involved; and
(II) the cost-sharing required
under a gold plan in the case of an
eligible individual not described in
subclause (I); and
(B) the benefits provided under the standard health
plans offered through the program cover at least the
essential health benefits described in section 1302(b).
For purposes of subparagraph (A)(i), the amount of the monthly
premium an individual is required to pay under either the
standard health plan or the applicable second lowest cost
silver plan shall be determined after reduction for any premium
tax credits and cost-sharing reductions allowable with respect
to either plan.
(b) Standard Health Plan.--In this section, the term ``standard
heath plan'' means a health benefits plan that the State contracts with
under this section--
(1) under which the only individuals eligible to enroll are
eligible individuals;
(2) that provides at least the essential health benefits
described in section 1302(b); and
(3) in the case of a plan that provides health insurance
coverage offered by a health insurance issuer, that has a
medical loss ratio of at least 85 percent.
(c) Contracting Process.--
(1) In general.--A State basic health program shall
establish a competitive process for entering into contracts
with standard health plans under subsection (a), including
negotiation of premiums and cost-sharing and negotiation of
benefits in addition to the essential health benefits described
in section 1302(b).
(2) Specific items to be considered.--A State shall, as
part of its competitive process under paragraph (1), include at
least the following:
(A) Innovation.--Negotiation with offerors of a
standard health plan for the inclusion of innovative
features in the plan, including--
(i) care coordination and care management
for enrollees, especially for those with
chronic health conditions;
(ii) incentives for use of preventive
services; and
(iii) the establishment of relationships
between providers and patients that maximize
patient involvement in health care decision-
making, including providing incentives for
appropriate utilization under the plan.
(B) Health and resource differences.--Consideration
of, and the making of suitable allowances for,
differences in health care needs of enrollees and
differences in local availability of, and access to,
health care providers. Nothing in this subparagraph
shall be construed as allowing discrimination on the
basis of pre-existing conditions or other health
status-related factors.
(C) Managed care.--Contracting with managed care
systems, or with systems that offer as many of the
attributes of managed care as are feasible in the local
health care market.
(D) Performance measures.--Establishing specific
performance measures and standards for issuers of
standard health plans that focus on quality of care and
improved health outcomes, requiring such plans to
report to the State with respect to the measures and
standards, and making the performance and quality
information available to enrollees in a useful form.
(3) Enhanced availability.--
(A) Multiple plans.--A State shall, to the maximum
extent feasible, seek to make multiple standard health
plans available to eligible individuals within a State
to ensure individuals have a choice of such plans.
(B) Regional compacts.--A State may negotiate a
regional compact with other States to include coverage
of eligible individuals in all such States in
agreements with issuers of standard health plans.
(4) Coordination with other state programs.--A State shall
seek to coordinate the administration of, and provision of
benefits under, its program under this section with the State
medicaid program under title XIX of the Social Security Act,
the State child health plan under title XXI of such Act, and
other State-administered health programs to maximize the
efficiency of such programs and to improve the continuity of
care.
(d) Transfer of Funds to States.--
(1) In general.--If the Secretary determines that a State
electing the application of this section meets the requirements
of the program established under subsection (a), the Secretary
shall transfer to the State for each fiscal year for which 1 or
more standard health plans are operating within the State the
amount determined under paragraph (3).
(2) Use of funds.--A State shall establish a trust for the
deposit of the amounts received under paragraph (1) and amounts
in the trust fund shall only be used to reduce the premiums and
cost-sharing of, or to provide additional benefits for,
eligible individuals enrolled in standard health plans within
the State. Amounts in the trust fund, and expenditures of such
amounts, shall not be included in determining the amount of any
non-Federal funds for purposes of meeting any matching or
expenditure requirement of any federally-funded program.
(3) Amount of payment.--
(A) Secretarial determination.--
(i) In general.--The amount determined
under this paragraph for any fiscal year is the
amount the Secretary determines is equal to 85
percent of the premium tax credits under
section 36B of the Internal Revenue Code of
1986, and the cost-sharing reductions under
section 1402, that would have been provided for
the fiscal year to eligible individuals
enrolled in standard health plans in the State
if such eligible individuals were allowed to
enroll in qualified health plans through an
Exchange established under this subtitle.
(ii) Specific requirements.--The Secretary
shall make the determination under clause (i)
on a per enrollee basis and shall take into
account all relevant factors necessary to
determine the value of the premium tax credits
and cost-sharing reductions that would have
been provided to eligible individuals described
in clause (i), including the age and income of
the enrollee, whether the enrollment is for
self-only or family coverage, geographic
differences in average spending for health care
across rating areas, the health status of the
enrollee for purposes of determining risk
adjustment payments and reinsurance payments
that would have been made if the enrollee had
enrolled in a qualified health plan through an
Exchange, and whether any reconciliation of the
credit or cost-sharing reductions would have
occurred if the enrollee had been so enrolled.
This determination shall take into
consideration the experience of other States
with respect to participation in an Exchange
and such credits and reductions provided to
residents of the other States, with a special
focus on enrollees with income below 200
percent of poverty.
(iii) Certification.--The Chief Actuary of
the Centers for Medicare & Medicaid Services,
in consultation with the Office of Tax Analysis
of the Department of the Treasury, shall
certify whether the methodology used to make
determinations under this subparagraph, and
such determinations, meet the requirements of
clause (ii). Such certifications shall be based
on sufficient data from the State and from
comparable States about their experience with
programs created by this Act.
(B) Corrections.--The Secretary shall adjust the
payment for any fiscal year to reflect any error in the
determinations under subparagraph (A) for any preceding
fiscal year.
(4) Application of special rules.--The provisions of
section 1303 shall apply to a State basic health program, and
to standard health plans offered through such program, in the
same manner as such rules apply to qualified health plans.
(e) Eligible Individual.--
(1) In general.--In this section, the term ``eligible
individual'' means, with respect to any State, an individual--
(A) who a resident of the State who is not eligible
to enroll in the State's medicaid program under title
XIX of the Social Security Act for benefits that at a
minimum consist of the essential health benefits
described in section 1302(b);
(B) whose household income exceeds 133 percent but
does not exceed 200 percent of the poverty line for the
size of the family involved;
(C) who is not eligible for minimum essential
coverage (as defined in section 5000A(f) of the
Internal Revenue Code of 1986) or is eligible for an
employer-sponsored plan that is not affordable coverage
(as determined under section 5000A(e)(2) of such Code);
and
(D) who has not attained age 65 as of the beginning
of the plan year.
Such term shall not include any individual who is not a
qualified individual under section 1312 who is eligible to be
covered by a qualified health plan offered through an Exchange.
(2) Eligible individuals may not use exchange.--An eligible
individual shall not be treated as a qualified individual under
section 1312 eligible for enrollment in a qualified health plan
offered through an Exchange established under section 1311.
(f) Secretarial Oversight.--The Secretary shall each year conduct a
review of each State program to ensure compliance with the requirements
of this section, including ensuring that the State program meets--
(1) eligibility verification requirements for participation
in the program;
(2) the requirements for use of Federal funds received by
the program; and
(3) the quality and performance standards under this
section.
(g) Standard Health Plan Offerors.--A State may provide that
persons eligible to offer standard health plans under a basic health
program established under this section may include a licensed health
maintenance organization, a licensed health insurance insurer, or a
network of health care providers established to offer services under
the program.
(h) Definitions.--Any term used in this section which is also used
in section 36B of the Internal Revenue Code of 1986 shall have the
meaning given such term by such section.
SEC. 1332. WAIVER FOR STATE INNOVATION.
(a) Application.--
(1) In general.--A State may apply to the Secretary for the
waiver of all or any requirements described in paragraph (2)
with respect to health insurance coverage within that State for
plan years beginning on or after January 1, 2017. Such
application shall--
(A) be filed at such time and in such manner as the
Secretary may require;
(B) contain such information as the Secretary may
require, including--
(i) a comprehensive description of the
State legislation and program to implement a
plan meeting the requirements for a waiver
under this section; and
(ii) a 10-year budget plan for such plan
that is budget neutral for the Federal
Government; and
(C) provide an assurance that the State has enacted
the law described in subsection (b)(2).
(2) Requirements.--The requirements described in this
paragraph with respect to health insurance coverage within the
State for plan years beginning on or after January 1, 2014, are
as follows:
(A) Part I of subtitle D.
(B) Part II of subtitle D.
(C) Section 1402.
(D) Sections 36B, 4980H, and 5000A of the Internal
Revenue Code of 1986.
(3) Pass through of funding.--With respect to a State
waiver under paragraph (1), under which, due to the structure
of the State plan, individuals and small employers in the State
would not qualify for the premium tax credits, cost-sharing
reductions, or small business credits under sections 36B of the
Internal Revenue Code of 1986 or under part I of subtitle E for
which they would otherwise be eligible, the Secretary shall
provide for an alternative means by which the aggregate amount
of such credits or reductions that would have been paid on
behalf of participants in the Exchanges established under this
title had the State not received such waiver, shall be paid to
the State for purposes of implementing the State plan under the
waiver. Such amount shall be determined annually by the
Secretary, taking into consideration the experience of other
States with respect to participation in an Exchange and credits
and reductions provided under such provisions to residents of
the other States.
(4) Waiver consideration and transparency.--
(A) In general.--An application for a waiver under
this section shall be considered by the Secretary in
accordance with the regulations described in
subparagraph (B).
(B) Regulations.--Not later than 180 days after the
date of enactment of this Act, the Secretary shall
promulgate regulations relating to waivers under this
section that provide--
(i) a process for public notice and comment
at the State level, including public hearings,
sufficient to ensure a meaningful level of
public input;
(ii) a process for the submission of an
application that ensures the disclosure of--
(I) the provisions of law that the
State involved seeks to waive; and
(II) the specific plans of the
State to ensure that the waiver will be
in compliance with subsection (b);
(iii) a process for providing public notice
and comment after the application is received
by the Secretary, that is sufficient to ensure
a meaningful level of public input and that
does not impose requirements that are in
addition to, or duplicative of, requirements
imposed under the Administrative Procedures
Act, or requirements that are unreasonable or
unnecessarily burdensome with respect to State
compliance;
(iv) a process for the submission to the
Secretary of periodic reports by the State
concerning the implementation of the program
under the waiver; and
(v) a process for the periodic evaluation
by the Secretary of the program under the
waiver.
(C) Report.--The Secretary shall annually report to
Congress concerning actions taken by the Secretary with
respect to applications for waivers under this section.
(5) Coordinated waiver process.--The Secretary shall
develop a process for coordinating and consolidating the State
waiver processes applicable under the provisions of this
section, and the existing waiver processes applicable under
titles XVIII, XIX, and XXI of the Social Security Act, and any
other Federal law relating to the provision of health care
items or services. Such process shall permit a State to submit
a single application for a waiver under any or all of such
provisions.
(6) Definition.--In this section, the term ``Secretary''
means--
(A) the Secretary of Health and Human Services with
respect to waivers relating to the provisions described
in subparagraph (A) through (C) of paragraph (2); and
(B) the Secretary of the Treasury with respect to
waivers relating to the provisions described in
paragraph (2)(D).
(b) Granting of Waivers.--
(1) In general.--The Secretary may grant a request for a
waiver under subsection (a)(1) only if the Secretary determines
that the State plan--
(A) will provide coverage that is at least as
comprehensive as the coverage defined in section
1302(b) and offered through Exchanges established under
this title as certified by Office of the Actuary of the
Centers for Medicare & Medicaid Services based on
sufficient data from the State and from comparable
States about their experience with programs created by
this Act and the provisions of this Act that would be
waived;
(B) will provide coverage and cost sharing
protections against excessive out-of-pocket spending
that are at least as affordable as the provisions of
this title would provide;
(C) will provide coverage to at least a comparable
number of its residents as the provisions of this title
would provide; and
(D) will not increase the Federal deficit.
(2) Requirement to enact a law.--
(A) In general.--A law described in this paragraph
is a State law that provides for State actions under a
waiver under this section, including the implementation
of the State plan under subsection (a)(1)(B).
(B) Termination of opt out.--A State may repeal a
law described in subparagraph (A) and terminate the
authority provided under the waiver with respect to the
State.
(c) Scope of Waiver.--
(1) In general.--The Secretary shall determine the scope of
a waiver of a requirement described in subsection (a)(2)
granted to a State under subsection (a)(1).
(2) Limitation.--The Secretary may not waive under this
section any Federal law or requirement that is not within the
authority of the Secretary.
(d) Determinations by Secretary.--
(1) Time for determination.--The Secretary shall make a
determination under subsection (a)(1) not later than 180 days
after the receipt of an application from a State under such
subsection.
(2) Effect of determination.--
(A) Granting of waivers.--If the Secretary
determines to grant a waiver under subsection (a)(1),
the Secretary shall notify the State involved of such
determination and the terms and effectiveness of such
waiver.
(B) Denial of waiver.--If the Secretary determines
a waiver should not be granted under subsection (a)(1),
the Secretary shall notify the State involved, and the
appropriate committees of Congress of such
determination and the reasons therefore.
(e) Term of Waiver.--No waiver under this section may extend over a
period of longer than 5 years unless the State requests continuation of
such waiver, and such request shall be deemed granted unless the
Secretary, within 90 days after the date of its submission to the
Secretary, either denies such request in writing or informs the State
in writing with respect to any additional information which is needed
in order to make a final determination with respect to the request.
SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE THAN ONE
STATE.
(a) Health Care Choice Compacts.--
(1) In general.--Not later than July 1, 2013, the Secretary
shall, in consultation with the National Association of
Insurance Commissioners, issue regulations for the creation of
health care choice compacts under which 2 or more States may
enter into an agreement under which--
(A) 1 or more qualified health plans could be
offered in the individual markets in all such States
but, except as provided in subparagraph (B), only be
subject to the laws and regulations of the State in
which the plan was written or issued;
(B) the issuer of any qualified health plan to
which the compact applies--
(i) would continue to be subject to market
conduct, unfair trade practices, network
adequacy, and consumer protection standards
(including standards relating to rating),
including addressing disputes as to the
performance of the contract, of the State in
which the purchaser resides;
(ii) would be required to be licensed in
each State in which it offers the plan under
the compact or to submit to the jurisdiction of
each such State with regard to the standards
described in clause (i) (including allowing
access to records as if the insurer were
licensed in the State); and
(iii) must clearly notify consumers that
the policy may not be subject to all the laws
and regulations of the State in which the
purchaser resides.
(2) State authority.--A State may not enter into an
agreement under this subsection unless the State enacts a law
after the date of the enactment of this title that specifically
authorizes the State to enter into such agreements.
(3) Approval of compacts.--The Secretary may approve
interstate health care choice compacts under paragraph (1) only
if the Secretary determines that such health care choice
compact--
(A) will provide coverage that is at least as
comprehensive as the coverage defined in section
1302(b) and offered through Exchanges established under
this title;
(B) will provide coverage and cost sharing
protections against excessive out-of-pocket spending
that are at least as affordable as the provisions of
this title would provide;
(C) will provide coverage to at least a comparable
number of its residents as the provisions of this title
would provide;
(D) will not increase the Federal deficit; and
(E) will not weaken enforcement of laws and
regulations described in paragraph (1)(B)(i) in any
State that is included in such compact.
(4) Effective date.--A health care choice compact described
in paragraph (1) shall not take effect before January 1, 2016.
(b) Authority for Nationwide Plans.--
(1) In general.--Except as provided in paragraph (2), if an
issuer (including a group of health insurance issuers
affiliated either by common ownership and control or by the
common use of a nationally licensed service mark) of a
qualified health plan in the individual or small group market
meets the requirements of this subsection (in this subsection a
``nationwide qualified health plan'')--
(A) the issuer of the plan may offer the nationwide
qualified health plan in the individual or small group
market in more than 1 State; and
(B) with respect to State laws mandating benefit
coverage by a health plan, only the State laws of the
State in which such plan is written or issued shall
apply to the nationwide qualified health plan.
(2) State opt-out.--A State may, by specific reference in a
law enacted after the date of enactment of this title, provide
that this subsection shall not apply to that State. Such opt-
out shall be effective until such time as the State by law
revokes it.
(3) Plan requirements.--An issuer meets the requirements of
this subsection with respect to a nationwide qualified health
plan if, in the determination of the Secretary--
(A) the plan offers a benefits package that is
uniform in each State in which the plan is offered and
meets the requirements set forth in paragraphs (4)
through (6);
(B) the issuer is licensed in each State in which
it offers the plan and is subject to all requirements
of State law not inconsistent with this section,
including but not limited to, the standards and
requirements that a State imposes that do not prevent
the application of a requirement of part A of title
XXVII of the Public Health Service Act or a requirement
of this title;
(C) the issuer meets all requirements of this title
with respect to a qualified health plan, including the
requirement to offer the silver and gold levels of the
plan in each Exchange in the State for the market in
which the plan is offered;
(D) the issuer determines the premiums for the plan
in any State on the basis of the rating rules in effect
in that State for the rating areas in which it is
offered;
(E) the issuer offers the nationwide qualified
health plan in at least 60 percent of the participating
States in the first year in which the plan is offered,
65 percent of such States in the second year, 70
percent of such States in the third year, 75 percent of
such States in the fourth year, and 80 percent of such
States in the fifth and subsequent years;
(F) the issuer shall offer the plan in
participating States across the country, in all
geographic regions, and in all States that have adopted
adjusted community rating before the date of enactment
of this Act; and
(G) the issuer clearly notifies consumers that the
policy may not contain some benefits otherwise mandated
for plans in the State in which the purchaser resides
and provides a detailed statement of the benefits
offered and the benefit differences in that State, in
accordance with rules promulgated by the Secretary.
(4) Form review for nationwide plans.--Notwithstanding any
contrary provision of State law, at least 3 months before any
nationwide qualified health plan is offered, the issuer shall
file all nationwide qualified health plan forms with the
regulator in each participating State in which the plan will be
offered. An issuer may appeal the disapproval of a nationwide
qualified health plan form to the Secretary.
(5) Applicable rules.--The Secretary shall, in consultation
with the National Association of Insurance Commissioners, issue
rules for the offering of nationwide qualified health plans
under this subsection. Nationwide qualified health plans may be
offered only after such rules have taken effect.
(6) Coverage.--The Secretary shall provide that the health
benefits coverage provided to an individual through a
nationwide qualified health plan under this subsection shall
include at least the essential benefits package described in
section 1302.
(7) State law mandating benefit coverage by a health
benefits plan.--For the purposes of this subsection, a State
law mandating benefit coverage by a health plan is a law that
mandates health insurance coverage or the offer of health
insurance coverage for specific health services or specific
diseases. A law that mandates health insurance coverage or
reimbursement for services provided by certain classes of
providers of health care services, or a law that mandates that
certain classes of individuals must be covered as a group or as
dependents, is not a State law mandating benefit coverage by a
health benefits plan.
PART V--REINSURANCE AND RISK ADJUSTMENT
SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL AND SMALL
GROUP MARKETS IN EACH STATE.
(a) In General.--Each State shall, not later than January 1, 2014--
(1) include in the Federal standards or State law or
regulation the State adopts and has in effect under section
1321(b) the provisions described in subsection (b); and
(2) establish (or enter into a contract with) 1 or more
applicable reinsurance entities to carry out the reinsurance
program under this section.
(b) Model Regulation.--
(1) In general.--In establishing the Federal standards
under section 1321(a), the Secretary, in consultation with the
National Association of Insurance Commissioners (the ``NAIC''),
shall include provisions that enable States to establish and
maintain a program under which--
(A) health insurance issuers, and third party
administrators on behalf of group health plans, are
required to make payments to an applicable reinsurance
entity for any plan year beginning in the 3-year period
beginning January 1, 2014 (as specified in paragraph
(3); and
(B) the applicable reinsurance entity collects
payments under subparagraph (A) and uses amounts so
collected to make reinsurance payments to health
insurance issuers described in subparagraph (A) that
cover high risk individuals in the individual market
(excluding grandfathered health plans) for any plan
year beginning in such 3-year period.
(2) High-risk individual; payment amounts.--The Secretary
shall include the following in the provisions under paragraph
(1):
(A) Determination of high-risk individuals.--The
method by which individuals will be identified as high
risk individuals for purposes of the reinsurance
program established under this section. Such method
shall provide for identification of individuals as
high-risk individuals on the basis of--
(i) a list of at least 50 but not more than
100 medical conditions that are identified as
high-risk conditions and that may be based on
the identification of diagnostic and procedure
codes that are indicative of individuals with
pre-existing, high-risk conditions; or
(ii) any other comparable objective method
of identification recommended by the American
Academy of Actuaries.
(B) Payment amount.--The formula for determining
the amount of payments that will be paid to health
insurance issuers described in paragraph (1)(A) that
insure high-risk individuals. Such formula shall
provide for the equitable allocation of available funds
through reconciliation and may be designed--
(i) to provide a schedule of payments that
specifies the amount that will be paid for each
of the conditions identified under subparagraph
(A); or
(ii) to use any other comparable method for
determining payment amounts that is recommended
by the American Academy of Actuaries and that
encourages the use of care coordination and
care management programs for high risk
conditions.
(3) Determination of required contributions.--
(A) In general.--The Secretary shall include in the
provisions under paragraph (1) the method for
determining the amount each health insurance issuer and
group health plan described in paragraph (1)(A)
contributing to the reinsurance program under this
section is required to contribute under such paragraph
for each plan year beginning in the 36-month period
beginning January 1, 2014. The contribution amount for
any plan year may be based on the percentage of revenue
of each issuer and the total costs of providing
benefits to enrollees in self-insured plans or on a
specified amount per enrollee and may be required to be
paid in advance or periodically throughout the plan
year.
(B) Specific requirements.--The method under this
paragraph shall be designed so that--
(i) the contribution amount for each issuer
proportionally reflects each issuer's fully
insured commercial book of business for all
major medical products and the total value of
all fees charged by the issuer and the costs of
coverage administered by the issuer as a third
party administrator;
(ii) the contribution amount can include an
additional amount to fund the administrative
expenses of the applicable reinsurance entity;
(iii) the aggregate contribution amounts
for all States shall, based on the best
estimates of the NAIC and without regard to
amounts described in clause (ii), equal
$10,000,000,000 for plan years beginning in
2014, $6,000,000,000 for plan years beginning
2015, and $4,000,000,000 for plan years
beginning in 2016; and
(iv) in addition to the aggregate
contribution amounts under clause (iii), each
issuer's contribution amount for any calendar
year under clause (iii) reflects its
proportionate share of an additional
$2,000,000,000 for 2014, an additional
$2,000,000,000 for 2015, and an additional
$1,000,000,000 for 2016.
Nothing in this subparagraph shall be construed to
preclude a State from collecting additional amounts
from issuers on a voluntary basis.
(4) Expenditure of funds.--The provisions under paragraph
(1) shall provide that--
(A) the contribution amounts collected for any
calendar year may be allocated and used in any of the
three calendar years for which amounts are collected
based on the reinsurance needs of a particular period
or to reflect experience in a prior period; and
(B) amounts remaining unexpended as of December,
2016, may be used to make payments under any
reinsurance program of a State in the individual market
in effect in the 2-year period beginning on January 1,
2017.
Notwithstanding the preceding sentence, any contribution
amounts described in paragraph (3)(B)(iv) shall be deposited
into the general fund of the Treasury of the United States and
may not be used for the program established under this section.
(c) Applicable Reinsurance Entity.--For purposes of this section--
(1) In general.--The term ``applicable reinsurance entity''
means a not-for-profit organization--
(A) the purpose of which is to help stabilize
premiums for coverage in the individual and small group
markets in a State during the first 3 years of
operation of an Exchange for such markets within the
State when the risk of adverse selection related to new
rating rules and market changes is greatest; and
(B) the duties of which shall be to carry out the
reinsurance program under this section by coordinating
the funding and operation of the risk-spreading
mechanisms designed to implement the reinsurance
program.
(2) State discretion.--A State may have more than 1
applicable reinsurance entity to carry out the reinsurance
program under this section within the State and 2 or more
States may enter into agreements to provide for an applicable
reinsurance entity to carry out such program in all such
States.
(3) Entities are tax-exempt.--An applicable reinsurance
entity established under this section shall be exempt from
taxation under chapter 1 of the Internal Revenue Code of 1986.
The preceding sentence shall not apply to the tax imposed by
section 511 such Code (relating to tax on unrelated business
taxable income of an exempt organization).
(d) Coordination With State High-risk Pools.--The State shall
eliminate or modify any State high-risk pool to the extent necessary to
carry out the reinsurance program established under this section. The
State may coordinate the State high-risk pool with such program to the
extent not inconsistent with the provisions of this section.
SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN INDIVIDUAL AND
SMALL GROUP MARKETS.
(a) In General.--The Secretary shall establish and administer a
program of risk corridors for calendar years 2014, 2015, and 2016 under
which a qualified health plan offered in the individual or small group
market shall participate in a payment adjustment system based on the
ratio of the allowable costs of the plan to the plan's aggregate
premiums. Such program shall be based on the program for regional
participating provider organizations under part D of title XVIII of the
Social Security Act.
(b) Payment Methodology.--
(1) Payments out.--The Secretary shall provide under the
program established under subsection (a) that if--
(A) a participating plan's allowable costs for any
plan year are more than 103 percent but not more than
108 percent of the target amount, the Secretary shall
pay to the plan an amount equal to 50 percent of the
target amount in excess of 103 percent of the target
amount; and
(B) a participating plan's allowable costs for any
plan year are more than 108 percent of the target
amount, the Secretary shall pay to the plan an amount
equal to the sum of 2.5 percent of the target amount
plus 80 percent of allowable costs in excess of 108
percent of the target amount.
(2) Payments in.--The Secretary shall provide under the
program established under subsection (a) that if--
(A) a participating plan's allowable costs for any
plan year are less than 97 percent but not less than 92
percent of the target amount, the plan shall pay to the
Secretary an amount equal to 50 percent of the excess
of 97 percent of the target amount over the allowable
costs; and
(B) a participating plan's allowable costs for any
plan year are less than 92 percent of the target
amount, the plan shall pay to the Secretary an amount
equal to the sum of 2.5 percent of the target amount
plus 80 percent of the excess of 92 percent of the
target amount over the allowable costs.
(c) Definitions.--In this section:
(1) Allowable costs.--
(A) In general.--The amount of allowable costs of a
plan for any year is an amount equal to the total costs
(other than administrative costs) of the plan in
providing benefits covered by the plan.
(B) Reduction for risk adjustment and reinsurance
payments.--Allowable costs shall reduced by any risk
adjustment and reinsurance payments received under
section 1341 and 1343.
(2) Target amount.--The target amount of a plan for any
year is an amount equal to the total premiums (including any
premium subsidies under any governmental program), reduced by
the administrative costs of the plan.
SEC. 1343. RISK ADJUSTMENT.
(a) In General.--
(1) Low actuarial risk plans.--Using the criteria and
methods developed under subsection (b), each State shall assess
a charge on health plans and health insurance issuers (with
respect to health insurance coverage) described in subsection
(c) if the actuarial risk of the enrollees of such plans or
coverage for a year is less than the average actuarial risk of
all enrollees in all plans or coverage in such State for such
year that are not self-insured group health plans (which are
subject to the provisions of the Employee Retirement Income
Security Act of 1974).
(2) High actuarial risk plans.--Using the criteria and
methods developed under subsection (b), each State shall
provide a payment to health plans and health insurance issuers
(with respect to health insurance coverage) described in
subsection (c) if the actuarial risk of the enrollees of such
plans or coverage for a year is greater than the average
actuarial risk of all enrollees in all plans and coverage in
such State for such year that are not self-insured group health
plans (which are subject to the provisions of the Employee
Retirement Income Security Act of 1974).
(b) Criteria and Methods.--The Secretary, in consultation with
States, shall establish criteria and methods to be used in carrying out
the risk adjustment activities under this section. The Secretary may
utilize criteria and methods similar to the criteria and methods
utilized under part C or D of title XVIII of the Social Security Act.
Such criteria and methods shall be included in the standards and
requirements the Secretary prescribes under section 1321.
(c) Scope.--A health plan or a health insurance issuer is described
in this subsection if such health plan or health insurance issuer
provides coverage in the individual or small group market within the
State. This subsection shall not apply to a grandfathered health plan
or the issuer of a grandfathered health plan with respect to that plan.
Subtitle E--Affordable Coverage Choices for All Americans
PART I--PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
Subpart A--Premium Tax Credits and Cost-sharing Reductions
SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSISTANCE FOR
COVERAGE UNDER A QUALIFIED HEALTH PLAN.
(a) In General.--Subpart C of part IV of subchapter A of chapter 1
of the Internal Revenue Code of 1986 (relating to refundable credits)
is amended by inserting after section 36A the following new section:
``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED HEALTH
PLAN.
``(a) In General.--In the case of an applicable taxpayer, there
shall be allowed as a credit against the tax imposed by this subtitle
for any taxable year an amount equal to the premium assistance credit
amount of the taxpayer for the taxable year.
``(b) Premium Assistance Credit Amount.--For purposes of this
section--
``(1) In general.--The term `premium assistance credit
amount' means, with respect to any taxable year, the sum of the
premium assistance amounts determined under paragraph (2) with
respect to all coverage months of the taxpayer occurring during
the taxable year.
``(2) Premium assistance amount.--The premium assistance
amount determined under this subsection with respect to any
coverage month is the amount equal to the lesser of--
``(A) the monthly premiums for such month for 1 or
more qualified health plans offered in the individual
market within a State which cover the taxpayer, the
taxpayer's spouse, or any dependent (as defined in
section 152) of the taxpayer and which were enrolled in
through an Exchange established by the State under 1311
of the Patient Protection and Affordable Care Act, or
``(B) the excess (if any) of--
``(i) the adjusted monthly premium for such
month for the applicable second lowest cost
silver plan with respect to the taxpayer, over
``(ii) an amount equal to 1/12 of the
product of the applicable percentage and the
taxpayer's household income for the taxable
year.
``(3) Other terms and rules relating to premium assistance
amounts.--For purposes of paragraph (2)--
``(A) Applicable percentage.--
``(i) In general.--Except as provided in
clause (ii), the applicable percentage with
respect to any taxpayer for any taxable year is
equal to 2.8 percent, increased by the number
of percentage points (not greater than 7) which
bears the same ratio to 7 percentage points
as--
``(I) the taxpayer's household
income for the taxable year in excess
of 100 percent of the poverty line for
a family of the size involved, bears to
``(II) an amount equal to 200
percent of the poverty line for a
family of the size involved.
``(ii) Special rule for taxpayers under 133
percent of poverty line.--If a taxpayer's
household income for the taxable year is in
excess of 100 percent, but not more than 133
percent, of the poverty line for a family of
the size involved, the taxpayer's applicable
percentage shall be 2 percent.
``(iii) Indexing.--In the case of taxable
years beginning in any calendar year after
2014, the Secretary shall adjust the initial
and final applicable percentages under clause
(i), and the 2 percent under clause (ii), for
the calendar year to reflect the excess of the
rate of premium growth between the preceding
calendar year and 2013 over the rate of income
growth for such period.
``(B) Applicable second lowest cost silver plan.--
The applicable second lowest cost silver plan with
respect to any applicable taxpayer is the second lowest
cost silver plan of the individual market in the rating
area in which the taxpayer resides which--
``(i) is offered through the same Exchange
through which the qualified health plans taken
into account under paragraph (2)(A) were
offered, and
``(ii) provides--
``(I) self-only coverage in the
case of an applicable taxpayer--
``(aa) whose tax for the
taxable year is determined
under section 1(c) (relating to
unmarried individuals other
than surviving spouses and
heads of households) and who is
not allowed a deduction under
section 151 for the taxable
year with respect to a
dependent, or
``(bb) who is not described
in item (aa) but who purchases
only self-only coverage, and
``(II) family coverage in the case
of any other applicable taxpayer.
If a taxpayer files a joint return and no credit is
allowed under this section with respect to 1 of the
spouses by reason of subsection (e), the taxpayer shall
be treated as described in clause (ii)(I) unless a
deduction is allowed under section 151 for the taxable
year with respect to a dependent other than either
spouse and subsection (e) does not apply to the
dependent.
``(C) Adjusted monthly premium.--The adjusted
monthly premium for an applicable second lowest cost
silver plan is the monthly premium which would have
been charged (for the rating area with respect to which
the premiums under paragraph (2)(A) were determined)
for the plan if each individual covered under a
qualified health plan taken into account under
paragraph (2)(A) were covered by such silver plan and
the premium was adjusted only for the age of each such
individual in the manner allowed under section 2701 of
the Public Health Service Act. In the case of a State
participating in the wellness discount demonstration
project under section 2705(d) of the Public Health
Service Act, the adjusted monthly premium shall be
determined without regard to any premium discount or
rebate under such project.
``(D) Additional benefits.--If--
``(i) a qualified health plan under section
1302(b)(5) of the Patient Protection and
Affordable Care Act offers benefits in addition
to the essential health benefits required to be
provided by the plan, or
``(ii) a State requires a qualified health
plan under section 1311(d)(3)(B) of such Act to
cover benefits in addition to the essential
health benefits required to be provided by the
plan,
the portion of the premium for the plan properly
allocable (under rules prescribed by the Secretary of
Health and Human Services) to such additional benefits
shall not be taken into account in determining either
the monthly premium or the adjusted monthly premium
under paragraph (2).
``(E) Special rule for pediatric dental coverage.--
For purposes of determining the amount of any monthly
premium, if an individual enrolls in both a qualified
health plan and a plan described in section
1311(d)(2)(B)(ii)(I) of the Patient Protection and
Affordable Care Act for any plan year, the portion of
the premium for the plan described in such section that
(under regulations prescribed by the Secretary) is
properly allocable to pediatric dental benefits which
are included in the essential health benefits required
to be provided by a qualified health plan under section
1302(b)(1)(J) of such Act shall be treated as a premium
payable for a qualified health plan.
``(c) Definition and Rules Relating to Applicable Taxpayers,
Coverage Months, and Qualified Health Plan.--For purposes of this
section--
``(1) Applicable taxpayer.--
``(A) In general.--The term `applicable taxpayer'
means, with respect to any taxable year, a taxpayer
whose household income for the taxable year exceeds 100
percent but does not exceed 400 percent of an amount
equal to the poverty line for a family of the size
involved.
``(B) Special rule for certain individuals lawfully
present in the united states.--If--
``(i) a taxpayer has a household income
which is not greater than 100 percent of an
amount equal to the poverty line for a family
of the size involved, and
``(ii) the taxpayer is an alien lawfully
present in the United States, but is not
eligible for the medicaid program under title
XIX of the Social Security Act by reason of
such alien status,
the taxpayer shall, for purposes of the credit under
this section, be treated as an applicable taxpayer with
a household income which is equal to 100 percent of the
poverty line for a family of the size involved.
``(C) Married couples must file joint return.--If
the taxpayer is married (within the meaning of section
7703) at the close of the taxable year, the taxpayer
shall be treated as an applicable taxpayer only if the
taxpayer and the taxpayer's spouse file a joint return
for the taxable year.
``(D) Denial of credit to dependents.--No credit
shall be allowed under this section to any individual
with respect to whom a deduction under section 151 is
allowable to another taxpayer for a taxable year
beginning in the calendar year in which such
individual's taxable year begins.
``(2) Coverage month.--For purposes of this subsection--
``(A) In general.--The term `coverage month' means,
with respect to an applicable taxpayer, any month if--
``(i) as of the first day of such month the
taxpayer, the taxpayer's spouse, or any
dependent of the taxpayer is covered by a
qualified health plan described in subsection
(b)(2)(A) that was enrolled in through an
Exchange established by the State under section
1311 of the Patient Protection and Affordable
Care Act, and
``(ii) the premium for coverage under such
plan for such month is paid by the taxpayer (or
through advance payment of the credit under
subsection (a) under section 1412 of the
Patient Protection and Affordable Care Act).
``(B) Exception for minimum essential coverage.--
``(i) In general.--The term `coverage
month' shall not include any month with respect
to an individual if for such month the
individual is eligible for minimum essential
coverage other than eligibility for coverage
described in section 5000A(f)(1)(C) (relating
to coverage in the individual market).
``(ii) Minimum essential coverage.--The
term `minimum essential coverage' has the
meaning given such term by section 5000A(f).
``(C) Special rule for employer-sponsored minimum
essential coverage.--For purposes of subparagraph (B)--
``(i) Coverage must be affordable.--Except
as provided in clause (iii), an employee shall
not be treated as eligible for minimum
essential coverage if such coverage--
``(I) consists of an eligible
employer-sponsored plan (as defined in
section 5000A(f)(2)), and
``(II) the employee's required
contribution (within the meaning of
section 5000A(e)(1)(B)) with respect to
the plan exceeds 9.8 percent of the
applicable taxpayer's household income.
This clause shall also apply to an individual
who is eligible to enroll in the plan by reason
of a relationship the individual bears to the
employee.
``(ii) Coverage must provide minimum
value.--Except as provided in clause (iii), an
employee shall not be treated as eligible for
minimum essential coverage if such coverage
consists of an eligible employer-sponsored plan
(as defined in section 5000A(f)(2)) and the
plan's share of the total allowed costs of
benefits provided under the plan is less than
60 percent of such costs.
``(iii) Employee or family must not be
covered under employer plan.--Clauses (i) and
(ii) shall not apply if the employee (or any
individual described in the last sentence of
clause (i)) is covered under the eligible
employer-sponsored plan or the grandfathered
health plan.
``(iv) Indexing.--In the case of plan years
beginning in any calendar year after 2014, the
Secretary shall adjust the 9.8 percent under
clause (i)(II) in the same manner as the
percentages are adjusted under subsection
(b)(3)(A)(ii).
``(3) Definitions and other rules.--
``(A) Qualified health plan.--The term `qualified
health plan' has the meaning given such term by section
1301(a) of the Patient Protection and Affordable Care
Act, except that such term shall not include a
qualified health plan which is a catastrophic plan
described in section 1302(e) of such Act.
``(B) Grandfathered health plan.--The term
`grandfathered health plan' has the meaning given such
term by section 1251 of the Patient Protection and
Affordable Care Act.
``(d) Terms Relating to Income and Families.--For purposes of this
section--
``(1) Family size.--The family size involved with respect
to any taxpayer shall be equal to the number of individuals for
whom the taxpayer is allowed a deduction under section 151
(relating to allowance of deduction for personal exemptions)
for the taxable year.
``(2) Household income.--
``(A) Household income.--The term `household
income' means, with respect to any taxpayer, an amount
equal to the sum of--
``(i) the modified gross income of the
taxpayer, plus
``(ii) the aggregate modified gross incomes
of all other individuals who--
``(I) were taken into account in
determining the taxpayer's family size
under paragraph (1), and
``(II) were required to file a
return of tax imposed by section 1 for
the taxable year.
``(B) Modified gross income.--The term `modified
gross income' means gross income--
``(i) decreased by the amount of any
deduction allowable under paragraph (1), (3),
(4), or (10) of section 62(a),
``(ii) increased by the amount of interest
received or accrued during the taxable year
which is exempt from tax imposed by this
chapter, and
``(iii) determined without regard to
sections 911, 931, and 933.
``(3) Poverty line.--
``(A) In general.--The term `poverty line' has the
meaning given that term in section 2110(c)(5) of the
Social Security Act (42 U.S.C. 1397jj(c)(5)).
``(B) Poverty line used.--In the case of any
qualified health plan offered through an Exchange for
coverage during a taxable year beginning in a calendar
year, the poverty line used shall be the most recently
published poverty line as of the 1st day of the regular
enrollment period for coverage during such calendar
year.
``(e) Rules for Individuals Not Lawfully Present.--
``(1) In general.--If 1 or more individuals for whom a
taxpayer is allowed a deduction under section 151 (relating to
allowance of deduction for personal exemptions) for the taxable
year (including the taxpayer or his spouse) are individuals who
are not lawfully present--
``(A) the aggregate amount of premiums otherwise
taken into account under clauses (i) and (ii) of
subsection (b)(2)(A) shall be reduced by the portion
(if any) of such premiums which is attributable to such
individuals, and
``(B) for purposes of applying this section, the
determination as to what percentage a taxpayer's
household income bears to the poverty level for a
family of the size involved shall be made under one of
the following methods:
``(i) A method under which--
``(I) the taxpayer's family size is
determined by not taking such
individuals into account, and
``(II) the taxpayer's household
income is equal to the product of the
taxpayer's household income (determined
without regard to this subsection) and
a fraction--
``(aa) the numerator of
which is the poverty line for
the taxpayer's family size
determined after application of
subclause (I), and
``(bb) the denominator of
which is the poverty line for
the taxpayer's family size
determined without regard to
subclause (I).
``(ii) A comparable method reaching the
same result as the method under clause (i).
``(2) Lawfully present.--For purposes of this section, an
individual shall be treated as lawfully present only if the
individual is, and is reasonably expected to be for the entire
period of enrollment for which the credit under this section is
being claimed, a citizen or national of the United States or an
alien lawfully present in the United States.
``(3) Secretarial authority.--The Secretary of Health and
Human Services, in consultation with the Secretary, shall
prescribe rules setting forth the methods by which calculations
of family size and household income are made for purposes of
this subsection. Such rules shall be designed to ensure that
the least burden is placed on individuals enrolling in
qualified health plans through an Exchange and taxpayers
eligible for the credit allowable under this section.
``(f) Reconciliation of Credit and Advance Credit.--
``(1) In general.--The amount of the credit allowed under
this section for any taxable year shall be reduced (but not
below zero) by the amount of any advance payment of such credit
under section 1412 of the Patient Protection and Affordable
Care Act.
``(2) Excess advance payments.--
``(A) In general.--If the advance payments to a
taxpayer under section 1412 of the Patient Protection
and Affordable Care Act for a taxable year exceed the
credit allowed by this section (determined without
regard to paragraph (1)), the tax imposed by this
chapter for the taxable year shall be increased by the
amount of such excess.
``(B) Limitation on increase where income less than
400 percent of poverty line.--
``(i) In general.--In the case of an
applicable taxpayer whose household income is
less than 400 percent of the poverty line for
the size of the family involved for the taxable
year, the amount of the increase under
subparagraph (A) shall in no event exceed $400
($250 in the case of a taxpayer whose tax is
determined under section 1(c) for the taxable
year).
``(ii) Indexing of amount.--In the case of
any calendar year beginning after 2014, each of
the dollar amounts under clause (i) shall be
increased by an amount equal to--
``(I) such dollar amount,
multiplied by
``(II) the cost-of-living
adjustment determined under section
1(f)(3) for the calendar year,
determined by substituting `calendar
year 2013' for `calendar year 1992' in
subparagraph (B) thereof.
If the amount of any increase under clause (i)
is not a multiple of $50, such increase shall
be rounded to the next lowest multiple of $50.
``(g) Regulations.--The Secretary shall prescribe such regulations
as may be necessary to carry out the provisions of this section,
including regulations which provide for--
``(1) the coordination of the credit allowed under this
section with the program for advance payment of the credit
under section 1412 of the Patient Protection and Affordable
Care Act, and
``(2) the application of subsection (f) where the filing
status of the taxpayer for a taxable year is different from
such status used for determining the advance payment of the
credit.''.
(b) Disallowance of Deduction.--Section 280C of the Internal
Revenue Code of 1986 is amended by adding at the end the following new
subsection:
``(g) Credit for Health Insurance Premiums.--No deduction shall be
allowed for the portion of the premiums paid by the taxpayer for
coverage of 1 or more individuals under a qualified health plan which
is equal to the amount of the credit determined for the taxable year
under section 36B(a) with respect to such premiums.''.
(c) Study on Affordable Coverage.--
(1) Study and report.--
(A) In general.--Not later than 5 years after the
date of the enactment of this Act, the Comptroller
General shall conduct a study on the affordability of
health insurance coverage, including--
(i) the impact of the tax credit for
qualified health insurance coverage of
individuals under section 36B of the Internal
Revenue Code of 1986 and the tax credit for
employee health insurance expenses of small
employers under section 45R of such Code on
maintaining and expanding the health insurance
coverage of individuals;
(ii) the availability of affordable health
benefits plans, including a study of whether
the percentage of household income used for
purposes of section 36B(c)(2)(C) of the
Internal Revenue Code of 1986 (as added by this
section) is the appropriate level for
determining whether employer-provided coverage
is affordable for an employee and whether such
level may be lowered without significantly
increasing the costs to the Federal Government
and reducing employer-provided coverage; and
(iii) the ability of individuals to
maintain essential health benefits coverage (as
defined in section 5000A(f) of the Internal
Revenue Code of 1986).
(B) Report.--The Comptroller General shall submit
to the appropriate committees of Congress a report on
the study conducted under subparagraph (A), together
with legislative recommendations relating to the
matters studied under such subparagraph.
(2) Appropriate committees of congress.--In this
subsection, the term ``appropriate committees of Congress''
means the Committee on Ways and Means, the Committee on
Education and Labor, and the Committee on Energy and Commerce
of the House of Representatives and the Committee on Finance
and the Committee on Health, Education, Labor and Pensions of
the Senate.
(d) Conforming Amendments.--
(1) Paragraph (2) of section 1324(b) of title 31, United
States Code, is amended by inserting ``36B,'' after ``36A,''.
(2) The table of sections for subpart C of part IV of
subchapter A of chapter 1 of the Internal Revenue Code of 1986
is amended by inserting after the item relating to section 36A
the following new item:
``Sec. 36B. Refundable credit for coverage under a qualified health
plan.''.
(e) Effective Date.--The amendments made by this section shall
apply to taxable years ending after December 31, 2013.
SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN QUALIFIED
HEALTH PLANS.
(a) In General.--In the case of an eligible insured enrolled in a
qualified health plan--
(1) the Secretary shall notify the issuer of the plan of
such eligibility; and
(2) the issuer shall reduce the cost-sharing under the plan
at the level and in the manner specified in subsection (c).
(b) Eligible Insured.--In this section, the term ``eligible
insured'' means an individual--
(1) who enrolls in a qualified health plan in the silver
level of coverage in the individual market offered through an
Exchange; and
(2) whose household income exceeds 100 percent but does not
exceed 400 percent of the poverty line for a family of the size
involved.
In the case of an individual described in section 36B(c)(1)(B) of the
Internal Revenue Code of 1986, the individual shall be treated as
having household income equal to 100 percent for purposes of applying
this section.
(c) Determination of Reduction in Cost-sharing.--
(1) Reduction in out-of-pocket limit.--
(A) In general.--The reduction in cost-sharing
under this subsection shall first be achieved by
reducing the applicable out-of pocket limit under
section 1302(c)(1) in the case of--
(i) an eligible insured whose household
income is more than 100 percent but not more
than 200 percent of the poverty line for a
family of the size involved, by two-thirds;
(ii) an eligible insured whose household
income is more than 200 percent but not more
than 300 percent of the poverty line for a
family of the size involved, by one-half; and
(iii) an eligible insured whose household
income is more than 300 percent but not more
than 400 percent of the poverty line for a
family of the size involved, by one-third.
(B) Coordination with actuarial value limits.--
(i) In general.--The Secretary shall ensure
the reduction under this paragraph shall not
result in an increase in the plan's share of
the total allowed costs of benefits provided
under the plan above--
(I) 90 percent in the case of an
eligible insured described in paragraph
(2)(A);
(II) 80 percent in the case of an
eligible insured described in paragraph
(2)(B); and
(III) 70 percent in the case of an
eligible insured described in clause
(ii) or (iii) of subparagraph (A).
(ii) Adjustment.--The Secretary shall
adjust the out-of pocket limits under paragraph
(1) if necessary to ensure that such limits do
not cause the respective actuarial values to
exceed the levels specified in clause (i).
(2) Additional reduction for lower income insureds.--The
Secretary shall establish procedures under which the issuer of
a qualified health plan to which this section applies shall
further reduce cost-sharing under the plan in a manner
sufficient to--
(A) in the case of an eligible insured whose
household income is not less than 100 percent but not
more than 150 percent of the poverty line for a family
of the size involved, increase the plan's share of the
total allowed costs of benefits provided under the plan
to 90 percent of such costs; and
(B) in the case of an eligible insured whose
household income is more than 150 percent but not more
than 200 percent of the poverty line for a family of
the size involved, increase the plan's share of the
total allowed costs of benefits provided under the plan
to 80 percent of such costs.
(3) Methods for reducing cost-sharing.--
(A) In general.--An issuer of a qualified health
plan making reductions under this subsection shall
notify the Secretary of such reductions and the
Secretary shall make periodic and timely payments to
the issuer equal to the value of the reductions.
(B) Capitated payments.--The Secretary may
establish a capitated payment system to carry out the
payment of cost-sharing reductions under this section.
Any such system shall take into account the value of
the reductions and make appropriate risk adjustments to
such payments.
(4) Additional benefits.--If a qualified health plan under
section 1302(b)(5) offers benefits in addition to the essential
health benefits required to be provided by the plan, or a State
requires a qualified health plan under section 1311(d)(3)(B) to
cover benefits in addition to the essential health benefits
required to be provided by the plan, the reductions in cost-
sharing under this section shall not apply to such additional
benefits.
(5) Special rule for pediatric dental plans.--If an
individual enrolls in both a qualified health plan and a plan
described in section 1311(d)(2)(B)(ii)(I) for any plan year,
subsection (a) shall not apply to that portion of any reduction
in cost-sharing under subsection (c) that (under regulations
prescribed by the Secretary) is properly allocable to pediatric
dental benefits which are included in the essential health
benefits required to be provided by a qualified health plan
under section 1302(b)(1)(J).
(d) Special Rules for Indians.--
(1) Indians under 300 percent of poverty.--If an individual
enrolled in any qualified health plan in the individual market
through an Exchange is an Indian (as defined in section 4(d) of
the Indian Self-Determination and Education Assistance Act (25
U.S.C. 450b(d))) whose household income is not more than 300
percent of the poverty line for a family of the size involved,
then, for purposes of this section--
(A) such individual shall be treated as an eligible
insured; and
(B) the issuer of the plan shall eliminate any
cost-sharing under the plan.
(2) Items or services furnished through indian health
providers.--If an Indian (as so defined) enrolled in a
qualified health plan is furnished an item or service directly
by the Indian Health Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization or through referral
under contract health services--
(A) no cost-sharing under the plan shall be imposed
under the plan for such item or service; and
(B) the issuer of the plan shall not reduce the
payment to any such entity for such item or service by
the amount of any cost-sharing that would be due from
the Indian but for subparagraph (A).
(3) Payment.--The Secretary shall pay to the issuer of a
qualified health plan the amount necessary to reflect the
increase in actuarial value of the plan required by reason of
this subsection.
(e) Rules for Individuals Not Lawfully Present.--
(1) In general.--If an individual who is an eligible
insured is not lawfully present--
(A) no cost-sharing reduction under this section
shall apply with respect to the individual; and
(B) for purposes of applying this section, the
determination as to what percentage a taxpayer's
household income bears to the poverty level for a
family of the size involved shall be made under one of
the following methods:
(i) A method under which--
(I) the taxpayer's family size is
determined by not taking such
individuals into account, and
(II) the taxpayer's household
income is equal to the product of the
taxpayer's household income (determined
without regard to this subsection) and
a fraction--
(aa) the numerator of which
is the poverty line for the
taxpayer's family size
determined after application of
subclause (I), and
(bb) the denominator of
which is the poverty line for
the taxpayer's family size
determined without regard to
subclause (I).
(ii) A comparable method reaching the same
result as the method under clause (i).
(2) Lawfully present.--For purposes of this section, an
individual shall be treated as lawfully present only if the
individual is, and is reasonably expected to be for the entire
period of enrollment for which the cost-sharing reduction under
this section is being claimed, a citizen or national of the
United States or an alien lawfully present in the United
States.
(3) Secretarial authority.--The Secretary, in consultation
with the Secretary of the Treasury, shall prescribe rules
setting forth the methods by which calculations of family size
and household income are made for purposes of this subsection.
Such rules shall be designed to ensure that the least burden is
placed on individuals enrolling in qualified health plans
through an Exchange and taxpayers eligible for the credit
allowable under this section.
(f) Definitions and Special Rules.--In this section:
(1) In general.--Any term used in this section which is
also used in section 36B of the Internal Revenue Code of 1986
shall have the meaning given such term by such section.
(2) Limitations on reduction.--No cost-sharing reduction
shall be allowed under this section with respect to coverage
for any month unless the month is a coverage month with respect
to which a credit is allowed to the insured (or an applicable
taxpayer on behalf of the insured) under section 36B of such
Code.
(3) Data used for eligibility.--Any determination under
this section shall be made on the basis of the taxable year for
which the advance determination is made under section 1412 and
not the taxable year for which the credit under section 36B of
such Code is allowed.
Subpart B--Eligibility Determinations
SEC. 1411. PROCEDURES FOR DETERMINING ELIGIBILITY FOR EXCHANGE
PARTICIPATION, PREMIUM TAX CREDITS AND REDUCED COST-
SHARING, AND INDIVIDUAL RESPONSIBILITY EXEMPTIONS.
(a) Establishment of Program.--The Secretary shall establish a
program meeting the requirements of this section for determining--
(1) whether an individual who is to be covered in the
individual market by a qualified health plan offered through an
Exchange, or who is claiming a premium tax credit or reduced
cost-sharing, meets the requirements of sections 1312(f)(3),
1402(e), and 1412(d) of this title and section 36B(e) of the
Internal Revenue Code of 1986 that the individual be a citizen
or national of the United States or an alien lawfully present
in the United States;
(2) in the case of an individual claiming a premium tax
credit or reduced cost-sharing under section 36B of such Code
or section 1402--
(A) whether the individual meets the income and
coverage requirements of such sections; and
(B) the amount of the tax credit or reduced cost-
sharing;
(3) whether an individual's coverage under an employer-
sponsored health benefits plan is treated as unaffordable under
sections 36B(c)(2)(C) and 5000A(e)(2); and
(4) whether to grant a certification under section
1311(d)(4)(H) attesting that, for purposes of the individual
responsibility requirement under section 5000A of the Internal
Revenue Code of 1986, an individual is entitled to an exemption
from either the individual responsibility requirement or the
penalty imposed by such section.
(b) Information Required To Be Provided by Applicants.--
(1) In general.--An applicant for enrollment in a qualified
health plan offered through an Exchange in the individual
market shall provide--
(A) the name, address, and date of birth of each
individual who is to be covered by the plan (in this
subsection referred to as an ``enrollee''); and
(B) the information required by any of the
following paragraphs that is applicable to an enrollee.
(2) Citizenship or immigration status.--The following
information shall be provided with respect to every enrollee:
(A) In the case of an enrollee whose eligibility is
based on an attestation of citizenship of the enrollee,
the enrollee's social security number.
(B) In the case of an individual whose eligibility
is based on an attestation of the enrollee's
immigration status, the enrollee's social security
number (if applicable) and such identifying information
with respect to the enrollee's immigration status as
the Secretary, after consultation with the Secretary of
Homeland Security, determines appropriate.
(3) Eligibility and amount of tax credit or reduced cost-
sharing.--In the case of an enrollee with respect to whom a
premium tax credit or reduced cost-sharing under section 36B of
such Code or section 1402 is being claimed, the following
information:
(A) Information regarding income and family size.--
The information described in section 6103(l)(21) for
the taxable year ending with or within the second
calendar year preceding the calendar year in which the
plan year begins.
(B) Changes in circumstances.--The information
described in section 1412(b)(2), including information
with respect to individuals who were not required to
file an income tax return for the taxable year
described in subparagraph (A) or individuals who
experienced changes in marital status or family size or
significant reductions in income.
(4) Employer-sponsored coverage.--In the case of an
enrollee with respect to whom eligibility for a premium tax
credit under section 36B of such Code or cost-sharing reduction
under section 1402 is being established on the basis that the
enrollee's (or related individual's) employer is not treated
under section 36B(c)(2)(C) of such Code as providing minimum
essential coverage or affordable minimum essential coverage,
the following information:
(A) The name, address, and employer identification
number (if available) of the employer.
(B) Whether the enrollee or individual is a full-
time employee and whether the employer provides such
minimum essential coverage.
(C) If the employer provides such minimum essential
coverage, the lowest cost option for the enrollee's or
individual's enrollment status and the enrollee's or
individual's required contribution (within the meaning
of section 5000A(e)(1)(B) of such Code) under the
employer-sponsored plan.
(D) If an enrollee claims an employer's minimum
essential coverage is unaffordable, the information
described in paragraph (3).
If an enrollee changes employment or obtains additional
employment while enrolled in a qualified health plan for which
such credit or reduction is allowed, the enrollee shall notify
the Exchange of such change or additional employment and
provide the information described in this paragraph with
respect to the new employer.
(5) Exemptions from individual responsibility
requirements.--In the case of an individual who is seeking an
exemption certificate under section 1311(d)(4)(H) from any
requirement or penalty imposed by section 5000A, the following
information:
(A) In the case of an individual seeking exemption
based on the individual's status as a member of an
exempt religious sect or division, as a member of a
health care sharing ministry, as an Indian, or as an
individual eligible for a hardship exemption, such
information as the Secretary shall prescribe.
(B) In the case of an individual seeking exemption
based on the lack of affordable coverage or the
individual's status as a taxpayer with household income
less than 100 percent of the poverty line, the
information described in paragraphs (3) and (4), as
applicable.
(c) Verification of Information Contained in Records of Specific
Federal Officials.--
(1) Information transferred to secretary.--An Exchange
shall submit the information provided by an applicant under
subsection (b) to the Secretary for verification in accordance
with the requirements of this subsection and subsection (d).
(2) Citizenship or immigration status.--
(A) Commissioner of social security.--The Secretary
shall submit to the Commissioner of Social Security the
following information for a determination as to whether
the information provided is consistent with the
information in the records of the Commissioner:
(i) The name, date of birth, and social
security number of each individual for whom
such information was provided under subsection
(b)(2).
(ii) The attestation of an individual that
the individual is a citizen.
(B) Secretary of homeland security.--
(i) In general.--In the case of an
individual--
(I) who attests that the individual
is an alien lawfully present in the
United States; or
(II) who attests that the
individual is a citizen but with
respect to whom the Commissioner of
Social Security has notified the
Secretary under subsection (e)(3) that
the attestation is inconsistent with
information in the records maintained
by the Commissioner;
the Secretary shall submit to the Secretary of
Homeland Security the information described in
clause (ii) for a determination as to whether
the information provided is consistent with the
information in the records of the Secretary of
Homeland Security.
(ii) Information.--The information
described in clause (ii) is the following:
(I) The name, date of birth, and
any identifying information with
respect to the individual's immigration
status provided under subsection
(b)(2).
(II) The attestation that the
individual is an alien lawfully present
in the United States or in the case of
an individual described in clause
(i)(II), the attestation that the
individual is a citizen.
(3) Eligibility for tax credit and cost-sharing
reduction.--The Secretary shall submit the information
described in subsection (b)(3)(A) provided under paragraph (3),
(4), or (5) of subsection (b) to the Secretary of the Treasury
for verification of household income and family size for
purposes of eligibility.
(4) Methods.--
(A) In general.--The Secretary, in consultation
with the Secretary of the Treasury, the Secretary of
Homeland Security, and the Commissioner of Social
Security, shall provide that verifications and
determinations under this subsection shall be done--
(i) through use of an on-line system or
otherwise for the electronic submission of, and
response to, the information submitted under
this subsection with respect to an applicant;
or
(ii) by determining the consistency of the
information submitted with the information
maintained in the records of the Secretary of
the Treasury, the Secretary of Homeland
Security, or the Commissioner of Social
Security through such other method as is
approved by the Secretary.
(B) Flexibility.--The Secretary may modify the
methods used under the program established by this
section for the Exchange and verification of
information if the Secretary determines such
modifications would reduce the administrative costs and
burdens on the applicant, including allowing an
applicant to request the Secretary of the Treasury to
provide the information described in paragraph (3)
directly to the Exchange or to the Secretary. The
Secretary shall not make any such modification unless
the Secretary determines that any applicable
requirements under this section and section 6103 of the
Internal Revenue Code of 1986 with respect to the
confidentiality, disclosure, maintenance, or use of
information will be met.
(d) Verification by Secretary.--In the case of information provided
under subsection (b) that is not required under subsection (c) to be
submitted to another person for verification, the Secretary shall
verify the accuracy of such information in such manner as the Secretary
determines appropriate, including delegating responsibility for
verification to the Exchange.
(e) Actions Relating to Verification.--
(1) In general.--Each person to whom the Secretary provided
information under subsection (c) shall report to the Secretary
under the method established under subsection (c)(4) the
results of its verification and the Secretary shall notify the
Exchange of such results. Each person to whom the Secretary
provided information under subsection (d) shall report to the
Secretary in such manner as the Secretary determines
appropriate.
(2) Verification.--
(A) Eligibility for enrollment and premium tax
credits and cost-sharing reductions.--If information
provided by an applicant under paragraphs (1), (2),
(3), and (4) of subsection (b) is verified under
subsections (c) and (d)--
(i) the individual's eligibility to enroll
through the Exchange and to apply for premium
tax credits and cost-sharing reductions shall
be satisfied; and
(ii) the Secretary shall, if applicable,
notify the Secretary of the Treasury under
section 1412(c) of the amount of any advance
payment to be made.
(B) Exemption from individual responsibility.--If
information provided by an applicant under subsection
(b)(5) is verified under subsections (c) and (d), the
Secretary shall issue the certification of exemption
described in section 1311(d)(4)(H).
(3) Inconsistencies involving attestation of citizenship or
lawful presence.--If the information provided by any applicant
under subsection (b)(2) is inconsistent with information in the
records maintained by the Commissioner of Social Security or
Secretary of Homeland Security, whichever is applicable, the
applicant's eligibility will be determined in the same manner
as an individual's eligibility under the medicaid program is
determined under section 1902(ee) of the Social Security Act
(as in effect on January 1, 2010).
(4) Inconsistencies involving other information.--
(A) In general.--If the information provided by an
applicant under subsection (b) (other than subsection
(b)(2)) is inconsistent with information in the records
maintained by persons under subsection (c) or is not
verified under subsection (d), the Secretary shall
notify the Exchange and the Exchange shall take the
following actions:
(i) Reasonable effort.--The Exchange shall
make a reasonable effort to identify and
address the causes of such inconsistency,
including through typographical or other
clerical errors, by contacting the applicant to
confirm the accuracy of the information, and by
taking such additional actions as the
Secretary, through regulation or other
guidance, may identify.
(ii) Notice and opportunity to correct.--In
the case the inconsistency or inability to
verify is not resolved under subparagraph (A),
the Exchange shall--
(I) notify the applicant of such
fact;
(II) provide the applicant an
opportunity to either present
satisfactory documentary evidence or
resolve the inconsistency with the
person verifying the information under
subsection (c) or (d) during the 90-day
period beginning the date on which the
notice required under subclause (I) is
sent to the applicant.
The Secretary may extend the 90-day period
under subclause (II) for enrollments occurring
during 2014.
(B) Specific actions not involving citizenship or
lawful presence.--
(i) In general.--Except as provided in
paragraph (3), the Exchange shall, during any
period before the close of the period under
subparagraph (A)(ii)(II), make any
determination under paragraphs (2), (3), and
(4) of subsection (a) on the basis of the
information contained on the application.
(ii) Eligibility or amount of credit or
reduction.--If an inconsistency involving the
eligibility for, or amount of, any premium tax
credit or cost-sharing reduction is unresolved
under this subsection as of the close of the
period under subparagraph (A)(ii)(II), the
Exchange shall notify the applicant of the
amount (if any) of the credit or reduction that
is determined on the basis of the records
maintained by persons under subsection (c).
(iii) Employer affordability.--If the
Secretary notifies an Exchange that an enrollee
is eligible for a premium tax credit under
section 36B of such Code or cost-sharing
reduction under section 1402 because the
enrollee's (or related individual's) employer
does not provide minimum essential coverage
through an employer-sponsored plan or that the
employer does provide that coverage but it is
not affordable coverage, the Exchange shall
notify the employer of such fact and that the
employer may be liable for the payment assessed
under section 4980H of such Code.
(iv) Exemption.--In any case where the
inconsistency involving, or inability to
verify, information provided under subsection
(b)(5) is not resolved as of the close of the
period under subparagraph (A)(ii)(II), the
Exchange shall notify an applicant that no
certification of exemption from any requirement
or payment under section 5000A of such Code
will be issued.
(C) Appeals process.--The Exchange shall also
notify each person receiving notice under this
paragraph of the appeals processes established under
subsection (f).
(f) Appeals and Redeterminations.--
(1) In general.--The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland Security,
and the Commissioner of Social Security, shall establish
procedures by which the Secretary or one of such other Federal
officers--
(A) hears and makes decisions with respect to
appeals of any determination under subsection (e); and
(B) redetermines eligibility on a periodic basis in
appropriate circumstances.
(2) Employer liability.--
(A) In general.--The Secretary shall establish a
separate appeals process for employers who are notified
under subsection (e)(4)(C) that the employer may be
liable for a tax imposed by section 4980H of the
Internal Revenue Code of 1986 with respect to an
employee because of a determination that the employer
does not provide minimum essential coverage through an
employer-sponsored plan or that the employer does
provide that coverage but it is not affordable coverage
with respect to an employee. Such process shall provide
an employer the opportunity to--
(i) present information to the Exchange for
review of the determination either by the
Exchange or the person making the
determination, including evidence of the
employer-sponsored plan and employer
contributions to the plan; and
(ii) have access to the data used to make
the determination to the extent allowable by
law.
Such process shall be in addition to any rights of
appeal the employer may have under subtitle F of such
Code.
(B) Confidentiality.--Notwithstanding any provision
of this title (or the amendments made by this title) or
section 6103 of the Internal Revenue Code of 1986, an
employer shall not be entitled to any taxpayer return
information with respect to an employee for purposes of
determining whether the employer is subject to the
penalty under section 4980H of such Code with respect
to the employee, except that--
(i) the employer may be notified as to the
name of an employee and whether or not the
employee's income is above or below the
threshold by which the affordability of an
employer's health insurance coverage is
measured; and
(ii) this subparagraph shall not apply to
an employee who provides a waiver (at such time
and in such manner as the Secretary may
prescribe) authorizing an employer to have
access to the employee's taxpayer return
information.
(g) Confidentiality of Applicant Information.--
(1) In general.--An applicant for insurance coverage or for
a premium tax credit or cost-sharing reduction shall be
required to provide only the information strictly necessary to
authenticate identity, determine eligibility, and determine the
amount of the credit or reduction.
(2) Receipt of information.--Any person who receives
information provided by an applicant under subsection (b)
(whether directly or by another person at the request of the
applicant), or receives information from a Federal agency under
subsection (c), (d), or (e), shall--
(A) use the information only for the purposes of,
and to the extent necessary in, ensuring the efficient
operation of the Exchange, including verifying the
eligibility of an individual to enroll through an
Exchange or to claim a premium tax credit or cost-
sharing reduction or the amount of the credit or
reduction; and
(B) not disclose the information to any other
person except as provided in this section.
(h) Penalties.--
(1) False or fraudulent information.--
(A) Civil penalty.--
(i) In general.--If--
(I) any person fails to provides
correct information under subsection
(b); and
(II) such failure is attributable
to negligence or disregard of any rules
or regulations of the Secretary,
such person shall be subject, in addition to
any other penalties that may be prescribed by
law, to a civil penalty of not more than
$25,000 with respect to any failures involving
an application for a plan year. For purposes of
this subparagraph, the terms ``negligence'' and
``disregard'' shall have the same meanings as
when used in section 6662 of the Internal
Revenue Code of 1986.
(ii) Reasonable cause exception.--No
penalty shall be imposed under clause (i) if
the Secretary determines that there was a
reasonable cause for the failure and that the
person acted in good faith.
(B) Knowing and willful violations.--Any person who
knowingly and willfully provides false or fraudulent
information under subsection (b) shall be subject, in
addition to any other penalties that may be prescribed
by law, to a civil penalty of not more than $250,000.
(2) Improper use or disclosure of information.--Any person
who knowingly and willfully uses or discloses information in
violation of subsection (g) shall be subject, in addition to
any other penalties that may be prescribed by law, to a civil
penalty of not more than $25,000.
(3) Limitations on liens and levies.--The Secretary (or, if
applicable, the Attorney General of the United States) shall
not--
(A) file notice of lien with respect to any
property of a person by reason of any failure to pay
the penalty imposed by this subsection; or
(B) levy on any such property with respect to such
failure.
(i) Study of Administration of Employer Responsibility.--
(1) In general.--The Secretary of Health and Human Services
shall, in consultation with the Secretary of the Treasury,
conduct a study of the procedures that are necessary to ensure
that in the administration of this title and section 4980H of
the Internal Revenue Code of 1986 (as added by section 1513)
that the following rights are protected:
(A) The rights of employees to preserve their right
to confidentiality of their taxpayer return information
and their right to enroll in a qualified health plan
through an Exchange if an employer does not provide
affordable coverage.
(B) The rights of employers to adequate due process
and access to information necessary to accurately
determine any payment assessed on employers.
(2) Report.--Not later than January 1, 2013, the Secretary
of Health and Human Services shall report the results of the
study conducted under paragraph (1), including any
recommendations for legislative changes, to the Committees on
Finance and Health, Education, Labor and Pensions of the Senate
and the Committees of Education and Labor and Ways and Means of
the House of Representatives.
SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM TAX CREDITS AND
COST-SHARING REDUCTIONS.
(a) In General.--The Secretary, in consultation with the Secretary
of the Treasury, shall establish a program under which--
(1) upon request of an Exchange, advance determinations are
made under section 1411 with respect to the income eligibility
of individuals enrolling in a qualified health plan in the
individual market through the Exchange for the premium tax
credit allowable under section 36B of the Internal Revenue Code
of 1986 and the cost-sharing reductions under section 1402;
(2) the Secretary notifies--
(A) the Exchange and the Secretary of the Treasury
of the advance determinations; and
(B) the Secretary of the Treasury of the name and
employer identification number of each employer with
respect to whom 1 or more employee of the employer were
determined to be eligible for the premium tax credit
under section 36B of the Internal Revenue Code of 1986
and the cost-sharing reductions under section 1402
because--
(i) the employer did not provide minimum
essential coverage; or
(ii) the employer provided such minimum
essential coverage but it was determined under
section 36B(c)(2)(C) of such Code to either be
unaffordable to the employee or not provide the
required minimum actuarial value; and
(3) the Secretary of the Treasury makes advance payments of
such credit or reductions to the issuers of the qualified
health plans in order to reduce the premiums payable by
individuals eligible for such credit.
(b) Advance Determinations.--
(1) In general.--The Secretary shall provide under the
program established under subsection (a) that advance
determination of eligibility with respect to any individual
shall be made--
(A) during the annual open enrollment period
applicable to the individual (or such other enrollment
period as may be specified by the Secretary); and
(B) on the basis of the individual's household
income for the most recent taxable year for which the
Secretary, after consultation with the Secretary of the
Treasury, determines information is available.
(2) Changes in circumstances.--The Secretary shall provide
procedures for making advance determinations on the basis of
information other than that described in paragraph (1)(B) in
cases where information included with an application form
demonstrates substantial changes in income, changes in family
size or other household circumstances, change in filing status,
the filing of an application for unemployment benefits, or
other significant changes affecting eligibility, including--
(A) allowing an individual claiming a decrease of
20 percent or more in income, or filing an application
for unemployment benefits, to have eligibility for the
credit determined on the basis of household income for
a later period or on the basis of the individual's
estimate of such income for the taxable year; and
(B) the determination of household income in cases
where the taxpayer was not required to file a return of
tax imposed by this chapter for the second preceding
taxable year.
(c) Payment of Premium Tax Credits and Cost-sharing Reductions.--
(1) In general.--The Secretary shall notify the Secretary
of the Treasury and the Exchange through which the individual
is enrolling of the advance determination under section 1411.
(2) Premium tax credit.--
(A) In general.--The Secretary of the Treasury
shall make the advance payment under this section of
any premium tax credit allowed under section 36B of the
Internal Revenue Code of 1986 to the issuer of a
qualified health plan on a monthly basis (or such other
periodic basis as the Secretary may provide).
(B) Issuer responsibilities.--An issuer of a
qualified health plan receiving an advance payment with
respect to an individual enrolled in the plan shall--
(i) reduce the premium charged the insured
for any period by the amount of the advance
payment for the period;
(ii) notify the Exchange and the Secretary
of such reduction;
(iii) include with each billing statement
the amount by which the premium for the plan
has been reduced by reason of the advance
payment; and
(iv) in the case of any nonpayment of
premiums by the insured--
(I) notify the Secretary of such
nonpayment; and
(II) allow a 3-month grace period
for nonpayment of premiums before
discontinuing coverage.
(3) Cost-sharing reductions.--The Secretary shall also
notify the Secretary of the Treasury and the Exchange under
paragraph (1) if an advance payment of the cost-sharing
reductions under section 1402 is to be made to the issuer of
any qualified health plan with respect to any individual
enrolled in the plan. The Secretary of the Treasury shall make
such advance payment at such time and in such amount as the
Secretary specifies in the notice.
(d) No Federal Payments for Individuals Not Lawfully Present.--
Nothing in this subtitle or the amendments made by this subtitle allows
Federal payments, credits, or cost-sharing reductions for individuals
who are not lawfully present in the United States.
(e) State Flexibility.--Nothing in this subtitle or the amendments
made by this subtitle shall be construed to prohibit a State from
making payments to or on behalf of an individual for coverage under a
qualified health plan offered through an Exchange that are in addition
to any credits or cost-sharing reductions allowable to the individual
under this subtitle and such amendments.
SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH AN
EXCHANGE AND STATE MEDICAID, CHIP, AND HEALTH SUBSIDY
PROGRAMS.
(a) In General.--The Secretary shall establish a system meeting the
requirements of this section under which residents of each State may
apply for enrollment in, receive a determination of eligibility for
participation in, and continue participation in, applicable State
health subsidy programs. Such system shall ensure that if an individual
applying to an Exchange is found through screening to be eligible for
medical assistance under the State medicaid plan under title XIX, or
eligible for enrollment under a State children's health insurance
program (CHIP) under title XXI of such Act, the individual is enrolled
for assistance under such plan or program.
(b) Requirements Relating to Forms and Notice.--
(1) Requirements relating to forms.--
(A) In general.--The Secretary shall develop and
provide to each State a single, streamlined form that--
(i) may be used to apply for all applicable
State health subsidy programs within the State;
(ii) may be filed online, in person, by
mail, or by telephone;
(iii) may be filed with an Exchange or with
State officials operating one of the other
applicable State health subsidy programs; and
(iv) is structured to maximize an
applicant's ability to complete the form
satisfactorily, taking into account the
characteristics of individuals who qualify for
applicable State health subsidy programs.
(B) State authority to establish form.--A State may
develop and use its own single, streamlined form as an
alternative to the form developed under subparagraph
(A) if the alternative form is consistent with
standards promulgated by the Secretary under this
section.
(C) Supplemental eligibility forms.--The Secretary
may allow a State to use a supplemental or alternative
form in the case of individuals who apply for
eligibility that is not determined on the basis of the
household income (as defined in section 36B of the
Internal Revenue Code of 1986).
(2) Notice.--The Secretary shall provide that an applicant
filing a form under paragraph (1) shall receive notice of
eligibility for an applicable State health subsidy program
without any need to provide additional information or paperwork
unless such information or paperwork is specifically required
by law when information provided on the form is inconsistent
with data used for the electronic verification under paragraph
(3) or is otherwise insufficient to determine eligibility.
(c) Requirements Relating to Eligibility Based on Data Exchanges.--
(1) Development of secure interfaces.--Each State shall
develop for all applicable State health subsidy programs a
secure, electronic interface allowing an exchange of data
(including information contained in the application forms
described in subsection (b)) that allows a determination of
eligibility for all such programs based on a single
application. Such interface shall be compatible with the method
established for data verification under section 1411(c)(4).
(2) Data matching program.--Each applicable State health
subsidy program shall participate in a data matching
arrangement for determining eligibility for participation in
the program under paragraph (3) that--
(A) provides access to data described in paragraph
(3);
(B) applies only to individuals who--
(i) receive assistance from an applicable
State health subsidy program; or
(ii) apply for such assistance--
(I) by filing a form described in
subsection (b); or
(II) by requesting a determination
of eligibility and authorizing
disclosure of the information described
in paragraph (3) to applicable State
health coverage subsidy programs for
purposes of determining and
establishing eligibility; and
(C) consistent with standards promulgated by the
Secretary, including the privacy and data security
safeguards described in section 1942 of the Social
Security Act or that are otherwise applicable to such
programs.
(3) Determination of eligibility.--
(A) In general.--Each applicable State health
subsidy program shall, to the maximum extent
practicable--
(i) establish, verify, and update
eligibility for participation in the program
using the data matching arrangement under
paragraph (2); and
(ii) determine such eligibility on the
basis of reliable, third party data, including
information described in sections 1137, 453(i),
and 1942(a) of the Social Security Act,
obtained through such arrangement.
(B) Exception.--This paragraph shall not apply in
circumstances with respect to which the Secretary
determines that the administrative and other costs of
use of the data matching arrangement under paragraph
(2) outweigh its expected gains in accuracy,
efficiency, and program participation.
(4) Secretarial standards.--The Secretary shall, after
consultation with persons in possession of the data to be
matched and representatives of applicable State health subsidy
programs, promulgate standards governing the timing, contents,
and procedures for data matching described in this subsection.
Such standards shall take into account administrative and other
costs and the value of data matching to the establishment,
verification, and updating of eligibility for applicable State
health subsidy programs.
(d) Administrative Authority.--
(1) Agreements.--Subject to section 1411 and section
6103(l)(21) of the Internal Revenue Code of 1986 and any other
requirement providing safeguards of privacy and data integrity,
the Secretary may establish model agreements, and enter into
agreements, for the sharing of data under this section.
(2) Authority of exchange to contract out.--Nothing in this
section shall be construed to--
(A) prohibit contractual arrangements through which
a State medicaid agency determines eligibility for all
applicable State health subsidy programs, but only if
such agency complies with the Secretary's requirements
ensuring reduced administrative costs, eligibility
errors, and disruptions in coverage; or
(B) change any requirement under title XIX that
eligibility for participation in a State's medicaid
program must be determined by a public agency.
(e) Applicable State Health Subsidy Program.--In this section, the
term ``applicable State health subsidy program'' means--
(1) the program under this title for the enrollment in
qualified health plans offered through an Exchange, including
the premium tax credits under section 36B of the Internal
Revenue Code of 1986 and cost-sharing reductions under section
1402;
(2) a State medicaid program under title XIX of the Social
Security Act;
(3) a State children's health insurance program (CHIP)
under title XXI of such Act; and
(4) a State program under section 1331 establishing
qualified basic health plans.
SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS FOR
CERTAIN PROGRAMS.
(a) Disclosure of Taxpayer Return Information and Social Security
Numbers.--
(1) Taxpayer return information.--Subsection (l) of section
6103 of the Internal Revenue Code of 1986 is amended by adding
at the end the following new paragraph:
``(21) Disclosure of return information to carry out
eligibility requirements for certain programs.--
``(A) In general.--The Secretary, upon written
request from the Secretary of Health and Human
Services, shall disclose to officers, employees, and
contractors of the Department of Health and Human
Services return information of any taxpayer whose
income is relevant in determining any premium tax
credit under section 36B or any cost-sharing reduction
under section 1402 of the Patient Protection and
Affordable Care Act or eligibility for participation in
a State medicaid program under title XIX of the Social
Security Act, a State's children's health insurance
program under title XXI of the Social Security Act, or
a basic health program under section 1331 of Patient
Protection and Affordable Care Act. Such return
information shall be limited to--
``(i) taxpayer identity information with
respect to such taxpayer,
``(ii) the filing status of such taxpayer,
``(iii) the number of individuals for whom
a deduction is allowed under section 151 with
respect to the taxpayer (including the taxpayer
and the taxpayer's spouse),
``(iv) the modified gross income (as
defined in section 36B) of such taxpayer and
each of the other individuals included under
clause (iii) who are required to file a return
of tax imposed by chapter 1 for the taxable
year,
``(v) such other information as is
prescribed by the Secretary by regulation as
might indicate whether the taxpayer is eligible
for such credit or reduction (and the amount
thereof), and
``(vi) the taxable year with respect to
which the preceding information relates or, if
applicable, the fact that such information is
not available.
``(B) Information to exchange and state agencies.--
The Secretary of Health and Human Services may disclose
to an Exchange established under the Patient Protection
and Affordable Care Act or its contractors, or to a
State agency administering a State program described in
subparagraph (A) or its contractors, any inconsistency
between the information provided by the Exchange or
State agency to the Secretary and the information
provided to the Secretary under subparagraph (A).
``(C) Restriction on use of disclosed
information.--Return information disclosed under
subparagraph (A) or (B) may be used by officers,
employees, and contractors of the Department of Health
and Human Services, an Exchange, or a State agency only
for the purposes of, and to the extent necessary in--
``(i) establishing eligibility for
participation in the Exchange, and verifying
the appropriate amount of, any credit or
reduction described in subparagraph (A),
``(ii) determining eligibility for
participation in the State programs described
in subparagraph (A).''.
(2) Social security numbers.--Section 205(c)(2)(C) of the
Social Security Act is amended by adding at the end the
following new clause:
``(x) The Secretary of Health and Human
Services, and the Exchanges established under
section 1311 of the Patient Protection and
Affordable Care Act, are authorized to collect
and use the names and social security account
numbers of individuals as required to
administer the provisions of, and the
amendments made by, the such Act.''.
(b) Confidentiality and Disclosure.--Paragraph (3) of section
6103(a) of such Code is amended by striking ``or (20)'' and inserting
``(20), or (21)''.
(c) Procedures and Recordkeeping Related to Disclosures.--Paragraph
(4) of section 6103(p) of such Code is amended--
(1) by inserting ``, or any entity described in subsection
(l)(21),'' after ``or (20)'' in the matter preceding
subparagraph (A),
(2) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii), and
(3) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (20)'' both places it appears in the
matter after subparagraph (F).
(d) Unauthorized Disclosure or Inspection.--Paragraph (2) of
section 7213(a) of such Code is amended by striking ``or (20)'' and
inserting ``(20), or (21)''.
SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING REDUCTION PAYMENTS
DISREGARDED FOR FEDERAL AND FEDERALLY-ASSISTED PROGRAMS.
For purposes of determining the eligibility of any individual for
benefits or assistance, or the amount or extent of benefits or
assistance, under any Federal program or under any State or local
program financed in whole or in part with Federal funds--
(1) any credit or refund allowed or made to any individual
by reason of section 36B of the Internal Revenue Code of 1986
(as added by section 1401) shall not be taken into account as
income and shall not be taken into account as resources for the
month of receipt and the following 2 months; and
(2) any cost-sharing reduction payment or advance payment
of the credit allowed under such section 36B that is made under
section 1402 or 1412 shall be treated as made to the qualified
health plan in which an individual is enrolled and not to that
individual.
PART II--SMALL BUSINESS TAX CREDIT
SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL
BUSINESSES.
(a) In General.--Subpart D of part IV of subchapter A of chapter 1
of the Internal Revenue Code of 1986 (relating to business-related
credits) is amended by inserting after section 45Q the following:
``SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL EMPLOYERS.
``(a) General Rule.--For purposes of section 38, in the case of an
eligible small employer, the small employer health insurance credit
determined under this section for any taxable year in the credit period
is the amount determined under subsection (b).
``(b) Health Insurance Credit Amount.--Subject to subsection (c),
the amount determined under this subsection with respect to any
eligible small employer is equal to 50 percent (35 percent in the case
of a tax-exempt eligible small employer) of the lesser of--
``(1) the aggregate amount of nonelective contributions the
employer made on behalf of its employees during the taxable
year under the arrangement described in subsection (d)(4) for
premiums for qualified health plans offered by the employer to
its employees through an Exchange, or
``(2) the aggregate amount of nonelective contributions
which the employer would have made during the taxable year
under the arrangement if each employee taken into account under
paragraph (1) had enrolled in a qualified health plan which had
a premium equal to the average premium (as determined by the
Secretary of Health and Human Services) for the small group
market in the rating area in which the employee enrolls for
coverage.
``(c) Phaseout of Credit Amount Based on Number of Employees and
Average Wages.--The amount of the credit determined under subsection
(b) without regard to this subsection shall be reduced (but not below
zero) by the sum of the following amounts:
``(1) Such amount multiplied by a fraction the numerator of
which is the total number of full-time equivalent employees of
the employer in excess of 10 and the denominator of which is
15.
``(2) Such amount multiplied by a fraction the numerator of
which is the average annual wages of the employer in excess of
the dollar amount in effect under subsection (d)(3)(B) and the
denominator of which is such dollar amount.
``(d) Eligible Small Employer.--For purposes of this section--
``(1) In general.--The term `eligible small employer'
means, with respect to any taxable year, an employer--
``(A) which has no more than 25 full-time
equivalent employees for the taxable year,
``(B) the average annual wages of which do not
exceed an amount equal to twice the dollar amount in
effect under paragraph (3)(B) for the taxable year, and
``(C) which has in effect an arrangement described
in paragraph (4).
``(2) Full-time equivalent employees.--
``(A) In general.--The term `full-time equivalent
employees' means a number of employees equal to the
number determined by dividing--
``(i) the total number of hours of service
for which wages were paid by the employer to
employees during the taxable year, by
``(ii) 2,080.
Such number shall be rounded to the next lowest whole
number if not otherwise a whole number.
``(B) Excess hours not counted.--If an employee
works in excess of 2,080 hours of service during any
taxable year, such excess shall not be taken into
account under subparagraph (A).
``(C) Hours of service.--The Secretary, in
consultation with the Secretary of Labor, shall
prescribe such regulations, rules, and guidance as may
be necessary to determine the hours of service of an
employee, including rules for the application of this
paragraph to employees who are not compensated on an
hourly basis.
``(3) Average annual wages.--
``(A) In general.--The average annual wages of an
eligible small employer for any taxable year is the
amount determined by dividing--
``(i) the aggregate amount of wages which
were paid by the employer to employees during
the taxable year, by
``(ii) the number of full-time equivalent
employees of the employee determined under
paragraph (2) for the taxable year.
Such amount shall be rounded to the next lowest
multiple of $1,000 if not otherwise such a multiple.
``(B) Dollar amount.--For purposes of paragraph
(1)(B)--
``(i) 2011, 2012, and 2013.--The dollar
amount in effect under this paragraph for
taxable years beginning in 2011, 2012, or 2013
is $20,000.
``(ii) Subsequent years.--In the case of a
taxable year beginning in a calendar year after
2013, the dollar amount in effect under this
paragraph shall be equal to $20,000, multiplied
by the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year,
determined by substituting `calendar year 2012'
for `calendar year 1992' in subparagraph (B)
thereof.
``(4) Contribution arrangement.--An arrangement is
described in this paragraph if it requires an eligible small
employer to make a nonelective contribution on behalf of each
employee who enrolls in a qualified health plan offered to
employees by the employer through an exchange in an amount
equal to a uniform percentage (not less than 50 percent) of the
premium cost of the qualified health plan.
``(5) Seasonal worker hours and wages not counted.--For
purposes of this subsection--
``(A) In general.--The number of hours of service
worked by, and wages paid to, a seasonal worker of an
employer shall not be taken into account in determining
the full-time equivalent employees and average annual
wages of the employer unless the worker works for the
employer on more than 120 days during the taxable year.
``(B) Definition of seasonal worker.--The term
`seasonal worker' means a worker who performs labor or
services on a seasonal basis as defined by the
Secretary of Labor, including workers covered by
section 500.20(s)(1) of title 29, Code of Federal
Regulations and retail workers employed exclusively
during holiday seasons.
``(e) Other Rules and Definitions.--For purposes of this section--
``(1) Employee.--
``(A) Certain employees excluded.--The term
`employee' shall not include--
``(i) an employee within the meaning of
section 401(c)(1),
``(ii) any 2-percent shareholder (as
defined in section 1372(b)) of an eligible
small business which is an S corporation,
``(iii) any 5-percent owner (as defined in
section 416(i)(1)(B)(i)) of an eligible small
business, or
``(iv) any individual who bears any of the
relationships described in subparagraphs (A)
through (G) of section 152(d)(2) to, or is a
dependent described in section 152(d)(2)(H) of,
an individual described in clause (i), (ii), or
(iii).
``(B) Leased employees.--The term `employee' shall
include a leased employee within the meaning of section
414(n).
``(2) Credit period.--The term `credit period' means, with
respect to any eligible small employer, the 2-consecutive-
taxable year period beginning with the 1st taxable year in
which the employer (or any predecessor) offers 1 or more
qualified health plans to its employees through an Exchange.
``(3) Nonelective contribution.--The term `nonelective
contribution' means an employer contribution other than an
employer contribution pursuant to a salary reduction
arrangement.
``(4) Wages.--The term `wages' has the meaning given such
term by section 3121(a) (determined without regard to any
dollar limitation contained in such section).
``(5) Aggregation and other rules made applicable.--
``(A) Aggregation rules.--All employers treated as
a single employer under subsection (b), (c), (m), or
(o) of section 414 shall be treated as a single
employer for purposes of this section.
``(B) Other rules.--Rules similar to the rules of
subsections (c), (d), and (e) of section 52 shall
apply.
``(f) Credit Made Available to Tax-exempt Eligible Small
Employers.--
``(1) In general.--In the case of a tax-exempt eligible
small employer, there shall be treated as a credit allowable
under subpart C (and not allowable under this subpart) the
lesser of--
``(A) the amount of the credit determined under
this section with respect to such employer, or
``(B) the amount of the payroll taxes of the
employer during the calendar year in which the taxable
year begins.
``(2) Tax-exempt eligible small employer.--For purposes of
this section, the term `tax-exempt eligible small employer'
means an eligible small employer which is any organization
described in section 501(c) which is exempt from taxation under
section 501(a).
``(3) Payroll taxes.--For purposes of this subsection--
``(A) In general.--The term `payroll taxes' means--
``(i) amounts required to be withheld from
the employees of the tax-exempt eligible small
employer under section 3401(a),
``(ii) amounts required to be withheld from
such employees under section 3101(b), and
``(iii) amounts of the taxes imposed on the
tax-exempt eligible small employer under
section 3111(b).
``(B) Special rule.--A rule similar to the rule of
section 24(d)(2)(C) shall apply for purposes of
subparagraph (A).
``(g) Application of Section for Calendar Years 2011, 2012, and
2013.--In the case of any taxable year beginning in 2011, 2012, or
2013, the following modifications to this section shall apply in
determining the amount of the credit under subsection (a):
``(1) No credit period required.--The credit shall be
determined without regard to whether the taxable year is in a
credit period and for purposes of applying this section to
taxable years beginning after 2013, no credit period shall be
treated as beginning with a taxable year beginning before 2014.
``(2) Amount of credit.--The amount of the credit
determined under subsection (b) shall be determined--
``(A) by substituting `35 percent (25 percent in
the case of a tax-exempt eligible small employer)' for
`50 percent (35 percent in the case of a tax-exempt
eligible small employer)',
``(B) by reference to an eligible small employer's
nonelective contributions for premiums paid for health
insurance coverage (within the meaning of section
9832(b)(1)) of an employee, and
``(C) by substituting for the average premium
determined under subsection (b)(2) the amount the
Secretary of Health and Human Services determines is
the average premium for the small group market in the
State in which the employer is offering health
insurance coverage (or for such area within the State
as is specified by the Secretary).
``(3) Contribution arrangement.--An arrangement shall not
fail to meet the requirements of subsection (d)(4) solely
because it provides for the offering of insurance outside of an
Exchange.
``(h) Insurance Definitions.--Any term used in this section which
is also used in the Public Health Service Act or subtitle A of title I
of the Patient Protection and Affordable Care Act shall have the
meaning given such term by such Act or subtitle.
``(i) Regulations.--The Secretary shall prescribe such regulations
as may be necessary to carry out the provisions of this section,
including regulations to prevent the avoidance of the 2-year limit on
the credit period through the use of successor entities and the
avoidance of the limitations under subsection (c) through the use of
multiple entities.''.
(b) Credit To Be Part of General Business Credit.--Section 38(b) of
the Internal Revenue Code of 1986 (relating to current year business
credit) is amended by striking ``plus'' at the end of paragraph (34),
by striking the period at the end of paragraph (35) and inserting ``,
plus'', and by inserting after paragraph (35) the following:
``(36) the small employer health insurance credit
determined under section 45R.''.
(c) Credit Allowed Against Alternative Minimum Tax.--Section
38(c)(4)(B) of the Internal Revenue Code of 1986 (defining specified
credits) is amended by redesignating clauses (vi), (vii), and (viii) as
clauses (vii), (viii), and (ix), respectively, and by inserting after
clause (v) the following new clause:
``(vi) the credit determined under section
45R,''.
(d) Disallowance of Deduction for Certain Expenses for Which Credit
Allowed.--
(1) In general.--Section 280C of the Internal Revenue Code
of 1986 (relating to disallowance of deduction for certain
expenses for which credit allowed), as amended by section
1401(b), is amended by adding at the end the following new
subsection:
``(h) Credit for Employee Health Insurance Expenses of Small
Employers.--No deduction shall be allowed for that portion of the
premiums for qualified health plans (as defined in section 1301(a) of
the Patient Protection and Affordable Care Act), or for health
insurance coverage in the case of taxable years beginning in 2011,
2012, or 2013, paid by an employer which is equal to the amount of the
credit determined under section 45R(a) with respect to the premiums.''.
(2) Deduction for expiring credits.--Section 196(c) of such
Code is amended by striking ``and'' at the end of paragraph
(12), by striking the period at the end of paragraph (13) and
inserting ``, and'', and by adding at the end the following new
paragraph:
``(14) the small employer health insurance credit
determined under section 45R(a).''.
(e) Clerical Amendment.--The table of sections for subpart D of
part IV of subchapter A of chapter 1 of the Internal Revenue Code of
1986 is amended by adding at the end the following:
``Sec. 45R. Employee health insurance expenses of small employers.''.
(f) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply to amounts paid or incurred in taxable years beginning
after December 31, 2010.
(2) Minimum tax.--The amendments made by subsection (c)
shall apply to credits determined under section 45R of the
Internal Revenue Code of 1986 in taxable years beginning after
December 31, 2010, and to carrybacks of such credits.
Subtitle F--Shared Responsibility for Health Care
PART I--INDIVIDUAL RESPONSIBILITY
SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.
(a) Findings.--Congress makes the following findings:
(1) In general.--The individual responsibility requirement
provided for in this section (in this subsection referred to as
the ``requirement'') is commercial and economic in nature, and
substantially affects interstate commerce, as a result of the
effects described in paragraph (2).
(2) Effects on the national economy and interstate
commerce.--The effects described in this paragraph are the
following:
(A) The requirement regulates activity that is
commercial and economic in nature: economic and
financial decisions about how and when health care is
paid for, and when health insurance is purchased.
(B) Health insurance and health care services are a
significant part of the national economy. National
health spending is projected to increase from
$2,500,000,000,000, or 17.6 percent of the economy, in
2009 to $4,700,000,000,000 in 2019. Private health
insurance spending is projected to be $854,000,000,000
in 2009, and pays for medical supplies, drugs, and
equipment that are shipped in interstate commerce.
Since most health insurance is sold by national or
regional health insurance companies, health insurance
is sold in interstate commerce and claims payments flow
through interstate commerce.
(C) The requirement, together with the other
provisions of this Act, will add millions of new
consumers to the health insurance market, increasing
the supply of, and demand for, health care services.
According to the Congressional Budget Office, the
requirement will increase the number and share of
Americans who are insured.
(D) The requirement achieves near-universal
coverage by building upon and strengthening the private
employer-based health insurance system, which covers
176,000,000 Americans nationwide. In Massachusetts, a
similar requirement has strengthened private employer-
based coverage: despite the economic downturn, the
number of workers offered employer-based coverage has
actually increased.
(E) Half of all personal bankruptcies are caused in
part by medical expenses. By significantly increasing
health insurance coverage, the requirement, together
with the other provisions of this Act, will improve
financial security for families.
(F) Under the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health
Service Act (42 U.S.C. 201 et seq.), and this Act, the
Federal Government has a significant role in regulating
health insurance which is in interstate commerce.
(G) Under sections 2704 and 2705 of the Public
Health Service Act (as added by section 1201 of this
Act), if there were no requirement, many individuals
would wait to purchase health insurance until they
needed care. By significantly increasing health
insurance coverage, the requirement, together with the
other provisions of this Act, will minimize this
adverse selection and broaden the health insurance risk
pool to include healthy individuals, which will lower
health insurance premiums. The requirement is essential
to creating effective health insurance markets in which
improved health insurance products that are guaranteed
issue and do not exclude coverage of pre-existing
conditions can be sold.
(H) Administrative costs for private health
insurance, which were $90,000,000,000 in 2006, are 26
to 30 percent of premiums in the current individual and
small group markets. By significantly increasing health
insurance coverage and the size of purchasing pools,
which will increase economies of scale, the
requirement, together with the other provisions of this
Act, will significantly reduce administrative costs and
lower health insurance premiums. The requirement is
essential to creating effective health insurance
markets that do not require underwriting and eliminate
its associated administrative costs.
(3) Supreme court ruling.--In United States v. South-
Eastern Underwriters Association (322 U.S. 533 (1944)), the
Supreme Court of the United States ruled that insurance is
interstate commerce subject to Federal regulation.
(b) In General.--Subtitle D of the Internal Revenue Code of 1986 is
amended by adding at the end the following new chapter:
``CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE
``Sec. 5000A. Requirement to maintain minimum essential coverage.
``SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.
``(a) Requirement To Maintain Minimum Essential Coverage.--An
applicable individual shall for each month beginning after 2013 ensure
that the individual, and any dependent of the individual who is an
applicable individual, is covered under minimum essential coverage for
such month.
``(b) Shared Responsibility Payment.--
``(1) In general.--If an applicable individual fails to
meet the requirement of subsection (a) for 1 or more months
during any calendar year beginning after 2013, then, except as
provided in subsection (d), there is hereby imposed a penalty
with respect to the individual in the amount determined under
subsection (c).
``(2) Inclusion with return.--Any penalty imposed by this
section with respect to any month shall be included with a
taxpayer's return under chapter 1 for the taxable year which
includes such month.
``(3) Payment of penalty.--If an individual with respect to
whom a penalty is imposed by this section for any month--
``(A) is a dependent (as defined in section 152) of
another taxpayer for the other taxpayer's taxable year
including such month, such other taxpayer shall be
liable for such penalty, or
``(B) files a joint return for the taxable year
including such month, such individual and the spouse of
such individual shall be jointly liable for such
penalty.
``(c) Amount of Penalty.--
``(1) In general.--The penalty determined under this
subsection for any month with respect to any individual is an
amount equal to \1/12\ of the applicable dollar amount for the
calendar year.
``(2) Dollar limitation.--The amount of the penalty imposed
by this section on any taxpayer for any taxable year with
respect to all individuals for whom the taxpayer is liable
under subsection (b)(3) shall not exceed an amount equal to 300
percent the applicable dollar amount (determined without regard
to paragraph (3)(C)) for the calendar year with or within which
the taxable year ends.
``(3) Applicable dollar amount.--For purposes of paragraph
(1)--
``(A) In general.--Except as provided in
subparagraphs (B) and (C), the applicable dollar amount
is $750.
``(B) Phase in.--The applicable dollar amount is
$95 for 2014 and $350 for 2015.
``(C) Special rule for individuals under age 18.--
If an applicable individual has not attained the age of
18 as of the beginning of a month, the applicable
dollar amount with respect to such individual for the
month shall be equal to one-half of the applicable
dollar amount for the calendar year in which the month
occurs.
``(D) Indexing of amount.--In the case of any
calendar year beginning after 2016, the applicable
dollar amount shall be equal to $750, increased by an
amount equal to--
``(i) $750, multiplied by
``(ii) the cost-of-living adjustment
determined under section 1(f)(3) for the
calendar year, determined by substituting
`calendar year 2015' for `calendar year 1992'
in subparagraph (B) thereof.
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the
next lowest multiple of $50.
``(4) Terms relating to income and families.--For purposes
of this section--
``(A) Family size.--The family size involved with
respect to any taxpayer shall be equal to the number of
individuals for whom the taxpayer is allowed a
deduction under section 151 (relating to allowance of
deduction for personal exemptions) for the taxable
year.
``(B) Household income.--The term `household
income' means, with respect to any taxpayer for any
taxable year, an amount equal to the sum of--
``(i) the modified gross income of the
taxpayer, plus
``(ii) the aggregate modified gross incomes
of all other individuals who--
``(I) were taken into account in
determining the taxpayer's family size
under paragraph (1), and
``(II) were required to file a
return of tax imposed by section 1 for
the taxable year.
``(C) Modified gross income.--The term `modified
gross income' means gross income--
``(i) decreased by the amount of any
deduction allowable under paragraph (1), (3),
(4), or (10) of section 62(a),
``(ii) increased by the amount of interest
received or accrued during the taxable year
which is exempt from tax imposed by this
chapter, and
``(iii) determined without regard to
sections 911, 931, and 933.
``(D) Poverty line.--
``(i) In general.--The term `poverty line'
has the meaning given that term in section
2110(c)(5) of the Social Security Act (42
U.S.C. 1397jj(c)(5)).
``(ii) Poverty line used.--In the case of
any taxable year ending with or within a
calendar year, the poverty line used shall be
the most recently published poverty line as of
the 1st day of such calendar year.
``(d) Applicable Individual.--For purposes of this section--
``(1) In general.--The term `applicable individual' means,
with respect to any month, an individual other than an
individual described in paragraph (2), (3), or (4).
``(2) Religious exemptions.--
``(A) Religious conscience exemption.--Such term
shall not include any individual for any month if such
individual has in effect an exemption under section
1311(d)(4)(H) of the Patient Protection and Affordable
Care Act which certifies that such individual is a
member of a recognized religious sect or division
thereof described in section 1402(g)(1) and an adherent
of established tenets or teachings of such sect or
division as described in such section.
``(B) Health care sharing ministry.--
``(i) In general.--Such term shall not
include any individual for any month if such
individual is a member of a health care sharing
ministry for the month.
``(ii) Health care sharing ministry.--The
term `health care sharing ministry' means an
organization--
``(I) which is described in section
501(c)(3) and is exempt from taxation
under section 501(a),
``(II) members of which share a
common set of ethical or religious
beliefs and share medical expenses
among members in accordance with those
beliefs and without regard to the State
in which a member resides or is
employed,
``(III) members of which retain
membership even after they develop a
medical condition,
``(IV) which (or a predecessor of
which) has been in existence at all
times since December 31, 1999, and
medical expenses of its members have
been shared continuously and without
interruption since at least December
31, 1999, and
``(V) which conducts an annual
audit which is performed by an
independent certified public accounting
firm in accordance with generally
accepted accounting principles and
which is made available to the public
upon request.
``(3) Individuals not lawfully present.--Such term shall
not include an individual for any month if for the month the
individual is not a citizen or national of the United States or
an alien lawfully present in the United States.
``(4) Incarcerated individuals.--Such term shall not
include an individual for any month if for the month the
individual is incarcerated, other than incarceration pending
the disposition of charges.
``(e) Exemptions.--No penalty shall be imposed under subsection (a)
with respect to--
``(1) Individuals who cannot afford coverage.--
``(A) In general.--Any applicable individual for
any month if the applicable individual's required
contribution (determined on an annual basis) for
coverage for the month exceeds 8 percent of such
individual's household income for the taxable year
described in section 1412(b)(1)(B) of the Patient
Protection and Affordable Care Act. For purposes of
applying this subparagraph, the taxpayer's household
income shall be increased by any exclusion from gross
income for any portion of the required contribution
made through a salary reduction arrangement.
``(B) Required contribution.--For purposes of this
paragraph, the term `required contribution' means--
``(i) in the case of an individual eligible
to purchase minimum essential coverage
consisting of coverage through an eligible-
employer-sponsored plan, the portion of the
annual premium which would be paid by the
individual (without regard to whether paid
through salary reduction or otherwise) for
self-only coverage, or
``(ii) in the case of an individual
eligible only to purchase minimum essential
coverage described in subsection (f)(1)(C), the
annual premium for the lowest cost bronze plan
available in the individual market through the
Exchange in the State in the rating area in
which the individual resides (without regard to
whether the individual purchased a qualified
health plan through the Exchange), reduced by
the amount of the credit allowable under
section 36B for the taxable year (determined as
if the individual was covered by a qualified
health plan offered through the Exchange for
the entire taxable year).
``(C) Special rules for individuals related to
employees.--For purposes of subparagraph (B)(i), if an
applicable individual is eligible for minimum essential
coverage through an employer by reason of a
relationship to an employee, the determination shall be
made by reference to the affordability of the coverage
to the employee.
``(D) Indexing.--In the case of plan years
beginning in any calendar year after 2014, subparagraph
(A) shall be applied by substituting for `8 percent'
the percentage the Secretary of Health and Human
Services determines reflects the excess of the rate of
premium growth between the preceding calendar year and
2013 over the rate of income growth for such period.
``(2) Taxpayers with income under 100 percent of poverty
line.--Any applicable individual for any month during a
calendar year if the individual's household income for the
taxable year described in section 1412(b)(1)(B) of the Patient
Protection and Affordable Care Act is less than 100 percent of
the poverty line for the size of the family involved
(determined in the same manner as under subsection (b)(4)).
``(3) Members of indian tribes.--Any applicable individual
for any month during which the individual is a member of an
Indian tribe (as defined in section 45A(c)(6)).
``(4) Months during short coverage gaps.--
``(A) In general.--Any month the last day of which
occurred during a period in which the applicable
individual was not covered by minimum essential
coverage for a continuous period of less than 3 months.
``(B) Special rules.--For purposes of applying this
paragraph--
``(i) the length of a continuous period
shall be determined without regard to the
calendar years in which months in such period
occur,
``(ii) if a continuous period is greater
than the period allowed under subparagraph (A),
no exception shall be provided under this
paragraph for any month in the period, and
``(iii) if there is more than 1 continuous
period described in subparagraph (A) covering
months in a calendar year, the exception
provided by this paragraph shall only apply to
months in the first of such periods.
The Secretary shall prescribe rules for the collection
of the penalty imposed by this section in cases where
continuous periods include months in more than 1
taxable year.
``(5) Hardships.--Any applicable individual who for any
month is determined by the Secretary of Health and Human
Services under section 1311(d)(4)(H) to have suffered a
hardship with respect to the capability to obtain coverage
under a qualified health plan.
``(f) Minimum Essential Coverage.--For purposes of this section--
``(1) In general.--The term `minimum essential coverage'
means any of the following:
``(A) Government sponsored programs.--Coverage
under--
``(i) the Medicare program under part A of
title XVIII of the Social Security Act,
``(ii) the Medicaid program under title XIX
of the Social Security Act,
``(iii) the CHIP program under title XXI of
the Social Security Act,
``(iv) the TRICARE for Life program,
``(v) the veteran's health care program
under chapter 17 of title 38, United States
Code, or
``(vi) a health plan under section 2504(e)
of title 22, United States Code (relating to
Peace Corps volunteers).
``(B) Employer-sponsored plan.--Coverage under an
eligible employer-sponsored plan.
``(C) Plans in the individual market.--Coverage
under a health plan offered in the individual market
within a State.
``(D) Grandfathered health plan.--Coverage under a
grandfathered health plan.
``(E) Other coverage.--Such other health benefits
coverage, such as a State health benefits risk pool, as
the Secretary of Health and Human Services, in
coordination with the Secretary, recognizes for
purposes of this subsection.
``(2) Eligible employer-sponsored plan.--The term `eligible
employer-sponsored plan' means, with respect to any employee, a
group health plan or group health insurance coverage offered by
an employer to the employee which is--
``(A) a governmental plan (within the meaning of
section 2791(d)(8) of the Public Health Service Act),
or
``(B) any other plan or coverage offered in the
small or large group market within a State.
Such term shall include a grandfathered health plan described
in paragraph (1)(D) offered in a group market.
``(3) Excepted benefits not treated as minimum essential
coverage.--The term `minimum essential coverage' shall not
include health insurance coverage which consists of coverage of
excepted benefits--
``(A) described in paragraph (1) of subsection (c)
of section 2791 of the Public Health Service Act; or
``(B) described in paragraph (2), (3), or (4) of
such subsection if the benefits are provided under a
separate policy, certificate, or contract of insurance.
``(4) Individuals residing outside united states or
residents of territories.--Any applicable individual shall be
treated as having minimum essential coverage for any month--
``(A) if such month occurs during any period
described in subparagraph (A) or (B) of section
911(d)(1) which is applicable to the individual, or
``(B) if such individual is a bona fide resident of
any possession of the United States (as determined
under section 937(a)) for such month.
``(5) Insurance-related terms.--Any term used in this
section which is also used in title I of the Patient Protection
and Affordable Care Act shall have the same meaning as when
used in such title.
``(g) Administration and Procedure.--
``(1) In general.--The penalty provided by this section
shall be paid upon notice and demand by the Secretary, and
except as provided in paragraph (2), shall be assessed and
collected in the same manner as an assessable penalty under
subchapter B of chapter 68.
``(2) Special rules.--Notwithstanding any other provision
of law--
``(A) Waiver of criminal penalties.--In the case of
any failure by a taxpayer to timely pay any penalty
imposed by this section, such taxpayer shall not be
subject to any criminal prosecution or penalty with
respect to such failure.
``(B) Limitations on liens and levies.--The
Secretary shall not--
``(i) file notice of lien with respect to
any property of a taxpayer by reason of any
failure to pay the penalty imposed by this
section, or
``(ii) levy on any such property with
respect to such failure.''.
(c) Clerical Amendment.--The table of chapters for subtitle D of
the Internal Revenue Code of 1986 is amended by inserting after the
item relating to chapter 47 the following new item:
``Chapter 48--Maintenance of Minimum Essential Coverage.''.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years ending after December 31, 2013.
SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.
(a) In General.--Part III of subchapter A of chapter 61 of the
Internal Revenue Code of 1986 is amended by inserting after subpart C
the following new subpart:
``Subpart D--Information Regarding Health Insurance Coverage
``Sec. 6055. Reporting of health insurance coverage.
``SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.
``(a) In General.--Every person who provides minimum essential
coverage to an individual during a calendar year shall, at such time as
the Secretary may prescribe, make a return described in subsection (b).
``(b) Form and Manner of Return.--
``(1) In general.--A return is described in this subsection
if such return--
``(A) is in such form as the Secretary may
prescribe, and
``(B) contains--
``(i) the name, address and TIN of the
primary insured and the name and TIN of each
other individual obtaining coverage under the
policy,
``(ii) the dates during which such
individual was covered under minimum essential
coverage during the calendar year,
``(iii) in the case of minimum essential
coverage which consists of health insurance
coverage, information concerning--
``(I) whether or not the coverage
is a qualified health plan offered
through an Exchange established under
section 1311 of the Patient Protection
and Affordable Care Act, and
``(II) in the case of a qualified
health plan, the amount (if any) of any
advance payment under section 1412 of
the Patient Protection and Affordable
Care Act of any cost-sharing reduction
under section 1402 of such Act or of
any premium tax credit under section
36B with respect to such coverage, and
``(iv) such other information as the
Secretary may require.
``(2) Information relating to employer-provided coverage.--
If minimum essential coverage provided to an individual under
subsection (a) consists of health insurance coverage of a
health insurance issuer provided through a group health plan of
an employer, a return described in this subsection shall
include--
``(A) the name, address, and employer
identification number of the employer maintaining the
plan,
``(B) the portion of the premium (if any) required
to be paid by the employer, and
``(C) if the health insurance coverage is a
qualified health plan in the small group market offered
through an Exchange, such other information as the
Secretary may require for administration of the credit
under section 45R (relating to credit for employee
health insurance expenses of small employers).
``(c) Statements To Be Furnished to Individuals With Respect to
Whom Information Is Reported.--
``(1) In general.--Every person required to make a return
under subsection (a) shall furnish to each individual whose
name is required to be set forth in such return a written
statement showing--
``(A) the name and address of the person required
to make such return and the phone number of the
information contact for such person, and
``(B) the information required to be shown on the
return with respect to such individual.
``(2) Time for furnishing statements.--The written
statement required under paragraph (1) shall be furnished on or
before January 31 of the year following the calendar year for
which the return under subsection (a) was required to be made.
``(d) Coverage Provided by Governmental Units.--In the case of
coverage provided by any governmental unit or any agency or
instrumentality thereof, the officer or employee who enters into the
agreement to provide such coverage (or the person appropriately
designated for purposes of this section) shall make the returns and
statements required by this section.
``(e) Minimum Essential Coverage.--For purposes of this section,
the term `minimum essential coverage' has the meaning given such term
by section 5000A(f).''.
(b) Assessable Penalties.--
(1) Subparagraph (B) of section 6724(d)(1) of the Internal
Revenue Code of 1986 (relating to definitions) is amended by
striking ``or'' at the end of clause (xxii), by striking
``and'' at the end of clause (xxiii) and inserting ``or'', and
by inserting after clause (xxiii) the following new clause:
``(xxiv) section 6055 (relating to returns
relating to information regarding health
insurance coverage), and''.
(2) Paragraph (2) of section 6724(d) of such Code is
amended by striking ``or'' at the end of subparagraph (EE), by
striking the period at the end of subparagraph (FF) and
inserting ``, or'' and by inserting after subparagraph (FF) the
following new subparagraph:
``(GG) section 6055(c) (relating to statements
relating to information regarding health insurance
coverage).''.
(c) Notification of Nonenrollment.--Not later than June 30 of each
year, the Secretary of the Treasury, acting through the Internal
Revenue Service and in consultation with the Secretary of Health and
Human Services, shall send a notification to each individual who files
an individual income tax return and who is not enrolled in minimum
essential coverage (as defined in section 5000A of the Internal Revenue
Code of 1986). Such notification shall contain information on the
services available through the Exchange operating in the State in which
such individual resides.
(d) Conforming Amendment.--The table of subparts for part III of
subchapter A of chapter 61 of such Code is amended by inserting after
the item relating to subpart C the following new item:
``subpart d--information regarding health insurance coverage''.
(e) Effective Date.--The amendments made by this section shall
apply to calendar years beginning after 2013.
PART II--EMPLOYER RESPONSIBILITIES
SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE EMPLOYERS.
The Fair Labor Standards Act of 1938 is amended by inserting after
section 18 (29 U.S.C. 218) the following:
``SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE EMPLOYERS.
``In accordance with regulations promulgated by the Secretary, an
employer to which this Act applies that has more than 200 full-time
employees and that offers employees enrollment in 1 or more health
benefits plans shall automatically enroll new full-time employees in
one of the plans offered (subject to any waiting period authorized by
law) and to continue the enrollment of current employees in a health
benefits plan offered through the employer. Any automatic enrollment
program shall include adequate notice and the opportunity for an
employee to opt out of any coverage the individual or employee were
automatically enrolled in. Nothing in this section shall be construed
to supersede any State law which establishes, implements, or continues
in effect any standard or requirement relating to employers in
connection with payroll except to the extent that such standard or
requirement prevents an employer from instituting the automatic
enrollment program under this section.''.
SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF COVERAGE
OPTIONS.
The Fair Labor Standards Act of 1938 is amended by inserting after
section 18A (as added by section 1513) the following:
``SEC. 18B. NOTICE TO EMPLOYEES.
``(a) In General.--In accordance with regulations promulgated by
the Secretary, an employer to which this Act applies, shall provide to
each employee at the time of hiring (or with respect to current
employees, not later than March 1, 2013), written notice--
``(1) informing the employee of the existence of an
Exchange, including a description of the services provided by
such Exchange, and the manner in which the employee may contact
the Exchange to request assistance;
``(2) if the employer plan's share of the total allowed
costs of benefits provided under the plan is less than 60
percent of such costs, that the employee may be eligible for a
premium tax credit under section 36B of the Internal Revenue
Code of 1986 and a cost sharing reduction under section 1402 of
the Patient Protection and Affordable Care Act if the employee
purchases a qualified health plan through the Exchange; and
``(3) if the employee purchases a qualified health plan
through the Exchange, the employee will lose the employer
contribution (if any) to any health benefits plan offered by
the employer and that all or a portion of such contribution may
be excludable from income for Federal income tax purposes.
``(b) Effective Date.--Subsection (a) shall take effect with
respect to employers in a State beginning on March 1, 2013.''.
SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS.
(a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is
amended by adding at the end the following:
``SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING HEALTH
COVERAGE.
``(a) Large Employers Not Offering Health Coverage.--If--
``(1) any applicable large employer fails to offer to its
full-time employees (and their dependents) the opportunity to
enroll in minimum essential coverage under an eligible
employer-sponsored plan (as defined in section 5000A(f)(2)) for
any month, and
``(2) at least one full-time employee of the applicable
large employer has been certified to the employer under section
1411 of the Patient Protection and Affordable Care Act as
having enrolled for such month in a qualified health plan with
respect to which an applicable premium tax credit or cost-
sharing reduction is allowed or paid with respect to the
employee,
then there is hereby imposed on the employer an assessable payment
equal to the product of the applicable payment amount and the number of
individuals employed by the employer as full-time employees during such
month.
``(b) Large Employers With Waiting Periods Exceeding 30 Days.--
``(1) In general.--In the case of any applicable large
employer which requires an extended waiting period to enroll in
any minimum essential coverage under an employer-sponsored plan
(as defined in section 5000A(f)(2)), there is hereby imposed on
the employer an assessable payment, in the amount specified in
paragraph (2), for each full-time employee of the employer to
whom the extended waiting period applies.
``(2) Amount.--For purposes of paragraph (1), the amount
specified in this paragraph for a full-time employee is--
``(A) in the case of an extended waiting period
which exceeds 30 days but does not exceed 60 days,
$400, and
``(B) in the case of an extended waiting period
which exceeds 60 days, $600.
``(3) Extended waiting period.--The term `extended waiting
period' means any waiting period (as defined in section
2701(b)(4) of the Public Health Service Act) which exceeds 30
days.
``(c) Large Employers Offering Coverage With Employees Who Qualify
for Premium Tax Credits or Cost-sharing Reductions.--
``(1) In general.--If--
``(A) an applicable large employer offers to its
full-time employees (and their dependents) the
opportunity to enroll in minimum essential coverage
under an eligible employer-sponsored plan (as defined
in section 5000A(f)(2)) for any month, and
``(B) 1 or more full-time employees of the
applicable large employer has been certified to the
employer under section 1411 of the Patient Protection
and Affordable Care Act as having enrolled for such
month in a qualified health plan with respect to which
an applicable premium tax credit or cost-sharing
reduction is allowed or paid with respect to the
employee,
then there is hereby imposed on the employer an assessable
payment equal to the product of the number of full-time
employees of the applicable large employer described in
subparagraph (B) for such month and 400 percent of the
applicable payment amount.
``(2) Overall limitation.--The aggregate amount of tax
determined under paragraph (1) with respect to all employees of
an applicable large employer for any month shall not exceed the
product of the applicable payment amount and the number of
individuals employed by the employer as full-time employees
during such month.
``(d) Definitions and Special Rules.--For purposes of this
section--
``(1) Applicable payment amount.--The term `applicable
payment amount' means, with respect to any month, \1/12\ of
$750.
``(2) Applicable large employer.--
``(A) In general.--The term `applicable large
employer' means, with respect to a calendar year, an
employer who employed an average of at least 50 full-
time employees on business days during the preceding
calendar year.
``(B) Exemption for certain employers.--
``(i) In general.--An employer shall not be
considered to employ more than 50 full-time
employees if--
``(I) the employer's workforce
exceeds 50 full-time employees for 120
days or fewer during the calendar year,
and
``(II) the employees in excess of
50 employed during such 120-day period
were seasonal workers.
``(ii) Definition of seasonal workers.--The
term `seasonal worker' means a worker who
performs labor or services on a seasonal basis
as defined by the Secretary of Labor, including
workers covered by section 500.20(s)(1) of
title 29, Code of Federal Regulations and
retail workers employed exclusively during
holiday seasons.
``(C) Rules for determining employer size.--For
purposes of this paragraph--
``(i) Application of aggregation rule for
employers.--All persons treated as a single
employer under subsection (b), (c), (m), or (o)
of section 414 of the Internal Revenue Code of
1986 shall be treated as 1 employer.
``(ii) Employers not in existence in
preceding year.--In the case of an employer
which was not in existence throughout the
preceding calendar year, the determination of
whether such employer is an applicable large
employer shall be based on the average number
of employees that it is reasonably expected
such employer will employ on business days in
the current calendar year.
``(iii) Predecessors.--Any reference in
this subsection to an employer shall include a
reference to any predecessor of such employer.
``(3) Applicable premium tax credit and cost-sharing
reduction.--The term `applicable premium tax credit and cost-
sharing reduction' means--
``(A) any premium tax credit allowed under section
36B,
``(B) any cost-sharing reduction under section 1402
of the Patient Protection and Affordable Care Act, and
``(C) any advance payment of such credit or
reduction under section 1412 of such Act.
``(4) Full-time employee.--
``(A) In general.--The term `full-time employee'
means an employee who is employed on average at least
30 hours of service per week.
``(B) Hours of service.--The Secretary, in
consultation with the Secretary of Labor, shall
prescribe such regulations, rules, and guidance as may
be necessary to determine the hours of service of an
employee, including rules for the application of this
paragraph to employees who are not compensated on an
hourly basis.
``(5) Inflation adjustment.--
``(A) In general.--In the case of any calendar year
after 2014, each of the dollar amounts in subsection
(b)(2) and (d)(1) shall be increased by an amount equal
to the product of--
``(i) such dollar amount, and
``(ii) the premium adjustment percentage
(as defined in section 1302(c)(4) of the
Patient Protection and Affordable Care Act) for
the calendar year.
``(B) Rounding.--If the amount of any increase
under subparagraph (A) is not a multiple of $10, such
increase shall be rounded to the next lowest multiple
of $10.
``(6) Other definitions.--Any term used in this section
which is also used in the Patient Protection and Affordable
Care Act shall have the same meaning as when used in such Act.
``(7) Tax nondeductible.--For denial of deduction for the
tax imposed by this section, see section 275(a)(6).
``(e) Administration and Procedure.--
``(1) In general.--Any assessable payment provided by this
section shall be paid upon notice and demand by the Secretary,
and shall be assessed and collected in the same manner as an
assessable penalty under subchapter B of chapter 68.
``(2) Time for payment.--The Secretary may provide for the
payment of any assessable payment provided by this section on
an annual, monthly, or other periodic basis as the Secretary
may prescribe.
``(3) Coordination with credits, etc..--The Secretary shall
prescribe rules, regulations, or guidance for the repayment of
any assessable payment (including interest) if such payment is
based on the allowance or payment of an applicable premium tax
credit or cost-sharing reduction with respect to an employee,
such allowance or payment is subsequently disallowed, and the
assessable payment would not have been required to be made but
for such allowance or payment.''.
(b) Clerical Amendment.--The table of sections for chapter 43 of
such Code is amended by adding at the end the following new item:
``Sec. 4980H. Shared responsibility for employers regarding health
coverage.''.
(c) Study and Report of Effect of Tax on Workers' Wages.--
(1) In general.--The Secretary of Labor shall conduct a
study to determine whether employees' wages are reduced by
reason of the application of the assessable payments under
section 4980H of the Internal Revenue Code of 1986 (as added by
the amendments made by this section). The Secretary shall make
such determination on the basis of the National Compensation
Survey published by the Bureau of Labor Statistics.
(2) Report.--The Secretary shall report the results of the
study under paragraph (1) to the Committee on Ways and Means of
the House of Representatives and to the Committee on Finance of
the Senate.
(d) Effective Date.--The amendments made by this section shall
apply to months beginning after December 31, 2013.
SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE.
(a) In General.--Subpart D of part III of subchapter A of chapter
61 of the Internal Revenue Code of 1986, as added by section 1502, is
amended by inserting after section 6055 the following new section:
``SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON HEALTH INSURANCE
COVERAGE.
``(a) In General.--Every applicable large employer required to meet
the requirements of section 4980H with respect to its full-time
employees during a calendar year shall, at such time as the Secretary
may prescribe, make a return described in subsection (b).
``(b) Form and Manner of Return.--A return is described in this
subsection if such return--
``(1) is in such form as the Secretary may prescribe, and
``(2) contains--
``(A) the name, date, and employer identification
number of the employer,
``(B) a certification as to whether the employer
offers to its full-time employees (and their
dependents) the opportunity to enroll in minimum
essential coverage under an eligible employer-sponsored
plan (as defined in section 5000A(f)(2)),
``(C) if the employer certifies that the employer
did offer to its full-time employees (and their
dependents) the opportunity to so enroll--
``(i) the length of any waiting period (as
defined in section 2701(b)(4) of the Public
Health Service Act) with respect to such
coverage,
``(ii) the months during the calendar year
for which coverage under the plan was
available,
``(iii) the monthly premium for the lowest
cost option in each of the enrollment
categories under the plan, and
``(iv) the applicable large employer's
share of the total allowed costs of benefits
provided under the plan,
``(D) the number of full-time employees for each
month during the calendar year,
``(E) the name, address, and TIN of each full-time
employee during the calendar year and the months (if
any) during which such employee (and any dependents)
were covered under any such health benefits plans, and
``(F) such other information as the Secretary may
require.
``(c) Statements To Be Furnished to Individuals With Respect to
Whom Information Is Reported.--
``(1) In general.--Every person required to make a return
under subsection (a) shall furnish to each full-time employee
whose name is required to be set forth in such return under
subsection (b)(2)(E) a written statement showing--
``(A) the name and address of the person required
to make such return and the phone number of the
information contact for such person, and
``(B) the information required to be shown on the
return with respect to such individual.
``(2) Time for furnishing statements.--The written
statement required under paragraph (1) shall be furnished on or
before January 31 of the year following the calendar year for
which the return under subsection (a) was required to be made.
``(d) Coordination With Other Requirements.--To the maximum extent
feasible, the Secretary may provide that--
``(1) any return or statement required to be provided under
this section may be provided as part of any return or statement
required under section 6051 or 6055, and
``(2) in the case of an applicable large employer offering
health insurance coverage of a health insurance issuer, the
employer may enter into an agreement with the issuer to include
information required under this section with the return and
statement required to be provided by the issuer under section
6055.
``(e) Coverage Provided by Governmental Units.--In the case of any
applicable large employer which is a governmental unit or any agency or
instrumentality thereof, the person appropriately designated for
purposes of this section shall make the returns and statements required
by this section.
``(f) Definitions.--For purposes of this section, any term used in
this section which is also used in section 4980H shall have the meaning
given such term by section 4980H.''.
(b) Assessable Penalties.--
(1) Subparagraph (B) of section 6724(d)(1) of the Internal
Revenue Code of 1986 (relating to definitions), as amended by
section 1502, is amended by striking ``or'' at the end of
clause (xxiii), by striking ``and'' at the end of clause (xxiv)
and inserting ``or'', and by inserting after clause (xxiv) the
following new clause:
``(xxv) section 6056 (relating to returns
relating to large employers required to report
on health insurance coverage), and''.
(2) Paragraph (2) of section 6724(d) of such Code, as so
amended, is amended by striking ``or'' at the end of
subparagraph (FF), by striking the period at the end of
subparagraph (GG) and inserting ``, or'' and by inserting after
subparagraph (GG) the following new subparagraph:
``(HH) section 6056(c) (relating to statements
relating to large employers required to report on
health insurance coverage).''.
(c) Conforming Amendment.--The table of sections for subpart D of
part III of subchapter A of chapter 61 of such Code, as added by
section 1502, is amended by adding at the end the following new item:
``Sec. 6056. Large employers required to report on health insurance
coverage.''.
(d) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2013.
SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED HEALTH PLANS
THROUGH CAFETERIA PLANS.
(a) In General.--Subsection (f) of section 125 of the Internal
Revenue Code of 1986 is amended by adding at the end the following new
paragraph:
``(3) Certain exchange-participating qualified health plans
not qualified.--
``(A) In general.--The term `qualified benefit'
shall not include any qualified health plan (as defined
in section 1301(a) of the Patient Protection and
Affordable Care Act) offered through an Exchange
established under section 1311 of such Act.
``(B) Exception for exchange-eligible employers.--
Subparagraph (A) shall not apply with respect to any
employee if such employee's employer is a qualified
employer (as defined in section 1312(f)(2) of the
Patient Protection and Affordable Care Act) offering
the employee the opportunity to enroll through such an
Exchange in a qualified health plan in a group
market.''.
(b) Conforming Amendments.--Subsection (f) of section 125 of such
Code is amended--
(1) by striking ``For purposes of this section, the term''
and inserting ``For purposes of this section--
``(1) In General.--The term'', and
(2) by striking ``Such term shall not include'' and
inserting the following:
``(2) Long-term care insurance not qualified.--The term
`qualified benefit' shall not include''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2013.
Subtitle G--Miscellaneous Provisions
SEC. 1551. DEFINITIONS.
Unless specifically provided for otherwise, the definitions
contained in section 2791 of the Public Health Service Act (42 U.S.C.
300gg-91) shall apply with respect to this title.
SEC. 1552. TRANSPARENCY IN GOVERNMENT.
Not later than 30 days after the date of enactment of this Act, the
Secretary of Health and Human Services shall publish on the Internet
website of the Department of Health and Human Services, a list of all
of the authorities provided to the Secretary under this Act (and the
amendments made by this Act).
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED SUICIDE.
(a) In General.--The Federal Government, and any State or local
government or health care provider that receives Federal financial
assistance under this Act (or under an amendment made by this Act) or
any health plan created under this Act (or under an amendment made by
this Act), may not subject an individual or institutional health care
entity to discrimination on the basis that the entity does not provide
any health care item or service furnished for the purpose of causing,
or for the purpose of assisting in causing, the death of any
individual, such as by assisted suicide, euthanasia, or mercy killing.
(b) Definition.--In this section, the term ``health care entity''
includes an individual physician or other health care professional, a
hospital, a provider-sponsored organization, a health maintenance
organization, a health insurance plan, or any other kind of health care
facility, organization, or plan.
(c) Construction and Treatment of Certain Services.--Nothing in
subsection (a) shall be construed to apply to, or to affect, any
limitation relating to--
(1) the withholding or withdrawing of medical treatment or
medical care;
(2) the withholding or withdrawing of nutrition or
hydration;
(3) abortion; or
(4) the use of an item, good, benefit, or service furnished
for the purpose of alleviating pain or discomfort, even if such
use may increase the risk of death, so long as such item, good,
benefit, or service is not also furnished for the purpose of
causing, or the purpose of assisting in causing, death, for any
reason.
(d) Administration.--The Office for Civil Rights of the Department
of Health and Human Services is designated to receive complaints of
discrimination based on this section.
SEC. 1554. ACCESS TO THERAPIES.
Notwithstanding any other provision of this Act, the Secretary of
Health and Human Services shall not promulgate any regulation that--
(1) creates any unreasonable barriers to the ability of
individuals to obtain appropriate medical care;
(2) impedes timely access to health care services;
(3) interferes with communications regarding a full range
of treatment options between the patient and the provider;
(4) restricts the ability of health care providers to
provide full disclosure of all relevant information to patients
making health care decisions;
(5) violates the principles of informed consent and the
ethical standards of health care professionals; or
(6) limits the availability of health care treatment for
the full duration of a patient's medical needs.
SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH INSURANCE
PROGRAMS.
No individual, company, business, nonprofit entity, or health
insurance issuer offering group or individual health insurance coverage
shall be required to participate in any Federal health insurance
program created under this Act (or any amendments made by this Act), or
in any Federal health insurance program expanded by this Act (or any
such amendments), and there shall be no penalty or fine imposed upon
any such issuer for choosing not to participate in such programs.
SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS.
(a) Rebuttable Presumption.--Section 411(c)(4) of the Black Lung
Benefits Act (30 U.S.C. 921(c)(4)) is amended by striking the last
sentence.
(b) Continuation of Benefits.--Section 422(l) of the Black Lung
Benefits Act (30 U.S.C. 932(l)) is amended by striking ``, except with
respect to a claim filed under this part on or after the effective date
of the Black Lung Benefits Amendments of 1981''.
(c) Effective Date.--The amendments made by this section shall
apply with respect to claims filed under part B or part C of the Black
Lung Benefits Act (30 U.S.C. 921 et seq., 931 et seq.) after January 1,
2005, that are pending on or after the date of enactment of this Act.
SEC. 1557. NONDISCRIMINATION.
(a) In General.--Except as otherwise provided for in this title (or
an amendment made by this title), an individual shall not, on the
ground prohibited under title VI of the Civil Rights Act of 1964 (42
U.S.C. 2000d et seq.), title IX of the Education Amendments of 1972 (20
U.S.C. 1681 et seq.), the Age Discrimination Act of 1975 (42 U.S.C.
6101 et seq.), or section 504 of the Rehabilitation Act of 1973 (29
U.S.C. 794), be excluded from participation in, be denied the benefits
of, or be subjected to discrimination under, any health program or
activity, any part of which is receiving Federal financial assistance,
including credits, subsidies, or contracts of insurance, or under any
program or activity that is administered by an Executive Agency or any
entity established under this title (or amendments). The enforcement
mechanisms provided for and available under such title VI, title IX,
section 504, or such Age Discrimination Act shall apply for purposes of
violations of this subsection.
(b) Continued Application of Laws.--Nothing in this title (or an
amendment made by this title) shall be construed to invalidate or limit
the rights, remedies, procedures, or legal standards available to
individuals aggrieved under title VI of the Civil Rights Act of 1964
(42 U.S.C. 2000d et seq.), title VII of the Civil Rights Act of 1964
(42 U.S.C. 2000e et seq.), title IX of the Education Amendments of 1972
(20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation Act of 1973
(29 U.S.C. 794), or the Age Discrimination Act of 1975 (42 U.S.C. 611
et seq.), or to supersede State laws that provide additional
protections against discrimination on any basis described in subsection
(a).
(c) Regulations.--The Secretary may promulgate regulations to
implement this section.
SEC. 1558. PROTECTIONS FOR EMPLOYEES.
The Fair Labor Standards Act of 1938 is amended by inserting after
section 18B (as added by section 1512) the following:
``SEC. 18C. PROTECTIONS FOR EMPLOYEES.
``(a) Prohibition.--No employer shall discharge or in any manner
discriminate against any employee with respect to his or her
compensation, terms, conditions, or other privileges of employment
because the employee (or an individual acting at the request of the
employee) has--
``(1) received a credit under section 36B of the Internal
Revenue Code of 1986 or a subsidy under section 1402 of this
Act;
``(2) provided, caused to be provided, or is about to
provide or cause to be provided to the employer, the Federal
Government, or the attorney general of a State information
relating to any violation of, or any act or omission the
employee reasonably believes to be a violation of, any
provision of this title (or an amendment made by this title);
``(3) testified or is about to testify in a proceeding
concerning such violation;
``(4) assisted or participated, or is about to assist or
participate, in such a proceeding; or
``(5) objected to, or refused to participate in, any
activity, policy, practice, or assigned task that the employee
(or other such person) reasonably believed to be in violation
of any provision of this title (or amendment), or any order,
rule, regulation, standard, or ban under this title (or
amendment).
``(b) Complaint Procedure.--
``(1) In general.--An employee who believes that he or she
has been discharged or otherwise discriminated against by any
employer in violation of this section may seek relief in
accordance with the procedures, notifications, burdens of
proof, remedies, and statutes of limitation set forth in
section 2087(b) of title 15, United States Code.
``(2) No limitation on rights.--Nothing in this section
shall be deemed to diminish the rights, privileges, or remedies
of any employee under any Federal or State law or under any
collective bargaining agreement. The rights and remedies in
this section may not be waived by any agreement, policy, form,
or condition of employment.''.
SEC. 1559. OVERSIGHT.
The Inspector General of the Department of Health and Human
Services shall have oversight authority with respect to the
administration and implementation of this title as it relates to such
Department.
SEC. 1560. RULES OF CONSTRUCTION.
(a) No Effect on Antitrust Laws.--Nothing in this title (or an
amendment made by this title) shall be construed to modify, impair, or
supersede the operation of any of the antitrust laws. For the purposes
of this section, the term ``antitrust laws'' has the meaning given such
term in subsection (a) of the first section of the Clayton Act, except
that such term includes section 5 of the Federal Trade Commission Act
to the extent that such section 5 applies to unfair methods of
competition.
(b) Rule of Construction Regarding Hawaii's Prepaid Health Care
Act.--Nothing in this title (or an amendment made by this title) shall
be construed to modify or limit the application of the exemption for
Hawaii's Prepaid Health Care Act (Haw. Rev. Stat. Sec. Sec. 393-1 et
seq.) as provided for under section 514(b)(5) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)).
(c) Student Health Insurance Plans.--Nothing in this title (or an
amendment made by this title) shall be construed to prohibit an
institution of higher education (as such term is defined for purposes
of the Higher Education Act of 1965) from offering a student health
insurance plan, to the extent that such requirement is otherwise
permitted under applicable Federal, State or local law.
(d) No Effect on Existing Requirements.--Nothing in this title (or
an amendment made by this title, unless specified by direct statutory
reference) shall be construed to modify any existing Federal
requirement concerning the State agency responsible for determining
eligibility for programs identified in section 1413.
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS AND
PROTOCOLS.
Title XXX of the Public Health Service Act (42 U.S.C. 300jj et
seq.) is amended by adding at the end the following:
``Subtitle C--Other Provisions
``SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS AND
PROTOCOLS.
``(a) In General.--
``(1) Standards and protocols.--Not later than 180 days
after the date of enactment of this title, the Secretary, in
consultation with the HIT Policy Committee and the HIT
Standards Committee, shall develop interoperable and secure
standards and protocols that facilitate enrollment of
individuals in Federal and State health and human services
programs, as determined by the Secretary.
``(2) Methods.--The Secretary shall facilitate enrollment
in such programs through methods determined appropriate by the
Secretary, which shall include providing individuals and third
parties authorized by such individuals and their designees
notification of eligibility and verification of eligibility
required under such programs.
``(b) Content.--The standards and protocols for electronic
enrollment in the Federal and State programs described in subsection
(a) shall allow for the following:
``(1) Electronic matching against existing Federal and
State data, including vital records, employment history,
enrollment systems, tax records, and other data determined
appropriate by the Secretary to serve as evidence of
eligibility and in lieu of paper-based documentation.
``(2) Simplification and submission of electronic
documentation, digitization of documents, and systems
verification of eligibility.
``(3) Reuse of stored eligibility information (including
documentation) to assist with retention of eligible
individuals.
``(4) Capability for individuals to apply, recertify and
manage their eligibility information online, including at home,
at points of service, and other community-based locations.
``(5) Ability to expand the enrollment system to integrate
new programs, rules, and functionalities, to operate at
increased volume, and to apply streamlined verification and
eligibility processes to other Federal and State programs, as
appropriate.
``(6) Notification of eligibility, recertification, and
other needed communication regarding eligibility, which may
include communication via email and cellular phones.
``(7) Other functionalities necessary to provide eligibles
with streamlined enrollment process.
``(c) Approval and Notification.--With respect to any standard or
protocol developed under subsection (a) that has been approved by the
HIT Policy Committee and the HIT Standards Committee, the Secretary--
``(1) shall notify States of such standards or protocols;
and
``(2) may require, as a condition of receiving Federal
funds for the health information technology investments, that
States or other entities incorporate such standards and
protocols into such investments.
``(d) Grants for Implementation of Appropriate Enrollment HIT.--
``(1) In general.--The Secretary shall award grant to
eligible entities to develop new, and adapt existing,
technology systems to implement the HIT enrollment standards
and protocols developed under subsection (a) (referred to in
this subsection as `appropriate HIT technology').
``(2) Eligible entities.--To be eligible for a grant under
this subsection, an entity shall--
``(A) be a State, political subdivision of a State,
or a local governmental entity; and
``(B) submit to the Secretary an application at
such time, in such manner, and containing--
``(i) a plan to adopt and implement
appropriate enrollment technology that
includes--
``(I) proposed reduction in
maintenance costs of technology
systems;
``(II) elimination or updating of
legacy systems; and
``(III) demonstrated collaboration
with other entities that may receive a
grant under this section that are
located in the same State, political
subdivision, or locality;
``(ii) an assurance that the entity will
share such appropriate enrollment technology in
accordance with paragraph (4); and
``(iii) such other information as the
Secretary may require.
``(3) Sharing.--
``(A) In general.--The Secretary shall ensure that
appropriate enrollment HIT adopted under grants under
this subsection is made available to other qualified
State, qualified political subdivisions of a State, or
other appropriate qualified entities (as described in
subparagraph (B)) at no cost.
``(B) Qualified entities.--The Secretary shall
determine what entities are qualified to receive
enrollment HIT under subparagraph (A), taking into
consideration the recommendations of the HIT Policy
Committee and the HIT Standards Committee.''.
SEC. 1562. CONFORMING AMENDMENTS.
(a) Applicability.--Section 2735 of the Public Health Service Act
(42 U.S.C. 300gg-21), as so redesignated by section 1001(4), is
amended--
(1) by striking subsection (a);
(2) in subsection (b)--
(A) in paragraph (1), by striking ``1 through 3''
and inserting ``1 and 2''; and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking
``subparagraph (D)'' and inserting
``subparagraph (D) or (E)'';
(ii) by striking ``1 through 3'' and
inserting ``1 and 2''; and
(iii) by adding at the end the following:
``(E) Election not applicable.--The election
described in subparagraph (A) shall not be available
with respect to the provisions of subpart 1.'';
(3) in subsection (c), by striking ``1 through 3 shall not
apply to any group'' and inserting ``1 and 2 shall not apply to
any individual coverage or any group''; and
(4) in subsection (d)--
(A) in paragraph (1), by striking ``1 through 3
shall not apply to any group'' and inserting ``1 and 2
shall not apply to any individual coverage or any
group'';
(B) in paragraph (2)--
(i) in the matter preceding subparagraph
(A), by striking ``1 through 3 shall not apply
to any group'' and inserting ``1 and 2 shall
not apply to any individual coverage or any
group''; and
(ii) in subparagraph (C), by inserting
``or, with respect to individual coverage,
under any health insurance coverage maintained
by the same health insurance issuer''; and
(C) in paragraph (3), by striking ``any group'' and
inserting ``any individual coverage or any group''.
(b) Definitions.--Section 2791(d) of the Public Health Service Act
(42 U.S.C. 300gg-91(d)) is amended by adding at the end the following:
``(20) Qualified health plan.--The term `qualified health
plan' has the meaning given such term in section 1301(a) of the
Patient Protection and Affordable Care Act.
``(21) Exchange.--The term `Exchange' means an American
Health Benefit Exchange established under section 1311 of the
Patient Protection and Affordable Care Act.''.
(c) Technical and Conforming Amendments.--Title XXVII of the Public
Health Service Act (42 U.S.C. 300gg et seq.) is amended--
(1) in section 2704 (42 U.S.C. 300gg), as so redesignated
by section 1201(2)--
(A) in subsection (c)--
(i) in paragraph (2), by striking ``group
health plan'' each place that such term appears
and inserting ``group or individual health
plan''; and
(ii) in paragraph (3)--
(I) by striking ``group health
insurance'' each place that such term
appears and inserting ``group or
individual health insurance''; and
(II) in subparagraph (D), by
striking ``small or large'' and
inserting ``individual or group'';
(B) in subsection (d), by striking ``group health
insurance'' each place that such term appears and
inserting ``group or individual health insurance''; and
(C) in subsection (e)(1)(A), by striking ``group
health insurance'' and inserting ``group or individual
health insurance'';
(2) by striking the second heading for subpart 2 of part A
(relating to other requirements);
(3) in section 2725 (42 U.S.C. 300gg-4), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``health
insurance issuer offering group health insurance
coverage'' and inserting ``health insurance issuer
offering group or individual health insurance
coverage'';
(B) in subsection (b)--
(i) by striking ``health insurance issuer
offering group health insurance coverage in
connection with a group health plan'' in the
matter preceding paragraph (1) and inserting
``health insurance issuer offering group or
individual health insurance coverage''; and
(ii) in paragraph (1), by striking ``plan''
and inserting ``plan or coverage'';
(C) in subsection (c)--
(i) in paragraph (2), by striking ``group
health insurance coverage offered by a health
insurance issuer'' and inserting ``health
insurance issuer offering group or individual
health insurance coverage''; and
(ii) in paragraph (3), by striking
``issuer'' and inserting ``health insurance
issuer''; and
(D) in subsection (e), by striking ``health
insurance issuer offering group health insurance
coverage'' and inserting ``health insurance issuer
offering group or individual health insurance
coverage'';
(4) in section 2726 (42 U.S.C. 300gg-5), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``(or health
insurance coverage offered in connection with such a
plan)'' each place that such term appears and inserting
``or a health insurance issuer offering group or
individual health insurance coverage'';
(B) in subsection (b), by striking ``(or health
insurance coverage offered in connection with such a
plan)'' each place that such term appears and inserting
``or a health insurance issuer offering group or
individual health insurance coverage''; and
(C) in subsection (c)--
(i) in paragraph (1), by striking ``(and
group health insurance coverage offered in
connection with a group health plan)'' and
inserting ``and a health insurance issuer
offering group or individual health insurance
coverage'';
(ii) in paragraph (2), by striking ``(or
health insurance coverage offered in connection
with such a plan)'' each place that such term
appears and inserting ``or a health insurance
issuer offering group or individual health
insurance coverage'';
(5) in section 2727 (42 U.S.C. 300gg-6), as so redesignated
by section 1001(2), by striking ``health insurance issuers
providing health insurance coverage in connection with group
health plans'' and inserting ``and health insurance issuers
offering group or individual health insurance coverage'';
(6) in section 2728 (42 U.S.C. 300gg-7), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``health
insurance coverage offered in connection with such
plan'' and inserting ``individual health insurance
coverage'';
(B) in subsection (b)--
(i) in paragraph (1), by striking ``or a
health insurance issuer that provides health
insurance coverage in connection with a group
health plan'' and inserting ``or a health
insurance issuer that offers group or
individual health insurance coverage'';
(ii) in paragraph (2), by striking ``health
insurance coverage offered in connection with
the plan'' and inserting ``individual health
insurance coverage''; and
(iii) in paragraph (3), by striking
``health insurance coverage offered by an
issuer in connection with such plan'' and
inserting ``individual health insurance
coverage'';
(C) in subsection (c), by striking ``health
insurance issuer providing health insurance coverage in
connection with a group health plan'' and inserting
``health insurance issuer that offers group or
individual health insurance coverage''; and
(D) in subsection (e)(1), by striking ``health
insurance coverage offered in connection with such a
plan'' and inserting ``individual health insurance
coverage'';
(7) by striking the heading for subpart 3;
(8) in section 2731 (42 U.S.C. 300gg-11), as so
redesignated by section 1001(3)--
(A) by striking the section heading and all that
follows through subsection (b);
(B) in subsection (c)--
(i) in paragraph (1)--
(I) in the matter preceding
subparagraph (A), by striking ``small
group'' and inserting ``group and
individual''; and
(II) in subparagraph (B)--
(aa) in the matter
preceding clause (i), by
inserting ``and individuals''
after ``employers'';
(bb) in clause (i), by
inserting ``or any additional
individuals'' after
``additional groups''; and
(cc) in clause (ii), by
striking ``without regard to
the claims experience of those
employers and their employees
(and their dependents) or any
health status-related factor
relating to such'' and
inserting ``and individuals
without regard to the claims
experience of those
individuals, employers and
their employees (and their
dependents) or any health
status-related factor relating
to such individuals''; and
(ii) in paragraph (2), by striking ``small
group'' and inserting ``group or individual'';
(C) in subsection (d)--
(i) by striking ``small group'' each place
that such appears and inserting ``group or
individual''; and
(ii) in paragraph (1)(B)--
(I) by striking ``all employers''
and inserting ``all employers and
individuals'';
(II) by striking ``those
employers'' and inserting ``those
individuals, employers''; and
(III) by striking ``such
employees'' and inserting ``such
individuals, employees'';
(D) by striking subsection (e);
(E) by striking subsection (f); and
(F) by transferring such section (as amended by
this paragraph) to appear at the end of section 2702
(as added by section 1001(4));
(9) in section 2732 (42 U.S.C. 300gg-12), as so
redesignated by section 1001(3)--
(A) by striking the section heading and all that
follows through subsection (a);
(B) in subsection (b)--
(i) in the matter preceding paragraph (1),
by striking ``group health plan in the small or
large group market'' and inserting ``health
insurance coverage offered in the group or
individual market'';
(ii) in paragraph (1), by inserting ``, or
individual, as applicable,'' after ``plan
sponsor'';
(iii) in paragraph (2), by inserting ``, or
individual, as applicable,'' after ``plan
sponsor''; and
(iv) by striking paragraph (3) and
inserting the following:
``(3) Violation of participation or contribution rates.--In
the case of a group health plan, the plan sponsor has failed to
comply with a material plan provision relating to employer
contribution or group participation rules, pursuant to
applicable State law.'';
(C) in subsection (c)--
(i) in paragraph (1)--
(I) in the matter preceding
subparagraph (A), by striking ``group
health insurance coverage offered in
the small or large group market'' and
inserting ``group or individual health
insurance coverage'';
(II) in subparagraph (A), by
inserting ``or individual, as
applicable,'' after ``plan sponsor'';
(III) in subparagraph (B)--
(aa) by inserting ``or
individual, as applicable,''
after ``plan sponsor''; and
(bb) by inserting ``or
individual health insurance
coverage''; and
(IV) in subparagraph (C), by
inserting ``or individuals, as
applicable,'' after ``those sponsors'';
and
(ii) in paragraph (2)(A)--
(I) in the matter preceding clause
(i), by striking ``small group market
or the large group market, or both
markets,'' and inserting ``individual
or group market, or all markets,''; and
(II) in clause (i), by inserting
``or individual, as applicable,'' after
``plan sponsor''; and
(D) by transferring such section (as amended by
this paragraph) to appear at the end of section 2703
(as added by section 1001(4));
(10) in section 2733 (42 U.S.C. 300gg-13), as so
redesignated by section 1001(4)--
(A) in subsection (a)--
(i) in the matter preceding paragraph (1),
by striking ``small employer'' and inserting
``small employer or an individual'';
(ii) in paragraph (1), by inserting ``, or
individual, as applicable,'' after ``employer''
each place that such appears; and
(iii) in paragraph (2), by striking ``small
employer'' and inserting ``employer, or
individual, as applicable,'';
(B) in subsection (b)--
(i) in paragraph (1)--
(I) in the matter preceding
subparagraph (A), by striking ``small
employer'' and inserting ``employer, or
individual, as applicable,'';
(II) in subparagraph (A), by adding
``and'' at the end;
(III) by striking subparagraphs (B)
and (C); and
(IV) in subparagraph (D)--
(aa) by inserting ``, or
individual, as applicable,''
after ``employer''; and
(bb) by redesignating such
subparagraph as subparagraph
(B);
(ii) in paragraph (2)--
(I) by striking ``small employers''
each place that such term appears and
inserting ``employers, or individuals,
as applicable,''; and
(II) by striking ``small employer''
and inserting ``employer, or
individual, as applicable,''; and
(C) by redesignating such section (as amended by
this paragraph) as section 2709 and transferring such
section to appear after section 2708 (as added by
section 1001(5));
(11) by redesignating subpart 4 as subpart 2;
(12) in section 2735 (42 U.S.C. 300gg-21), as so
redesignated by section 1001(4)--
(A) by striking subsection (a);
(B) by striking ``subparts 1 through 3'' each place
that such appears and inserting ``subpart 1'';
(C) by redesignating subsections (b) through (e) as
subsections (a) through (d), respectively; and
(D) by redesignating such section (as amended by
this paragraph) as section 2722;
(13) in section 2736 (42 U.S.C. 300gg-22), as so
redesignated by section 1001(4)--
(A) in subsection (a)--
(i) in paragraph (1), by striking ``small
or large group markets'' and inserting
``individual or group market''; and
(ii) in paragraph (2), by inserting ``or
individual health insurance coverage'' after
``group health plans'';
(B) in subsection (b)(1)(B), by inserting
``individual health insurance coverage or'' after
``respect to''; and
(C) by redesignating such section (as amended by
this paragraph) as section 2723;
(14) in section 2737(a)(1) (42 U.S.C. 300gg-23), as so
redesignated by section 1001(4)--
(A) by inserting ``individual or'' before ``group
health insurance''; and
(B) by redesignating such section(as amended by
this paragraph) as section 2724;
(15) in section 2762 (42 U.S.C. 300gg-62)--
(A) in the section heading by inserting ``and
application'' before the period; and
(B) by adding at the end the following:
``(c) Application of Part A Provisions.--
``(1) In general.--The provisions of part A shall apply to
health insurance issuers providing health insurance coverage in
the individual market in a State as provided for in such part.
``(2) Clarification.--To the extent that any provision of
this part conflicts with a provision of part A with respect to
health insurance issuers providing health insurance coverage in
the individual market in a State, the provisions of such part A
shall apply.''; and
(16) in section 2791(e) (42 U.S.C. 300gg-91(e))--
(A) in paragraph (2), by striking ``51'' and
inserting ``101''; and
(B) in paragraph (4)--
(i) by striking ``at least 2'' each place
that such appears and inserting ``at least 1'';
and
(ii) by striking ``50'' and inserting
``100''.
(d) Application.--Notwithstanding any other provision of the
Patient Protection and Affordable Care Act, nothing in such Act (or an
amendment made by such Act) shall be construed to--
(1) prohibit (or authorize the Secretary of Health and
Human Services to promulgate regulations that prohibit) a group
health plan or health insurance issuer from carrying out
utilization management techniques that are commonly used as of
the date of enactment of this Act; or
(2) restrict the application of the amendments made by this
subtitle.
(e) Technical Amendment to the Employee Retirement Income Security
Act of 1974.--Subpart B of part 7 of subtitle A of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181 et.
seq.) is amended, by adding at the end the following:
``SEC. 715. ADDITIONAL MARKET REFORMS.
``(a) General Rule.--Except as provided in subsection (b)--
``(1) the provisions of part A of title XXVII of the Public
Health Service Act (as amended by the Patient Protection and
Affordable Care Act) shall apply to group health plans, and
health insurance issuers providing health insurance coverage in
connection with group health plans, as if included in this
subpart; and
``(2) to the extent that any provision of this part
conflicts with a provision of such part A with respect to group
health plans, or health insurance issuers providing health
insurance coverage in connection with group health plans, the
provisions of such part A shall apply.
``(b) Exception.--Notwithstanding subsection (a), the provisions of
sections 2716 and 2718 of title XXVII of the Public Health Service Act
(as amended by the Patient Protection and Affordable Care Act) shall
not apply with respect to self-insured group health plans, and the
provisions of this part shall continue to apply to such plans as if
such sections of the Public Health Service Act (as so amended) had not
been enacted.''.
(f) Technical Amendment to the Internal Revenue Code of 1986.--
Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is
amended by adding at the end the following:
``SEC. 9815. ADDITIONAL MARKET REFORMS.
``(a) General Rule.--Except as provided in subsection (b)--
``(1) the provisions of part A of title XXVII of the Public
Health Service Act (as amended by the Patient Protection and
Affordable Care Act) shall apply to group health plans, and
health insurance issuers providing health insurance coverage in
connection with group health plans, as if included in this
subchapter; and
``(2) to the extent that any provision of this subchapter
conflicts with a provision of such part A with respect to group
health plans, or health insurance issuers providing health
insurance coverage in connection with group health plans, the
provisions of such part A shall apply.
``(b) Exception.--Notwithstanding subsection (a), the provisions of
sections 2716 and 2718 of title XXVII of the Public Health Service Act
(as amended by the Patient Protection and Affordable Care Act) shall
not apply with respect to self-insured group health plans, and the
provisions of this subchapter shall continue to apply to such plans as
if such sections of the Public Health Service Act (as so amended) had
not been enacted.''.
SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL RESPONSIBILITY.
(a) Findings.--The Senate makes the following findings:
(1) Based on Congressional Budget Office (CBO) estimates,
this Act will reduce the Federal deficit between 2010 and 2019.
(2) CBO projects this Act will continue to reduce budget
deficits after 2019.
(3) Based on CBO estimates, this Act will extend the
solvency of the Medicare HI Trust Fund.
(4) This Act will increase the surplus in the Social
Security Trust Fund, which should be reserved to strengthen the
finances of Social Security.
(5) The initial net savings generated by the Community
Living Assistance Services and Supports (CLASS) program are
necessary to ensure the long-term solvency of that program.
(b) Sense of the Senate.--It is the sense of the Senate that--
(1) the additional surplus in the Social Security Trust
Fund generated by this Act should be reserved for Social
Security and not spent in this Act for other purposes; and
(2) the net savings generated by the CLASS program should
be reserved for the CLASS program and not spent in this Act for
other purposes.
TITLE II--ROLE OF PUBLIC PROGRAMS
Subtitle A--Improved Access to Medicaid
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPULATIONS.
(a) Coverage for Individuals With Income at or Below 133 Percent of
the Poverty Line.--
(1) Beginning 2014.--Section 1902(a)(10)(A)(i) of the
Social Security Act (42 U.S.C. 1396a) is amended--
(A) by striking ``or'' at the end of subclause
(VI);
(B) by adding ``or'' at the end of subclause (VII);
and
(C) by inserting after subclause (VII) the
following:
``(VIII) beginning January 1, 2014,
who are under 65 years of age, not
pregnant, not entitled to, or enrolled
for, benefits under part A of title
XVIII, or enrolled for benefits under
part B of title XVIII, and are not
described in a previous subclause of
this clause, and whose income (as
determined under subsection (e)(14))
does not exceed 133 percent of the
poverty line (as defined in section
2110(c)(5)) applicable to a family of
the size involved, subject to
subsection (k);''.
(2) Provision of at least minimum essential coverage.--
(A) In general.--Section 1902 of such Act (42
U.S.C. 1396a) is amended by inserting after subsection
(j) the following:
``(k)(1) The medical assistance provided to an individual described
in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of
benchmark coverage described in section 1937(b)(1) or benchmark
equivalent coverage described in section 1937(b)(2). Such medical
assistance shall be provided subject to the requirements of section
1937, without regard to whether a State otherwise has elected the
option to provide medical assistance through coverage under that
section, unless an individual described in subclause (VIII) of
subsection (a)(10)(A)(i) is also an individual for whom, under
subparagraph (B) of section 1937(a)(2), the State may not require
enrollment in benchmark coverage described in subsection (b)(1) of
section 1937 or benchmark equivalent coverage described in subsection
(b)(2) of that section.''.
(B) Conforming amendment.--Section 1903(i) of the
Social Security Act, as amended by section 6402(c), is
amended--
(i) in paragraph (24), by striking ``or''
at the end;
(ii) in paragraph (25), by striking the
period and inserting ``; or''; and
(iii) by adding at the end the following:
``(26) with respect to any amounts expended for medical
assistance for individuals described in subclause (VIII) of
subsection (a)(10)(A)(i) other than medical assistance provided
through benchmark coverage described in section 1937(b)(1) or
benchmark equivalent coverage described in section
1937(b)(2).''.
(3) Federal funding for cost of covering newly eligible
individuals.--Section 1905 of the Social Security Act (42
U.S.C. 1396d), is amended--
(A) in subsection (b), in the first sentence, by
inserting ``subsection (y) and'' before ``section
1933(d)''; and
(B) by adding at the end the following new
subsection:
``(y) Increased FMAP for Medical Assistance for Newly Eligible
Mandatory Individuals.--
``(1) Amount of increase.--
``(A) 100 percent fmap.--During the period that
begins on January 1, 2014, and ends on December 31,
2016, notwithstanding subsection (b), the Federal
medical assistance percentage determined for a State
that is one of the 50 States or the District of
Columbia for each fiscal year occurring during that
period with respect to amounts expended for medical
assistance for newly eligible individuals described in
subclause (VIII) of section 1902(a)(10)(A)(i) shall be
equal to 100 percent.
``(B) 2017 and 2018.--
``(i) In general.--During the period that
begins on January 1, 2017, and ends on December
31, 2018, notwithstanding subsection (b) and
subject to subparagraph (D), the Federal
medical assistance percentage determined for a
State that is one of the 50 States or the
District of Columbia for each fiscal year
occurring during that period with respect to
amounts expended for medical assistance for
newly eligible individuals described in
subclause (VIII) of section 1902(a)(10)(A)(i),
shall be increased by the applicable percentage
point increase specified in clause (ii) for the
quarter and the State.
``(ii) Applicable percentage point
increase.--
``(I) In general.--For purposes of
clause (i), the applicable percentage
point increase for a quarter is the
following:
----------------------------------------------------------------------------------------------------------------
If the State is an expansion State, If the State is not an expansion
``For any fiscal year quarter the applicable percentage point State, the applicable percentage
occurring in the calendar year: increase is: point increase is:
----------------------------------------------------------------------------------------------------------------
2017 30.3 34.3
----------------------------------------------------------------------------------------------------------------
2018 31.3 33.3
----------------------------------------------------------------------------------------------------------------
``(II) Expansion state defined.--
For purposes of the table in subclause
(I), a State is an expansion State if,
on the date of the enactment of the
Patient Protection and Affordable Care
Act, the State offers health benefits
coverage statewide to parents and
nonpregnant, childless adults whose
income is at least 100 percent of the
poverty line, that is not dependent on
access to employer coverage, employer
contribution, or employment and is not
limited to premium assistance,
hospital-only benefits, a high
deductible health plan, or alternative
benefits under a demonstration program
authorized under section 1938. A State
that offers health benefits coverage to
only parents or only nonpregnant
childless adults described in the
preceding sentence shall not be
considered to be an expansion State.
``(C) 2019 and succeeding years.--Beginning January
1, 2019, notwithstanding subsection (b) but subject to
subparagraph (D), the Federal medical assistance
percentage determined for a State that is one of the 50
States or the District of Columbia for each fiscal year
quarter occurring during that period with respect to
amounts expended for medical assistance for newly
eligible individuals described in subclause (VIII) of
section 1902(a)(10)(A)(i), shall be increased by 32.3
percentage points.
``(D) Limitation.--The Federal medical assistance
percentage determined for a State under subparagraph
(B) or (C) shall in no case be more than 95 percent.
``(2) Definitions.--In this subsection:
``(A) Newly eligible.--The term `newly eligible'
means, with respect to an individual described in
subclause (VIII) of section 1902(a)(10)(A)(i), an
individual who is not under 19 years of age (or such
higher age as the State may have elected) and who, on
the date of enactment of the Patient Protection and
Affordable Care Act, is not eligible under the State
plan or under a waiver of the plan for full benefits or
for benchmark coverage described in subparagraph (A),
(B), or (C) of section 1937(b)(1) or benchmark
equivalent coverage described in section 1937(b)(2)
that has an aggregate actuarial value that is at least
actuarially equivalent to benchmark coverage described
in subparagraph (A), (B), or (C) of section 1937(b)(1),
or is eligible but not enrolled (or is on a waiting
list) for such benefits or coverage through a waiver
under the plan that has a capped or limited enrollment
that is full.
``(B) Full benefits.--The term `full benefits'
means, with respect to an individual, medical
assistance for all services covered under the State
plan under this title that is not less in amount,
duration, or scope, or is determined by the Secretary
to be substantially equivalent, to the medical
assistance available for an individual described in
section 1902(a)(10)(A)(i).''.
(4) State options to offer coverage earlier and presumptive
eligibility; children required to have coverage for parents to
be eligible.--
(A) In general.--Subsection (k) of section 1902 of
the Social Security Act (as added by paragraph (2)), is
amended by inserting after paragraph (1) the following:
``(2) Beginning with the first day of any fiscal year quarter that
begins on or after January 1, 2011, and before January 1, 2014, a State
may elect through a State plan amendment to provide medical assistance
to individuals who would be described in subclause (VIII) of subsection
(a)(10)(A)(i) if that subclause were effective before January 1, 2014.
A State may elect to phase-in the extension of eligibility for medical
assistance to such individuals based on income, so long as the State
does not extend such eligibility to individuals described in such
subclause with higher income before making individuals described in
such subclause with lower income eligible for medical assistance.
``(3) If an individual described in subclause (VIII) of subsection
(a)(10)(A)(i) is the parent of a child who is under 19 years of age (or
such higher age as the State may have elected) who is eligible for
medical assistance under the State plan or under a waiver of such plan
(under that subclause or under a State plan amendment under paragraph
(2), the individual may not be enrolled under the State plan unless the
individual's child is enrolled under the State plan or under a waiver
of the plan or is enrolled in other health insurance coverage. For
purposes of the preceding sentence, the term `parent' includes an
individual treated as a caretaker relative for purposes of carrying out
section 1931.''.
(B) Presumptive eligibility.--Section 1920 of the
Social Security Act (42 U.S.C. 1396r-1) is amended by
adding at the end the following:
``(e) If the State has elected the option to provide a presumptive
eligibility period under this section or section 1920A, the State may
elect to provide a presumptive eligibility period (as defined in
subsection (b)(1)) for individuals who are eligible for medical
assistance under clause (i)(VIII) of subsection (a)(10)(A) or section
1931 in the same manner as the State provides for such a period under
this section or section 1920A, subject to such guidance as the
Secretary shall establish.''.
(5) Conforming amendments.--
(A) Section 1902(a)(10) of such Act (42 U.S.C.
1396a(a)(10)) is amended in the matter following
subparagraph (G), by striking ``and (XIV)'' and
inserting ``(XIV)'' and by inserting ``and (XV) the
medical assistance made available to an individual
described in subparagraph (A)(i)(VIII) shall be limited
to medical assistance described in subsection (k)(1)''
before the semicolon.
(B) Section 1902(l)(2)(C) of such Act (42 U.S.C.
1396a(l)(2)(C)) is amended by striking ``100'' and
inserting ``133''.
(C) Section 1905(a) of such Act (42 U.S.C.
1396d(a)) is amended in the matter preceding paragraph
(1)--
(i) by striking ``or'' at the end of clause
(xii);
(ii) by inserting ``or'' at the end of
clause (xiii); and
(iii) by inserting after clause (xiii) the
following:
``(xiv) individuals described in section
1902(a)(10)(A)(i)(VIII),''.
(D) Section 1903(f)(4) of such Act (42 U.S.C.
1396b(f)(4)) is amended by inserting
``1902(a)(10)(A)(i)(VIII),'' after
``1902(a)(10)(A)(i)(VII),''.
(E) Section 1937(a)(1)(B) of such Act (42 U.S.C.
1396u-7(a)(1)(B)) is amended by inserting ``subclause
(VIII) of section 1902(a)(10)(A)(i) or under'' after
``eligible under''.
(b) Maintenance of Medicaid Income Eligibility.--Section 1902 of
the Social Security Act (42 U.S.C. 1396a) is amended--
(1) in subsection (a)--
(A) by striking ``and'' at the end of paragraph
(72);
(B) by striking the period at the end of paragraph
(73) and inserting ``; and''; and
(C) by inserting after paragraph (73) the following
new paragraph:
``(74) provide for maintenance of effort under the State
plan or under any waiver of the plan in accordance with
subsection (gg).''; and
(2) by adding at the end the following new subsection:
``(gg) Maintenance of Effort.--
``(1) General requirement to maintain eligibility standards
until state exchange is fully operational.--Subject to the
succeeding paragraphs of this subsection, during the period
that begins on the date of enactment of the Patient Protection
and Affordable Care Act and ends on the date on which the
Secretary determines that an Exchange established by the State
under section 1311 of the Patient Protection and Affordable
Care Act is fully operational, as a condition for receiving any
Federal payments under section 1903(a) for calendar quarters
occurring during such period, a State shall not have in effect
eligibility standards, methodologies, or procedures under the
State plan under this title or under any waiver of such plan
that is in effect during that period, that are more restrictive
than the eligibility standards, methodologies, or procedures,
respectively, under the plan or waiver that are in effect on
the date of enactment of the Patient Protection and Affordable
Care Act.
``(2) Continuation of eligibility standards for children
until october 1, 2019.--The requirement under paragraph (1)
shall continue to apply to a State through September 30, 2019,
with respect to the eligibility standards, methodologies, and
procedures under the State plan under this title or under any
waiver of such plan that are applicable to determining the
eligibility for medical assistance of any child who is under 19
years of age (or such higher age as the State may have
elected).
``(3) Nonapplication.--During the period that begins on
January 1, 2011, and ends on December 31, 2013, the requirement
under paragraph (1) shall not apply to a State with respect to
nonpregnant, nondisabled adults who are eligible for medical
assistance under the State plan or under a waiver of the plan
at the option of the State and whose income exceeds 133 percent
of the poverty line (as defined in section 2110(c)(5))
applicable to a family of the size involved if, on or after
December 31, 2010, the State certifies to the Secretary that,
with respect to the State fiscal year during which the
certification is made, the State has a budget deficit, or with
respect to the succeeding State fiscal year, the State is
projected to have a budget deficit. Upon submission of such a
certification to the Secretary, the requirement under paragraph
(1) shall not apply to the State with respect to any remaining
portion of the period described in the preceding sentence.
``(4) Determination of compliance.--
``(A) States shall apply modified gross income.--A
State's determination of income in accordance with
subsection (e)(14) shall not be considered to be
eligibility standards, methodologies, or procedures
that are more restrictive than the standards,
methodologies, or procedures in effect under the State
plan or under a waiver of the plan on the date of
enactment of the Patient Protection and Affordable Care
Act for purposes of determining compliance with the
requirements of paragraph (1), (2), or (3).
``(B) States may expand eligibility or move
waivered populations into coverage under the state
plan.--With respect to any period applicable under
paragraph (1), (2), or (3), a State that applies
eligibility standards, methodologies, or procedures
under the State plan under this title or under any
waiver of the plan that are less restrictive than the
eligibility standards, methodologies, or procedures,
applied under the State plan or under a waiver of the
plan on the date of enactment of the Patient Protection
and Affordable Care Act, or that makes individuals who,
on such date of enactment, are eligible for medical
assistance under a waiver of the State plan, after such
date of enactment eligible for medical assistance
through a State plan amendment with an income
eligibility level that is not less than the income
eligibility level that applied under the waiver, or as
a result of the application of subclause (VIII) of
section 1902(a)(10)(A)(i), shall not be considered to
have in effect eligibility standards, methodologies, or
procedures that are more restrictive than the
standards, methodologies, or procedures in effect under
the State plan or under a waiver of the plan on the
date of enactment of the Patient Protection and
Affordable Care Act for purposes of determining
compliance with the requirements of paragraph (1), (2),
or (3).''.
(c) Medicaid Benchmark Benefits Must Consist of at Least Minimum
Essential Coverage.--Section 1937(b) of such Act (42 U.S.C. 1396u-7(b))
is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by inserting ``subject to paragraphs (5) and (6),'' before
``each'';
(2) in paragraph (2)--
(A) in the matter preceding subparagraph (A), by
inserting ``subject to paragraphs (5) and (6)'' after
``subsection (a)(1),'';
(B) in subparagraph (A)--
(i) by redesignating clauses (iv) and (v)
as clauses (vi) and (vii), respectively; and
(ii) by inserting after clause (iii), the
following:
``(iv) Coverage of prescription drugs.
``(v) Mental health services.''; and
(C) in subparagraph (C)--
(i) by striking clauses (i) and (ii); and
(ii) by redesignating clauses (iii) and
(iv) as clauses (i) and (ii), respectively; and
(3) by adding at the end the following new paragraphs:
``(5) Minimum standards.--Effective January 1, 2014, any
benchmark benefit package under paragraph (1) or benchmark
equivalent coverage under paragraph (2) must provide at least
essential health benefits as described in section 1302(b) of
the Patient Protection and Affordable Care Act.
``(6) Mental health services parity.--
``(A) In general.--In the case of any benchmark
benefit package under paragraph (1) or benchmark
equivalent coverage under paragraph (2) that is offered
by an entity that is not a medicaid managed care
organization and that provides both medical and
surgical benefits and mental health or substance use
disorder benefits, the entity shall ensure that the
financial requirements and treatment limitations
applicable to such mental health or substance use
disorder benefits comply with the requirements of
section 2705(a) of the Public Health Service Act in the
same manner as such requirements apply to a group
health plan.
``(B) Deemed compliance.--Coverage provided with
respect to an individual described in section
1905(a)(4)(B) and covered under the State plan under
section 1902(a)(10)(A) of the services described in
section 1905(a)(4)(B) (relating to early and periodic
screening, diagnostic, and treatment services defined
in section 1905(r)) and provided in accordance with
section 1902(a)(43), shall be deemed to satisfy the
requirements of subparagraph (A).''.
(d) Annual Reports on Medicaid Enrollment.--
(1) State reports.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is
amended--
(A) by striking ``and'' at the end of paragraph
(73);
(B) by striking the period at the end of paragraph
(74) and inserting ``; and''; and
(C) by inserting after paragraph (74) the following
new paragraph:
``(75) provide that, beginning January 2015, and annually
thereafter, the State shall submit a report to the Secretary
that contains--
``(A) the total number of enrolled and newly
enrolled individuals in the State plan or under a
waiver of the plan for the fiscal year ending on
September 30 of the preceding calendar year,
disaggregated by population, including children,
parents, nonpregnant childless adults, disabled
individuals, elderly individuals, and such other
categories or sub-categories of individuals eligible
for medical assistance under the State plan or under a
waiver of the plan as the Secretary may require;
``(B) a description, which may be specified by
population, of the outreach and enrollment processes
used by the State during such fiscal year; and
``(C) any other data reporting determined necessary
by the Secretary to monitor enrollment and retention of
individuals eligible for medical assistance under the
State plan or under a waiver of the plan.''.
(2) Reports to congress.--Beginning April 2015, and
annually thereafter, the Secretary of Health and Human Services
shall submit a report to the appropriate committees of Congress
on the total enrollment and new enrollment in Medicaid for the
fiscal year ending on September 30 of the preceding calendar
year on a national and State-by-State basis, and shall include
in each such report such recommendations for administrative or
legislative changes to improve enrollment in the Medicaid
program as the Secretary determines appropriate.
(e) State Option for Coverage for Individuals With Income That
Exceeds 133 Percent of the Poverty Line.--
(1) Coverage as optional categorically needy group.--
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is
amended--
(A) in subsection (a)(10)(A)(ii)--
(i) in subclause (XVIII), by striking
``or'' at the end;
(ii) in subclause (XIX), by adding ``or''
at the end; and
(iii) by adding at the end the following
new subclause:
``(XX) beginning January 1, 2014,
who are under 65 years of age and are
not described in or enrolled under a
previous subclause of this clause, and
whose income (as determined under
subsection (e)(14)) exceeds 133 percent
of the poverty line (as defined in
section 2110(c)(5)) applicable to a
family of the size involved but does
not exceed the highest income
eligibility level established under the
State plan or under a waiver of the
plan, subject to subsection (hh);'' and
(B) by adding at the end the following new
subsection:
``(hh)(1) A State may elect to phase-in the extension of
eligibility for medical assistance to individuals described in
subclause (XX) of subsection (a)(10)(A)(ii) based on the categorical
group (including nonpregnant childless adults) or income, so long as
the State does not extend such eligibility to individuals described in
such subclause with higher income before making individuals described
in such subclause with lower income eligible for medical assistance.
``(2) If an individual described in subclause (XX) of subsection
(a)(10)(A)(ii) is the parent of a child who is under 19 years of age
(or such higher age as the State may have elected) who is eligible for
medical assistance under the State plan or under a waiver of such plan,
the individual may not be enrolled under the State plan unless the
individual's child is enrolled under the State plan or under a waiver
of the plan or is enrolled in other health insurance coverage. For
purposes of the preceding sentence, the term `parent' includes an
individual treated as a caretaker relative for purposes of carrying out
section 1931.''.
(2) Conforming amendments.--
(A) Section 1905(a) of such Act (42 U.S.C.
1396d(a)), as amended by subsection (a)(5)(C), is
amended in the matter preceding paragraph (1)--
(i) by striking ``or'' at the end of clause
(xiii);
(ii) by inserting ``or'' at the end of
clause (xiv); and
(iii) by inserting after clause (xiv) the
following:
``(xv) individuals described in section
1902(a)(10)(A)(ii)(XX),''.
(B) Section 1903(f)(4) of such Act (42 U.S.C.
1396b(f)(4)) is amended by inserting
``1902(a)(10)(A)(ii)(XX),'' after
``1902(a)(10)(A)(ii)(XIX),''.
(C) Section 1920(e) of such Act (42 U.S.C. 1396r-
1(e)), as added by subsection (a)(4)(B), is amended by
inserting ``or clause (ii)(XX)'' after ``clause
(i)(VIII)''.
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING MODIFIED
GROSS INCOME.
(a) In General.--Section 1902(e) of the Social Security Act (42
U.S.C. 1396a(e)) is amended by adding at the end the following:
``(14) Income determined using modified gross income.--
``(A) In general.--Notwithstanding subsection (r)
or any other provision of this title, except as
provided in subparagraph (D), for purposes of
determining income eligibility for medical assistance
under the State plan or under any waiver of such plan
and for any other purpose applicable under the plan or
waiver for which a determination of income is required,
including with respect to the imposition of premiums
and cost-sharing, a State shall use the modified gross
income of an individual and, in the case of an
individual in a family greater than 1, the household
income of such family. A State shall establish income
eligibility thresholds for populations to be eligible
for medical assistance under the State plan or a waiver
of the plan using modified gross income and household
income that are not less than the effective income
eligibility levels that applied under the State plan or
waiver on the date of enactment of the Patient
Protection and Affordable Care Act. For purposes of
complying with the maintenance of effort requirements
under subsection (gg) during the transition to modified
gross income and household income, a State shall,
working with the Secretary, establish an equivalent
income test that ensures individuals eligible for
medical assistance under the State plan or under a
waiver of the plan on the date of enactment of the
Patient Protection and Affordable Care Act, do not lose
coverage under the State plan or under a waiver of the
plan. The Secretary may waive such provisions of this
title and title XXI as are necessary to ensure that
States establish income and eligibility determination
systems that protect beneficiaries.
``(B) No income or expense disregards.--No type of
expense, block, or other income disregard shall be
applied by a State to determine income eligibility for
medical assistance under the State plan or under any
waiver of such plan or for any other purpose applicable
under the plan or waiver for which a determination of
income is required.
``(C) No assets test.--A State shall not apply any
assets or resources test for purposes of determining
eligibility for medical assistance under the State plan
or under a waiver of the plan.
``(D) Exceptions.--
``(i) Individuals eligible because of other
aid or assistance, elderly individuals,
medically needy individuals, and individuals
eligible for medicare cost-sharing.--
Subparagraphs (A), (B), and (C) shall not apply
to the determination of eligibility under the
State plan or under a waiver for medical
assistance for the following:
``(I) Individuals who are eligible
for medical assistance under the State
plan or under a waiver of the plan on a
basis that does not require a
determination of income by the State
agency administering the State plan or
waiver, including as a result of
eligibility for, or receipt of, other
Federal or State aid or assistance,
individuals who are eligible on the
basis of receiving (or being treated as
if receiving) supplemental security
income benefits under title XVI, and
individuals who are eligible as a
result of being or being deemed to be a
child in foster care under the
responsibility of the State.
``(II) Individuals who have
attained age 65.
``(III) Individuals who qualify for
medical assistance under the State plan
or under any waiver of such plan on the
basis of being blind or disabled (or
being treated as being blind or
disabled) without regard to whether the
individual is eligible for supplemental
security income benefits under title
XVI on the basis of being blind or
disabled and including an individual
who is eligible for medical assistance
on the basis of section 1902(e)(3).
``(IV) Individuals described in
subsection (a)(10)(C).
``(V) Individuals described in any
clause of subsection (a)(10)(E).
``(ii) Express lane agency findings.--In
the case of a State that elects the Express
Lane option under paragraph (13),
notwithstanding subparagraphs (A), (B), and
(C), the State may rely on a finding made by an
Express Lane agency in accordance with that
paragraph relating to the income of an
individual for purposes of determining the
individual's eligibility for medical assistance
under the State plan or under a waiver of the
plan.
``(iii) Medicare prescription drug
subsidies determinations.--Subparagraphs (A),
(B), and (C) shall not apply to any
determinations of eligibility for premium and
cost-sharing subsidies under and in accordance
with section 1860D-14 made by the State
pursuant to section 1935(a)(2).
``(iv) Long-term care.--Subparagraphs (A),
(B), and (C) shall not apply to any
determinations of eligibility of individuals
for purposes of medical assistance for nursing
facility services, a level of care in any
institution equivalent to that of nursing
facility services, home or community-based
services furnished under a waiver or State plan
amendment under section 1915 or a waiver under
section 1115, and services described in section
1917(c)(1)(C)(ii).
``(v) Grandfather of current enrollees
until date of next regular redetermination.--An
individual who, on January 1, 2014, is enrolled
in the State plan or under a waiver of the plan
and who would be determined ineligible for
medical assistance solely because of the
application of the modified gross income or
household income standard described in
subparagraph (A), shall remain eligible for
medical assistance under the State plan or
waiver (and subject to the same premiums and
cost-sharing as applied to the individual on
that date) through March 31, 2014, or the date
on which the individual's next regularly
scheduled redetermination of eligibility is to
occur, whichever is later.
``(E) Transition planning and oversight.--Each
State shall submit to the Secretary for the Secretary's
approval the income eligibility thresholds proposed to
be established using modified gross income and
household income, the methodologies and procedures to
be used to determine income eligibility using modified
gross income and household income and, if applicable, a
State plan amendment establishing an optional
eligibility category under subsection
(a)(10)(A)(ii)(XX). To the extent practicable, the
State shall use the same methodologies and procedures
for purposes of making such determinations as the State
used on the date of enactment of the Patient Protection
and Affordable Care Act. The Secretary shall ensure
that the income eligibility thresholds proposed to be
established using modified gross income and household
income, including under the eligibility category
established under subsection (a)(10)(A)(ii)(XX), and
the methodologies and procedures proposed to be used to
determine income eligibility, will not result in
children who would have been eligible for medical
assistance under the State plan or under a waiver of
the plan on the date of enactment of the Patient
Protection and Affordable Care Act no longer being
eligible for such assistance.
``(F) Limitation on secretarial authority.--The
Secretary shall not waive compliance with the
requirements of this paragraph except to the extent
necessary to permit a State to coordinate eligibility
requirements for dual eligible individuals (as defined
in section 1915(h)(2)(B)) under the State plan or under
a waiver of the plan and under title XVIII and
individuals who require the level of care provided in a
hospital, a nursing facility, or an intermediate care
facility for the mentally retarded.
``(G) Definitions of modified gross income and
household income.--In this paragraph, the terms
`modified gross income' and `household income' have the
meanings given such terms in section 36B(d)(2) of the
Internal Revenue Code of 1986.
``(H) Continued application of medicaid rules
regarding point-in-time income and sources of income.--
The requirement under this paragraph for States to use
modified gross income and household income to determine
income eligibility for medical assistance under the
State plan or under any waiver of such plan and for any
other purpose applicable under the plan or waiver for
which a determination of income is required shall not
be construed as affecting or limiting the application
of--
``(i) the requirement under this title and
under the State plan or a waiver of the plan to
determine an individual's income as of the
point in time at which an application for
medical assistance under the State plan or a
waiver of the plan is processed; or
``(ii) any rules established under this
title or under the State plan or a waiver of
the plan regarding sources of countable
income.''.
(b) Conforming Amendment.--Section 1902(a)(17) of such Act (42
U.S.C. 1396a(a)(17)) is amended by inserting ``(e)(14),'' before
``(l)(3)''.
(c) Effective Date.--The amendments made by subsections (a) and (b)
take effect on January 1, 2014.
SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR EMPLOYER-
SPONSORED INSURANCE.
(a) In General.--Section 1906A of such Act (42 U.S.C. 1396e-1) is
amended--
(1) in subsection (a)--
(A) by striking ``may elect to'' and inserting
``shall'';
(B) by striking ``under age 19''; and
(C) by inserting ``, in the case of an individual
under age 19,'' after ``(and'';
(2) in subsection (c), in the first sentence, by striking
``under age 19''; and
(3) in subsection (d)--
(A) in paragraph (2)--
(i) in the first sentence, by striking
``under age 19''; and
(ii) by striking the third sentence and
inserting ``A State may not require, as a
condition of an individual (or the individual's
parent) being or remaining eligible for medical
assistance under this title, that the
individual (or the individual's parent) apply
for enrollment in qualified employer-sponsored
coverage under this section.''; and
(B) in paragraph (3), by striking ``the parent of
an individual under age 19'' and inserting ``an
individual (or the parent of an individual)''; and
(4) in subsection (e), by striking ``under age 19'' each
place it appears.
(b) Conforming Amendment.--The heading for section 1906A of such
Act (42 U.S.C. 1396e-1) is amended by striking ``option for children''.
(c) Effective Date.--The amendments made by this section take
effect on January 1, 2014.
SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN.
(a) In General.--Section 1902(a)(10)(A)(i) of the Social Security
Act (42 U.S.C. 1396a), as amended by section 2001(a)(1), is amended--
(1) by striking ``or'' at the end of subclause (VII);
(2) by adding ``or'' at the end of subclause (VIII); and
(3) by inserting after subclause (VIII) the following:
``(IX) who were in foster care
under the responsibility of a State for
more than 6 months (whether or not
consecutive) but are no longer in such
care, who are not described in any of
subclauses (I) through (VII) of this
clause, and who are under 25 years of
age;''.
(b) Option To Provide Presumptive Eligibility.--Section 1920(e) of
such Act (42 U.S.C. 1396r-1(e)), as added by section 2001(a)(4)(B) and
amended by section 2001(e)(2)(C), is amended by inserting ``, clause
(i)(IX),'' after ``clause (i)(VIII)''.
(c) Conforming Amendments.--
(1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)),
as amended by section 2001(a)(5)(D), is amended by inserting
``1902(a)(10)(A)(i)(IX),'' after ``1902(a)(10)(A)(i)(VIII),''.
(2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C.
1396u-7(a)(2)(B)(viii)) is amended by inserting ``, or the
individual qualifies for medical assistance on the basis of
section 1902(a)(10)(A)(i)(IX)'' before the period.
(d) Effective Date.--The amendments made by this section take
effect on January 1, 2019.
SEC. 2005. PAYMENTS TO TERRITORIES.
(a) Increase in Limit on Payments.--Section 1108(g) of the Social
Security Act (42 U.S.C. 1308(g)) is amended--
(1) in paragraph (2), in the matter preceding subparagraph
(A), by striking ``paragraph (3)'' and inserting ``paragraphs
(3) and (5)'';
(2) in paragraph (4), by striking ``and (3)'' and inserting
``(3), and (4)''; and
(3) by adding at the end the following paragraph:
``(5) Fiscal year 2011 and thereafter.--The amounts
otherwise determined under this subsection for Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa for the second, third, and fourth quarters of
fiscal year 2011, and for each fiscal year after fiscal year
2011 (after the application of subsection (f) and the preceding
paragraphs of this subsection), shall be increased by 30
percent.''.
(b) Disregard of Payments for Mandatory Expanded Enrollment.--
Section 1108(g)(4) of such Act (42 U.S.C. 1308(g)(4)) is amended--
(1) by striking ``to fiscal years beginning'' and inserting
``to--
``(A) fiscal years beginning'';
(2) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following:
``(B) fiscal years beginning with fiscal year 2014,
payments made to Puerto Rico, the Virgin Islands, Guam,
the Northern Mariana Islands, or American Samoa with
respect to amounts expended for medical assistance for
newly eligible (as defined in section 1905(y)(2))
nonpregnant childless adults who are eligible under
subclause (VIII) of section 1902(a)(10)(A)(i) and whose
income (as determined under section 1902(e)(14)) does
not exceed (in the case of each such commonwealth and
territory respectively) the income eligibility level in
effect for that population under title XIX or under a
waiver on the date of enactment of the Patient
Protection and Affordable Care Act, shall not be taken
into account in applying subsection (f) (as increased
in accordance with paragraphs (1), (2), (3), and (5) of
this subsection) to such commonwealth or territory for
such fiscal year.''.
(c) Increased FMAP.--
(1) In general.--The first sentence of section 1905(b) of
the Social Security Act (42 U.S.C. 1396d(b)) is amended by
striking ``shall be 50 per centum'' and inserting ``shall be 55
percent''.
(2) Effective date.--The amendment made by paragraph (1)
takes effect on January 1, 2011.
SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR CERTAIN STATES
RECOVERING FROM A MAJOR DISASTER.
Section 1905 of the Social Security Act (42 U.S.C. 1396d), as
amended by sections 2001(a)(3) and 2001(b)(2), is amended--
(1) in subsection (b), in the first sentence, by striking
``subsection (y)'' and inserting ``subsections (y) and (aa)'';
and
(2) by adding at the end the following new subsection:
``(aa)(1) Notwithstanding subsection (b), beginning January 1,
2011, the Federal medical assistance percentage for a fiscal year for a
disaster-recovery FMAP adjustment State shall be equal to the
following:
``(A) In the case of the first fiscal year (or part of a
fiscal year) for which this subsection applies to the State,
the Federal medical assistance percentage determined for the
fiscal year without regard to this subsection and subsection
(y), increased by 50 percent of the number of percentage points
by which the Federal medical assistance percentage determined
for the State for the fiscal year without regard to this
subsection and subsection (y), is less than the Federal medical
assistance percentage determined for the State for the
preceding fiscal year after the application of only subsection
(a) of section 5001 of Public Law 111-5 (if applicable to the
preceding fiscal year) and without regard to this subsection,
subsection (y), and subsections (b) and (c) of section 5001 of
Public Law 111-5.
``(B) In the case of the second or any succeeding fiscal
year for which this subsection applies to the State, the
Federal medical assistance percentage determined for the
preceding fiscal year under this subsection for the State,
increased by 25 percent of the number of percentage points by
which the Federal medical assistance percentage determined for
the State for the fiscal year without regard to this subsection
and subsection (y), is less than the Federal medical assistance
percentage determined for the State for the preceding fiscal
year under this subsection.
``(2) In this subsection, the term `disaster-recovery FMAP
adjustment State' means a State that is one of the 50 States or the
District of Columbia, for which, at any time during the preceding 7
fiscal years, the President has declared a major disaster under section
401 of the Robert T. Stafford Disaster Relief and Emergency Assistance
Act and determined as a result of such disaster that every county or
parish in the State warrant individual and public assistance or public
assistance from the Federal Government under such Act and for which--
``(A) in the case of the first fiscal year (or part of a
fiscal year) for which this subsection applies to the State,
the Federal medical assistance percentage determined for the
State for the fiscal year without regard to this subsection and
subsection (y), is less than the Federal medical assistance
percentage determined for the State for the preceding fiscal
year after the application of only subsection (a) of section
5001 of Public Law 111-5 (if applicable to the preceding fiscal
year) and without regard to this subsection, subsection (y),
and subsections (b) and (c) of section 5001 of Public Law 111-
5, by at least 3 percentage points; and
``(B) in the case of the second or any succeeding fiscal
year for which this subsection applies to the State, the
Federal medical assistance percentage determined for the State
for the fiscal year without regard to this subsection and
subsection (y), is less than the Federal medical assistance
percentage determined for the State for the preceding fiscal
year under this subsection by at least 3 percentage points.
``(3) The Federal medical assistance percentage determined for a
disaster-recovery FMAP adjustment State under paragraph (1) shall apply
for purposes of this title (other than with respect to disproportionate
share hospital payments described in section 1923 and payments under
this title that are based on the enhanced FMAP described in 2105(b))
and shall not apply with respect to payments under title IV (other than
under part E of title IV) or payments under title XXI.''.
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION.
(a) Rescission.--Any amounts available to the Medicaid Improvement
Fund established under section 1941 of the Social Security Act (42
U.S.C. 1396w-1) for any of fiscal years 2014 through 2018 that are
available for expenditure from the Fund and that are not so obligated
as of the date of the enactment of this Act are rescinded.
(b) Conforming Amendments.--Section 1941(b)(1) of the Social
Security Act (42 U.S.C. 1396w-1(b)(1)) is amended--
(1) in subparagraph (A), by striking ``$100,000,000'' and
inserting ``$0''; and
(2) in subparagraph (B), by striking ``$150,000,000'' and
inserting ``$0''.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR CHIP.
(a) In General.--Section 2105(b) of the Social Security Act (42
U.S.C. 1397ee(b)) is amended by adding at the end the following:
``Notwithstanding the preceding sentence, during the period that begins
on October 1, 2013, and ends on September 30, 2019, the enhanced FMAP
determined for a State for a fiscal year (or for any portion of a
fiscal year occurring during such period) shall be increased by 23
percentage points, but in no case shall exceed 100 percent. The
increase in the enhanced FMAP under the preceding sentence shall not
apply with respect to determining the payment to a State under
subsection (a)(1) for expenditures described in subparagraph (D)(iv),
paragraphs (8), (9), (11) of subsection (c), or clause (4) of the first
sentence of section 1905(b).''.
(b) Maintenance of Effort.--
(1) In general.--Section 2105(d) of the Social Security Act
(42 U.S.C. 1397ee(d)) is amended by adding at the end the
following:
``(3) Continuation of eligibility standards for children
until october 1, 2019.--
``(A) In general.--During the period that begins on
the date of enactment of the Patient Protection and
Affordable Care Act and ends on September 30, 2019, a
State shall not have in effect eligibility standards,
methodologies, or procedures under its State child
health plan (including any waiver under such plan) for
children (including children provided medical
assistance for which payment is made under section
2105(a)(1)(A)) that are more restrictive than the
eligibility standards, methodologies, or procedures,
respectively, under such plan (or waiver) as in effect
on the date of enactment of that Act. The preceding
sentence shall not be construed as preventing a State
during such period from--
``(i) applying eligibility standards,
methodologies, or procedures for children under
the State child health plan or under any waiver
of the plan that are less restrictive than the
eligibility standards, methodologies, or
procedures, respectively, for children under
the plan or waiver that are in effect on the
date of enactment of such Act; or
``(ii) imposing a limitation described in
section 2112(b)(7) for a fiscal year in order
to limit expenditures under the State child
health plan to those for which Federal
financial participation is available under this
section for the fiscal year.
``(B) Assurance of exchange coverage for targeted
low-income children unable to be provided child health
assistance as a result of funding shortfalls.--In the
event that allotments provided under section 2104 are
insufficient to provide coverage to all children who
are eligible to be targeted low-income children under
the State child health plan under this title, a State
shall establish procedures to ensure that such children
are provided coverage through an Exchange established
by the State under section 1311 of the Patient
Protection and Affordable Care Act.''.
(2) Conforming amendment to title xxi medicaid maintenance
of effort.--Section 2105(d)(1) of the Social Security Act (42
U.S.C. 1397ee(d)(1)) is amended by adding before the period ``,
except as required under section 1902(e)(14)''.
(c) No Enrollment Bonus Payments for Children Enrolled After Fiscal
Year 2013.--Section 2105(a)(3)(F)(iii) of the Social Security Act (42
U.S.C. 1397ee(a)(3)(F)(iii)) is amended by inserting ``or any children
enrolled on or after October 1, 2013'' before the period.
(d) Income Eligibility Determined Using Modified Gross Income.--
(1) State plan requirement.--Section 2102(b)(1)(B) of the
Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
(A) in clause (iii), by striking ``and'' after the
semicolon;
(B) in clause (iv), by striking the period and
inserting ``; and''; and
(C) by adding at the end the following:
``(v) shall, beginning January 1, 2014, use
modified gross income and household income (as
defined in section 36B(d)(2) of the Internal
Revenue Code of 1986) to determine eligibility
for child health assistance under the State
child health plan or under any waiver of such
plan and for any other purpose applicable under
the plan or waiver for which a determination of
income is required, including with respect to
the imposition of premiums and cost-sharing,
consistent with section 1902(e)(14).''.
(2) Conforming amendment.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (E) through (L)
as subparagraphs (F) through (M), respectively; and
(B) by inserting after subparagraph (D), the
following:
``(E) Section 1902(e)(14) (relating to income
determined using modified gross income and household
income).''.
(e) Application of Streamlined Enrollment System.--Section
2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)), as
amended by subsection (d)(2), is amended by adding at the end the
following:
``(N) Section 1943(b) (relating to coordination
with State Exchanges and the State Medicaid agency).''.
(f) CHIP Eligibility for Children Ineligible for Medicaid as a
Result of Elimination of Disregards.--Notwithstanding any other
provision of law, a State shall treat any child who is determined to be
ineligible for medical assistance under the State Medicaid plan or
under a waiver of the plan as a result of the elimination of the
application of an income disregard based on expense or type of income,
as required under section 1902(e)(14) of the Social Security Act (as
added by this Act), as a targeted low-income child under section
2110(b) (unless the child is excluded under paragraph (2) of that
section) and shall provide child health assistance to the child under
the State child health plan (whether implemented under title XIX or
XXI, or both, of the Social Security Act).
SEC. 2102. TECHNICAL CORRECTIONS.
(a) CHIPRA.--Effective as if included in the enactment of the
Children's Health Insurance Program Reauthorization Act of 2009 (Public
Law 111-3) (in this section referred to as ``CHIPRA''):
(1) Section 2104(m) of the Social Security Act, as added by
section 102 of CHIPRA, is amended--
(A) by redesignating paragraph (7) as paragraph
(8); and
(B) by inserting after paragraph (6), the
following:
``(7) Adjustment of fiscal year 2010 allotments to account
for changes in projected spending for certain previously
approved expansion programs.--For purposes of recalculating the
fiscal year 2010 allotment, in the case of one of the 50 States
or the District of Columbia that has an approved State plan
amendment effective January 1, 2006, to provide child health
assistance through the provision of benefits under the State
plan under title XIX for children from birth through age 5
whose family income does not exceed 200 percent of the poverty
line, the Secretary shall increase the allotment by an amount
that would be equal to the Federal share of expenditures that
would have been claimed at the enhanced FMAP rate rather than
the Federal medical assistance percentage matching rate for
such population.''.
(2) Section 605 of CHIPRA is amended by striking ``legal
residents'' and insert ``lawfully residing in the United
States''.
(3) Subclauses (I) and (II) of paragraph (3)(C)(i) of
section 2105(a) of the Social Security Act (42 U.S.C.
1397ee(a)(3)(ii)), as added by section 104 of CHIPRA, are each
amended by striking ``, respectively''.
(4) Section 2105(a)(3)(E)(ii) of the Social Security Act
(42 U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of
CHIPRA, is amended by striking subclause (IV).
(5) Section 2105(c)(9)(B) of the Social Security Act (42
U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of
CHIPRA, is amended by striking ``section 1903(a)(3)(F)'' and
inserting ``section 1903(a)(3)(G)''.
(6) Section 2109(b)(2)(B) of the Social Security Act (42
U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, is
amended by striking ``the child population growth factor under
section 2104(m)(5)(B)'' and inserting ``a high-performing State
under section 2111(b)(3)(B)''.
(7) Section 2110(c)(9)(B)(v) of the Social Security Act (42
U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of
CHIPRA, is amended by striking ``school or school system'' and
inserting ``local educational agency (as defined under section
9101 of the Elementary and Secondary Education Act of 1965''.
(8) Section 211(a)(1)(B) of CHIPRA is amended--
(A) by striking ``is amended'' and all that follows
through ``adding'' and inserting ``is amended by
adding''; and
(B) by redesignating the new subparagraph to be
added by such section to section 1903(a)(3) of the
Social Security Act as a new subparagraph (H).
(b) ARRA.--Effective as if included in the enactment of section
5006(a) of division B of the American Recovery and Reinvestment Act of
2009 (Public Law 111-5), the second sentence of section 1916A(a)(1) of
the Social Security Act (42 U.S.C. 1396o-1(a)(1)) is amended by
striking ``or (i)'' and inserting ``, (i), or (j)''.
Subtitle C--Medicaid and CHIP Enrollment Simplification
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH STATE HEALTH
INSURANCE EXCHANGES.
Title XIX of the Social Security Act (42 U.S.C. 1397aa et seq.) is
amended by adding at the end the following:
``SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH STATE
HEALTH INSURANCE EXCHANGES.
``(a) Condition for Participation in Medicaid.--As a condition of
the State plan under this title and receipt of any Federal financial
assistance under section 1903(a) for calendar quarters beginning after
January 1, 2014, a State shall ensure that the requirements of
subsection (b) is met.
``(b) Enrollment Simplification and Coordination With State Health
Insurance Exchanges and Chip.--
``(1) In general.--A State shall establish procedures for--
``(A) enabling individuals, through an Internet
website that meets the requirements of paragraph (4),
to apply for medical assistance under the State plan or
under a waiver of the plan, to be enrolled in the State
plan or waiver, to renew their enrollment in the plan
or waiver, and to consent to enrollment or reenrollment
in the State plan through electronic signature;
``(B) enrolling, without any further determination
by the State and through such website, individuals who
are identified by an Exchange established by the State
under section 1311 of the Patient Protection and
Affordable Care Act as being eligible for--
``(i) medical assistance under the State
plan or under a waiver of the plan; or
``(ii) child health assistance under the
State child health plan under title XXI;
``(C) ensuring that individuals who apply for but
are determined to be ineligible for medical assistance
under the State plan or a waiver or ineligible for
child health assistance under the State child health
plan under title XXI, are screened for eligibility for
enrollment in qualified health plans offered through
such an Exchange and, if applicable, premium assistance
for the purchase of a qualified health plan under
section 36B of the Internal Revenue Code of 1986 (and,
if applicable, advance payment of such assistance under
section 1412 of the Patient Protection and Affordable
Care Act), and, if eligible, enrolled in such a plan
without having to submit an additional or separate
application, and that such individuals receive
information regarding reduced cost-sharing for eligible
individuals under section 1402 of the Patient
Protection and Affordable Care Act, and any other
assistance or subsidies available for coverage obtained
through the Exchange;
``(D) ensuring that the State agency responsible
for administering the State plan under this title (in
this section referred to as the `State Medicaid
agency'), the State agency responsible for
administering the State child health plan under title
XXI (in this section referred to as the `State CHIP
agency') and an Exchange established by the State under
section 1311 of the Patient Protection and Affordable
Care Act utilize a secure electronic interface
sufficient to allow for a determination of an
individual's eligibility for such medical assistance,
child health assistance, or premium assistance, and
enrollment in the State plan under this title, title
XXI, or a qualified health plan, as appropriate;
``(E) coordinating, for individuals who are
enrolled in the State plan or under a waiver of the
plan and who are also enrolled in a qualified health
plan offered through such an Exchange, and for
individuals who are enrolled in the State child health
plan under title XXI and who are also enrolled in a
qualified health plan, the provision of medical
assistance or child health assistance to such
individuals with the coverage provided under the
qualified health plan in which they are enrolled,
including services described in section 1905(a)(4)(B)
(relating to early and periodic screening, diagnostic,
and treatment services defined in section 1905(r)) and
provided in accordance with the requirements of section
1902(a)(43); and
``(F) conducting outreach to and enrolling
vulnerable and underserved populations eligible for
medical assistance under this title XIX or for child
health assistance under title XXI, including children,
unaccompanied homeless youth, children and youth with
special health care needs, pregnant women, racial and
ethnic minorities, rural populations, victims of abuse
or trauma, individuals with mental health or substance-
related disorders, and individuals with HIV/AIDS.
``(2) Agreements with state health insurance exchanges.--
The State Medicaid agency and the State CHIP agency may enter
into an agreement with an Exchange established by the State
under section 1311 of the Patient Protection and Affordable
Care Act under which the State Medicaid agency or State CHIP
agency may determine whether a State resident is eligible for
premium assistance for the purchase of a qualified health plan
under section 36B of the Internal Revenue Code of 1986 (and, if
applicable, advance payment of such assistance under section
1412 of the Patient Protection and Affordable Care Act), so
long as the agreement meets such conditions and requirements as
the Secretary of the Treasury may prescribe to reduce
administrative costs and the likelihood of eligibility errors
and disruptions in coverage.
``(3) Streamlined enrollment system.--The State Medicaid
agency and State CHIP agency shall participate in and comply
with the requirements for the system established under section
1413 of the Patient Protection and Affordable Care Act
(relating to streamlined procedures for enrollment through an
Exchange, Medicaid, and CHIP).
``(4) Enrollment website requirements.--The procedures
established by State under paragraph (1) shall include
establishing and having in operation, not later than January 1,
2014, an Internet website that is linked to any website of an
Exchange established by the State under section 1311 of the
Patient Protection and Affordable Care Act and to the State
CHIP agency (if different from the State Medicaid agency) and
allows an individual who is eligible for medical assistance
under the State plan or under a waiver of the plan and who is
eligible to receive premium credit assistance for the purchase
of a qualified health plan under section 36B of the Internal
Revenue Code of 1986 to compare the benefits, premiums, and
cost-sharing applicable to the individual under the State plan
or waiver with the benefits, premiums, and cost-sharing
available to the individual under a qualified health plan
offered through such an Exchange, including, in the case of a
child, the coverage that would be provided for the child
through the State plan or waiver with the coverage that would
be provided to the child through enrollment in family coverage
under that plan and as supplemental coverage by the State under
the State plan or waiver.
``(5) Continued need for assessment for home and community-
based services.--Nothing in paragraph (1) shall limit or modify
the requirement that the State assess an individual for
purposes of providing home and community-based services under
the State plan or under any waiver of such plan for individuals
described in subsection (a)(10)(A)(ii)(VI).''.
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE ELIGIBILITY
DETERMINATIONS FOR ALL MEDICAID ELIGIBLE POPULATIONS.
(a) In General.--Section 1902(a)(47) of the Social Security Act (42
U.S.C. 1396a(a)(47)) is amended--
(1) by striking ``at the option of the State, provide'' and
inserting ``provide--
``(A) at the option of the State,'';
(2) by inserting ``and'' after the semicolon; and
(3) by adding at the end the following:
``(B) that any hospital that is a participating
provider under the State plan may elect to be a
qualified entity for purposes of determining, on the
basis of preliminary information, whether any
individual is eligible for medical assistance under the
State plan or under a waiver of the plan for purposes
of providing the individual with medical assistance
during a presumptive eligibility period, in the same
manner, and subject to the same requirements, as apply
to the State options with respect to populations
described in section 1920, 1920A, or 1920B (but without
regard to whether the State has elected to provide for
a presumptive eligibility period under any such
sections), subject to such guidance as the Secretary
shall establish;''.
(b) Conforming Amendment.--Section 1903(u)(1)(D)(v) of such Act (42
U.S.C. 1396b(u)(1)(D)v)) is amended--
(1) by striking ``or for'' and inserting ``for''; and
(2) by inserting before the period at the end the
following: ``, or for medical assistance provided to an
individual during a presumptive eligibility period resulting
from a determination of presumptive eligibility made by a
hospital that elects under section 1902(a)(47)(B) to be a
qualified entity for such purpose''.
(c) Effective Date.--The amendments made by this section take
effect on January 1, 2014, and apply to services furnished on or after
that date.
Subtitle D--Improvements to Medicaid Services
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), is amended--
(1) in subsection (a)--
(A) in paragraph (27), by striking ``and'' at the
end;
(B) by redesignating paragraph (28) as paragraph
(29); and
(C) by inserting after paragraph (27) the following
new paragraph:
``(28) freestanding birth center services (as defined in
subsection (l)(3)(A)) and other ambulatory services that are
offered by a freestanding birth center (as defined in
subsection (l)(3)(B)) and that are otherwise included in the
plan; and''; and
(2) in subsection (l), by adding at the end the following
new paragraph:
``(3)(A) The term `freestanding birth center services' means
services furnished to an individual at a freestanding birth center (as
defined in subparagraph (B)) at such center.
``(B) The term `freestanding birth center' means a health
facility--
``(i) that is not a hospital;
``(ii) where childbirth is planned to occur away from the
pregnant woman's residence;
``(iii) that is licensed or otherwise approved by the State
to provide prenatal labor and delivery or postpartum care and
other ambulatory services that are included in the plan; and
``(iv) that complies with such other requirements relating
to the health and safety of individuals furnished services by
the facility as the State shall establish.
``(C) A State shall provide separate payments to providers
administering prenatal labor and delivery or postpartum care in a
freestanding birth center (as defined in subparagraph (B)), such as
nurse midwives and other providers of services such as birth attendants
recognized under State law, as determined appropriate by the Secretary.
For purposes of the preceding sentence, the term `birth attendant'
means an individual who is recognized or registered by the State
involved to provide health care at childbirth and who provides such
care within the scope of practice under which the individual is legally
authorized to perform such care under State law (or the State
regulatory mechanism provided by State law), regardless of whether the
individual is under the supervision of, or associated with, a physician
or other health care provider. Nothing in this subparagraph shall be
construed as changing State law requirements applicable to a birth
attendant.''.
(b) Conforming Amendment.--Section 1902(a)(10)(A) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended in the matter
preceding clause (i) by striking ``and (21)'' and inserting ``, (21),
and (28)''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of the enactment of this Act and shall apply to services
furnished on or after such date.
(2) Exception if state legislation required.--In the case
of a State plan for medical assistance under title XIX of the
Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than
legislation appropriating funds) in order for the plan to meet
the additional requirement imposed by the amendments made by
this section, the State plan shall not be regarded as failing
to comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement before
the first day of the first calendar quarter beginning after the
close of the first regular session of the State legislature
that begins after the date of the enactment of this Act. For
purposes of the previous sentence, in the case of a State that
has a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of the State
legislature.
SEC. 2302. CONCURRENT CARE FOR CHILDREN.
(a) In General.--Section 1905(o)(1) of the Social Security Act (42
U.S.C. 1396d(o)(1)) is amended--
(1) in subparagraph (A), by striking ``subparagraph (B)''
and inserting ``subparagraphs (B) and (C)''; and
(2) by adding at the end the following new subparagraph:
``(C) A voluntary election to have payment made for hospice care
for a child (as defined by the State) shall not constitute a waiver of
any rights of the child to be provided with, or to have payment made
under this title for, services that are related to the treatment of the
child's condition for which a diagnosis of terminal illness has been
made.''.
(b) Application to CHIP.--Section 2110(a)(23) of the Social
Security Act (42 U.S.C. 1397jj(a)(23)) is amended by inserting
``(concurrent, in the case of an individual who is a child, with care
related to the treatment of the child's condition with respect to which
a diagnosis of terminal illness has been made'' after ``hospice care''.
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERVICES.
(a) Coverage as Optional Categorically Needy Group.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by
section 2001(e), is amended--
(A) in subclause (XIX), by striking ``or'' at the
end;
(B) in subclause (XX), by adding ``or'' at the end;
and
(C) by adding at the end the following new
subclause:
``(XXI) who are described in
subsection (ii) (relating to
individuals who meet certain income
standards);''.
(2) Group described.--Section 1902 of such Act (42 U.S.C.
1396a), as amended by section 2001(d), is amended by adding at
the end the following new subsection:
``(ii)(1) Individuals described in this subsection are
individuals--
``(A) whose income does not exceed an income
eligibility level established by the State that does
not exceed the highest income eligibility level
established under the State plan under this title (or
under its State child health plan under title XXI) for
pregnant women; and
``(B) who are not pregnant.
``(2) At the option of a State, individuals described in
this subsection may include individuals who, had individuals
applied on or before January 1, 2007, would have been made
eligible pursuant to the standards and processes imposed by
that State for benefits described in clause (XV) of the matter
following subparagraph (G) of section subsection (a)(10)
pursuant to a waiver granted under section 1115.
``(3) At the option of a State, for purposes of subsection
(a)(17)(B), in determining eligibility for services under this
subsection, the State may consider only the income of the
applicant or recipient.''.
(3) Limitation on benefits.--Section 1902(a)(10) of the
Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by
section 2001(a)(5)(A), is amended in the matter following
subparagraph (G)--
(A) by striking ``and (XV)'' and inserting
``(XV)''; and
(B) by inserting ``, and (XVI) the medical
assistance made available to an individual described in
subsection (ii) shall be limited to family planning
services and supplies described in section
1905(a)(4)(C) including medical diagnosis and treatment
services that are provided pursuant to a family
planning service in a family planning setting'' before
the semicolon.
(4) Conforming amendments.--
(A) Section 1905(a) of the Social Security Act (42
U.S.C. 1396d(a)), as amended by section 2001(e)(2)(A),
is amended in the matter preceding paragraph (1)--
(i) in clause (xiv), by striking ``or'' at
the end;
(ii) in clause (xv), by adding ``or'' at
the end; and
(iii) by inserting after clause (xv) the
following:
``(xvi) individuals described in section
1902(ii),''.
(B) Section 1903(f)(4) of such Act (42 U.S.C.
1396b(f)(4)), as amended by section 2001(e)(2)(B), is
amended by inserting ``1902(a)(10)(A)(ii)(XXI),'' after
``1902(a)(10)(A)(ii)(XX),''.
(b) Presumptive Eligibility.--
(1) In general.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended by inserting after section
1920B the following:
``presumptive eligibility for family planning services
``Sec. 1920C. (a) State Option.--State plan approved under section
1902 may provide for making medical assistance available to an
individual described in section 1902(ii) (relating to individuals who
meet certain income eligibility standard) during a presumptive
eligibility period. In the case of an individual described in section
1902(ii), such medical assistance shall be limited to family planning
services and supplies described in 1905(a)(4)(C) and, at the State's
option, medical diagnosis and treatment services that are provided in
conjunction with a family planning service in a family planning
setting.
``(b) Definitions.--For purposes of this section:
``(1) Presumptive eligibility period.--The term
`presumptive eligibility period' means, with respect to an
individual described in subsection (a), the period that--
``(A) begins with the date on which a qualified
entity determines, on the basis of preliminary
information, that the individual is described in
section 1902(ii); and
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is
made with respect to the eligibility of such
individual for services under the State plan;
or
``(ii) in the case of such an individual
who does not file an application by the last
day of the month following the month during
which the entity makes the determination
referred to in subparagraph (A), such last day.
``(2) Qualified entity.--
``(A) In general.--Subject to subparagraph (B), the
term `qualified entity' means any entity that--
``(i) is eligible for payments under a
State plan approved under this title; and
``(ii) is determined by the State agency to
be capable of making determinations of the type
described in paragraph (1)(A).
``(B) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a State from
limiting the classes of entities that may become
qualified entities in order to prevent fraud and abuse.
``(c) Administration.--
``(1) In general.--The State agency shall provide qualified
entities with--
``(A) such forms as are necessary for an
application to be made by an individual described in
subsection (a) for medical assistance under the State
plan; and
``(B) information on how to assist such individuals
in completing and filing such forms.
``(2) Notification requirements.--A qualified entity that
determines under subsection (b)(1)(A) that an individual
described in subsection (a) is presumptively eligible for
medical assistance under a State plan shall--
``(A) notify the State agency of the determination
within 5 working days after the date on which
determination is made; and
``(B) inform such individual at the time the
determination is made that an application for medical
assistance is required to be made by not later than the
last day of the month following the month during which
the determination is made.
``(3) Application for medical assistance.--In the case of
an individual described in subsection (a) who is determined by
a qualified entity to be presumptively eligible for medical
assistance under a State plan, the individual shall apply for
medical assistance by not later than the last day of the month
following the month during which the determination is made.
``(d) Payment.--Notwithstanding any other provision of law, medical
assistance that--
``(1) is furnished to an individual described in subsection
(a)--
``(A) during a presumptive eligibility period; and
``(B) by a entity that is eligible for payments
under the State plan; and
``(2) is included in the care and services covered by the
State plan,
shall be treated as medical assistance provided by such plan for
purposes of clause (4) of the first sentence of section 1905(b).''.
(2) Conforming amendments.--
(A) Section 1902(a)(47) of the Social Security Act
(42 U.S.C. 1396a(a)(47)), as amended by section
2202(a), is amended--
(i) in subparagraph (A), by inserting
before the semicolon at the end the following:
``and provide for making medical assistance
available to individuals described in
subsection (a) of section 1920C during a
presumptive eligibility period in accordance
with such section''; and
(ii) in subparagraph (B), by striking ``or
1920B'' and inserting ``1920B, or 1920C''.
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C.
1396b(u)(1)(D)(v)), as amended by section 2202(b), is
amended by inserting ``or for medical assistance
provided to an individual described in subsection (a)
of section 1920C during a presumptive eligibility
period under such section,'' after ``1920B during a
presumptive eligibility period under such section,''.
(c) Clarification of Coverage of Family Planning Services and
Supplies.--Section 1937(b) of the Social Security Act (42 U.S.C. 1396u-
7(b)), as amended by section 2001(c), is amended by adding at the end
the following:
``(7) Coverage of family planning services and supplies.--
Notwithstanding the previous provisions of this section, a
State may not provide for medical assistance through enrollment
of an individual with benchmark coverage or benchmark-
equivalent coverage under this section unless such coverage
includes for any individual described in section 1905(a)(4)(C),
medical assistance for family planning services and supplies in
accordance with such section.''.
(d) Effective Date.--The amendments made by this section take
effect on the date of the enactment of this Act and shall apply to
items and services furnished on or after such date.
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE.
Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is
amended by inserting ``or the care and services themselves, or both''
before ``(if provided in or after''.
Subtitle E--New Options for States to Provide Long-Term Services and
Supports
SEC. 2401. COMMUNITY FIRST CHOICE OPTION.
Section 1915 of the Social Security Act (42 U.S.C. 1396n) is
amended by adding at the end the following:
``(k) State Plan Option To Provide Home and Community-based
Attendant Services and Supports.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, beginning October 1, 2010, a State may provide
through a State plan amendment for the provision of medical
assistance for home and community-based attendant services and
supports for individuals who are eligible for medical
assistance under the State plan whose income does not exceed
150 percent of the poverty line (as defined in section
2110(c)(5)) or, if greater, the income level applicable for an
individual who has been determined to require an institutional
level of care to be eligible for nursing facility services
under the State plan and with respect to whom there has been a
determination that, but for the provision of such services, the
individuals would require the level of care provided in a
hospital, a nursing facility, an intermediate care facility for
the mentally retarded, or an institution for mental diseases,
the cost of which could be reimbursed under the State plan, but
only if the individual chooses to receive such home and
community-based attendant services and supports, and only if
the State meets the following requirements:
``(A) Availability.--The State shall make available
home and community-based attendant services and
supports to eligible individuals, as needed, to assist
in accomplishing activities of daily living,
instrumental activities of daily living, and health-
related tasks through hands-on assistance, supervision,
or cueing--
``(i) under a person-centered plan of
services and supports that is based on an
assessment of functional need and that is
agreed to in writing by the individual or, as
appropriate, the individual's representative;
``(ii) in a home or community setting,
which does not include a nursing facility,
institution for mental diseases, or an
intermediate care facility for the mentally
retarded;
``(iii) under an agency-provider model or
other model (as defined in paragraph (6)(C ));
and
``(iv) the furnishing of which--
``(I) is selected, managed, and
dismissed by the individual, or, as
appropriate, with assistance from the
individual's representative;
``(II) is controlled, to the
maximum extent possible, by the
individual or where appropriate, the
individual's representative, regardless
of who may act as the employer of
record; and
``(III) provided by an individual
who is qualified to provide such
services, including family members (as
defined by the Secretary).
``(B) Included services and supports.--In addition
to assistance in accomplishing activities of daily
living, instrumental activities of daily living, and
health related tasks, the home and community-based
attendant services and supports made available
include--
``(i) the acquisition, maintenance, and
enhancement of skills necessary for the
individual to accomplish activities of daily
living, instrumental activities of daily
living, and health related tasks;
``(ii) back-up systems or mechanisms (such
as the use of beepers or other electronic
devices) to ensure continuity of services and
supports; and
``(iii) voluntary training on how to
select, manage, and dismiss attendants.
``(C) Excluded services and supports.--Subject to
subparagraph (D), the home and community-based
attendant services and supports made available do not
include--
``(i) room and board costs for the
individual;
``(ii) special education and related
services provided under the Individuals with
Disabilities Education Act and vocational
rehabilitation services provided under the
Rehabilitation Act of 1973;
``(iii) assistive technology devices and
assistive technology services other than those
under (1)(B)(ii);
``(iv) medical supplies and equipment; or
``(v) home modifications.
``(D) Permissible services and supports.--The home
and community-based attendant services and supports may
include--
``(i) expenditures for transition costs
such as rent and utility deposits, first
month's rent and utilities, bedding, basic
kitchen supplies, and other necessities
required for an individual to make the
transition from a nursing facility, institution
for mental diseases, or intermediate care
facility for the mentally retarded to a
community-based home setting where the
individual resides; and
``(ii) expenditures relating to a need
identified in an individual's person-centered
plan of services that increase independence or
substitute for human assistance, to the extent
that expenditures would otherwise be made for
the human assistance.
``(2) Increased federal financial participation.--For
purposes of payments to a State under section 1903(a)(1), with
respect to amounts expended by the State to provide medical
assistance under the State plan for home and community-based
attendant services and supports to eligible individuals in
accordance with this subsection during a fiscal year quarter
occurring during the period described in paragraph (1), the
Federal medical assistance percentage applicable to the State
(as determined under section 1905(b)) shall be increased by 6
percentage points.
``(3) State requirements.--In order for a State plan
amendment to be approved under this subsection, the State
shall--
``(A) develop and implement such amendment in
collaboration with a Development and Implementation
Council established by the State that includes a
majority of members with disabilities, elderly
individuals, and their representatives and consults and
collaborates with such individuals;
``(B) provide consumer controlled home and
community-based attendant services and supports to
individuals on a statewide basis, in a manner that
provides such services and supports in the most
integrated setting appropriate to the individual's
needs, and without regard to the individual's age, type
or nature of disability, severity of disability, or the
form of home and community-based attendant services and
supports that the individual requires in order to lead
an independent life;
``(C) with respect to expenditures during the first
full fiscal year in which the State plan amendment is
implemented, maintain or exceed the level of State
expenditures for medical assistance that is provided
under section 1905(a), section 1915, section 1115, or
otherwise to individuals with disabilities or elderly
individuals attributable to the preceding fiscal year;
``(D) establish and maintain a comprehensive,
continuous quality assurance system with respect to
community- based attendant services and supports that--
``(i) includes standards for agency-based
and other delivery models with respect to
training, appeals for denials and
reconsideration procedures of an individual
plan, and other factors as determined by the
Secretary;
``(ii) incorporates feedback from consumers
and their representatives, disability
organizations, providers, families of disabled
or elderly individuals, members of the
community, and others and maximizes consumer
independence and consumer control;
``(iii) monitors the health and well-being
of each individual who receives home and
community-based attendant services and
supports, including a process for the mandatory
reporting, investigation, and resolution of
allegations of neglect, abuse, or exploitation
in connection with the provision of such
services and supports; and
``(iv) provides information about the
provisions of the quality assurance required
under clauses (i) through (iii) to each
individual receiving such services; and
``(E) collect and report information, as determined
necessary by the Secretary, for the purposes of
approving the State plan amendment, providing Federal
oversight, and conducting an evaluation under paragraph
(5)(A), including data regarding how the State provides
home and community-based attendant services and
supports and other home and community-based services,
the cost of such services and supports, and how the
State provides individuals with disabilities who
otherwise qualify for institutional care under the
State plan or under a waiver the choice to instead
receive home and community-based services in lieu of
institutional care.
``(4) Compliance with certain laws.--A State shall ensure
that, regardless of whether the State uses an agency-provider
model or other models to provide home and community-based
attendant services and supports under a State plan amendment
under this subsection, such services and supports are provided
in accordance with the requirements of the Fair Labor Standards
Act of 1938 and applicable Federal and State laws regarding--
``(A) withholding and payment of Federal and State
income and payroll taxes;
``(B) the provision of unemployment and workers
compensation insurance;
``(C) maintenance of general liability insurance;
and
``(D) occupational health and safety.
``(5) Evaluation, data collection, and report to
congress.--
``(A) Evaluation.--The Secretary shall conduct an
evaluation of the provision of home and community-based
attendant services and supports under this subsection
in order to determine the effectiveness of the
provision of such services and supports in allowing the
individuals receiving such services and supports to
lead an independent life to the maximum extent
possible; the impact on the physical and emotional
health of the individuals who receive such services;
and an comparative analysis of the costs of services
provided under the State plan amendment under this
subsection and those provided under institutional care
in a nursing facility, institution for mental diseases,
or an intermediate care facility for the mentally
retarded.
``(B) Data collection.--The State shall provide the
Secretary with the following information regarding the
provision of home and community-based attendant
services and supports under this subsection for each
fiscal year for which such services and supports are
provided:
``(i) The number of individuals who are
estimated to receive home and community-based
attendant services and supports under this
subsection during the fiscal year.
``(ii) The number of individuals that
received such services and supports during the
preceding fiscal year.
``(iii) The specific number of individuals
served by type of disability, age, gender,
education level, and employment status.
``(iv) Whether the specific individuals
have been previously served under any other
home and community based services program under
the State plan or under a waiver.
``(C) Reports.--Not later than--
``(i) December 31, 2013, the Secretary
shall submit to Congress and make available to
the public an interim report on the findings of
the evaluation under subparagraph (A); and
``(ii) December 31, 2015, the Secretary
shall submit to Congress and make available to
the public a final report on the findings of
the evaluation under subparagraph (A).
``(6) Definitions.--In this subsection:
``(A) Activities of daily living.--The term
`activities of daily living' includes tasks such as
eating, toileting, grooming, dressing, bathing, and
transferring.
``(B) Consumer controlled.--The term `consumer
controlled' means a method of selecting and providing
services and supports that allow the individual, or
where appropriate, the individual's representative,
maximum control of the home and community-based
attendant services and supports, regardless of who acts
as the employer of record.
``(C) Delivery models.--
``(i) Agency-provider model.--The term
`agency-provider model' means, with respect to
the provision of home and community-based
attendant services and supports for an
individual, subject to paragraph (4), a method
of providing consumer controlled services and
supports under which entities contract for the
provision of such services and supports.
``(ii) Other models.--The term `other
models' means, subject to paragraph (4),
methods, other than an agency-provider model,
for the provision of consumer controlled
services and supports. Such models may include
the provision of vouchers, direct cash
payments, or use of a fiscal agent to assist in
obtaining services.
``(D) Health-related tasks.--The term `health-
related tasks' means specific tasks related to the
needs of an individual, which can be delegated or
assigned by licensed health-care professionals under
State law to be performed by an attendant.
``(E) Individual's representative.--The term
`individual's representative' means a parent, family
member, guardian, advocate, or other authorized
representative of an individual
``(F) Instrumental activities of daily living.--The
term `instrumental activities of daily living' includes
(but is not limited to) meal planning and preparation,
managing finances, shopping for food, clothing, and
other essential items, performing essential household
chores, communicating by phone or other media, and
traveling around and participating in the community.''.
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND COMMUNITY-BASED
SERVICES.
(a) Oversight and Assessment of the Administration of Home and
Community-based Services.--The Secretary of Health and Human Services
shall promulgate regulations to ensure that all States develop service
systems that are designed to--
(1) allocate resources for services in a manner that is
responsive to the changing needs and choices of beneficiaries
receiving non-institutionally-based long-term services and
supports (including such services and supports that are
provided under programs other the State Medicaid program), and
that provides strategies for beneficiaries receiving such
services to maximize their independence, including through the
use of client-employed providers;
(2) provide the support and coordination needed for a
beneficiary in need of such services (and their family
caregivers or representative, if applicable) to design an
individualized, self-directed, community-supported life; and
(3) improve coordination among, and the regulation of, all
providers of such services under federally and State-funded
programs in order to--
(A) achieve a more consistent administration of
policies and procedures across programs in relation to
the provision of such services; and
(B) oversee and monitor all service system
functions to assure--
(i) coordination of, and effectiveness of,
eligibility determinations and individual
assessments;
(ii) development and service monitoring of
a complaint system, a management system, a
system to qualify and monitor providers, and
systems for role-setting and individual budget
determinations; and
(iii) an adequate number of qualified
direct care workers to provide self-directed
personal assistance services.
(b) Additional State Options.--Section 1915(i) of the Social
Security Act (42 U.S.C. 1396n(i)) is amended by adding at the end the
following new paragraphs:
``(6) State option to provide home and community-based
services to individuals eligible for services under a waiver.--
``(A) In general.--A State that provides home and
community-based services in accordance with this
subsection to individuals who satisfy the needs-based
criteria for the receipt of such services established
under paragraph (1)(A) may, in addition to continuing
to provide such services to such individuals, elect to
provide home and community-based services in accordance
with the requirements of this paragraph to individuals
who are eligible for home and community-based services
under a waiver approved for the State under subsection
(c), (d), or (e) or under section 1115 to provide such
services, but only for those individuals whose income
does not exceed 300 percent of the supplemental
security income benefit rate established by section
1611(b)(1).
``(B) Application of same requirements for
individuals satisfying needs-based criteria.--Subject
to subparagraph (C), a State shall provide home and
community-based services to individuals under this
paragraph in the same manner and subject to the same
requirements as apply under the other paragraphs of
this subsection to the provision of home and community-
based services to individuals who satisfy the needs-
based criteria established under paragraph (1)(A).
``(C) Authority to offer different type, amount,
duration, or scope of home and community-based
services.--A State may offer home and community-based
services to individuals under this paragraph that
differ in type, amount, duration, or scope from the
home and community-based services offered for
individuals who satisfy the needs-based criteria
established under paragraph (1)(A), so long as such
services are within the scope of services described in
paragraph (4)(B) of subsection (c) for which the
Secretary has the authority to approve a waiver and do
not include room or board.
``(7) State option to offer home and community-based
services to specific, targeted populations.--
``(A) In general.--A State may elect in a State
plan amendment under this subsection to target the
provision of home and community-based services under
this subsection to specific populations and to differ
the type, amount, duration, or scope of such services
to such specific populations.
``(B) 5-year term.--
``(i) In general.--An election by a State
under this paragraph shall be for a period of 5
years.
``(ii) Phase-in of services and eligibility
permitted during initial 5-year period.--A
State making an election under this paragraph
may, during the first 5-year period for which
the election is made, phase-in the enrollment
of eligible individuals, or the provision of
services to such individuals, or both, so long
as all eligible individuals in the State for
such services are enrolled, and all such
services are provided, before the end of the
initial 5-year period.
``(C) Renewal.--An election by a State under this
paragraph may be renewed for additional 5-year terms if
the Secretary determines, prior to beginning of each
such renewal period, that the State has--
``(i) adhered to the requirements of this
subsection and paragraph in providing services
under such an election; and
``(ii) met the State's objectives with
respect to quality improvement and beneficiary
outcomes.''.
(c) Removal of Limitation on Scope of Services.--Paragraph (1) of
section 1915(i) of the Social Security Act (42 U.S.C. 1396n(i)), as
amended by subsection (a), is amended by striking ``or such other
services requested by the State as the Secretary may approve''.
(d) Optional Eligibility Category To Provide Full Medicaid Benefits
to Individuals Receiving Home and Community-based Services Under a
State Plan Amendment.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by
section 2304(a)(1), is amended--
(A) in subclause (XX), by striking ``or'' at the
end;
(B) in subclause (XXI), by adding ``or'' at the
end; and
(C) by inserting after subclause (XXI), the
following new subclause:
``(XXII) who are eligible for home
and community-based services under
needs-based criteria established under
paragraph (1)(A) of section 1915(i), or
who are eligible for home and
community-based services under
paragraph (6) of such section, and who
will receive home and community-based
services pursuant to a State plan
amendment under such subsection;''.
(2) Conforming amendments.--
(A) Section 1903(f)(4) of the Social Security Act
(42 U.S.C. 1396b(f)(4)), as amended by section
2304(a)(4)(B), is amended in the matter preceding
subparagraph (A), by inserting
``1902(a)(10)(A)(ii)(XXII),'' after
``1902(a)(10)(A)(ii)(XXI),''.
(B) Section 1905(a) of the Social Security Act (42
U.S.C. 1396d(a)), as so amended, is amended in the
matter preceding paragraph (1)--
(i) in clause (xv), by striking ``or'' at
the end;
(ii) in clause (xvi), by adding ``or'' at
the end; and
(iii) by inserting after clause (xvi) the
following new clause:
``(xvii) individuals who are eligible for home and
community-based services under needs-based criteria established
under paragraph (1)(A) of section 1915(i), or who are eligible
for home and community-based services under paragraph (6) of
such section, and who will receive home and community-based
services pursuant to a State plan amendment under such
subsection,''.
(e) Elimination of Option To Limit Number of Eligible Individuals
or Length of Period for Grandfathered Individuals if Eligibility
Criteria Is Modified.--Paragraph (1) of section 1915(i) of such Act (42
U.S.C. 1396n(i)) is amended--
(1) by striking subparagraph (C) and inserting the
following:
``(C) Projection of number of individuals to be
provided home and community-based services.--The State
submits to the Secretary, in such form and manner, and
upon such frequency as the Secretary shall specify, the
projected number of individuals to be provided home and
community-based services.''; and
(2) in subclause (II) of subparagraph (D)(ii), by striking
``to be eligible for such services for a period of at least 12
months beginning on the date the individual first received
medical assistance for such services'' and inserting ``to
continue to be eligible for such services after the effective
date of the modification and until such time as the individual
no longer meets the standard for receipt of such services under
such pre-modified criteria''.
(f) Elimination of Option To Waive Statewideness; Addition of
Option To Waive Comparability.--Paragraph (3) of section 1915(i) of
such Act (42 U.S.C. 1396n(3)) is amended by striking ``1902(a)(1)
(relating to statewideness)'' and inserting ``1902(a)(10)(B) (relating
to comparability)''.
(g) Effective Date.--The amendments made by subsections (b) through
(f) take effect on the first day of the first fiscal year quarter that
begins after the date of enactment of this Act.
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION.
(a) Extension of Demonstration.--
(1) In general.--Section 6071(h) of the Deficit Reduction
Act of 2005 (42 U.S.C. 1396a note) is amended--
(A) in paragraph (1)(E), by striking ``fiscal year
2011'' and inserting ``each of fiscal years 2011
through 2016''; and
(B) in paragraph (2), by striking ``2011'' and
inserting ``2016''.
(2) Evaluation.--Paragraphs (2) and (3) of section 6071(g)
of such Act is amended are each amended by striking ``2011''
and inserting ``2016''.
(b) Reduction of Institutional Residency Period.--
(1) In general.--Section 6071(b)(2) of the Deficit
Reduction Act of 2005 (42 U.S.C. 1396a note) is amended--
(A) in subparagraph (A)(i), by striking ``, for a
period of not less than 6 months or for such longer
minimum period, not to exceed 2 years, as may be
specified by the State'' and inserting ``for a period
of not less than 90 consecutive days''; and
(B) by adding at the end the following:
``Any days that an individual resides in an institution on the
basis of having been admitted solely for purposes of receiving
short-term rehabilitative services for a period for which
payment for such services is limited under title XVIII shall
not be taken into account for purposes of determining the 90-
day period required under subparagraph (A)(i).''.
(2) Effective date.--The amendments made by this subsection
take effect 30 days after the date of enactment of this Act.
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY-BASED
SERVICES AGAINST SPOUSAL IMPOVERISHMENT.
During the 5-year period that begins on January 1, 2014, section
1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r-5(h)(1)(A))
shall be applied as though ``is eligible for medical assistance for
home and community-based services provided under subsection (c), (d),
or (i) of section 1915, under a waiver approved under section 1115, or
who is eligible for such medical assistance by reason of being
determined eligible under section 1902(a)(10)(C) or by reason of
section 1902(f) or otherwise on the basis of a reduction of income
based on costs incurred for medical or other remedial care, or who is
eligible for medical assistance for home and community-based attendant
services and supports under section 1915(k)'' were substituted in such
section for ``(at the option of the State) is described in section
1902(a)(10)(A)(ii)(VI)''.
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY RESOURCE
CENTERS.
Out of any funds in the Treasury not otherwise appropriated, there
is appropriated to the Secretary of Health and Human Services, acting
through the Assistant Secretary for Aging, $10,000,000 for each of
fiscal years 2010 through 2014, to carry out subsections
(a)(20)(B)(iii) and (b)(8) of section 202 of the Older Americans Act of
1965 (42 U.S.C. 3012).
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE.
(a) Findings.--The Senate makes the following findings:
(1) Nearly 2 decades have passed since Congress seriously
considered long-term care reform. The United States Bipartisan
Commission on Comprehensive Health Care, also know as the
``Pepper Commission'', released its ``Call for Action''
blueprint for health reform in September 1990. In the 20 years
since those recommendations were made, Congress has never acted
on the report.
(2) In 1999, under the United States Supreme Court's
decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals
with disabilities have the right to choose to receive their
long-term services and supports in the community, rather than
in an institutional setting.
(3) Despite the Pepper Commission and Olmstead decision,
the long-term care provided to our Nation's elderly and
disabled has not improved. In fact, for many, it has gotten far
worse.
(4) In 2007, 69 percent of Medicaid long-term care spending
for elderly individuals and adults with physical disabilities
paid for institutional services. Only 6 states spent 50 percent
or more of their Medicaid long-term care dollars on home and
community-based services for elderly individuals and adults
with physical disabilities while \1/2\ of the States spent less
than 25 percent. This disparity continues even though, on
average, it is estimated that Medicaid dollars can support
nearly 3 elderly individuals and adults with physical
disabilities in home and community-based services for every
individual in a nursing home. Although every State has chosen
to provide certain services under home and community-based
waivers, these services are unevenly available within and
across States, and reach a small percentage of eligible
individuals.
(b) Sense of the Senate.--It is the sense of the Senate that--
(1) during the 111th session of Congress, Congress should
address long-term services and supports in a comprehensive way
that guarantees elderly and disabled individuals the care they
need; and
(2) long term services and supports should be made
available in the community in addition to in institutions.
Subtitle F--Medicaid Prescription Drug Coverage
SEC. 2501. PRESCRIPTION DRUG REBATES.
(a) Increase in Minimum Rebate Percentage for Single Source Drugs
and Innovator Multiple Source Drugs.--
(1) In general.--Section 1927(c)(1)(B) of the Social
Security Act (42 U.S.C. 1396r-8(c)(1)(B)) is amended--
(A) in clause (i)--
(i) in subclause (IV), by striking ``and''
at the end;
(ii) in subclause (V)--
(I) by inserting ``and before
January 1, 2010'' after ``December 31,
1995,''; and
(II) by striking the period at the
end and inserting ``; and''; and
(iii) by adding at the end the following
new subclause:
``(VI) except as provided in clause
(iii), after December 31, 2009, 23.1
percent.''; and
(B) by adding at the end the following new clause:
``(iii) Minimum rebate percentage for
certain drugs.--
``(I) In general.--In the case of a
single source drug or an innovator
multiple source drug described in
subclause (II), the minimum rebate
percentage for rebate periods specified
in clause (i)(VI) is 17.1 percent.
``(II) Drug described.--For
purposes of subclause (I), a single
source drug or an innovator multiple
source drug described in this subclause
is any of the following drugs:
``(aa) A clotting factor
for which a separate furnishing
payment is made under section
1842(o)(5) and which is
included on a list of such
factors specified and updated
regularly by the Secretary.
``(bb) A drug approved by
the Food and Drug
Administration exclusively for
pediatric indications.''.
(2) Recapture of total savings due to increase.--Section
1927(b)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended by
adding at the end the following new subparagraph:
``(C) Special rule for increased minimum rebate
percentage.--
``(i) In general.--In addition to the
amounts applied as a reduction under
subparagraph (B), for rebate periods beginning
on or after January 1, 2010, during a fiscal
year, the Secretary shall reduce payments to a
State under section 1903(a) in the manner
specified in clause (ii), in an amount equal to
the product of--
``(I) 100 percent minus the Federal
medical assistance percentage
applicable to the rebate period for the
State; and
``(II) the amounts received by the
State under such subparagraph that are
attributable (as estimated by the
Secretary based on utilization and
other data) to the increase in the
minimum rebate percentage effected by
the amendments made by subsections
(a)(1), (b), and (d) of section 2501 of
the Patient Protection and Affordable
Care Act, taking into account the
additional drugs included under the
amendments made by subsection (c) of
section 2501 of such Act.
The Secretary shall adjust such payment
reduction for a calendar quarter to the extent
the Secretary determines, based upon subsequent
utilization and other data, that the reduction
for such quarter was greater or less than the
amount of payment reduction that should have
been made.
``(ii) Manner of payment reduction.--The
amount of the payment reduction under clause
(i) for a State for a quarter shall be deemed
an overpayment to the State under this title to
be disallowed against the State's regular
quarterly draw for all Medicaid spending under
section 1903(d)(2). Such a disallowance is not
subject to a reconsideration under section
1116(d).''.
(b) Increase in Rebate for Other Drugs.--Section 1927(c)(3)(B) of
such Act (42 U.S.C. 1396r-8(c)(3)(B)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by inserting ``and before January 1, 2010,''
after ``December 31, 1993,''; and
(B) by striking the period and inserting ``; and'';
and
(3) by adding at the end the following new clause:
``(iii) after December 31, 2009, is 13
percent.''.
(c) Extension of Prescription Drug Discounts to Enrollees of
Medicaid Managed Care Organizations.--
(1) In general.--Section 1903(m)(2)(A) of such Act (42
U.S.C. 1396b(m)(2)(A)) is amended--
(A) in clause (xi), by striking ``and'' at the end;
(B) in clause (xii), by striking the period at the
end and inserting ``; and''; and
(C) by adding at the end the following:
``(xiii) such contract provides that (I)
covered outpatient drugs dispensed to
individuals eligible for medical assistance who
are enrolled with the entity shall be subject
to the same rebate required by the agreement
entered into under section 1927 as the State is
subject to and that the State shall collect
such rebates from manufacturers, (II)
capitation rates paid to the entity shall be
based on actual cost experience related to
rebates and subject to the Federal regulations
requiring actuarially sound rates, and (III)
the entity shall report to the State, on such
timely and periodic basis as specified by the
Secretary in order to include in the
information submitted by the State to a
manufacturer and the Secretary under section
1927(b)(2)(A), information on the total number
of units of each dosage form and strength and
package size by National Drug Code of each
covered outpatient drug dispensed to
individuals eligible for medical assistance who
are enrolled with the entity and for which the
entity is responsible for coverage of such drug
under this subsection (other than covered
outpatient drugs that under subsection (j)(1)
of section 1927 are not subject to the
requirements of that section) and such other
data as the Secretary determines necessary to
carry out this subsection.''.
(2) Conforming amendments.--Section 1927 (42 U.S.C. 1396r-
8) is amended--
(A) in subsection (b)--
(i) in paragraph (1)(A), in the first
sentence, by inserting ``, including such drugs
dispensed to individuals enrolled with a
medicaid managed care organization if the
organization is responsible for coverage of
such drugs'' before the period; and
(ii) in paragraph (2)(A), by inserting
``including such information reported by each
medicaid managed care organization,'' after
``for which payment was made under the plan
during the period,''; and
(B) in subsection (j), by striking paragraph (1)
and inserting the following:
``(1) Covered outpatient drugs are not subject to the
requirements of this section if such drugs are--
``(A) dispensed by health maintenance
organizations, including Medicaid managed care
organizations that contract under section 1903(m); and
``(B) subject to discounts under section 340B of
the Public Health Service Act.''.
(d) Additional Rebate for New Formulations of Existing Drugs.--
(1) In general.--Section 1927(c)(2) of the Social Security
Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end
the following new subparagraph:
``(C) Treatment of new formulations.--
``(i) In general.--Except as provided in
clause (ii), in the case of a drug that is a
new formulation, such as an extended-release
formulation, of a single source drug or an
innovator multiple source drug, the rebate
obligation with respect to the drug under this
section shall be the amount computed under this
section for the new formulation of the drug or,
if greater, the product of--
``(I) the average manufacturer
price for each dosage form and strength
of the new formulation of the single
source drug or innovator multiple
source drug;
``(II) the highest additional
rebate (calculated as a percentage of
average manufacturer price) under this
section for any strength of the
original single source drug or
innovator multiple source drug; and
``(III) the total number of units
of each dosage form and strength of the
new formulation paid for under the
State plan in the rebate period (as
reported by the State).
``(ii) No application to new formulations
of orphan drugs.--Clause (i) shall not apply to
a new formulation of a covered outpatient drug
that is or has been designated under section
526 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 360bb) for a rare disease or
condition, without regard to whether the period
of market exclusivity for the drug under
section 527 of such Act has expired or the
specific indication for use of the drug.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to drugs that are paid for by a State after
December 31, 2009.
(e) Maximum Rebate Amount.--Section 1927(c)(2) of such Act (42
U.S.C. 1396r-8(c)(2)), as amended by subsection (d), is amended by
adding at the end the following new subparagraph:
``(D) Maximum rebate amount.--In no case shall the
sum of the amounts applied under paragraph (1)(A)(ii)
and this paragraph with respect to each dosage form and
strength of a single source drug or an innovator
multiple source drug for a rebate period beginning
after December 31, 2009, exceed 100 percent of the
average manufacturer price of the drug.''.
(f) Conforming Amendments.--
(1) In general.--Section 340B of the Public Health Service
Act (42 U.S.C. 256b) is amended--
(A) in subsection (a)(2)(B)(i), by striking
``1927(c)(4)'' and inserting ``1927(c)(3)''; and
(B) by striking subsection (c); and
(C) redesignating subsection (d) as subsection (c).
(2) Effective date.--The amendments made by this subsection
take effect on January 1, 2010.
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN DRUGS.
(a) In General.--Section 1927(d) of the Social Security Act (42
U.S.C. 1397r-8(d)) is amended--
(1) in paragraph (2)--
(A) by striking subparagraphs (E), (I), and (J),
respectively; and
(B) by redesignating subparagraphs (F), (G), (H),
and (K) as subparagraphs (E), (F), (G), and (H),
respectively; and
(2) by adding at the end the following new paragraph:
``(7) Non-excludable drugs.--The following drugs or classes
of drugs, or their medical uses, shall not be excluded from
coverage:
``(A) Agents when used to promote smoking
cessation, including agents approved by the Food and
Drug Administration under the over-the-counter
monograph process for purposes of promoting, and when
used to promote, tobacco cessation.
``(B) Barbiturates.
``(C) Benzodiazepines.''.
(b) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2014.
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT.
(a) Pharmacy Reimbursement Limits.--
(1) In general.--Section 1927(e) of the Social Security Act
(42 U.S.C. 1396r-8(e)) is amended--
(A) in paragraph (4), by striking ``(or, effective
January 1, 2007, two or more)''; and
(B) by striking paragraph (5) and inserting the
following:
``(5) Use of amp in upper payment limits.--The Secretary
shall calculate the Federal upper reimbursement limit
established under paragraph (4) as no less than 175 percent of
the weighted average (determined on the basis of utilization)
of the most recently reported monthly average manufacturer
prices for pharmaceutically and therapeutically equivalent
multiple source drug products that are available for purchase
by retail community pharmacies on a nationwide basis. The
Secretary shall implement a smoothing process for average
manufacturer prices. Such process shall be similar to the
smoothing process used in determining the average sales price
of a drug or biological under section 1847A.''.
(2) Definition of amp.--Section 1927(k)(1) of such Act (42
U.S.C. 1396r-8(k)(1)) is amended--
(A) in subparagraph (A), by striking ``by'' and all
that follows through the period and inserting ``by--
``(i) wholesalers for drugs distributed to
retail community pharmacies; and
``(ii) retail community pharmacies that
purchase drugs directly from the
manufacturer.''; and
(B) by striking subparagraph (B) and inserting the
following:
``(B) Exclusion of customary prompt pay discounts
and other payments.--
``(i) In general.--The average manufacturer
price for a covered outpatient drug shall
exclude--
``(I) customary prompt pay
discounts extended to wholesalers;
``(II) bona fide service fees paid
by manufacturers to wholesalers or
retail community pharmacies, including
(but not limited to) distribution
service fees, inventory management
fees, product stocking allowances, and
fees associated with administrative
services agreements and patient care
programs (such as medication compliance
programs and patient education
programs);
``(III) reimbursement by
manufacturers for recalled, damaged,
expired, or otherwise unsalable
returned goods, including (but not
limited to) reimbursement for the cost
of the goods and any reimbursement of
costs associated with return goods
handling and processing, reverse
logistics, and drug destruction; and
``(IV) payments received from, and
rebates or discounts provided to,
pharmacy benefit managers, managed care
organizations, health maintenance
organizations, insurers, hospitals,
clinics, mail order pharmacies, long
term care providers, manufacturers, or
any other entity that does not conduct
business as a wholesaler or a retail
community pharmacy.
``(ii) Inclusion of other discounts and
payments.--Notwithstanding clause (i), any
other discounts, rebates, payments, or other
financial transactions that are received by,
paid by, or passed through to, retail community
pharmacies shall be included in the average
manufacturer price for a covered outpatient
drug.''; and
(C) in subparagraph (C), by striking ``the retail
pharmacy class of trade'' and inserting ``retail
community pharmacies''.
(3) Definition of multiple source drug.--Section 1927(k)(7)
of such Act (42 U.S.C. 1396r-8(k)(7)) is amended--
(A) in subparagraph (A)(i)(III), by striking ``the
State'' and inserting ``the United States''; and
(B) in subparagraph (C)--
(i) in clause (i), by inserting ``and''
after the semicolon;
(ii) in clause (ii), by striking ``; and''
and inserting a period; and
(iii) by striking clause (iii).
(4) Definitions of retail community pharmacy; wholesaler.--
Section 1927(k) of such Act (42 U.S.C. 1396r-8(k)) is amended
by adding at the end the following new paragraphs:
``(10) Retail community pharmacy.--The term `retail
community pharmacy' means an independent pharmacy, a chain
pharmacy, a supermarket pharmacy, or a mass merchandiser
pharmacy that is licensed as a pharmacy by the State and that
dispenses medications to the general public at retail prices.
Such term does not include a pharmacy that dispenses
prescription medications to patients primarily through the
mail, nursing home pharmacies, long-term care facility
pharmacies, hospital pharmacies, clinics, charitable or not-
for-profit pharmacies, government pharmacies, or pharmacy
benefit managers.
``(11) Wholesaler.--The term `wholesaler' means a drug
wholesaler that is engaged in wholesale distribution of
prescription drugs to retail community pharmacies, including
(but not limited to) manufacturers, repackers, distributors,
own-label distributors, private-label distributors, jobbers,
brokers, warehouses (including manufacturer's and distributor's
warehouses, chain drug warehouses, and wholesale drug
warehouses) independent wholesale drug traders, and retail
community pharmacies that conduct wholesale distributions.''.
(b) Disclosure of Price Information to the Public.--Section
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
(1) in subparagraph (A)--
(A) in the first sentence, by inserting after
clause (iii) the following:
``(iv) not later than 30 days after the
last day of each month of a rebate period under
the agreement, on the manufacturer's total
number of units that are used to calculate the
monthly average manufacturer price for each
covered outpatient drug;''; and
(B) in the second sentence, by inserting
``(relating to the weighted average of the most
recently reported monthly average manufacturer
prices)'' after ``(D)(v)''; and
(2) in subparagraph (D)(v), by striking ``average
manufacturer prices'' and inserting ``the weighted average of
the most recently reported monthly average manufacturer prices
and the average retail survey price determined for each
multiple source drug in accordance with subsection (f)''.
(c) Clarification of Application of Survey of Retail Prices.--
Section 1927(f)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended--
(1) in subparagraph (A)(i), by inserting ``with respect to
a retail community pharmacy,'' before ``the determination'';
and
(2) in subparagraph (C)(ii), by striking ``retail
pharmacies'' and inserting ``retail community pharmacies''.
(d) Effective Date.--The amendments made by this section shall take
effect on the first day of the first calendar year quarter that begins
at least 180 days after the date of enactment of this Act, without
regard to whether or not final regulations to carry out such amendments
have been promulgated by such date.
Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.
(a) In General.--Section 1923(f) of the Social Security Act (42
U.S.C. 1396r-4(f)) is amended--
(1) in paragraph (1), by striking ``and (3)'' and inserting
``, (3), and (7)'';
(2) in paragraph (3)(A), by striking ``paragraph (6)'' and
inserting ``paragraphs (6) and (7)'';
(3) by redesignating paragraph (7) as paragraph (8); and
(4) by inserting after paragraph (6) the following new
paragraph:
``(7) Reduction of state dsh allotments once reduction in
uninsured threshold reached.--
``(A) In general.--Subject to subparagraph (E), the
DSH allotment for a State for fiscal years beginning
with the fiscal year described in subparagraph (C)
(with respect to the State), is equal to--
``(i) in the case of the first fiscal year
described in subparagraph (C) with respect to a
State, the DSH allotment that would be
determined under this subsection for the State
for the fiscal year without application of this
paragraph (but after the application of
subparagraph (D)), reduced by the applicable
percentage determined for the State for the
fiscal year under subparagraph (B)(i); and
``(ii) in the case of any subsequent fiscal
year with respect to the State, the DSH
allotment determined under this paragraph for
the State for the preceding fiscal year,
reduced by the applicable percentage determined
for the State for the fiscal year under
subparagraph (B)(ii).
``(B) Applicable percentage.--For purposes of
subparagraph (A), the applicable percentage for a State
for a fiscal year is the following:
``(i) Uninsured reduction threshold fiscal
year.--In the case of the first fiscal year
described in subparagraph (C) with respect to
the State--
``(I) if the State is a low DSH
State described in paragraph (5)(B),
the applicable percentage is equal to
25 percent; and
``(II) if the State is any other
State, the applicable percentage is 50
percent.
``(ii) Subsequent fiscal years in which the
percentage of uninsured decreases.--In the case
of any fiscal year after the first fiscal year
described in subparagraph (C) with respect to a
State, if the Secretary determines on the basis
of the most recent American Community Survey of
the Bureau of the Census, that the percentage
of uncovered individuals residing in the State
is less than the percentage of such individuals
determined for the State for the preceding
fiscal year--
``(I) if the State is a low DSH
State described in paragraph (5)(B),
the applicable percentage is equal to
the product of the percentage reduction
in uncovered individuals for the fiscal
year from the preceding fiscal year and
25 percent; and
``(II) if the State is any other
State, the applicable percentage is
equal to the product of the percentage
reduction in uncovered individuals for
the fiscal year from the preceding
fiscal year and 50 percent.
``(C) Fiscal year described.--For purposes of
subparagraph (A), the fiscal year described in this
subparagraph with respect to a State is the first
fiscal year that occurs after fiscal year 2012 for
which the Secretary determines, on the basis of the
most recent American Community Survey of the Bureau of
the Census, that the percentage of uncovered
individuals residing in the State is at least 45
percent less than the percentage of such individuals
determined for the State for fiscal year 2009.
``(D) Exclusion of portions diverted for coverage
expansions.--For purposes of applying the applicable
percentage reduction under subparagraph (A) to the DSH
allotment for a State for a fiscal year, the DSH
allotment for a State that would be determined under
this subsection for the State for the fiscal year
without the application of this paragraph (and prior to
any such reduction) shall not include any portion of
the allotment for which the Secretary has approved the
State's diversion to the costs of providing medical
assistance or other health benefits coverage under a
waiver that is in effect on July 2009.
``(E) Minimum allotment.--In no event shall the DSH
allotment determined for a State in accordance with
this paragraph for fiscal year 2013 or any succeeding
fiscal year be less than the amount equal to 35 percent
of the DSH allotment determined for the State for
fiscal year 2012 under this subsection (and after the
application of this paragraph, if applicable),
increased by the percentage change in the consumer
price index for all urban consumers (all items, U.S.
city average) for each previous fiscal year occurring
before the fiscal year.
``(F) Uncovered individuals.--In this paragraph,
the term `uncovered individuals' means individuals with
no health insurance coverage at any time during a year
(as determined by the Secretary based on the most
recent data available).''.
(b) Effective Date.--The amendments made by subsection (a) take
effect on October 1, 2011.
Subtitle H--Improved Coordination for Dual Eligible Beneficiaries
SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS.
(a) In General.--Section 1915(h) of the Social Security Act (42
U.S.C. 1396n(h)) is amended--
(1) by inserting ``(1)'' after ``(h)'';
(2) by inserting ``, or a waiver described in paragraph
(2)'' after ``(e)''; and
(3) by adding at the end the following new paragraph:
``(2)(A) Notwithstanding subsections (c)(3) and (d) (3), any waiver
under subsection (b), (c), or (d), or a waiver under section 1115, that
provides medical assistance for dual eligible individuals (including
any such waivers under which non dual eligible individuals may be
enrolled in addition to dual eligible individuals) may be conducted for
a period of 5 years and, upon the request of the State, may be extended
for additional 5-year periods unless the Secretary determines that for
the previous waiver period the conditions for the waiver have not been
met or it would no longer be cost-effective and efficient, or
consistent with the purposes of this title, to extend the waiver.
``(B) In this paragraph, the term `dual eligible individual' means
an individual who is entitled to, or enrolled for, benefits under part
A of title XVIII, or enrolled for benefits under part B of title XVIII,
and is eligible for medical assistance under the State plan under this
title or under a waiver of such plan.''.
(b) Conforming Amendments.--
(1) Section 1915 of such Act (42 U.S.C. 1396n) is amended--
(A) in subsection (b), by adding at the end the
following new sentence: ``Subsection (h)(2) shall apply
to a waiver under this subsection.'';
(B) in subsection (c)(3), in the second sentence,
by inserting ``(other than a waiver described in
subsection (h)(2))'' after ``A waiver under this
subsection'';
(C) in subsection (d)(3), in the second sentence,
by inserting ``(other than a waiver described in
subsection (h)(2))'' after ``A waiver under this
subsection''.
(2) Section 1115 of such Act (42 U.S.C. 1315) is amended--
(A) in subsection (e)(2), by inserting ``(5 years,
in the case of a waiver described in section
1915(h)(2))'' after ``3 years''; and
(B) in subsection (f)(6), by inserting ``(5 years,
in the case of a waiver described in section
1915(h)(2))'' after ``3 years''.
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT COORDINATION FOR DUAL
ELIGIBLE BENEFICIARIES.
(a) Establishment of Federal Coordinated Health Care Office.--
(1) In general.--Not later than March 1, 2010, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall establish a Federal
Coordinated Health Care Office.
(2) Establishment and reporting to cms administrator.--The
Federal Coordinated Health Care Office--
(A) shall be established within the Centers for
Medicare & Medicaid Services; and
(B) have as the Office a Director who shall be
appointed by, and be in direct line of authority to,
the Administrator of the Centers for Medicare &
Medicaid Services.
(b) Purpose.--The purpose of the Federal Coordinated Health Care
Office is to bring together officers and employees of the Medicare and
Medicaid programs at the Centers for Medicare & Medicaid Services in
order to--
(1) more effectively integrate benefits under the Medicare
program under title XVIII of the Social Security Act and the
Medicaid program under title XIX of such Act; and
(2) improve the coordination between the Federal Government
and States for individuals eligible for benefits under both
such programs in order to ensure that such individuals get full
access to the items and services to which they are entitled
under titles XVIII and XIX of the Social Security Act.
(c) Goals.--The goals of the Federal Coordinated Health Care Office
are as follows:
(1) Providing dual eligible individuals full access to the
benefits to which such individuals are entitled under the
Medicare and Medicaid programs.
(2) Simplifying the processes for dual eligible individuals
to access the items and services they are entitled to under the
Medicare and Medicaid programs.
(3) Improving the quality of health care and long-term
services for dual eligible individuals.
(4) Increasing dual eligible individuals' understanding of
and satisfaction with coverage under the Medicare and Medicaid
programs.
(5) Eliminating regulatory conflicts between rules under
the Medicare and Medicaid programs.
(6) Improving care continuity and ensuring safe and
effective care transitions for dual eligible individuals.
(7) Eliminating cost-shifting between the Medicare and
Medicaid program and among related health care providers.
(8) Improving the quality of performance of providers of
services and suppliers under the Medicare and Medicaid
programs.
(d) Specific Responsibilities.--The specific responsibilities of
the Federal Coordinated Health Care Office are as follows:
(1) Providing States, specialized MA plans for special
needs individuals (as defined in section 1859(b)(6) of the
Social Security Act (42 U.S.C. 1395w-28(b)(6))), physicians and
other relevant entities or individuals with the education and
tools necessary for developing programs that align benefits
under the Medicare and Medicaid programs for dual eligible
individuals.
(2) Supporting State efforts to coordinate and align acute
care and long-term care services for dual eligible individuals
with other items and services furnished under the Medicare
program.
(3) Providing support for coordination of contracting and
oversight by States and the Centers for Medicare & Medicaid
Services with respect to the integration of the Medicare and
Medicaid programs in a manner that is supportive of the goals
described in paragraph (3).
(4) To consult and coordinate with the Medicare Payment
Advisory Commission established under section 1805 of the
Social Security Act (42 U.S.C. 1395b-6) and the Medicaid and
CHIP Payment and Access Commission established under section
1900 of such Act (42 U.S.C. 1396) with respect to policies
relating to the enrollment in, and provision of, benefits to
dual eligible individuals under the Medicare program under
title XVIII of the Social Security Act and the Medicaid program
under title XIX of such Act.
(5) To study the provision of drug coverage for new full-
benefit dual eligible individuals (as defined in section
1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
5(c)(6)), as well as to monitor and report annual total
expenditures, health outcomes, and access to benefits for all
dual eligible individuals.
(e) Report.--The Secretary shall, as part of the budget transmitted
under section 1105(a) of title 31, United States Code, submit to
Congress an annual report containing recommendations for legislation
that would improve care coordination and benefits for dual eligible
individuals.
(f) Dual Eligible Defined.--In this section, the term ``dual
eligible individual'' means an individual who is entitled to, or
enrolled for, benefits under part A of title XVIII of the Social
Security Act, or enrolled for benefits under part B of title XVIII of
such Act, and is eligible for medical assistance under a State plan
under title XIX of such Act or under a waiver of such plan.
Subtitle I--Improving the Quality of Medicaid for Patients and
Providers
SEC. 2701. ADULT HEALTH QUALITY MEASURES.
Title XI of the Social Security Act (42 U.S.C. 1301 et seq.), as
amended by section 401 of the Children's Health Insurance Program
Reauthorization Act of 2009 (Public Law 111-3), is amended by inserting
after section 1139A the following new section:
``SEC. 1139B. ADULT HEALTH QUALITY MEASURES.
``(a) Development of Core Set of Health Care Quality Measures for
Adults Eligible for Benefits Under Medicaid.--The Secretary shall
identify and publish a recommended core set of adult health quality
measures for Medicaid eligible adults in the same manner as the
Secretary identifies and publishes a core set of child health quality
measures under section 1139A, including with respect to identifying and
publishing existing adult health quality measures that are in use under
public and privately sponsored health care coverage arrangements, or
that are part of reporting systems that measure both the presence and
duration of health insurance coverage over time, that may be applicable
to Medicaid eligible adults.
``(b) Deadlines.--
``(1) Recommended measures.--Not later than January 1,
2011, the Secretary shall identify and publish for comment a
recommended core set of adult health quality measures for
Medicaid eligible adults.
``(2) Dissemination.--Not later than January 1, 2012, the
Secretary shall publish an initial core set of adult health
quality measures that are applicable to Medicaid eligible
adults.
``(3) Standardized reporting.--Not later than January 1,
2013, the Secretary, in consultation with States, shall develop
a standardized format for reporting information based on the
initial core set of adult health quality measures and create
procedures to encourage States to use such measures to
voluntarily report information regarding the quality of health
care for Medicaid eligible adults.
``(4) Reports to congress.--Not later than January 1, 2014,
and every 3 years thereafter, the Secretary shall include in
the report to Congress required under section 1139A(a)(6)
information similar to the information required under that
section with respect to the measures established under this
section.
``(5) Establishment of medicaid quality measurement
program.--
``(A) In general.--Not later than 12 months after
the release of the recommended core set of adult health
quality measures under paragraph (1)), the Secretary
shall establish a Medicaid Quality Measurement Program
in the same manner as the Secretary establishes the
pediatric quality measures program under section
1139A(b). The aggregate amount awarded by the Secretary
for grants and contracts for the development, testing,
and validation of emerging and innovative evidence-
based measures under such program shall equal the
aggregate amount awarded by the Secretary for grants
under section 1139A(b)(4)(A)
``(B) Revising, strengthening, and improving
initial core measures.--Beginning not later than 24
months after the establishment of the Medicaid Quality
Measurement Program, and annually thereafter, the
Secretary shall publish recommended changes to the
initial core set of adult health quality measures that
shall reflect the results of the testing, validation,
and consensus process for the development of adult
health quality measures.
``(c) Construction.--Nothing in this section shall be construed as
supporting the restriction of coverage, under title XIX or XXI or
otherwise, to only those services that are evidence-based, or in anyway
limiting available services.
``(d) Annual State Reports Regarding State-Specific Quality of Care
Measures Applied Under Medicaid.--
``(1) Annual state reports.--Each State with a State plan
or waiver approved under title XIX shall annually report
(separately or as part of the annual report required under
section 1139A(c)), to the Secretary on the--
``(A) State-specific adult health quality measures
applied by the State under the such plan, including
measures described in subsection (a)(5); and
``(B) State-specific information on the quality of
health care furnished to Medicaid eligible adults under
such plan, including information collected through
external quality reviews of managed care organizations
under section 1932 and benchmark plans under section
1937.
``(2) Publication.--Not later than September 30, 2014, and
annually thereafter, the Secretary shall collect, analyze, and
make publicly available the information reported by States
under paragraph (1).
``(e) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated for each of fiscal years
2010 through 2014, $60,000,000 for the purpose of carrying out this
section. Funds appropriated under this subsection shall remain
available until expended.''.
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED CONDITIONS.
(a) In General.--The Secretary of Health and Human Services (in
this subsection referred to as the ``Secretary'') shall identify
current State practices that prohibit payment for health care-acquired
conditions and shall incorporate the practices identified, or elements
of such practices, which the Secretary determines appropriate for
application to the Medicaid program in regulations. Such regulations
shall be effective as of July 1, 2011, and shall prohibit payments to
States under section 1903 of the Social Security Act for any amounts
expended for providing medical assistance for health care-acquired
conditions specified in the regulations. The regulations shall ensure
that the prohibition on payment for health care-acquired conditions
shall not result in a loss of access to care or services for Medicaid
beneficiaries.
(b) Health Care-Acquired Condition.--In this section. the term
``health care-acquired condition'' means a medical condition for which
an individual was diagnosed that could be identified by a secondary
diagnostic code described in section 1886(d)(4)(D)(iv) of the Social
Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)).
(c) Medicare Provisions.--In carrying out this section, the
Secretary shall apply to State plans (or waivers) under title XIX of
the Social Security Act the regulations promulgated pursuant to section
1886(d)(4)(D) of such Act (42 U.S.C. 1395ww(d)(4)(D)) relating to the
prohibition of payments based on the presence of a secondary diagnosis
code specified by the Secretary in such regulations, as appropriate for
the Medicaid program. The Secretary may exclude certain conditions
identified under title XVIII of the Social Security Act for non-payment
under title XIX of such Act when the Secretary finds the inclusion of
such conditions to be inapplicable to beneficiaries under title XIX.
SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES WITH
CHRONIC CONDITIONS.
(a) State Plan Amendment.--Title XIX of the Social Security Act (42
U.S.C. 1396a et seq.), as amended by sections 2201 and 2305, is amended
by adding at the end the following new section:
``Sec. 1945. State Option To Provide Coordinated Care Through a
Health Home for Individuals With Chronic Conditions.--
``(a) In General.--Notwithstanding section 1902(a)(1) (relating to
statewideness), section 1902(a)(10)(B) (relating to comparability), and
any other provision of this title for which the Secretary determines it
is necessary to waive in order to implement this section, beginning
January 1, 2011, a State, at its option as a State plan amendment, may
provide for medical assistance under this title to eligible individuals
with chronic conditions who select a designated provider (as described
under subsection (h)(5)), a team of health care professionals (as
described under subsection (h)(6)) operating with such a provider, or a
health team (as described under subsection (h)(7)) as the individual's
health home for purposes of providing the individual with health home
services.
``(b) Health Home Qualification Standards.--The Secretary shall
establish standards for qualification as a designated provider for the
purpose of being eligible to be a health home for purposes of this
section.
``(c) Payments.--
``(1) In general.--A State shall provide a designated
provider, a team of health care professionals operating with
such a provider, or a health team with payments for the
provision of health home services to each eligible individual
with chronic conditions that selects such provider, team of
health care professionals, or health team as the individual's
health home. Payments made to a designated provider, a team of
health care professionals operating with such a provider, or a
health team for such services shall be treated as medical
assistance for purposes of section 1903(a), except that, during
the first 8 fiscal year quarters that the State plan amendment
is in effect, the Federal medical assistance percentage
applicable to such payments shall be equal to 90 percent.
``(2) Methodology.--
``(A) In general.--The State shall specify in the
State plan amendment the methodology the State will use
for determining payment for the provision of health
home services. Such methodology for determining
payment--
``(i) may be tiered to reflect, with
respect to each eligible individual with
chronic conditions provided such services by a
designated provider, a team of health care
professionals operating with such a provider,
or a health team, as well as the severity or
number of each such individual's chronic
conditions or the specific capabilities of the
provider, team of health care professionals, or
health team; and
``(ii) shall be established consistent with
section 1902(a)(30)(A).
``(B) Alternate models of payment.--The methodology
for determining payment for provision of health home
services under this section shall not be limited to a
per-member per-month basis and may provide (as proposed
by the State and subject to approval by the Secretary)
for alternate models of payment.
``(3) Planning grants.--
``(A) In general.--Beginning January 1, 2011, the
Secretary may award planning grants to States for
purposes of developing a State plan amendment under
this section. A planning grant awarded to a State under
this paragraph shall remain available until expended.
``(B) State contribution.--A State awarded a
planning grant shall contribute an amount equal to the
State percentage determined under section 1905(b)
(without regard to section 5001 of Public Law 111-5)
for each fiscal year for which the grant is awarded.
``(C) Limitation.--The total amount of payments
made to States under this paragraph shall not exceed
$25,000,000.
``(d) Hospital Referrals.--A State shall include in the State plan
amendment a requirement for hospitals that are participating providers
under the State plan or a waiver of such plan to establish procedures
for referring any eligible individuals with chronic conditions who seek
or need treatment in a hospital emergency department to designated
providers.
``(e) Coordination.--A State shall consult and coordinate, as
appropriate, with the Substance Abuse and Mental Health Services
Administration in addressing issues regarding the prevention and
treatment of mental illness and substance abuse among eligible
individuals with chronic conditions.
``(f) Monitoring.--A State shall include in the State plan
amendment--
``(1) a methodology for tracking avoidable hospital
readmissions and calculating savings that result from improved
chronic care coordination and management under this section;
and
``(2) a proposal for use of health information technology
in providing health home services under this section and
improving service delivery and coordination across the care
continuum (including the use of wireless patient technology to
improve coordination and management of care and patient
adherence to recommendations made by their provider).
``(g) Report on Quality Measures.--As a condition for receiving
payment for health home services provided to an eligible individual
with chronic conditions, a designated provider shall report to the
State, in accordance with such requirements as the Secretary shall
specify, on all applicable measures for determining the quality of such
services. When appropriate and feasible, a designated provider shall
use health information technology in providing the State with such
information.
``(h) Definitions.--In this section:
``(1) Eligible individual with chronic conditions.--
``(A) In general.--Subject to subparagraph (B), the
term `eligible individual with chronic conditions'
means an individual who--
``(i) is eligible for medical assistance
under the State plan or under a waiver of such
plan; and
``(ii) has at least--
``(I) 2 chronic conditions;
``(II) 1 chronic condition and is
at risk of having a second chronic
condition; or
``(III) 1 serious and persistent
mental health condition.
``(B) Rule of construction.--Nothing in this
paragraph shall prevent the Secretary from establishing
higher levels as to the number or severity of chronic
or mental health conditions for purposes of determining
eligibility for receipt of health home services under
this section.
``(2) Chronic condition.--The term `chronic condition' has
the meaning given that term by the Secretary and shall include,
but is not limited to, the following:
``(A) A mental health condition.
``(B) Substance use disorder.
``(C) Asthma.
``(D) Diabetes.
``(E) Heart disease.
``(F) Being overweight, as evidenced by having a
Body Mass Index (BMI) over 25.
``(3) Health home.--The term `health home' means a
designated provider (including a provider that operates in
coordination with a team of health care professionals) or a
health team selected by an eligible individual with chronic
conditions to provide health home services.
``(4) Health home services.--
``(A) In general.--The term `health home services'
means comprehensive and timely high-quality services
described in subparagraph (B) that are provided by a
designated provider, a team of health care
professionals operating with such a provider, or a
health team.
``(B) Services described.--The services described
in this subparagraph are--
``(i) comprehensive care management;
``(ii) care coordination and health
promotion;
``(iii) comprehensive transitional care,
including appropriate follow-up, from inpatient
to other settings;
``(iv) patient and family support
(including authorized representatives);
``(v) referral to community and social
support services, if relevant; and
``(vi) use of health information technology
to link services, as feasible and appropriate.
``(5) Designated provider.--The term `designated provider'
means a physician, clinical practice or clinical group
practice, rural clinic, community health center, community
mental health center, home health agency, or any other entity
or provider (including pediatricians, gynecologists, and
obstetricians) that is determined by the State and approved by
the Secretary to be qualified to be a health home for eligible
individuals with chronic conditions on the basis of
documentation evidencing that the physician, practice, or
clinic--
``(A) has the systems and infrastructure in place
to provide health home services; and
``(B) satisfies the qualification standards
established by the Secretary under subsection (b).
``(6) Team of health care professionals.--The term `team of
health care professionals' means a team of health professionals
(as described in the State plan amendment) that may--
``(A) include physicians and other professionals,
such as a nurse care coordinator, nutritionist, social
worker, behavioral health professional, or any
professionals deemed appropriate by the State; and
``(B) be free standing, virtual, or based at a
hospital, community health center, community mental
health center, rural clinic, clinical practice or
clinical group practice, academic health center, or any
entity deemed appropriate by the State and approved by
the Secretary.
``(7) Health team.--The term `health team' has the meaning
given such term for purposes of section 3502 of the Patient
Protection and Affordable Care Act.''.
(b) Evaluation.--
(1) Independent evaluation.--
(A) In general.--The Secretary shall enter into a
contract with an independent entity or organization to
conduct an evaluation and assessment of the States that
have elected the option to provide coordinated care
through a health home for Medicaid beneficiaries with
chronic conditions under section 1945 of the Social
Security Act (as added by subsection (a)) for the
purpose of determining the effect of such option on
reducing hospital admissions, emergency room visits,
and admissions to skilled nursing facilities.
(B) Evaluation report.--Not later than January 1,
2017, the Secretary shall report to Congress on the
evaluation and assessment conducted under subparagraph
(A).
(2) Survey and interim report.--
(A) In general.--Not later than January 1, 2014,
the Secretary of Health and Human Services shall survey
States that have elected the option under section 1945
of the Social Security Act (as added by subsection (a))
and report to Congress on the nature, extent, and use
of such option, particularly as it pertains to--
(i) hospital admission rates;
(ii) chronic disease management;
(iii) coordination of care for individuals
with chronic conditions;
(iv) assessment of program implementation;
(v) processes and lessons learned (as
described in subparagraph (B));
(vi) assessment of quality improvements and
clinical outcomes under such option; and
(vii) estimates of cost savings.
(B) Implementation reporting.--A State that has
elected the option under section 1945 of the Social
Security Act (as added by subsection (a)) shall report
to the Secretary, as necessary, on processes that have
been developed and lessons learned regarding provision
of coordinated care through a health home for Medicaid
beneficiaries with chronic conditions under such
option.
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE AROUND A
HOSPITALIZATION.
(a) Authority To Conduct Project.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a demonstration project under title XIX of the Social
Security Act to evaluate the use of bundled payments for the
provision of integrated care for a Medicaid beneficiary--
(A) with respect to an episode of care that
includes a hospitalization; and
(B) for concurrent physicians services provided
during a hospitalization.
(2) Duration.--The demonstration project shall begin on
January 1, 2012, and shall end on December 31, 2016.
(b) Requirements.--The demonstration project shall be conducted in
accordance with the following:
(1) The demonstration project shall be conducted in up to 8
States, determined by the Secretary based on consideration of
the potential to lower costs under the Medicaid program while
improving care for Medicaid beneficiaries. A State selected to
participate in the demonstration project may target the
demonstration project to particular categories of
beneficiaries, beneficiaries with particular diagnoses, or
particular geographic regions of the State, but the Secretary
shall insure that, as a whole, the demonstration project is, to
the greatest extent possible, representative of the demographic
and geographic composition of Medicaid beneficiaries
nationally.
(2) The demonstration project shall focus on conditions
where there is evidence of an opportunity for providers of
services and suppliers to improve the quality of care furnished
to Medicaid beneficiaries while reducing total expenditures
under the State Medicaid programs selected to participate, as
determined by the Secretary.
(3) A State selected to participate in the demonstration
project shall specify the 1 or more episodes of care the State
proposes to address in the project, the services to be included
in the bundled payments, and the rationale for the selection of
such episodes of care and services. The Secretary may modify
the episodes of care as well as the services to be included in
the bundled payments prior to or after approving the project.
The Secretary may also vary such factors among the different
States participating in the demonstration project.
(4) The Secretary shall ensure that payments made under the
demonstration project are adjusted for severity of illness and
other characteristics of Medicaid beneficiaries within a
category or having a diagnosis targeted as part of the
demonstration project. States shall ensure that Medicaid
beneficiaries are not liable for any additional cost sharing
than if their care had not been subject to payment under the
demonstration project.
(5) Hospitals participating in the demonstration project
shall have or establish robust discharge planning programs to
ensure that Medicaid beneficiaries requiring post-acute care
are appropriately placed in, or have ready access to, post-
acute care settings.
(6) The Secretary and each State selected to participate in
the demonstration project shall ensure that the demonstration
project does not result in the Medicaid beneficiaries whose
care is subject to payment under the demonstration project
being provided with less items and services for which medical
assistance is provided under the State Medicaid program than
the items and services for which medical assistance would have
been provided to such beneficiaries under the State Medicaid
program in the absence of the demonstration project.
(c) Waiver of Provisions.--Notwithstanding section 1115(a) of the
Social Security Act (42 U.S.C. 1315(a)), the Secretary may waive such
provisions of titles XIX, XVIII, and XI of that Act as may be necessary
to accomplish the goals of the demonstration, ensure beneficiary access
to acute and post-acute care, and maintain quality of care.
(d) Evaluation and Report.--
(1) Data.--Each State selected to participate in the
demonstration project under this section shall provide to the
Secretary, in such form and manner as the Secretary shall
specify, relevant data necessary to monitor outcomes, costs,
and quality, and evaluate the rationales for selection of the
episodes of care and services specified by States under
subsection (b)(3).
(2) Report.--Not later than 1 year after the conclusion of
the demonstration project, the Secretary shall submit a report
to Congress on the results of the demonstration project.
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION PROJECT.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall, in
coordination with the Center for Medicare and Medicaid Innovation (as
established under section 1115A of the Social Security Act, as added by
section 3021 of this Act), establish the Medicaid Global Payment System
Demonstration Project under which a participating State shall adjust
the payments made to an eligible safety net hospital system or network
from a fee-for-service payment structure to a global capitated payment
model.
(b) Duration and Scope.--The demonstration project conducted under
this section shall operate during a period of fiscal years 2010 through
2012. The Secretary shall select not more than 5 States to participate
in the demonstration project.
(c) Eligible Safety Net Hospital System or Network.--For purposes
of this section, the term ``eligible safety net hospital system or
network'' means a large, safety net hospital system or network (as
defined by the Secretary) that operates within a State selected by the
Secretary under subsection (b).
(d) Evaluation.--
(1) Testing.--The Innovation Center shall test and evaluate
the demonstration project conducted under this section to
examine any changes in health care quality outcomes and
spending by the eligible safety net hospital systems or
networks.
(2) Budget neutrality.--During the testing period under
paragraph (1), any budget neutrality requirements under section
1115A(b)(3) of the Social Security Act (as so added) shall not
be applicable.
(3) Modification.--During the testing period under
paragraph (1), the Secretary may, in the Secretary's
discretion, modify or terminate the demonstration project
conducted under this section.
(e) Report.--Not later than 12 months after the date of completion
of the demonstration project under this section, the Secretary shall
submit to Congress a report containing the results of the evaluation
and testing conducted under subsection (d), together with
recommendations for such legislation and administrative action as the
Secretary determines appropriate.
(f) Authorization of Appropriations.--There are authorized to be
appropriated such sums as are necessary to carry out this section.
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION
PROJECT.
(a) Authority To Conduct Demonstration.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall
establish the Pediatric Accountable Care Organization
Demonstration Project to authorize a participating State to
allow pediatric medical providers that meet specified
requirements to be recognized as an accountable care
organization for purposes of receiving incentive payments (as
described under subsection (d)), in the same manner as an
accountable care organization is recognized and provided with
incentive payments under section 1899 of the Social Security
Act (as added by section 3022).
(2) Duration.--The demonstration project shall begin on
January 1, 2012, and shall end on December 31, 2016.
(b) Application.--A State that desires to participate in the
demonstration project under this section shall submit to the Secretary
an application at such time, in such manner, and containing such
information as the Secretary may require.
(c) Requirements.--
(1) Performance guidelines.--The Secretary, in consultation
with the States and pediatric providers, shall establish
guidelines to ensure that the quality of care delivered to
individuals by a provider recognized as an accountable care
organization under this section is not less than the quality of
care that would have otherwise been provided to such
individuals.
(2) Savings requirement.--A participating State, in
consultation with the Secretary, shall establish an annual
minimal level of savings in expenditures for items and services
covered under the Medicaid program under title XIX of the
Social Security Act and the CHIP program under title XXI of
such Act that must be reached by an accountable care
organization in order for such organization to receive an
incentive payment under subsection (d).
(3) Minimum participation period.--A provider desiring to
be recognized as an accountable care organization under the
demonstration project shall enter into an agreement with the
State to participate in the project for not less than a 3-year
period.
(d) Incentive Payment.--An accountable care organization that meets
the performance guidelines established by the Secretary under
subsection (c)(1) and achieves savings greater than the annual minimal
savings level established by the State under subsection (c)(2) shall
receive an incentive payment for such year equal to a portion (as
determined appropriate by the Secretary) of the amount of such excess
savings. The Secretary may establish an annual cap on incentive
payments for an accountable care organization.
(e) Authorization of Appropriations.--There are authorized to be
appropriated such sums as are necessary to carry out this section.
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION PROJECT.
(a) Authority To Conduct Demonstration Project.--The Secretary of
Health and Human Services (in this section referred to as the
``Secretary'') shall establish a demonstration project under which an
eligible State (as described in subsection (c)) shall provide payment
under the State Medicaid plan under title XIX of the Social Security
Act to an institution for mental diseases that is not publicly owned or
operated and that is subject to the requirements of section 1867 of the
Social Security Act (42 U.S.C. 1395dd) for the provision of medical
assistance available under such plan to individuals who--
(1) have attained age 21, but have not attained age 65;
(2) are eligible for medical assistance under such plan;
and
(3) require such medical assistance to stabilize an
emergency medical condition.
(b) Stabilization Review.--A State shall specify in its application
described in subsection (c)(1) establish a mechanism for how it will
ensure that institutions participating in the demonstration will
determine whether or not such individuals have been stabilized (as
defined in subsection (h)(5)). This mechanism shall commence before the
third day of the inpatient stay. States participating in the
demonstration project may manage the provision of services for the
stabilization of medical emergency conditions through utilization
review, authorization, or management practices, or the application of
medical necessity and appropriateness criteria applicable to behavioral
health.
(c) Eligible State Defined.--
(1) In general.--An eligible State is a State that has made
an application and has been selected pursuant to paragraphs (2)
and (3).
(2) Application.--A State seeking to participate in the
demonstration project under this section shall submit to the
Secretary, at such time and in such format as the Secretary
requires, an application that includes such information,
provisions, and assurances, as the Secretary may require.
(3) Selection.--A State shall be determined eligible for
the demonstration by the Secretary on a competitive basis among
States with applications meeting the requirements of paragraph
(1). In selecting State applications for the demonstration
project, the Secretary shall seek to achieve an appropriate
national balance in the geographic distribution of such
projects.
(d) Length of Demonstration Project.--The demonstration project
established under this section shall be conducted for a period of 3
consecutive years.
(e) Limitations on Federal Funding.--
(1) Appropriation.--
(A) In general.--Out of any funds in the Treasury
not otherwise appropriated, there is appropriated to
carry out this section, $75,000,000 for fiscal year
2011.
(B) Budget authority.--Subparagraph (A) constitutes
budget authority in advance of appropriations Act and
represents the obligation of the Federal Government to
provide for the payment of the amounts appropriated
under that subparagraph.
(2) 5-year availability.--Funds appropriated under
paragraph (1) shall remain available for obligation through
December 31, 2015.
(3) Limitation on payments.--In no case may--
(A) the aggregate amount of payments made by the
Secretary to eligible States under this section exceed
$75,000,000; or
(B) payments be provided by the Secretary under
this section after December 31, 2015.
(4) Funds allocated to states.--Funds shall be allocated to
eligible States on the basis of criteria, including a State's
application and the availability of funds, as determined by the
Secretary.
(5) Payments to states.--The Secretary shall pay to each
eligible State, from its allocation under paragraph (4), an
amount each quarter equal to the Federal medical assistance
percentage of expenditures in the quarter for medical
assistance described in subsection (a). As a condition of
receiving payment, a State shall collect and report
information, as determined necessary by the Secretary, for the
purposes of providing Federal oversight and conducting an
evaluation under subsection (f)(1).
(f) Evaluation and Report to Congress.--
(1) Evaluation.--The Secretary shall conduct an evaluation
of the demonstration project in order to determine the impact
on the functioning of the health and mental health service
system and on individuals enrolled in the Medicaid program and
shall include the following:
(A) An assessment of access to inpatient mental
health services under the Medicaid program; average
lengths of inpatient stays; and emergency room visits.
(B) An assessment of discharge planning by
participating hospitals.
(C) An assessment of the impact of the
demonstration project on the costs of the full range of
mental health services (including inpatient, emergency
and ambulatory care).
(D) An analysis of the percentage of consumers with
Medicaid coverage who are admitted to inpatient
facilities as a result of the demonstration project as
compared to those admitted to these same facilities
through other means.
(E) A recommendation regarding whether the
demonstration project should be continued after
December 31, 2013, and expanded on a national basis.
(2) Report.--Not later than December 31, 2013, the
Secretary shall submit to Congress and make available to the
public a report on the findings of the evaluation under
paragraph (1).
(g) Waiver Authority.--
(1) In general.--The Secretary shall waive the limitation
of subdivision (B) following paragraph (28) of section 1905(a)
of the Social Security Act (42 U.S.C. 1396d(a)) (relating to
limitations on payments for care or services for individuals
under 65 years of age who are patients in an institution for
mental diseases) for purposes of carrying out the demonstration
project under this section.
(2) Limited other waiver authority.--The Secretary may
waive other requirements of titles XI and XIX of the Social
Security Act (including the requirements of sections 1902(a)(1)
(relating to statewideness) and 1902(1)(10)(B) (relating to
comparability)) only to extent necessary to carry out the
demonstration project under this section.
(h) Definitions.--In this section:
(1) Emergency medical condition.--The term ``emergency
medical condition'' means, with respect to an individual, an
individual who expresses suicidal or homicidal thoughts or
gestures, if determined dangerous to self or others.
(2) Federal medical assistance percentage.--The term
``Federal medical assistance percentage'' has the meaning given
that term with respect to a State under section 1905(b) of the
Social Security Act (42 U.S.C. 1396d(b)).
(3) Institution for mental diseases.--The term
``institution for mental diseases'' has the meaning given to
that term in section 1905(i) of the Social Security Act (42
U.S.C. 1396d(i)).
(4) Medical assistance.--The term ``medical assistance''
has the meaning given that term in section 1905(a) of the
Social Security Act (42 U.S.C. 1396d(a)).
(5) Stabilized.--The term ``stabilized'' means, with
respect to an individual, that the emergency medical condition
no longer exists with respect to the individual and the
individual is no longer dangerous to self or others.
(6) State.--The term ``State'' has the meaning given that
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
Subtitle J--Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL MEDICAID
BENEFICIARIES.
(a) In General.--Section 1900 of the Social Security Act (42 U.S.C.
1396) is amended--
(1) in subsection (b)--
(A) in paragraph (1)--
(i) in the paragraph heading, by inserting
``for all states'' before ``and annual''; and
(ii) in subparagraph (A), by striking
``children's'';
(iii) in subparagraph (B), by inserting ``,
the Secretary, and States'' after ``Congress'';
(iv) in subparagraph (C), by striking
``March 1'' and inserting ``March 15''; and
(v) in subparagraph (D), by striking ``June
1'' and inserting ``June 15'';
(B) in paragraph (2)--
(i) in subparagraph (A)--
(I) in clause (i)--
(aa) by inserting ``the
efficient provision of'' after
``expenditures for''; and
(bb) by striking
``hospital, skilled nursing
facility, physician, Federally-
qualified health center, rural
health center, and other fees''
and inserting ``payments to
medical, dental, and health
professionals, hospitals,
residential and long-term care
providers, providers of home
and community based services,
Federally-qualified health
centers and rural health
clinics, managed care entities,
and providers of other covered
items and services''; and
(II) in clause (iii), by inserting
``(including how such factors and
methodologies enable such beneficiaries
to obtain the services for which they
are eligible, affect provider supply,
and affect providers that serve a
disproportionate share of low-income
and other vulnerable populations)''
after ``beneficiaries'';
(ii) by redesignating subparagraphs (B) and
(C) as subparagraphs (F) and (H), respectively;
(iii) by inserting after subparagraph (A),
the following:
``(B) Eligibility policies.--Medicaid and CHIP
eligibility policies, including a determination of the
degree to which Federal and State policies provide
health care coverage to needy populations.
``(C) Enrollment and retention processes.--Medicaid
and CHIP enrollment and retention processes, including
a determination of the degree to which Federal and
State policies encourage the enrollment of individuals
who are eligible for such programs and screen out
individuals who are ineligible, while minimizing the
share of program expenses devoted to such processes.
``(D) Coverage policies.--Medicaid and CHIP benefit
and coverage policies, including a determination of the
degree to which Federal and State policies provide
access to the services enrollees require to improve and
maintain their health and functional status.
``(E) Quality of care.--Medicaid and CHIP policies
as they relate to the quality of care provided under
those programs, including a determination of the degree
to which Federal and State policies achieve their
stated goals and interact with similar goals
established by other purchasers of health care
services.'';
(iv) by inserting after subparagraph (F)
(as redesignated by clause (ii) of this
subparagraph), the following:
``(G) Interactions with medicare and medicaid.--
Consistent with paragraph (11), the interaction of
policies under Medicaid and the Medicare program under
title XVIII, including with respect to how such
interactions affect access to services, payments, and
dual eligible individuals.'' and
(v) in subparagraph (H) (as so
redesignated), by inserting ``and preventive,
acute, and long-term services and supports''
after ``barriers'';
(C) by redesignating paragraphs (3) through (9) as
paragraphs (4) through (10), respectively;
(D) by inserting after paragraph (2), the following
new paragraph:
``(3) Recommendations and reports of state-specific data.--
MACPAC shall--
``(A) review national and State-specific Medicaid
and CHIP data; and
``(B) submit reports and recommendations to
Congress, the Secretary, and States based on such
reviews.'';
(E) in paragraph (4), as redesignated by
subparagraph (C), by striking ``or any other problems''
and all that follows through the period and inserting
``, as well as other factors that adversely affect, or
have the potential to adversely affect, access to care
by, or the health care status of, Medicaid and CHIP
beneficiaries. MACPAC shall include in the annual
report required under paragraph (1)(D) a description of
all such areas or problems identified with respect to
the period addressed in the report.'';
(F) in paragraph (5), as so redesignated,--
(i) in the paragraph heading, by inserting
``and regulations'' after ``reports''; and
(ii) by striking ``If'' and inserting the
following:
``(A) Certain secretarial reports.--If''; and
(iii) in the second sentence, by inserting
``and the Secretary'' after ``appropriate
committees of Congress''; and
(iv) by adding at the end the following:
``(B) Regulations.--MACPAC shall review Medicaid
and CHIP regulations and may comment through submission
of a report to the appropriate committees of Congress
and the Secretary, on any such regulations that affect
access, quality, or efficiency of health care.'';
(G) in paragraph (10), as so redesignated, by
inserting ``, and shall submit with any
recommendations, a report on the Federal and State-
specific budget consequences of the recommendations''
before the period; and
(H) by adding at the end the following:
``(11) Consultation and coordination with medpac.--
``(A) In general.--MACPAC shall consult with the
Medicare Payment Advisory Commission (in this paragraph
referred to as `MedPAC') established under section 1805
in carrying out its duties under this section, as
appropriate and particularly with respect to the issues
specified in paragraph (2) as they relate to those
Medicaid beneficiaries who are dually eligible for
Medicaid and the Medicare program under title XVIII,
adult Medicaid beneficiaries (who are not dually
eligible for Medicare), and beneficiaries under
Medicare. Responsibility for analysis of and
recommendations to change Medicare policy regarding
Medicare beneficiaries, including Medicare
beneficiaries who are dually eligible for Medicare and
Medicaid, shall rest with MedPAC.
``(B) Information sharing.--MACPAC and MedPAC shall
have access to deliberations and records of the other
such entity, respectively, upon the request of the
other such entity.
``(12) Consultation with states.--MACPAC shall regularly
consult with States in carrying out its duties under this
section, including with respect to developing processes for
carrying out such duties, and shall ensure that input from
States is taken into account and represented in MACPAC's
recommendations and reports.
``(13) Coordinate and consult with the federal coordinated
health care office.--MACPAC shall coordinate and consult with
the Federal Coordinated Health Care Office established under
section 2081 of the Patient Protection and Affordable Care Act
before making any recommendations regarding dual eligible
individuals.
``(14) Programmatic oversight vested in the secretary.--
MACPAC's authority to make recommendations in accordance with
this section shall not affect, or be considered to duplicate,
the Secretary's authority to carry out Federal responsibilities
with respect to Medicaid and CHIP.'';
(2) in subsection (c)(2)--
(A) by striking subparagraphs (A) and (B) and
inserting the following:
``(A) In general.--The membership of MACPAC shall
include individuals who have had direct experience as
enrollees or parents or caregivers of enrollees in
Medicaid or CHIP and individuals with national
recognition for their expertise in Federal safety net
health programs, health finance and economics,
actuarial science, health plans and integrated delivery
systems, reimbursement for health care, health
information technology, and other providers of health
services, public health, and other related fields, who
provide a mix of different professions, broad
geographic representation, and a balance between urban
and rural representation.
``(B) Inclusion.--The membership of MACPAC shall
include (but not be limited to) physicians, dentists,
and other health professionals, employers, third-party
payers, and individuals with expertise in the delivery
of health services. Such membership shall also include
representatives of children, pregnant women, the
elderly, individuals with disabilities, caregivers, and
dual eligible individuals, current or former
representatives of State agencies responsible for
administering Medicaid, and current or former
representatives of State agencies responsible for
administering CHIP.''.
(3) in subsection (d)(2), by inserting ``and State'' after
``Federal'';
(4) in subsection (e)(1), in the first sentence, by
inserting ``and, as a condition for receiving payments under
sections 1903(a) and 2105(a), from any State agency responsible
for administering Medicaid or CHIP,'' after ``United States'';
and
(5) in subsection (f)--
(A) in the subsection heading, by striking
``Authorization of Appropriations'' and inserting
``Funding'';
(B) in paragraph (1), by inserting ``(other than
for fiscal year 2010)'' before ``in the same manner'';
and
(C) by adding at the end the following:
``(3) Funding for fiscal year 2010.--
``(A) In general.--Out of any funds in the Treasury
not otherwise appropriated, there is appropriated to
MACPAC to carry out the provisions of this section for
fiscal year 2010, $9,000,000.
``(B) Transfer of funds.--Notwithstanding section
2104(a)(13), from the amounts appropriated in such
section for fiscal year 2010, $2,000,000 is hereby
transferred and made available in such fiscal year to
MACPAC to carry out the provisions of this section.
``(4) Availability.--Amounts made available under
paragraphs (2) and (3) to MACPAC to carry out the provisions of
this section shall remain available until expended.''.
(b) Conforming MedPAC Amendments.--Section 1805(b) of the Social
Security Act (42 U.S.C. 1395b-6(b)), is amended--
(1) in paragraph (1)(C), by striking ``March 1 of each year
(beginning with 1998)'' and inserting ``March 15'';
(2) in paragraph (1)(D), by inserting ``, and (beginning
with 2012) containing an examination of the topics described in
paragraph (9), to the extent feasible'' before the period; and
(3) by adding at the end the following:
``(9) Review and annual report on medicaid and commercial
trends.--The Commission shall review and report on aggregate
trends in spending, utilization, and financial performance
under the Medicaid program under title XIX and the private
market for health care services with respect to providers for
which, on an aggregate national basis, a significant portion of
revenue or services is associated with the Medicaid program.
Where appropriate, the Commission shall conduct such review in
consultation with the Medicaid and CHIP Payment and Access
Commission established under section 1900 (in this section
referred to as `MACPAC').
``(10) Coordinate and consult with the federal coordinated
health care office.--The Commission shall coordinate and
consult with the Federal Coordinated Health Care Office
established under section 2081 of the Patient Protection and
Affordable Care Act before making any recommendations regarding
dual eligible individuals.
``(11) Interaction of medicaid and medicare.--The
Commission shall consult with MACPAC in carrying out its duties
under this section, as appropriate. Responsibility for analysis
of and recommendations to change Medicare policy regarding
Medicare beneficiaries, including Medicare beneficiaries who
are dually eligible for Medicare and Medicaid, shall rest with
the Commission. Responsibility for analysis of and
recommendations to change Medicaid policy regarding Medicaid
beneficiaries, including Medicaid beneficiaries who are dually
eligible for Medicare and Medicaid, shall rest with MACPAC.''.
Subtitle K--Protections for American Indians and Alaska Natives
SEC. 2901. SPECIAL RULES RELATING TO INDIANS.
(a) No Cost-sharing for Indians With Income at or Below 300 Percent
of Poverty Enrolled in Coverage Through a State Exchange.--For
provisions prohibiting cost sharing for Indians enrolled in any
qualified health plan in the individual market through an Exchange, see
section 1402(d) of the Patient Protection and Affordable Care Act.
(b) Payer of Last Resort.--Health programs operated by the Indian
Health Service, Indian tribes, tribal organizations, and Urban Indian
organizations (as those terms are defined in section 4 of the Indian
Health Care Improvement Act (25 U.S.C. 1603)) shall be the payer of
last resort for services provided by such Service, tribes, or
organizations to individuals eligible for services through such
programs, notwithstanding any Federal, State, or local law to the
contrary.
(c) Facilitating Enrollment of Indians Under the Express Lane
Option.--Section 1902(e)(13)(F)(ii) of the Social Security Act (42
U.S.C. 1396a(e)(13)(F)(ii)) is amended--
(1) in the clause heading, by inserting ``and indian tribes
and tribal organizations'' after ``agencies''; and
(2) by adding at the end the following:
``(IV) The Indian Health Service,
an Indian Tribe, Tribal Organization,
or Urban Indian Organization (as
defined in section 1139(c)).''.
(d) Technical Corrections.--Section 1139(c) of the Social Security
Act (42 U.S.C. 1320b-9(c)) is amended by striking ``In this section''
and inserting ``For purposes of this section, title XIX, and title
XXI''.
SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL MEDICARE
PART B SERVICES FURNISHED BY CERTAIN INDIAN HOSPITALS AND
CLINICS.
(a) Reimbursement for All Medicare Part B Services Furnished by
Certain Indian Hospitals and Clinics.--Section 1880(e)(1)(A) of the
Social Security Act (42 U.S.C. 1395qq(e)(1)(A)) is amended by striking
``during the 5-year period beginning on'' and inserting ``on or
after''.
(b) Effective Date.--The amendments made by this section shall
apply to items or services furnished on or after January 1, 2010.
Subtitle L--Maternal and Child Health Services
SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING
PROGRAMS.
Title V of the Social Security Act (42 U.S.C. 701 et seq.) is
amended by adding at the end the following new section:
``SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING
PROGRAMS.
``(a) Purposes.--The purposes of this section are--
``(1) to strengthen and improve the programs and activities
carried out under this title;
``(2) to improve coordination of services for at risk
communities; and
``(3) to identify and provide comprehensive services to
improve outcomes for families who reside in at risk
communities.
``(b) Requirement for All States To Assess Statewide Needs and
Identify at Risk Communities.--
``(1) In general.--Not later than 6 months after the date
of enactment of this section, each State shall, as a condition
of receiving payments from an allotment for the State under
section 502 for fiscal year 2011, conduct a statewide needs
assessment (which shall be separate from the statewide needs
assessment required under section 505(a)) that identifies--
``(A) communities with concentrations of--
``(i) premature birth, low-birth weight
infants, and infant mortality, including infant
death due to neglect, or other indicators of
at-risk prenatal, maternal, newborn, or child
health;
``(ii) poverty;
``(iii) crime;
``(iv) domestic violence;
``(v) high rates of high-school drop-outs;
``(vi) substance abuse;
``(vii) unemployment; or
``(viii) child maltreatment;
``(B) the quality and capacity of existing programs
or initiatives for early childhood home visitation in
the State including--
``(i) the number and types of individuals
and families who are receiving services under
such programs or initiatives;
``(ii) the gaps in early childhood home
visitation in the State; and
``(iii) the extent to which such programs
or initiatives are meeting the needs of
eligible families described in subsection
(k)(2); and
``(C) the State's capacity for providing substance
abuse treatment and counseling services to individuals
and families in need of such treatment or services.
``(2) Coordination with other assessments.--In conducting
the statewide needs assessment required under paragraph (1),
the State shall coordinate with, and take into account, other
appropriate needs assessments conducted by the State, as
determined by the Secretary, including the needs assessment
required under section 505(a) (both the most recently completed
assessment and any such assessment in progress), the
communitywide strategic planning and needs assessments
conducted in accordance with section 640(g)(1)(C) of the Head
Start Act, and the inventory of current unmet needs and current
community-based and prevention-focused programs and activities
to prevent child abuse and neglect, and other family resource
services operating in the State required under section 205(3)
of the Child Abuse Prevention and Treatment Act.
``(3) Submission to the secretary.--Each State shall submit
to the Secretary, in such form and manner as the Secretary
shall require--
``(A) the results of the statewide needs assessment
required under paragraph (1); and
``(B) a description of how the State intends to
address needs identified by the assessment,
particularly with respect to communities identified
under paragraph (1)(A), which may include applying for
a grant to conduct an early childhood home visitation
program in accordance with the requirements of this
section.
``(c) Grants for Early Childhood Home Visitation Programs.--
``(1) Authority to make grants.--In addition to any other
payments made under this title to a State, the Secretary shall
make grants to eligible entities to enable the entities to
deliver services under early childhood home visitation programs
that satisfy the requirements of subsection (d) to eligible
families in order to promote improvements in maternal and
prenatal health, infant health, child health and development,
parenting related to child development outcomes, school
readiness, and the socioeconomic status of such families, and
reductions in child abuse, neglect, and injuries.
``(2) Authority to use initial grant funds for planning or
implementation.--An eligible entity that receives a grant under
paragraph (1) may use a portion of the funds made available to
the entity during the first 6 months of the period for which
the grant is made for planning or implementation activities to
assist with the establishment of early childhood home
visitation programs that satisfy the requirements of subsection
(d).
``(3) Grant duration.--The Secretary shall determine the
period of years for which a grant is made to an eligible entity
under paragraph (1).
``(4) Technical assistance.--The Secretary shall provide an
eligible entity that receives a grant under paragraph (1) with
technical assistance in administering programs or activities
conducted in whole or in part with grant funds.
``(d) Requirements.--The requirements of this subsection for an
early childhood home visitation program conducted with a grant made
under this section are as follows:
``(1) Quantifiable, measurable improvement in benchmark
areas.--
``(A) In general.--The eligible entity establishes,
subject to the approval of the Secretary, quantifiable,
measurable 3- and 5-year benchmarks for demonstrating
that the program results in improvements for the
eligible families participating in the program in each
of the following areas:
``(i) Improved maternal and newborn health.
``(ii) Prevention of child injuries, child
abuse, neglect, or maltreatment, and reduction
of emergency department visits.
``(iii) Improvement in school readiness and
achievement.
``(iv) Reduction in crime or domestic
violence.
``(v) Improvements in family economic self-
sufficiency.
``(vi) Improvements in the coordination and
referrals for other community resources and
supports.
``(B) Demonstration of improvements after 3
years.--
``(i) Report to the secretary.--Not later
than 30 days after the end of the 3rd year in
which the eligible entity conducts the program,
the entity submits to the Secretary a report
demonstrating improvement in at least 4 of the
areas specified in subparagraph (A).
``(ii) Corrective action plan.--If the
report submitted by the eligible entity under
clause (i) fails to demonstrate improvement in
at least 4 of the areas specified in
subparagraph (A), the entity shall develop and
implement a plan to improve outcomes in each of
the areas specified in subparagraph (A),
subject to approval by the Secretary. The plan
shall include provisions for the Secretary to
monitor implementation of the plan and conduct
continued oversight of the program, including
through submission by the entity of regular
reports to the Secretary.
``(iii) Technical assistance.--
``(I) In general.--The Secretary
shall provide an eligible entity
required to develop and implement an
improvement plan under clause (ii) with
technical assistance to develop and
implement the plan. The Secretary may
provide the technical assistance
directly or through grants, contracts,
or cooperative agreements.
``(II) Advisory panel.--The
Secretary shall establish an advisory
panel for purposes of obtaining
recommendations regarding the technical
assistance provided to entities in
accordance with subclause (I).
``(iv) No improvement or failure to submit
report.--If the Secretary determines after a
period of time specified by the Secretary that
an eligible entity implementing an improvement
plan under clause (ii) has failed to
demonstrate any improvement in the areas
specified in subparagraph (A), or if the
Secretary determines that an eligible entity
has failed to submit the report required under
clause (i), the Secretary shall terminate the
entity's grant and may include any unexpended
grant funds in grants made to nonprofit
organizations under subsection (h)(2)(B).
``(C) Final report.--Not later than December 31,
2015, the eligible entity shall submit a report to the
Secretary demonstrating improvements (if any) in each
of the areas specified in subparagraph (A).
``(2) Improvements in outcomes for individual families.--
``(A) In general.--The program is designed, with
respect to an eligible family participating in the
program, to result in the participant outcomes
described in subparagraph (B) that the eligible entity
identifies on the basis of an individualized assessment
of the family, are relevant for that family.
``(B) Participant outcomes.--The participant
outcomes described in this subparagraph are the
following:
``(i) Improvements in prenatal, maternal,
and newborn health, including improved
pregnancy outcomes
``(ii) Improvements in child health and
development, including the prevention of child
injuries and maltreatment and improvements in
cognitive, language, social-emotional, and
physical developmental indicators.
``(iii) Improvements in parenting skills.
``(iv) Improvements in school readiness and
child academic achievement.
``(v) Reductions in crime or domestic
violence.
``(vi) Improvements in family economic
self-sufficiency.
``(vii) Improvements in the coordination of
referrals for, and the provision of, other
community resources and supports for eligible
families, consistent with State child welfare
agency training.
``(3) Core components.--The program includes the following
core components:
``(A) Service delivery model or models.--
``(i) In general.--Subject to clause (ii),
the program is conducted using 1 or more of the
service delivery models described in item (aa)
or (bb) of subclause (I) or in subclause (II)
selected by the eligible entity:
``(I) The model conforms to a clear
consistent home visitation model that
has been in existence for at least 3
years and is research-based, grounded
in relevant empirically-based
knowledge, linked to program determined
outcomes, associated with a national
organization or institution of higher
education that has comprehensive home
visitation program standards that
ensure high quality service delivery
and continuous program quality
improvement, and has demonstrated
significant, (and in the case of the
service delivery model described in
item (aa), sustained) positive
outcomes, as described in the benchmark
areas specified in paragraph (1)(A) and
the participant outcomes described in
paragraph (2)(B), when evaluated using
well-designed and rigorous--
``(aa) randomized
controlled research designs,
and the evaluation results have
been published in a peer-
reviewed journal; or
``(bb) quasi-experimental
research designs.
``(II) The model conforms to a
promising and new approach to achieving
the benchmark areas specified in
paragraph (1)(A) and the participant
outcomes described in paragraph (2)(B),
has been developed or identified by a
national organization or institution of
higher education, and will be evaluated
through well-designed and rigorous
process.
``(ii) Majority of grant funds used for
evidence-based models.--An eligible entity
shall use not more than 25 percent of the
amount of the grant paid to the entity for a
fiscal year for purposes of conducting a
program using the service delivery model
described in clause (i)(II).
``(iii) Criteria for evidence of
effectiveness of models.--The Secretary shall
establish criteria for evidence of
effectiveness of the service delivery models
and shall ensure that the process for
establishing the criteria is transparent and
provides the opportunity for public comment.
``(B) Additional requirements.--
``(i) The program adheres to a clear,
consistent model that satisfies the
requirements of being grounded in empirically-
based knowledge related to home visiting and
linked to the benchmark areas specified in
paragraph (1)(A) and the participant outcomes
described in paragraph (2)(B) related to the
purposes of the program.
``(ii) The program employs well-trained and
competent staff, as demonstrated by education
or training, such as nurses, social workers,
educators, child development specialists, or
other well-trained and competent staff, and
provides ongoing and specific training on the
model being delivered.
``(iii) The program maintains high quality
supervision to establish home visitor
competencies.
``(iv) The program demonstrates strong
organizational capacity to implement the
activities involved.
``(v) The program establishes appropriate
linkages and referral networks to other
community resources and supports for eligible
families.
``(vi) The program monitors the fidelity of
program implementation to ensure that services
are delivered pursuant to the specified model.
``(4) Priority for serving high-risk populations.--The
eligible entity gives priority to providing services under the
program to the following:
``(A) Eligible families who reside in communities
in need of such services, as identified in the
statewide needs assessment required under subsection
(b)(1)(A).
``(B) Low-income eligible families.
``(C) Eligible families who are pregnant women who
have not attained age 21.
``(D) Eligible families that have a history of
child abuse or neglect or have had interactions with
child welfare services.
``(E) Eligible families that have a history of
substance abuse or need substance abuse treatment.
``(F) Eligible families that have users of tobacco
products in the home.
``(G) Eligible families that are or have children
with low student achievement.
``(H) Eligible families with children with
developmental delays or disabilities.
``(I) Eligible families who, or that include
individuals who, are serving or formerly served in the
Armed Forces, including such families that have members
of the Armed Forces who have had multiple deployments
outside of the United States.
``(e) Application Requirements.--An eligible entity desiring a
grant under this section shall submit an application to the Secretary
for approval, in such manner as the Secretary may require, that
includes the following:
``(1) A description of the populations to be served by the
entity, including specific information regarding how the entity
will serve high risk populations described in subsection
(d)(4).
``(2) An assurance that the entity will give priority to
serving low-income eligible families and eligible families who
reside in at risk communities identified in the statewide needs
assessment required under subsection (b)(1)(A).
``(3) The service delivery model or models described in
subsection (d)(3)(A) that the entity will use under the program
and the basis for the selection of the model or models.
``(4) A statement identifying how the selection of the
populations to be served and the service delivery model or
models that the entity will use under the program for such
populations is consistent with the results of the statewide
needs assessment conducted under subsection (b).
``(5) The quantifiable, measurable benchmarks established
by the State to demonstrate that the program contributes to
improvements in the areas specified in subsection (d)(1)(A).
``(6) An assurance that the entity will obtain and submit
documentation or other appropriate evidence from the
organization or entity that developed the service delivery
model or models used under the program to verify that the
program is implemented and services are delivered according to
the model specifications.
``(7) Assurances that the entity will establish procedures
to ensure that--
``(A) the participation of each eligible family in
the program is voluntary; and
``(B) services are provided to an eligible family
in accordance with the individual assessment for that
family.
``(8) Assurances that the entity will--
``(A) submit annual reports to the Secretary
regarding the program and activities carried out under
the program that include such information and data as
the Secretary shall require; and
``(B) participate in, and cooperate with, data and
information collection necessary for the evaluation
required under subsection (g)(2) and other research and
evaluation activities carried out under subsection
(h)(3).
``(9) A description of other State programs that include
home visitation services, including, if applicable to the
State, other programs carried out under this title with funds
made available from allotments under section 502(c), programs
funded under title IV, title II of the Child Abuse Prevention
and Treatment Act (relating to community-based grants for the
prevention of child abuse and neglect), and section 645A of the
Head Start Act (relating to Early Head Start programs).
``(10) Other information as required by the Secretary.
``(f) Maintenance of Effort.--Funds provided to an eligible entity
receiving a grant under this section shall supplement, and not
supplant, funds from other sources for early childhood home visitation
programs or initiatives.
``(g) Evaluation.--
``(1) Independent, expert advisory panel.--The Secretary,
in accordance with subsection (h)(1)(A), shall appoint an
independent advisory panel consisting of experts in program
evaluation and research, education, and early childhood
development--
``(A) to review, and make recommendations on, the
design and plan for the evaluation required under
paragraph (2) within 1 year after the date of enactment
of this section;
``(B) to maintain and advise the Secretary
regarding the progress of the evaluation; and
``(C) to comment, if the panel so desires, on the
report submitted under paragraph (3).
``(2) Authority to conduct evaluation.--On the basis of the
recommendations of the advisory panel under paragraph (1), the
Secretary shall, by grant, contract, or interagency agreement,
conduct an evaluation of the statewide needs assessments
submitted under subsection (b) and the grants made under
subsections (c) and (h)(3)(B). The evaluation shall include--
``(A) an analysis, on a State-by-State basis, of
the results of such assessments, including indicators
of maternal and prenatal health and infant health and
mortality, and State actions in response to the
assessments; and
``(B) an assessment of--
``(i) the effect of early childhood home
visitation programs on child and parent
outcomes, including with respect to each of the
benchmark areas specified in subsection
(d)(1)(A) and the participant outcomes
described in subsection (d)(2)(B);
``(ii) the effectiveness of such programs
on different populations, including the extent
to which the ability of programs to improve
participant outcomes varies across programs and
populations; and
``(iii) the potential for the activities
conducted under such programs, if scaled
broadly, to improve health care practices,
eliminate health disparities, and improve
health care system quality, efficiencies, and
reduce costs.
``(3) Report.--Not later than March 31, 2015, the Secretary
shall submit a report to Congress on the results of the
evaluation conducted under paragraph (2) and shall make the
report publicly available.
``(h) Other Provisions.--
``(1) Intra-agency collaboration.--The Secretary shall
ensure that the Maternal and Child Health Bureau and the
Administration for Children and Families collaborate with
respect to carrying out this section, including with respect
to--
``(A) reviewing and analyzing the statewide needs
assessments required under subsection (b), the awarding
and oversight of grants awarded under this section, the
establishment of the advisory panels required under
subsections (d)(1)(B)(iii)(II) and (g)(1), and the
evaluation and report required under subsection (g);
and
``(B) consulting with other Federal agencies with
responsibility for administering or evaluating programs
that serve eligible families to coordinate and
collaborate with respect to research related to such
programs and families, including the Office of the
Assistant Secretary for Planning and Evaluation of the
Department of Health and Human Services, the Centers
for Disease Control and Prevention, the National
Institute of Child Health and Human Development of the
National Institutes of Health, the Office of Juvenile
Justice and Delinquency Prevention of the Department of
Justice, and the Institute of Education Sciences of the
Department of Education.
``(2) Grants to eligible entities that are not states.--
``(A) Indian tribes, tribal organizations, or urban
indian organizations.--The Secretary shall specify
requirements for eligible entities that are Indian
Tribes (or a consortium of Indian Tribes), Tribal
Organizations, or Urban Indian Organizations to apply
for and conduct an early childhood home visitation
program with a grant under this section. Such
requirements shall, to the greatest extent practicable,
be consistent with the requirements applicable to
eligible entities that are States and shall require an
Indian Tribe (or consortium), Tribal Organization, or
Urban Indian Organization to--
``(i) conduct a needs assessment similar to
the assessment required for all States under
subsection (b); and
``(ii) establish quantifiable, measurable
3- and 5-year benchmarks consistent with
subsection (d)(1)(A).
``(B) Nonprofit organizations.--If, as of the
beginning of fiscal year 2012, a State has not applied
or been approved for a grant under this section, the
Secretary may use amounts appropriated under paragraph
(1) of subsection (j) that are available for
expenditure under paragraph (3) of that subsection to
make a grant to an eligible entity that is a nonprofit
organization described in subsection (k)(1)(B) to
conduct an early childhood home visitation program in
the State. The Secretary shall specify the requirements
for such an organization to apply for and conduct the
program which shall, to the greatest extent
practicable, be consistent with the requirements
applicable to eligible entities that are States and
shall require the organization to--
``(i) carry out the program based on the
needs assessment conducted by the State under
subsection (b); and
``(ii) establish quantifiable, measurable
3- and 5-year benchmarks consistent with
subsection (d)(1)(A).
``(3) Research and other evaluation activities.--
``(A) In general.--The Secretary shall carry out a
continuous program of research and evaluation
activities in order to increase knowledge about the
implementation and effectiveness of home visiting
programs, using random assignment designs to the
maximum extent feasible. The Secretary may carry out
such activities directly, or through grants,
cooperative agreements, or contracts.
``(B) Requirements.--The Secretary shall ensure
that--
``(i) evaluation of a specific program or
project is conducted by persons or individuals
not directly involved in the operation of such
program or project; and
``(ii) the conduct of research and
evaluation activities includes consultation
with independent researchers, State officials,
and developers and providers of home visiting
programs on topics including research design
and administrative data matching.
``(4) Report and recommendation.--Not later than December
31, 2015, the Secretary shall submit a report to Congress
regarding the programs conducted with grants under this
section. The report required under this paragraph shall
include--
``(A) information regarding the extent to which
eligible entities receiving grants under this section
demonstrated improvements in each of the areas
specified in subsection (d)(1)(A);
``(B) information regarding any technical
assistance provided under subsection (d)(1)(B)(iii)(I),
including the type of any such assistance provided; and
``(C) recommendations for such legislative or
administrative action as the Secretary determines
appropriate.
``(i) Application of Other Provisions of Title.--
``(1) In general.--Except as provided in paragraph (2), the
other provisions of this title shall not apply to a grant made
under this section.
``(2) Exceptions.--The following provisions of this title
shall apply to a grant made under this section to the same
extent and in the same manner as such provisions apply to
allotments made under section 502(c):
``(A) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(B) Section 504(c) (relating to the use of funds
for the purchase of technical assistance).
``(C) Section 504(d) (relating to a limitation on
administrative expenditures).
``(D) Section 506 (relating to reports and audits),
but only to the extent determined by the Secretary to
be appropriate for grants made under this section.
``(E) Section 507 (relating to penalties for false
statements).
``(F) Section 508 (relating to nondiscrimination).
``(G) Section 509(a) (relating to the
administration of the grant program).
``(j) Appropriations.--
``(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
to carry out this section--
``(A) $100,000,000 for fiscal year 2010;
``(B) $250,000,000 for fiscal year 2011;
``(C) $350,000,000 for fiscal year 2012;
``(D) $400,000,000 for fiscal year 2013; and
``(E) $400,000,000 for fiscal year 2014.
``(2) Reservations.--Of the amount appropriated under this
subsection for a fiscal year, the Secretary shall reserve--
``(A) 3 percent of such amount for purposes of
making grants to eligible entities that are Indian
Tribes (or a consortium of Indian Tribes), Tribal
Organizations, or Urban Indian Organizations; and
``(B) 3 percent of such amount for purposes of
carrying out subsections (d)(1)(B)(iii), (g), and
(h)(3).
``(3) Availability.--Funds made available to an eligible
entity under this section for a fiscal year shall remain
available for expenditure by the eligible entity through the
end of the second succeeding fiscal year after award. Any funds
that are not expended by the eligible entity during the period
in which the funds are available under the preceding sentence
may be used for grants to nonprofit organizations under
subsection (h)(2)(B).
``(k) Definitions.--In this section:
``(1) Eligible entity.--
``(A) In general.--The term `eligible entity' means
a State, an Indian Tribe, Tribal Organization, or Urban
Indian Organization, Puerto Rico, Guam, the Virgin
Islands, the Northern Mariana Islands, and American
Samoa.
``(B) Nonprofit organizations.--Only for purposes
of awarding grants under subsection (h)(2)(B), such
term shall include a nonprofit organization with an
established record of providing early childhood home
visitation programs or initiatives in a State or
several States.
``(2) Eligible family.--The term `eligible family' means--
``(A) a woman who is pregnant, and the father of
the child if the father is available; or
``(B) a parent or primary caregiver of a child,
including grandparents or other relatives of the child,
and foster parents, who are serving as the child's
primary caregiver from birth to kindergarten entry, and
including a noncustodial parent who has an ongoing
relationship with, and at times provides physical care
for, the child.
``(3) Indian tribe; tribal organization.--The terms `Indian
Tribe' and `Tribal Organization', and `Urban Indian
Organization' have the meanings given such terms in section 4
of the Indian Health Care Improvement Act.''.
SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM DEPRESSION.
(a) Research on Postpartum Conditions.--
(1) Expansion and intensification of activities.--The
Secretary of Health and Human Services (in this subsection and
subsection (c) referred to as the ``Secretary'') is encouraged
to continue activities on postpartum depression or postpartum
psychosis (in this subsection and subsection (c) referred to as
``postpartum conditions''), including research to expand the
understanding of the causes of, and treatments for, postpartum
conditions. Activities under this paragraph shall include
conducting and supporting the following:
(A) Basic research concerning the etiology and
causes of the conditions.
(B) Epidemiological studies to address the
frequency and natural history of the conditions and the
differences among racial and ethnic groups with respect
to the conditions.
(C) The development of improved screening and
diagnostic techniques.
(D) Clinical research for the development and
evaluation of new treatments.
(E) Information and education programs for health
care professionals and the public, which may include a
coordinated national campaign to increase the awareness
and knowledge of postpartum conditions. Activities
under such a national campaign may--
(i) include public service announcements
through television, radio, and other means; and
(ii) focus on--
(I) raising awareness about
screening;
(II) educating new mothers and
their families about postpartum
conditions to promote earlier diagnosis
and treatment; and
(III) ensuring that such education
includes complete information
concerning postpartum conditions,
including its symptoms, methods of
coping with the illness, and treatment
resources.
(2) Sense of congress regarding longitudinal study of
relative mental health consequences for women of resolving a
pregnancy.--
(A) Sense of congress.--It is the sense of Congress
that the Director of the National Institute of Mental
Health may conduct a nationally representative
longitudinal study (during the period of fiscal years
2010 through 2019) of the relative mental health
consequences for women of resolving a pregnancy
(intended and unintended) in various ways, including
carrying the pregnancy to term and parenting the child,
carrying the pregnancy to term and placing the child
for adoption, miscarriage, and having an abortion. This
study may assess the incidence, timing, magnitude, and
duration of the immediate and long-term mental health
consequences (positive or negative) of these pregnancy
outcomes.
(B) Report.--Subject to the completion of the study
under subsection (a), beginning not later than 5 years
after the date of the enactment of this Act, and
periodically thereafter for the duration of the study,
such Director may prepare and submit to the Congress
reports on the findings of the study.
(b) Grants To Provide Services to Individuals With a Postpartum
Condition and Their Families.--Title V of the Social Security Act (42
U.S.C. 701 et seq.), as amended by section 2951, is amended by adding
at the end the following new section:
``SEC. 512. SERVICES TO INDIVIDUALS WITH A POSTPARTUM CONDITION AND
THEIR FAMILIES.
``(a) In General.--In addition to any other payments made under
this title to a State, the Secretary may make grants to eligible
entities for projects for the establishment, operation, and
coordination of effective and cost-efficient systems for the delivery
of essential services to individuals with or at risk for postpartum
conditions and their families.
``(b) Certain Activities.--To the extent practicable and
appropriate, the Secretary shall ensure that projects funded under
subsection (a) provide education and services with respect to the
diagnosis and management of postpartum conditions for individuals with
or at risk for postpartum conditions and their families. The Secretary
may allow such projects to include the following:
``(1) Delivering or enhancing outpatient and home-based
health and support services, including case management and
comprehensive treatment services.
``(2) Delivering or enhancing inpatient care management
services that ensure the well-being of the mother and family
and the future development of the infant.
``(3) Improving the quality, availability, and organization
of health care and support services (including transportation
services, attendant care, homemaker services, day or respite
care, and providing counseling on financial assistance and
insurance).
``(4) Providing education about postpartum conditions to
promote earlier diagnosis and treatment. Such education may
include--
``(A) providing complete information on postpartum
conditions, symptoms, methods of coping with the
illness, and treatment resources; and
``(B) in the case of a grantee that is a State,
hospital, or birthing facility--
``(i) providing education to new mothers
and fathers, and other family members as
appropriate, concerning postpartum conditions
before new mothers leave the health facility;
and
``(ii) ensuring that training programs
regarding such education are carried out at the
health facility.
``(c) Integration With Other Programs.--To the extent practicable
and appropriate, the Secretary may integrate the grant program under
this section with other grant programs carried out by the Secretary,
including the program under section 330 of the Public Health Service
Act.
``(d) Requirements.--The Secretary shall establish requirements for
grants made under this section that include a limit on the amount of
grants funds that may be used for administration, accounting,
reporting, or program oversight functions and a requirement for each
eligible entity that receives a grant to submit, for each grant period,
a report to the Secretary that describes how grant funds were used
during such period.
``(e) Technical Assistance.--The Secretary may provide technical
assistance to entities seeking a grant under this section in order to
assist such entities in complying with the requirements of this
section.
``(f) Application of Other Provisions of Title.--
``(1) In general.--Except as provided in paragraph (2), the
other provisions of this title shall not apply to a grant made
under this section.
``(2) Exceptions.--The following provisions of this title
shall apply to a grant made under this section to the same
extent and in the same manner as such provisions apply to
allotments made under section 502(c):
``(A) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(B) Section 504(c) (relating to the use of funds
for the purchase of technical assistance).
``(C) Section 504(d) (relating to a limitation on
administrative expenditures).
``(D) Section 506 (relating to reports and audits),
but only to the extent determined by the Secretary to
be appropriate for grants made under this section.
``(E) Section 507 (relating to penalties for false
statements).
``(F) Section 508 (relating to nondiscrimination).
``(G) Section 509(a) (relating to the
administration of the grant program).
``(g) Definitions.--In this section:
``(1) The term `eligible entity'--
``(A) means a public or nonprofit private entity;
and
``(B) includes a State or local government, public-
private partnership, recipient of a grant under section
330H of the Public Health Service Act (relating to the
Healthy Start Initiative), public or nonprofit private
hospital, community-based organization, hospice,
ambulatory care facility, community health center,
migrant health center, public housing primary care
center, or homeless health center.
``(2) The term `postpartum condition' means postpartum
depression or postpartum psychosis.''.
(c) General Provisions.--
(1) Authorization of appropriations.--To carry out this
section and the amendment made by subsection (b), there are
authorized to be appropriated, in addition to such other sums
as may be available for such purpose--
(A) $3,000,000 for fiscal year 2010; and
(B) such sums as may be necessary for fiscal years
2011 and 2012.
(2) Report by the secretary.--
(A) Study.--The Secretary shall conduct a study on
the benefits of screening for postpartum conditions.
(B) Report.--Not later than 2 years after the date
of the enactment of this Act, the Secretary shall
complete the study required by subparagraph (A) and
submit a report to the Congress on the results of such
study.
SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION.
Title V of the Social Security Act (42 U.S.C. 701 et seq.), as
amended by sections 2951 and 2952(c), is amended by adding at the end
the following:
``SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.
``(a) Allotments to States.--
``(1) Amount.--
``(A) In general.--For the purpose described in
subsection (b), subject to the succeeding provisions of
this section, for each of fiscal years 2010 through
2014, the Secretary shall allot to each State an amount
equal to the product of--
``(i) the amount appropriated under
subsection (f) for the fiscal year and
available for allotments to States after the
application of subsection (c); and
``(ii) the State youth population
percentage determined under paragraph (2).
``(B) Minimum allotment.--
``(i) In general.--Each State allotment
under this paragraph for a fiscal year shall be
at least $250,000.
``(ii) Pro rata adjustments.--The Secretary
shall adjust on a pro rata basis the amount of
the State allotments determined under this
paragraph for a fiscal year to the extent
necessary to comply with clause (i).
``(C) Application required to access allotments.--
``(i) In general.--A State shall not be
paid from its allotment for a fiscal year
unless the State submits an application to the
Secretary for the fiscal year and the Secretary
approves the application (or requires changes
to the application that the State satisfies)
and meets such additional requirements as the
Secretary may specify.
``(ii) Requirements.--The State application
shall contain an assurance that the State has
complied with the requirements of this section
in preparing and submitting the application and
shall include the following as well as such
additional information as the Secretary may
require:
``(I) Based on data from the
Centers for Disease Control and
Prevention National Center for Health
Statistics, the most recent pregnancy
rates for the State for youth ages 10
to 14 and youth ages 15 to 19 for which
data are available, the most recent
birth rates for such youth populations
in the State for which data are
available, and trends in those rates
for the most recently preceding 5-year
period for which such data are
available.
``(II) State-established goals for
reducing the pregnancy rates and birth
rates for such youth populations.
``(III) A description of the
State's plan for using the State
allotments provided under this section
to achieve such goals, especially among
youth populations that are the most
high-risk or vulnerable for pregnancies
or otherwise have special
circumstances, including youth in
foster care, homeless youth, youth with
HIV/AIDS, pregnant youth who are under
21 years of age, mothers who are under
21 years of age, and youth residing in
areas with high birth rates for youth.
``(2) State youth population percentage.--
``(A) In general.--For purposes of paragraph
(1)(A)(ii), the State youth population percentage is,
with respect to a State, the proportion (expressed as a
percentage) of--
``(i) the number of individuals who have
attained age 10 but not attained age 20 in the
State; to
``(ii) the number of such individuals in
all States.
``(B) Determination of number of youth.--The number
of individuals described in clauses (i) and (ii) of
subparagraph (A) in a State shall be determined on the
basis of the most recent Bureau of the Census data.
``(3) Availability of state allotments.--Subject to
paragraph (4)(A), amounts allotted to a State pursuant to this
subsection for a fiscal year shall remain available for
expenditure by the State through the end of the second
succeeding fiscal year.
``(4) Authority to award grants from state allotments to
local organizations and entities in nonparticipating states.--
``(A) Grants from unexpended allotments.--If a
State does not submit an application under this section
for fiscal year 2010 or 2011, the State shall no longer
be eligible to submit an application to receive funds
from the amounts allotted for the State for each of
fiscal years 2010 through 2014 and such amounts shall
be used by the Secretary to award grants under this
paragraph for each of fiscal years 2012 through 2014.
The Secretary also shall use any amounts from the
allotments of States that submit applications under
this section for a fiscal year that remain unexpended
as of the end of the period in which the allotments are
available for expenditure under paragraph (3) for
awarding grants under this paragraph.
``(B) 3-year grants.--
``(i) In general.--The Secretary shall
solicit applications to award 3-year grants in
each of fiscal years 2012, 2013, and 2014 to
local organizations and entities to conduct,
consistent with subsection (b), programs and
activities in States that do not submit an
application for an allotment under this section
for fiscal year 2010 or 2011.
``(ii) Faith-based organizations or
consortia.--The Secretary may solicit and award
grants under this paragraph to faith-based
organizations or consortia.
``(C) Evaluation.--An organization or entity
awarded a grant under this paragraph shall agree to
participate in a rigorous Federal evaluation.
``(5) Maintenance of effort.--No payment shall be made to a
State from the allotment determined for the State under this
subsection or to a local organization or entity awarded a grant
under paragraph (4), if the expenditure of non-federal funds by
the State, organization, or entity for activities, programs, or
initiatives for which amounts from allotments and grants under
this subsection may be expended is less than the amount
expended by the State, organization, or entity for such
programs or initiatives for fiscal year 2009.
``(6) Data collection and reporting.--A State or local
organization or entity receiving funds under this section shall
cooperate with such requirements relating to the collection of
data and information and reporting on outcomes regarding the
programs and activities carried out with such funds, as the
Secretary shall specify.
``(b) Purpose.--
``(1) In general.--The purpose of an allotment under
subsection (a)(1) to a State is to enable the State (or, in the
case of grants made under subsection (a)(4)(B), to enable a
local organization or entity) to carry out personal
responsibility education programs consistent with this
subsection.
``(2) Personal responsibility education programs.--
``(A) In general.--In this section, the term
`personal responsibility education program' means a
program that is designed to educate adolescents on--
``(i) both abstinence and contraception for
the prevention of pregnancy and sexually
transmitted infections, including HIV/AIDS,
consistent with the requirements of
subparagraph (B); and
``(ii) at least 3 of the adulthood
preparation subjects described in subparagraph
(C).
``(B) Requirements.--The requirements of this
subparagraph are the following:
``(i) The program replicates evidence-based
effective programs or substantially
incorporates elements of effective programs
that have been proven on the basis of rigorous
scientific research to change behavior, which
means delaying sexual activity, increasing
condom or contraceptive use for sexually active
youth, or reducing pregnancy among youth.
``(ii) The program is medically-accurate
and complete.
``(iii) The program includes activities to
educate youth who are sexually active regarding
responsible sexual behavior with respect to
both abstinence and the use of contraception.
``(iv) The program places substantial
emphasis on both abstinence and contraception
for the prevention of pregnancy among youth and
sexually transmitted infections.
``(v) The program provides age-appropriate
information and activities.
``(vi) The information and activities
carried out under the program are provided in
the cultural context that is most appropriate
for individuals in the particular population
group to which they are directed.
``(C) Adulthood preparation subjects.--The
adulthood preparation subjects described in this
subparagraph are the following:
``(i) Healthy relationships, such as
positive self-esteem and relationship dynamics,
friendships, dating, romantic involvement,
marriage, and family interactions.
``(ii) Adolescent development, such as the
development of healthy attitudes and values
about adolescent growth and development, body
image, racial and ethnic diversity, and other
related subjects.
``(iii) Financial literacy.
``(iv) Parent-child communication.
``(v) Educational and career success, such
as developing skills for employment
preparation, job seeking, independent living,
financial self-sufficiency, and workplace
productivity.
``(vi) Healthy life skills, such as goal-
setting, decision making, negotiation,
communication and interpersonal skills, and
stress management.
``(c) Reservations of Funds.--
``(1) Grants to implement innovative strategies.--From the
amount appropriated under subsection (f) for the fiscal year,
the Secretary shall reserve $10,000,000 of such amount for
purposes of awarding grants to entities to implement innovative
youth pregnancy prevention strategies and target services to
high-risk, vulnerable, and culturally under-represented youth
populations, including youth in foster care, homeless youth,
youth with HIV/AIDS, pregnant women who are under 21 years of
age and their partners, mothers who are under 21 years of age
and their partners, and youth residing in areas with high birth
rates for youth. An entity awarded a grant under this paragraph
shall agree to participate in a rigorous Federal evaluation of
the activities carried out with grant funds.
``(2) Other reservations.--From the amount appropriated
under subsection (f) for the fiscal year that remains after the
application of paragraph (1), the Secretary shall reserve the
following amounts:
``(A) Grants for indian tribes or tribal
organizations.--The Secretary shall reserve 5 percent
of such remainder for purposes of awarding grants to
Indian tribes and tribal organizations in such manner,
and subject to such requirements, as the Secretary, in
consultation with Indian tribes and tribal
organizations, determines appropriate.
``(B) Secretarial responsibilities.--
``(i) Reservation of funds.--The Secretary
shall reserve 10 percent of such remainder for
expenditures by the Secretary for the
activities described in clauses (ii) and (iii).
``(ii) Program support.--The Secretary
shall provide, directly or through a
competitive grant process, research, training
and technical assistance, including
dissemination of research and information
regarding effective and promising practices,
providing consultation and resources on a broad
array of teen pregnancy prevention strategies,
including abstinence and contraception, and
developing resources and materials to support
the activities of recipients of grants and
other State, tribal, and community
organizations working to reduce teen pregnancy.
In carrying out such functions, the Secretary
shall collaborate with a variety of entities
that have expertise in the prevention of teen
pregnancy, HIV and sexually transmitted
infections, healthy relationships, financial
literacy, and other topics addressed through
the personal responsibility education programs.
``(iii) Evaluation.--The Secretary shall
evaluate the programs and activities carried
out with funds made available through
allotments or grants under this section.
``(d) Administration.--
``(1) In general.--The Secretary shall administer this
section through the Assistant Secretary for the Administration
for Children and Families within the Department of Health and
Human Services.
``(2) Application of other provisions of title.--
``(A) In general.--Except as provided in
subparagraph (B), the other provisions of this title
shall not apply to allotments or grants made under this
section.
``(B) Exceptions.--The following provisions of this
title shall apply to allotments and grants made under
this section to the same extent and in the same manner
as such provisions apply to allotments made under
section 502(c):
``(i) Section 504(b)(6) (relating to
prohibition on payments to excluded individuals
and entities).
``(ii) Section 504(c) (relating to the use
of funds for the purchase of technical
assistance).
``(iii) Section 504(d) (relating to a
limitation on administrative expenditures).
``(iv) Section 506 (relating to reports and
audits), but only to the extent determined by
the Secretary to be appropriate for grants made
under this section.
``(v) Section 507 (relating to penalties
for false statements).
``(vi) Section 508 (relating to
nondiscrimination).
``(e) Definitions.--In this section:
``(1) Age-appropriate.--The term `age-appropriate', with
respect to the information in pregnancy prevention, means
topics, messages, and teaching methods suitable to particular
ages or age groups of children and adolescents, based on
developing cognitive, emotional, and behavioral capacity
typical for the age or age group.
``(2) Medically accurate and complete.--The term `medically
accurate and complete' means verified or supported by the
weight of research conducted in compliance with accepted
scientific methods and--
``(A) published in peer-reviewed journals, where
applicable; or
``(B) comprising information that leading
professional organizations and agencies with relevant
expertise in the field recognize as accurate,
objective, and complete.
``(3) Indian tribes; tribal organizations.--The terms
`Indian tribe' and `Tribal organization' have the meanings
given such terms in section 4 of the Indian Health Care
Improvement Act (25 U.S.C. 1603)).
``(4) Youth.--The term `youth' means an individual who has
attained age 10 but has not attained age 20.
``(f) Appropriation.--For the purpose of carrying out this section,
there is appropriated, out of any money in the Treasury not otherwise
appropriated, $75,000,000 for each of fiscal years 2010 through 2014.
Amounts appropriated under this subsection shall remain available until
expended.''.
SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION.
Section 510 of the Social Security Act (42 U.S.C. 710) is amended--
(1) in subsection (a), by striking ``fiscal year 1998 and
each subsequent fiscal year'' and inserting ``each of fiscal
years 2010 through 2014''; and
(2) in subsection (d)--
(A) in the first sentence, by striking ``1998
through 2003'' and inserting ``2010 through 2014''; and
(B) in the second sentence, by inserting ``(except
that such appropriation shall be made on the date of
enactment of the Patient Protection and Affordable Care
Act in the case of fiscal year 2010)'' before the
period.
SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE OF HAVING A
HEALTH CARE POWER OF ATTORNEY IN TRANSITION PLANNING FOR
CHILDREN AGING OUT OF FOSTER CARE AND INDEPENDENT LIVING
PROGRAMS.
(a) Transition Planning.--Section 475(5)(H) of the Social Security
Act (42 U.S.C. 675(5)(H)) is amended by inserting ``includes
information about the importance of designating another individual to
make health care treatment decisions on behalf of the child if the
child becomes unable to participate in such decisions and the child
does not have, or does not want, a relative who would otherwise be
authorized under State law to make such decisions, and provides the
child with the option to execute a health care power of attorney,
health care proxy, or other similar document recognized under State
law,'' after ``employment services,''.
(b) Independent Living Education.--Section 477(b)(3) of such Act
(42 U.S.C. 677(b)(3)) is amended by adding at the end the following:
``(K) A certification by the chief executive
officer of the State that the State will ensure that an
adolescent participating in the program under this
section are provided with education about the
importance of designating another individual to make
health care treatment decisions on behalf of the
adolescent if the adolescent becomes unable to
participate in such decisions and the adolescent does
not have, or does not want, a relative who would
otherwise be authorized under State law to make such
decisions, whether a health care power of attorney,
health care proxy, or other similar document is
recognized under State law, and how to execute such a
document if the adolescent wants to do so.''.
(c) Health Oversight and Coordination Plan.--Section 422(b)(15)(A)
of such Act (42 U.S.C. 622(b)(15)(A)) is amended--
(1) in clause (v), by striking ``and'' at the end; and
(2) by adding at the end the following:
``(vii) steps to ensure that the components
of the transition plan development process
required under section 475(5)(H) that relate to
the health care needs of children aging out of
foster care, including the requirements to
include options for health insurance,
information about a health care power of
attorney, health care proxy, or other similar
document recognized under State law, and to
provide the child with the option to execute
such a document, are met; and''.
(d) Effective Date.--The amendments made by this section take
effect on October 1, 2010.
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A--Transforming the Health Care Delivery System
PART I--LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM
SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM.
(a) Program.--
(1) In general.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 4102(a) of the HITECH
Act (Public Law 111-5), is amended by adding at the end the
following new subsection:
``(o) Hospital Value-Based Purchasing Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish a hospital value-based purchasing program (in
this subsection referred to as the `Program') under
which value-based incentive payments are made in a
fiscal year to hospitals that meet the performance
standards under paragraph (3) for the performance
period for such fiscal year (as established under
paragraph (4)).
``(B) Program to begin in fiscal year 2013.--The
Program shall apply to payments for discharges
occurring on or after October 1, 2012.
``(C) Applicability of program to hospitals.--
``(i) In general.--For purposes of this
subsection, subject to clause (ii), the term
`hospital' means a subsection (d) hospital (as
defined in subsection (d)(1)(B)).
``(ii) Exclusions.--The term `hospital'
shall not include, with respect to a fiscal
year, a hospital--
``(I) that is subject to the
payment reduction under subsection
(b)(3)(B)(viii)(I) for such fiscal
year;
``(II) for which, during the
performance period for such fiscal
year, the Secretary has cited
deficiencies that pose immediate
jeopardy to the health or safety of
patients;
``(III) for which there are not a
minimum number (as determined by the
Secretary) of measures that apply to
the hospital for the performance period
for such fiscal year; or
``(IV) for which there are not a
minimum number (as determined by the
Secretary) of cases for the measures
that apply to the hospital for the
performance period for such fiscal
year.
``(iii) Independent analysis.--For purposes
of determining the minimum numbers under
subclauses (III) and (IV) of clause (ii), the
Secretary shall have conducted an independent
analysis of what numbers are appropriate.
``(iv) Exemption.--In the case of a
hospital that is paid under section 1814(b)(3),
the Secretary may exempt such hospital from the
application of this subsection if the State
which is paid under such section submits an
annual report to the Secretary describing how a
similar program in the State for a
participating hospital or hospitals achieves or
surpasses the measured results in terms of
patient health outcomes and cost savings
established under this subsection.
``(2) Measures.--
``(A) In general.--The Secretary shall select
measures for purposes of the Program. Such measures
shall be selected from the measures specified under
subsection (b)(3)(B)(viii).
``(B) Requirements.--
``(i) For fiscal year 2013.--For value-
based incentive payments made with respect to
discharges occurring during fiscal year 2013,
the Secretary shall ensure the following:
``(I) Conditions or procedures.--
Measures are selected under
subparagraph (A) that cover at least
the following 5 specific conditions or
procedures:
``(aa) Acute myocardial
infarction (AMI).
``(bb) Heart failure.
``(cc) Pneumonia.
``(dd) Surgeries, as
measured by the Surgical Care
Improvement Project (formerly
referred to as `Surgical
Infection Prevention' for
discharges occurring before
July 2006).
``(ee) Healthcare-
associated infections, as
measured by the prevention
metrics and targets established
in the HHS Action Plan to
Prevent Healthcare-Associated
Infections (or any successor
plan) of the Department of
Health and Human Services.
``(II) HCAHPS.--Measures selected
under subparagraph (A) shall be related
to the Hospital Consumer Assessment of
Healthcare Providers and Systems survey
(HCAHPS).
``(ii) Inclusion of efficiency measures.--
For value-based incentive payments made with
respect to discharges occurring during fiscal
year 2014 or a subsequent fiscal year, the
Secretary shall ensure that measures selected
under subparagraph (A) include efficiency
measures, including measures of `Medicare
spending per beneficiary'. Such measures shall
be adjusted for factors such as age, sex, race,
severity of illness, and other factors that the
Secretary determines appropriate.
``(C) Limitations.--
``(i) Time requirement for prior reporting
and notice.--The Secretary may not select a
measure under subparagraph (A) for use under
the Program with respect to a performance
period for a fiscal year (as established under
paragraph (4)) unless such measure has been
specified under subsection (b)(3)(B)(viii) and
included on the Hospital Compare Internet
website for at least 1 year prior to the
beginning of such performance period.
``(ii) Measure not applicable unless
hospital furnishes services appropriate to the
measure.--A measure selected under subparagraph
(A) shall not apply to a hospital if such
hospital does not furnish services appropriate
to such measure.
``(D) Replacing measures.--Subclause (VI) of
subsection (b)(3)(B)(viii) shall apply to measures
selected under subparagraph (A) in the same manner as
such subclause applies to measures selected under such
subsection.
``(3) Performance standards.--
``(A) Establishment.--The Secretary shall establish
performance standards with respect to measures selected
under paragraph (2) for a performance period for a
fiscal year (as established under paragraph (4)).
``(B) Achievement and improvement.--The performance
standards established under subparagraph (A) shall
include levels of achievement and improvement.
``(C) Timing.--The Secretary shall establish and
announce the performance standards under subparagraph
(A) not later than 60 days prior to the beginning of
the performance period for the fiscal year involved.
``(D) Considerations in establishing standards.--In
establishing performance standards with respect to
measures under this paragraph, the Secretary shall take
into account appropriate factors, such as--
``(i) practical experience with the
measures involved, including whether a
significant proportion of hospitals failed to
meet the performance standard during previous
performance periods;
``(ii) historical performance standards;
``(iii) improvement rates; and
``(iv) the opportunity for continued
improvement.
``(4) Performance period.--For purposes of the Program, the
Secretary shall establish the performance period for a fiscal
year. Such performance period shall begin and end prior to the
beginning of such fiscal year.
``(5) Hospital performance score.--
``(A) In general.--Subject to subparagraph (B), the
Secretary shall develop a methodology for assessing the
total performance of each hospital based on performance
standards with respect to the measures selected under
paragraph (2) for a performance period (as established
under paragraph (4)). Using such methodology, the
Secretary shall provide for an assessment (in this
subsection referred to as the `hospital performance
score') for each hospital for each performance period.
``(B) Application.--
``(i) Appropriate distribution.--The
Secretary shall ensure that the application of
the methodology developed under subparagraph
(A) results in an appropriate distribution of
value-based incentive payments under paragraph
(6) among hospitals achieving different levels
of hospital performance scores, with hospitals
achieving the highest hospital performance
scores receiving the largest value-based
incentive payments.
``(ii) Higher of achievement or
improvement.--The methodology developed under
subparagraph (A) shall provide that the
hospital performance score is determined using
the higher of its achievement or improvement
score for each measure.
``(iii) Weights.--The methodology developed
under subparagraph (A) shall provide for the
assignment of weights for categories of
measures as the Secretary determines
appropriate.
``(iv) No minimum performance standard.--
The Secretary shall not set a minimum
performance standard in determining the
hospital performance score for any hospital.
``(v) Reflection of measures applicable to
the hospital.--The hospital performance score
for a hospital shall reflect the measures that
apply to the hospital.
``(6) Calculation of value-based incentive payments.--
``(A) In general.--In the case of a hospital that
the Secretary determines meets (or exceeds) the
performance standards under paragraph (3) for the
performance period for a fiscal year (as established
under paragraph (4)), the Secretary shall increase the
base operating DRG payment amount (as defined in
paragraph (7)(D)), as determined after application of
paragraph (7)(B)(i), for a hospital for each discharge
occurring in such fiscal year by the value-based
incentive payment amount.
``(B) Value-based incentive payment amount.--The
value-based incentive payment amount for each discharge
of a hospital in a fiscal year shall be equal to the
product of--
``(i) the base operating DRG payment amount
(as defined in paragraph (7)(D)) for the
discharge for the hospital for such fiscal
year; and
``(ii) the value-based incentive payment
percentage specified under subparagraph (C) for
the hospital for such fiscal year.
``(C) Value-based incentive payment percentage.--
``(i) In general.--The Secretary shall
specify a value-based incentive payment
percentage for a hospital for a fiscal year.
``(ii) Requirements.--In specifying the
value-based incentive payment percentage for
each hospital for a fiscal year under clause
(i), the Secretary shall ensure that--
``(I) such percentage is based on
the hospital performance score of the
hospital under paragraph (5); and
``(II) the total amount of value-
based incentive payments under this
paragraph to all hospitals in such
fiscal year is equal to the total
amount available for value-based
incentive payments for such fiscal year
under paragraph (7)(A), as estimated by
the Secretary.
``(7) Funding for value-based incentive payments.--
``(A) Amount.--The total amount available for
value-based incentive payments under paragraph (6) for
all hospitals for a fiscal year shall be equal to the
total amount of reduced payments for all hospitals
under subparagraph (B) for such fiscal year, as
estimated by the Secretary.
``(B) Adjustment to payments.--
``(i) In general.--The Secretary shall
reduce the base operating DRG payment amount
(as defined in subparagraph (D)) for a hospital
for each discharge in a fiscal year (beginning
with fiscal year 2013) by an amount equal to
the applicable percent (as defined in
subparagraph (C)) of the base operating DRG
payment amount for the discharge for the
hospital for such fiscal year. The Secretary
shall make such reductions for all hospitals in
the fiscal year involved, regardless of whether
or not the hospital has been determined by the
Secretary to have earned a value-based
incentive payment under paragraph (6) for such
fiscal year.
``(ii) No effect on other payments.--
Payments described in items (aa) and (bb) of
subparagraph (D)(i)(II) for a hospital shall be
determined as if this subsection had not been
enacted.
``(C) Applicable percent defined.--For purposes of
subparagraph (B), the term `applicable percent' means--
``(i) with respect to fiscal year 2013, 1.0
percent;
``(ii) with respect to fiscal year 2014,
1.25 percent;
``(iii) with respect to fiscal year 2015,
1.5 percent;
``(iv) with respect to fiscal year 2016,
1.75 percent; and
``(v) with respect to fiscal year 2017 and
succeeding fiscal years, 2 percent.
``(D) Base operating drg payment amount defined.--
``(i) In general.--Except as provided in
clause (ii), in this subsection, the term `base
operating DRG payment amount' means, with
respect to a hospital for a fiscal year--
``(I) the payment amount that would
otherwise be made under subsection (d)
(determined without regard to
subsection (q)) for a discharge if this
subsection did not apply; reduced by
``(II) any portion of such payment
amount that is attributable to--
``(aa) payments under
paragraphs (5)(A), (5)(B),
(5)(F), and (12) of subsection
(d); and
``(bb) such other payments
under subsection (d) determined
appropriate by the Secretary.
``(ii) Special rules for certain
hospitals.--
``(I) Sole community hospitals and
medicare-dependent, small rural
hospitals.--In the case of a medicare-
dependent, small rural hospital (with
respect to discharges occurring during
fiscal year 2012 and 2013) or a sole
community hospital, in applying
subparagraph (A)(i), the payment amount
that would otherwise be made under
subsection (d) shall be determined
without regard to subparagraphs (I) and
(L) of subsection (b)(3) and
subparagraphs (D) and (G) of subsection
(d)(5).
``(II) Hospitals paid under section
1814.--In the case of a hospital that
is paid under section 1814(b)(3), the
term `base operating DRG payment
amount' means the payment amount under
such section.
``(8) Announcement of net result of adjustments.--Under the
Program, the Secretary shall, not later than 60 days prior to
the fiscal year involved, inform each hospital of the
adjustments to payments to the hospital for discharges
occurring in such fiscal year under paragraphs (6) and
(7)(B)(i).
``(9) No effect in subsequent fiscal years.--The value-
based incentive payment under paragraph (6) and the payment
reduction under paragraph (7)(B)(i) shall each apply only with
respect to the fiscal year involved, and the Secretary shall
not take into account such value-based incentive payment or
payment reduction in making payments to a hospital under this
section in a subsequent fiscal year.
``(10) Public reporting.--
``(A) Hospital specific information.--
``(i) In general.--The Secretary shall make
information available to the public regarding
the performance of individual hospitals under
the Program, including--
``(I) the performance of the
hospital with respect to each measure
that applies to the hospital;
``(II) the performance of the
hospital with respect to each condition
or procedure; and
``(III) the hospital performance
score assessing the total performance
of the hospital.
``(ii) Opportunity to review and submit
corrections.--The Secretary shall ensure that a
hospital has the opportunity to review, and
submit corrections for, the information to be
made public with respect to the hospital under
clause (i) prior to such information being made
public.
``(iii) Website.--Such information shall be
posted on the Hospital Compare Internet website
in an easily understandable format.
``(B) Aggregate information.--The Secretary shall
periodically post on the Hospital Compare Internet
website aggregate information on the Program,
including--
``(i) the number of hospitals receiving
value-based incentive payments under paragraph
(6) and the range and total amount of such
value-based incentive payments; and
``(ii) the number of hospitals receiving
less than the maximum value-based incentive
payment available to the hospital for the
fiscal year involved and the range and amount
of such payments.
``(11) Implementation.--
``(A) Appeals.--The Secretary shall establish a
process by which hospitals may appeal the calculation
of a hospital's performance assessment with respect to
the performance standards established under paragraph
(3)(A) and the hospital performance score under
paragraph (5). The Secretary shall ensure that such
process provides for resolution of such appeals in a
timely manner.
``(B) Limitation on review.--Except as provided in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the
amount of the value-based incentive payment
under paragraph (6) and the determination of
such amount.
``(ii) The determination of the amount of
funding available for such value-based
incentive payments under paragraph (7)(A) and
the payment reduction under paragraph
(7)(B)(i).
``(iii) The establishment of the
performance standards under paragraph (3) and
the performance period under paragraph (4).
``(iv) The measures specified under
subsection (b)(3)(B)(viii) and the measures
selected under paragraph (2).
``(v) The methodology developed under
paragraph (5) that is used to calculate
hospital performance scores and the calculation
of such scores.
``(vi) The validation methodology specified
in subsection (b)(3)(B)(viii)(XI).
``(C) Consultation with small hospitals.--The
Secretary shall consult with small rural and urban
hospitals on the application of the Program to such
hospitals.
``(12) Promulgation of regulations.--The Secretary shall
promulgate regulations to carry out the Program, including the
selection of measures under paragraph (2), the methodology
developed under paragraph (5) that is used to calculate
hospital performance scores, and the methodology used to
determine the amount of value-based incentive payments under
paragraph (6).''.
(2) Amendments for reporting of hospital quality
information.--Section 1886(b)(3)(B)(viii) of the Social
Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended--
(A) in subclause (II), by adding at the end the
following sentence: ``The Secretary may require
hospitals to submit data on measures that are not used
for the determination of value-based incentive payments
under subsection (o).'';
(B) in subclause (V), by striking ``beginning with
fiscal year 2008'' and inserting ``for fiscal years
2008 through 2012'';
(C) in subclause (VII), in the first sentence, by
striking ``data submitted'' and inserting ``information
regarding measures submitted''; and
(D) by adding at the end the following new
subclauses:
``(VIII) Effective for payments beginning with fiscal year 2013,
with respect to quality measures for outcomes of care, the Secretary
shall provide for such risk adjustment as the Secretary determines to
be appropriate to maintain incentives for hospitals to treat patients
with severe illnesses or conditions.
``(IX)(aa) Subject to item (bb), effective for payments beginning
with fiscal year 2013, each measure specified by the Secretary under
this clause shall be endorsed by the entity with a contract under
section 1890(a).
``(bb) In the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical measure
has not been endorsed by the entity with a contract under section
1890(a), the Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been endorsed
or adopted by a consensus organization identified by the Secretary.
``(X) To the extent practicable, the Secretary shall, with input
from consensus organizations and other stakeholders, take steps to
ensure that the measures specified by the Secretary under this clause
are coordinated and aligned with quality measures applicable to--
``(aa) physicians under section 1848(k); and
``(bb) other providers of services and suppliers under this
title.
``(XI) The Secretary shall establish a process to validate measures
specified under this clause as appropriate. Such process shall include
the auditing of a number of randomly selected hospitals sufficient to
ensure validity of the reporting program under this clause as a whole
and shall provide a hospital with an opportunity to appeal the
validation of measures reported by such hospital.''.
(3) Website improvements.--Section 1886(b)(3)(B) of the
Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended by
section 4102(b) of the HITECH Act (Public Law 111-5), is
amended by adding at the end the following new clause:
``(x)(I) The Secretary shall develop standard Internet website
reports tailored to meet the needs of various stakeholders such as
hospitals, patients, researchers, and policymakers. The Secretary shall
seek input from such stakeholders in determining the type of
information that is useful and the formats that best facilitate the use
of the information.
``(II) The Secretary shall modify the Hospital Compare Internet
website to make the use and navigation of that website readily
available to individuals accessing it.''.
(4) GAO study and report.--
(A) Study.--The Comptroller General of the United
States shall conduct a study on the performance of the
hospital value-based purchasing program established
under section 1886(o) of the Social Security Act, as
added by paragraph (1). Such study shall include an
analysis of the impact of such program on--
(i) the quality of care furnished to
Medicare beneficiaries, including diverse
Medicare beneficiary populations (such as
diverse in terms of race, ethnicity, and
socioeconomic status);
(ii) expenditures under the Medicare
program, including any reduced expenditures
under Part A of title XVIII of such Act that
are attributable to the improvement in the
delivery of inpatient hospital services by
reason of such hospital value-based purchasing
program;
(iii) the quality performance among safety
net hospitals and any barriers such hospitals
face in meeting the performance standards
applicable under such hospital value-based
purchasing program; and
(iv) the quality performance among small
rural and small urban hospitals and any
barriers such hospitals face in meeting the
performance standards applicable under such
hospital value-based purchasing program.
(B) Reports.--
(i) Interim report.--Not later than October
1, 2015, the Comptroller General of the United
States shall submit to Congress an interim
report containing the results of the study
conducted under subparagraph (A), together with
recommendations for such legislation and
administrative action as the Comptroller
General determines appropriate.
(ii) Final report.--Not later than July 1,
2017, the Comptroller General of the United
States shall submit to Congress a report
containing the results of the study conducted
under subparagraph (A), together with
recommendations for such legislation and
administrative action as the Comptroller
General determines appropriate.
(5) HHS study and report.--
(A) Study.--The Secretary of Health and Human
Services shall conduct a study on the performance of
the hospital value-based purchasing program established
under section 1886(o) of the Social Security Act, as
added by paragraph (1). Such study shall include an
analysis--
(i) of ways to improve the hospital value-
based purchasing program and ways to address
any unintended consequences that may occur as a
result of such program;
(ii) of whether the hospital value-based
purchasing program resulted in lower spending
under the Medicare program under title XVIII of
such Act or other financial savings to
hospitals;
(iii) the appropriateness of the Medicare
program sharing in any savings generated
through the hospital value-based purchasing
program; and
(iv) any other area determined appropriate
by the Secretary.
(B) Report.--Not later than January 1, 2016, the
Secretary of Health and Human Services shall submit to
Congress a report containing the results of the study
conducted under subparagraph (A), together with
recommendations for such legislation and administrative
action as the Secretary determines appropriate.
(b) Value-Based Purchasing Demonstration Programs.--
(1) Value-based purchasing demonstration program for
inpatient critical access hospitals.--
(A) Establishment.--
(i) In general.--Not later than 2 years
after the date of enactment of this Act, the
Secretary of Health and Human Services (in this
subsection referred to as the ``Secretary'')
shall establish a demonstration program under
which the Secretary establishes a value-based
purchasing program under the Medicare program
under title XVIII of the Social Security Act
for critical access hospitals (as defined in
paragraph (1) of section 1861(mm) of such Act
(42 U.S.C. 1395x(mm))) with respect to
inpatient critical access hospital services (as
defined in paragraph (2) of such section) in
order to test innovative methods of measuring
and rewarding quality and efficient health care
furnished by such hospitals.
(ii) Duration.--The demonstration program
under this paragraph shall be conducted for a
3-year period.
(iii) Sites.--The Secretary shall conduct
the demonstration program under this paragraph
at an appropriate number (as determined by the
Secretary) of critical access hospitals. The
Secretary shall ensure that such hospitals are
representative of the spectrum of such
hospitals that participate in the Medicare
program.
(B) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social
Security Act as may be necessary to carry out the
demonstration program under this paragraph.
(C) Budget neutrality requirement.--In conducting
the demonstration program under this section, the
Secretary shall ensure that the aggregate payments made
by the Secretary do not exceed the amount which the
Secretary would have paid if the demonstration program
under this section was not implemented.
(D) Report.--Not later than 18 months after the
completion of the demonstration program under this
paragraph, the Secretary shall submit to Congress a
report on the demonstration program together with--
(i) recommendations on the establishment of
a permanent value-based purchasing program
under the Medicare program for critical access
hospitals with respect to inpatient critical
access hospital services; and
(ii) recommendations for such other
legislation and administrative action as the
Secretary determines appropriate.
(2) Value-based purchasing demonstration program for
hospitals excluded from hospital value-based purchasing program
as a result of insufficient numbers of measures and cases.--
(A) Establishment.--
(i) In general.--Not later than 2 years
after the date of enactment of this Act, the
Secretary shall establish a demonstration
program under which the Secretary establishes a
value-based purchasing program under the
Medicare program under title XVIII of the
Social Security Act for applicable hospitals
(as defined in clause (ii)) with respect to
inpatient hospital services (as defined in
section 1861(b) of the Social Security Act (42
U.S.C. 1395x(b))) in order to test innovative
methods of measuring and rewarding quality and
efficient health care furnished by such
hospitals.
(ii) Applicable hospital defined.--For
purposes of this paragraph, the term
``applicable hospital'' means a hospital
described in subclause (III) or (IV) of section
1886(o)(1)(C)(ii) of the Social Security Act,
as added by subsection (a)(1).
(iii) Duration.--The demonstration program
under this paragraph shall be conducted for a
3-year period.
(iv) Sites.--The Secretary shall conduct
the demonstration program under this paragraph
at an appropriate number (as determined by the
Secretary) of applicable hospitals. The
Secretary shall ensure that such hospitals are
representative of the spectrum of such
hospitals that participate in the Medicare
program.
(B) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social
Security Act as may be necessary to carry out the
demonstration program under this paragraph.
(C) Budget neutrality requirement.--In conducting
the demonstration program under this section, the
Secretary shall ensure that the aggregate payments made
by the Secretary do not exceed the amount which the
Secretary would have paid if the demonstration program
under this section was not implemented.
(D) Report.--Not later than 18 months after the
completion of the demonstration program under this
paragraph, the Secretary shall submit to Congress a
report on the demonstration program together with--
(i) recommendations on the establishment of
a permanent value-based purchasing program
under the Medicare program for applicable
hospitals with respect to inpatient hospital
services; and
(ii) recommendations for such other
legislation and administrative action as the
Secretary determines appropriate.
SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM.
(a) Extension.--Section 1848(m) of the Social Security Act (42
U.S.C. 1395w-4(m)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (A), in the matter preceding
clause (i), by striking ``2010'' and inserting
``2014''; and
(B) in subparagraph (B)--
(i) in clause (i), by striking ``and'' at
the end;
(ii) in clause (ii), by striking the period
at the end and inserting a semicolon; and
(iii) by adding at the end the following
new clauses:
``(iii) for 2011, 1.0 percent; and
``(iv) for 2012, 2013, and 2014, 0.5
percent.'';
(2) in paragraph (3)--
(A) in subparagraph (A), in the matter preceding
clause (i), by inserting ``(or, for purposes of
subsection (a)(8), for the quality reporting period for
the year)'' after ``reporting period''; and
(B) in subparagraph (C)(i), by inserting ``, or,
for purposes of subsection (a)(8), for a quality
reporting period for the year'' after ``(a)(5), for a
reporting period for a year'';
(3) in paragraph (5)(E)(iv), by striking ``subsection
(a)(5)(A)'' and inserting ``paragraphs (5)(A) and (8)(A) of
subsection (a)''; and
(4) in paragraph (6)(C)--
(A) in clause (i)(II), by striking ``, 2009, 2010,
and 2011'' and inserting ``and subsequent years''; and
(B) in clause (iii)--
(i) by inserting ``(a)(8)'' after
``(a)(5)''; and
(ii) by striking ``under subparagraph
(D)(iii) of such subsection'' and inserting
``under subsection (a)(5)(D)(iii) or the
quality reporting period under subsection
(a)(8)(D)(iii), respectively''.
(b) Incentive Payment Adjustment for Quality Reporting.--Section
1848(a) of the Social Security Act (42 U.S.C. 1395w-4(a)) is amended by
adding at the end the following new paragraph:
``(8) Incentives for quality reporting.--
``(A) Adjustment.--
``(i) In general.--With respect to covered
professional services furnished by an eligible
professional during 2015 or any subsequent
year, if the eligible professional does not
satisfactorily submit data on quality measures
for covered professional services for the
quality reporting period for the year (as
determined under subsection (m)(3)(A)), the fee
schedule amount for such services furnished by
such professional during the year (including
the fee schedule amount for purposes of
determining a payment based on such amount)
shall be equal to the applicable percent of the
fee schedule amount that would otherwise apply
to such services under this subsection
(determined after application of paragraphs
(3), (5), and (7), but without regard to this
paragraph).
``(ii) Applicable percent.--For purposes of
clause (i), the term `applicable percent'
means--
``(I) for 2015, 98.5 percent; and
``(II) for 2016 and each subsequent
year, 98 percent.
``(B) Application.--
``(i) Physician reporting system rules.--
Paragraphs (5), (6), and (8) of subsection (k)
shall apply for purposes of this paragraph in
the same manner as they apply for purposes of
such subsection.
``(ii) Incentive payment validation
rules.--Clauses (ii) and (iii) of subsection
(m)(5)(D) shall apply for purposes of this
paragraph in a similar manner as they apply for
purposes of such subsection.
``(C) Definitions.--For purposes of this paragraph:
``(i) Eligible professional; covered
professional services.--The terms `eligible
professional' and `covered professional
services' have the meanings given such terms in
subsection (k)(3).
``(ii) Physician reporting system.--The
term `physician reporting system' means the
system established under subsection (k).
``(iii) Quality reporting period.--The term
`quality reporting period' means, with respect
to a year, a period specified by the
Secretary.''.
(c) Maintenance of Certification Programs.--
(1) In general.--Section 1848(k)(4) of the Social Security
Act (42 U.S.C. 1395w-4(k)(4)) is amended by inserting ``or
through a Maintenance of Certification program operated by a
specialty body of the American Board of Medical Specialties
that meets the criteria for such a registry'' after
``Database)''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply for years after 2010.
(d) Integration of Physician Quality Reporting and EHR Reporting.--
Section 1848(m) of the Social Security Act (42 U.S.C. 1395w-4(m)) is
amended by adding at the end the following new paragraph:
``(7) Integration of physician quality reporting and ehr
reporting.--Not later than January 1, 2012, the Secretary shall
develop a plan to integrate reporting on quality measures under
this subsection with reporting requirements under subsection
(o) relating to the meaningful use of electronic health
records. Such integration shall consist of the following:
``(A) The selection of measures, the reporting of
which would both demonstrate--
``(i) meaningful use of an electronic
health record for purposes of subsection (o);
and
``(ii) quality of care furnished to an
individual.
``(B) Such other activities as specified by the
Secretary.''.
(e) Feedback.--Section 1848(m)(5) of the Social Security Act (42
U.S.C. 1395w-4(m)(5)) is amended by adding at the end the following new
subparagraph:
``(H) Feedback.--The Secretary shall provide timely
feedback to eligible professionals on the performance
of the eligible professional with respect to
satisfactorily submitting data on quality measures
under this subsection.''.
(f) Appeals.--Such section is further amended--
(1) in subparagraph (E), by striking ``There shall'' and
inserting ``Except as provided in subparagraph (I), there
shall''; and
(2) by adding at the end the following new subparagraph:
``(I) Informal appeals process.--The Secretary
shall, by not later than January 1, 2011, establish and
have in place an informal process for eligible
professionals to seek a review of the determination
that an eligible professional did not satisfactorily
submit data on quality measures under this
subsection.''.
SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM.
(a) In General.--Section 1848(n) of the Social Security Act (42
U.S.C. 1395w-4(n)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (A)--
(i) by striking ``general.--The Secretary''
and inserting ``general.--
``(i) Establishment.--The Secretary'';
(ii) in clause (i), as added by clause (i),
by striking ``the `Program')'' and all that
follows through the period at the end of the
second sentence and inserting ``the
`Program').''; and
(iii) by adding at the end the following
new clauses:
``(ii) Reports on resources.--The Secretary
shall use claims data under this title (and may
use other data) to provide confidential reports
to physicians (and, as determined appropriate
by the Secretary, to groups of physicians) that
measure the resources involved in furnishing
care to individuals under this title.
``(iii) Inclusion of certain information.--
If determined appropriate by the Secretary, the
Secretary may include information on the
quality of care furnished to individuals under
this title by the physician (or group of
physicians) in such reports.''; and
(B) in subparagraph (B), by striking ``subparagraph
(A)'' and inserting ``subparagraph (A)(ii)'';
(2) in paragraph (4)--
(A) in the heading, by inserting ``initial'' after
``focus''; and
(B) in the matter preceding subparagraph (A), by
inserting ``initial'' after ``focus the'';
(3) in paragraph (6), by adding at the end the following
new sentence: ``For adjustments for reports on utilization
under paragraph (9), see subparagraph (D) of such paragraph.'';
and
(4) by adding at the end the following new paragraphs:
``(9) Reports on utilization.--
``(A) Development of episode grouper.--
``(i) In general.--The Secretary shall
develop an episode grouper that combines
separate but clinically related items and
services into an episode of care for an
individual, as appropriate.
``(ii) Timeline for development.--The
episode grouper described in subparagraph (A)
shall be developed by not later than January 1,
2012.
``(iii) Public availability.--The Secretary
shall make the details of the episode grouper
described in subparagraph (A) available to the
public.
``(iv) Endorsement.--The Secretary shall
seek endorsement of the episode grouper
described in subparagraph (A) by the entity
with a contract under section 1890(a).
``(B) Reports on utilization.--Effective beginning
with 2012, the Secretary shall provide reports to
physicians that compare, as determined appropriate by
the Secretary, patterns of resource use of the
individual physician to such patterns of other
physicians.
``(C) Analysis of data.--The Secretary shall, for
purposes of preparing reports under this paragraph,
establish methodologies as appropriate, such as to--
``(i) attribute episodes of care, in whole
or in part, to physicians;
``(ii) identify appropriate physicians for
purposes of comparison under subparagraph (B);
and
``(iii) aggregate episodes of care
attributed to a physician under clause (i) into
a composite measure per individual.
``(D) Data adjustment.--In preparing reports under
this paragraph, the Secretary shall make appropriate
adjustments, including adjustments--
``(i) to account for differences in
socioeconomic and demographic characteristics,
ethnicity, and health status of individuals
(such as to recognize that less healthy
individuals may require more intensive
interventions); and
``(ii) to eliminate the effect of
geographic adjustments in payment rates (as
described in subsection (e)).
``(E) Public availability of methodology.--The
Secretary shall make available to the public--
``(i) the methodologies established under
subparagraph (C);
``(ii) information regarding any
adjustments made to data under subparagraph
(D); and
``(iii) aggregate reports with respect to
physicians.
``(F) Definition of physician.--In this paragraph:
``(i) In general.--The term `physician' has
the meaning given that term in section
1861(r)(1).
``(ii) Treatment of groups.--Such term
includes, as the Secretary determines
appropriate, a group of physicians.
``(G) Limitations on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the establishment of the
methodology under subparagraph (C), including the
determination of an episode of care under such
methodology.
``(10) Coordination with other value-based purchasing
reforms.--The Secretary shall coordinate the Program with the
value-based payment modifier established under subsection (p)
and, as the Secretary determines appropriate, other similar
provisions of this title.''.
(b) Conforming Amendment.--Section 1890(b) of the Social Security
Act (42 U.S.C. 1395aaa(b)) is amended by adding at the end the
following new paragraph:
``(6) Review and endorsement of episode grouper under the
physician feedback program.--The entity shall provide for the
review and, as appropriate, the endorsement of the episode
grouper developed by the Secretary under section 1848(n)(9)(A).
Such review shall be conducted on an expedited basis.''.
SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE HOSPITALS, INPATIENT
REHABILITATION HOSPITALS, AND HOSPICE PROGRAMS.
(a) Long-term Care Hospitals.--Section 1886(m) of the Social
Security Act (42 U.S.C. 1395ww(m)), as amended by section 3401(c), is
amended by adding at the end the following new paragraph:
``(5) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--Under the system
described in paragraph (1), for rate year 2014
and each subsequent rate year, in the case of a
long-term care hospital that does not submit
data to the Secretary in accordance with
subparagraph (C) with respect to such a rate
year, any annual update to a standard Federal
rate for discharges for the hospital during the
rate year, and after application of paragraph
(3), shall be reduced by 2 percentage points.
``(ii) Special rule.--The application of
this subparagraph may result in such annual
update being less than 0.0 for a rate year, and
may result in payment rates under the system
described in paragraph (1) for a rate year
being less than such payment rates for the
preceding rate year.
``(B) Noncumulative application.--Any reduction
under subparagraph (A) shall apply only with respect to
the rate year involved and the Secretary shall not take
into account such reduction in computing the payment
amount under the system described in paragraph (1) for
a subsequent rate year.
``(C) Submission of quality data.--For rate year
2014 and each subsequent rate year, each long-term care
hospital shall submit to the Secretary data on quality
measures specified under subparagraph (D). Such data
shall be submitted in a form and manner, and at a time,
specified by the Secretary for purposes of this
subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii),
any measure specified by the Secretary under
this subparagraph must have been endorsed by
the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a
specified area or medical topic determined
appropriate by the Secretary for which a
feasible and practical measure has not been
endorsed by the entity with a contract under
section 1890(a), the Secretary may specify a
measure that is not so endorsed as long as due
consideration is given to measures that have
been endorsed or adopted by a consensus
organization identified by the Secretary.
``(iii) Time frame.--Not later than October
1, 2012, the Secretary shall publish the
measures selected under this subparagraph that
will be applicable with respect to rate year
2014.
``(E) Public availability of data submitted.--The
Secretary shall establish procedures for making data
submitted under subparagraph (C) available to the
public. Such procedures shall ensure that a long-term
care hospital has the opportunity to review the data
that is to be made public with respect to the hospital
prior to such data being made public. The Secretary
shall report quality measures that relate to services
furnished in inpatient settings in long-term care
hospitals on the Internet website of the Centers for
Medicare & Medicaid Services.''.
(b) Inpatient Rehabilitation Hospitals.--Section 1886(j) of the
Social Security Act (42 U.S.C. 1395ww(j)) is amended--
(1) by redesignating paragraph (7) as paragraph (8); and
(2) by inserting after paragraph (6) the following new
paragraph:
``(7) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--For purposes of fiscal
year 2014 and each subsequent fiscal year, in
the case of a rehabilitation facility that does
not submit data to the Secretary in accordance
with subparagraph (C) with respect to such a
fiscal year, after determining the increase
factor described in paragraph (3)(C), and after
application of paragraph (3)(D), the Secretary
shall reduce such increase factor for payments
for discharges occurring during such fiscal
year by 2 percentage points.
``(ii) Special rule.--The application of
this subparagraph may result in the increase
factor described in paragraph (3)(C) being less
than 0.0 for a fiscal year, and may result in
payment rates under this subsection for a
fiscal year being less than such payment rates
for the preceding fiscal year.
``(B) Noncumulative application.--Any reduction
under subparagraph (A) shall apply only with respect to
the fiscal year involved and the Secretary shall not
take into account such reduction in computing the
payment amount under this subsection for a subsequent
fiscal year.
``(C) Submission of quality data.--For fiscal year
2014 and each subsequent rate year, each rehabilitation
facility shall submit to the Secretary data on quality
measures specified under subparagraph (D). Such data
shall be submitted in a form and manner, and at a time,
specified by the Secretary for purposes of this
subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii),
any measure specified by the Secretary under
this subparagraph must have been endorsed by
the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a
specified area or medical topic determined
appropriate by the Secretary for which a
feasible and practical measure has not been
endorsed by the entity with a contract under
section 1890(a), the Secretary may specify a
measure that is not so endorsed as long as due
consideration is given to measures that have
been endorsed or adopted by a consensus
organization identified by the Secretary.
``(iii) Time frame.--Not later than October
1, 2012, the Secretary shall publish the
measures selected under this subparagraph that
will be applicable with respect to fiscal year
2014.
``(E) Public availability of data submitted.--The
Secretary shall establish procedures for making data
submitted under subparagraph (C) available to the
public. Such procedures shall ensure that a
rehabilitation facility has the opportunity to review
the data that is to be made public with respect to the
facility prior to such data being made public. The
Secretary shall report quality measures that relate to
services furnished in inpatient settings in
rehabilitation facilities on the Internet website of
the Centers for Medicare & Medicaid Services.''.
(c) Hospice Programs.--Section 1814(i) of the Social Security Act
(42 U.S.C. 1395f(i)) is amended--
(1) by redesignating paragraph (5) as paragraph (6); and
(2) by inserting after paragraph (4) the following new
paragraph:
``(5) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--For purposes of fiscal
year 2014 and each subsequent fiscal year, in
the case of a hospice program that does not
submit data to the Secretary in accordance with
subparagraph (C) with respect to such a fiscal
year, after determining the market basket
percentage increase under paragraph
(1)(C)(ii)(VII) or paragraph (1)(C)(iii), as
applicable, and after application of paragraph
(1)(C)(iv), with respect to the fiscal year,
the Secretary shall reduce such market basket
percentage increase by 2 percentage points.
``(ii) Special rule.--The application of
this subparagraph may result in the market
basket percentage increase under paragraph
(1)(C)(ii)(VII) or paragraph (1)(C)(iii), as
applicable, being less than 0.0 for a fiscal
year, and may result in payment rates under
this subsection for a fiscal year being less
than such payment rates for the preceding
fiscal year.
``(B) Noncumulative application.--Any reduction
under subparagraph (A) shall apply only with respect to
the fiscal year involved and the Secretary shall not
take into account such reduction in computing the
payment amount under this subsection for a subsequent
fiscal year.
``(C) Submission of quality data.--For fiscal year
2014 and each subsequent fiscal year, each hospice
program shall submit to the Secretary data on quality
measures specified under subparagraph (D). Such data
shall be submitted in a form and manner, and at a time,
specified by the Secretary for purposes of this
subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii),
any measure specified by the Secretary under
this subparagraph must have been endorsed by
the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a
specified area or medical topic determined
appropriate by the Secretary for which a
feasible and practical measure has not been
endorsed by the entity with a contract under
section 1890(a), the Secretary may specify a
measure that is not so endorsed as long as due
consideration is given to measures that have
been endorsed or adopted by a consensus
organization identified by the Secretary.
``(iii) Time frame.--Not later than October
1, 2012, the Secretary shall publish the
measures selected under this subparagraph that
will be applicable with respect to fiscal year
2014.
``(E) Public availability of data submitted.--The
Secretary shall establish procedures for making data
submitted under subparagraph (C) available to the
public. Such procedures shall ensure that a hospice
program has the opportunity to review the data that is
to be made public with respect to the hospice program
prior to such data being made public. The Secretary
shall report quality measures that relate to hospice
care provided by hospice programs on the Internet
website of the Centers for Medicare & Medicaid
Services.''.
SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER HOSPITALS.
Section 1866 of the Social Security Act (42 U.S.C. 1395cc) is
amended--
(1) in subsection (a)(1)--
(A) in subparagraph (U), by striking ``and'' at the
end;
(B) in subparagraph (V), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(W) in the case of a hospital described in
section 1886(d)(1)(B)(v), to report quality data to the
Secretary in accordance with subsection (k).''; and
(2) by adding at the end the following new subsection:
``(k) Quality Reporting by Cancer Hospitals.--
``(1) In general.--For purposes of fiscal year 2014 and
each subsequent fiscal year, a hospital described in section
1886(d)(1)(B)(v) shall submit data to the Secretary in
accordance with paragraph (2) with respect to such a fiscal
year.
``(2) Submission of quality data.--For fiscal year 2014 and
each subsequent fiscal year, each hospital described in such
section shall submit to the Secretary data on quality measures
specified under paragraph (3). Such data shall be submitted in
a form and manner, and at a time, specified by the Secretary
for purposes of this subparagraph.
``(3) Quality measures.--
``(A) In general.--Subject to subparagraph (B), any
measure specified by the Secretary under this paragraph
must have been endorsed by the entity with a contract
under section 1890(a).
``(B) Exception.--In the case of a specified area
or medical topic determined appropriate by the
Secretary for which a feasible and practical measure
has not been endorsed by the entity with a contract
under section 1890(a), the Secretary may specify a
measure that is not so endorsed as long as due
consideration is given to measures that have been
endorsed or adopted by a consensus organization
identified by the Secretary.
``(C) Time frame.--Not later than October 1, 2012,
the Secretary shall publish the measures selected under
this paragraph that will be applicable with respect to
fiscal year 2014.
``(4) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
paragraph (4) available to the public. Such procedures shall
ensure that a hospital described in section 1886(d)(1)(B)(v)
has the opportunity to review the data that is to be made
public with respect to the hospital prior to such data being
made public. The Secretary shall report quality measures of
process, structure, outcome, patients' perspective on care,
efficiency, and costs of care that relate to services furnished
in such hospitals on the Internet website of the Centers for
Medicare & Medicaid Services.''.
SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR SKILLED
NURSING FACILITIES AND HOME HEALTH AGENCIES.
(a) Skilled Nursing Facilities.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a plan to implement a value-based purchasing program
for payments under the Medicare program under title XVIII of
the Social Security Act for skilled nursing facilities (as
defined in section 1819(a) of such Act (42 U.S.C. 1395i-3(a))).
(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
(A) The ongoing development, selection, and
modification process for measures (including under
section 1890 of the Social Security Act (42 U.S.C.
1395aaa) and section 1890A such Act, as added by
section 3014), to the extent feasible and practicable,
of all dimensions of quality and efficiency in skilled
nursing facilities.
(i) In general.--Subject to clause (ii),
any measure specified by the Secretary under
subparagraph (A)(iii) must have been endorsed
by the entity with a contract under section
1890(a).
(ii) Exception.--In the case of a specified
area or medical topic determined appropriate by
the Secretary for which a feasible and
practical measure has not been endorsed by the
entity with a contract under section 1890(a),
the Secretary may specify a measure that is not
so endorsed as long as due consideration is
given to measures that have been endorsed or
adopted by a consensus organization identified
by the Secretary.
(B) The reporting, collection, and validation of
quality data.
(C) The structure of value-based payment
adjustments, including the determination of thresholds
or improvements in quality that would substantiate a
payment adjustment, the size of such payments, and the
sources of funding for the value-based bonus payments.
(D) Methods for the public disclosure of
information on the performance of skilled nursing
facilities.
(E) Any other issues determined appropriate by the
Secretary.
(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
(A) consult with relevant affected parties; and
(B) consider experience with such demonstrations
that the Secretary determines are relevant to the
value-based purchasing program described in paragraph
(1).
(4) Report to congress.--Not later than October 1, 2011,
the Secretary shall submit to Congress a report containing the
plan developed under paragraph (1).
(b) Home Health Agencies.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a plan to implement a value-based purchasing program
for payments under the Medicare program under title XVIII of
the Social Security Act for home health agencies (as defined in
section 1861(o) of such Act (42 U.S.C. 1395x(o))).
(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
(A) The ongoing development, selection, and
modification process for measures (including under
section 1890 of the Social Security Act (42 U.S.C.
1395aaa) and section 1890A such Act, as added by
section 3014), to the extent feasible and practicable,
of all dimensions of quality and efficiency in home
health agencies.
(B) The reporting, collection, and validation of
quality data.
(C) The structure of value-based payment
adjustments, including the determination of thresholds
or improvements in quality that would substantiate a
payment adjustment, the size of such payments, and the
sources of funding for the value-based bonus payments.
(D) Methods for the public disclosure of
information on the performance of home health agencies.
(E) Any other issues determined appropriate by the
Secretary.
(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
(A) consult with relevant affected parties; and
(B) consider experience with such demonstrations
that the Secretary determines are relevant to the
value-based purchasing program described in paragraph
(1).
(4) Report to congress.--Not later than October 1, 2011,
the Secretary shall submit to Congress a report containing the
plan developed under paragraph (1).
SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN FEE
SCHEDULE.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is
amended--
(1) in subsection (b)(1), by inserting ``subject to
subsection (p),'' after ``1998,''; and
(2) by adding at the end the following new subsection:
``(p) Establishment of Value-based Payment Modifier.--
``(1) In general.--The Secretary shall establish a payment
modifier that provides for differential payment to a physician
or a group of physicians under the fee schedule established
under subsection (b) based upon the quality of care furnished
compared to cost (as determined under paragraphs (2) and (3),
respectively) during a performance period. Such payment
modifier shall be separate from the geographic adjustment
factors established under subsection (e).
``(2) Quality.--
``(A) In general.--For purposes of paragraph (1),
quality of care shall be evaluated, to the extent
practicable, based on a composite of measures of the
quality of care furnished (as established by the
Secretary under subparagraph (B)).
``(B) Measures.--
``(i) The Secretary shall establish
appropriate measures of the quality of care
furnished by a physician or group of physicians
to individuals enrolled under this part, such
as measures that reflect health outcomes. Such
measures shall be risk adjusted as determined
appropriate by the Secretary.
``(ii) The Secretary shall seek endorsement
of the measures established under this
subparagraph by the entity with a contract
under section 1890(a).
``(3) Costs.--For purposes of paragraph (1), costs shall be
evaluated, to the extent practicable, based on a composite of
appropriate measures of costs established by the Secretary
(such as the composite measure under the methodology
established under subsection (n)(9)(C)(iii)) that eliminate the
effect of geographic adjustments in payment rates (as described
in subsection (e)), and take into account risk factors (such as
socioeconomic and demographic characteristics, ethnicity, and
health status of individuals (such as to recognize that less
healthy individuals may require more intensive interventions)
and other factors determined appropriate by the Secretary.
``(4) Implementation.--
``(A) Publication of measures, dates of
implementation, performance period.--Not later than
January 1, 2012, the Secretary shall publish the
following:
``(i) The measures of quality of care and
costs established under paragraphs (2) and (3),
respectively.
``(ii) The dates for implementation of the
payment modifier (as determined under
subparagraph (B)).
``(iii) The initial performance period (as
specified under subparagraph (B)(ii)).
``(B) Deadlines for implementation.--
``(i) Initial implementation.--Subject to
the preceding provisions of this subparagraph,
the Secretary shall begin implementing the
payment modifier established under this
subsection through the rulemaking process
during 2013 for the physician fee schedule
established under subsection (b).
``(ii) Initial performance period.--
``(I) In general.--The Secretary
shall specify an initial performance
period for application of the payment
modifier established under this
subsection with respect to 2015.
``(II) Provision of information
during initial performance period.--
During the initial performance period,
the Secretary shall, to the extent
practicable, provide information to
physicians and groups of physicians
about the quality of care furnished by
the physician or group of physicians to
individuals enrolled under this part
compared to cost (as determined under
paragraphs (2) and (3), respectively)
with respect to the performance period.
``(iii) Application.--The Secretary shall
apply the payment modifier established under
this subsection for items and services
furnished--
``(I) beginning on January 1, 2015,
with respect to specific physicians and
groups of physicians the Secretary
determines appropriate; and
``(II) beginning not later than
January 1, 2017, with respect to all
physicians and groups of physicians.
``(C) Budget neutrality.--The payment modifier
established under this subsection shall be implemented
in a budget neutral manner.
``(5) Systems-based care.--The Secretary shall, as
appropriate, apply the payment modifier established under this
subsection in a manner that promotes systems-based care.
``(6) Consideration of special circumstances of certain
providers.--In applying the payment modifier under this
subsection, the Secretary shall, as appropriate, take into
account the special circumstances of physicians or groups of
physicians in rural areas and other underserved communities.
``(7) Application.--For purposes of the initial application
of the payment modifier established under this subsection
during the period beginning on January 1, 2015, and ending on
December 31, 2016, the term `physician' has the meaning given
such term in section 1861(r). On or after January 1, 2017, the
Secretary may apply this subsection to eligible professionals
(as defined in subsection (k)(3)(B)) as the Secretary
determines appropriate.
``(8) Definitions.--For purposes of this subsection:
``(A) Costs.--The term `costs' means expenditures
per individual as determined appropriate by the
Secretary. In making the determination under the
preceding sentence, the Secretary may take into account
the amount of growth in expenditures per individual for
a physician compared to the amount of such growth for
other physicians.
``(B) Performance period.--The term `performance
period' means a period specified by the Secretary.
``(9) Coordination with other value-based purchasing
reforms.--The Secretary shall coordinate the value-based
payment modifier established under this subsection with the
Physician Feedback Program under subsection (n) and, as the
Secretary determines appropriate, other similar provisions of
this title.
``(10) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the establishment of the value-based payment
modifier under this subsection;
``(B) the evaluation of quality of care under
paragraph (2), including the establishment of
appropriate measures of the quality of care under
paragraph (2)(B);
``(C) the evaluation of costs under paragraph (3),
including the establishment of appropriate measures of
costs under such paragraph;
``(D) the dates for implementation of the value-
based payment modifier;
``(E) the specification of the initial performance
period and any other performance period under
paragraphs (4)(B)(ii) and (8)(B), respectively;
``(F) the application of the value-based payment
modifier under paragraph (7); and
``(G) the determination of costs under paragraph
(8)(A).''.
SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS ACQUIRED IN HOSPITALS.
(a) In General.--Section 1886 of the Social Security Act (42 U.S.C.
1395ww), as amended by section 3001, is amended by adding at the end
the following new subsection:
``(p) Adjustment to Hospital Payments for Hospital Acquired
Conditions.--
``(1) In general.--In order to provide an incentive for
applicable hospitals to reduce hospital acquired conditions
under this title, with respect to discharges from an applicable
hospital occurring during fiscal year 2015 or a subsequent
fiscal year, the amount of payment under this section or
section 1814(b)(3), as applicable, for such discharges during
the fiscal year shall be equal to 99 percent of the amount of
payment that would otherwise apply to such discharges under
this section or section 1814(b)(3) (determined after the
application of subsections (o) and (q) and section 1814(l)(4)
but without regard to this subsection).
``(2) Applicable hospitals.--
``(A) In general.--For purposes of this subsection,
the term `applicable hospital' means a subsection (d)
hospital that meets the criteria described in
subparagraph (B).
``(B) Criteria described.--
``(i) In general.--The criteria described
in this subparagraph, with respect to a
subsection (d) hospital, is that the subsection
(d) hospital is in the top quartile of all
subsection (d) hospitals, relative to the
national average, of hospital acquired
conditions during the applicable period, as
determined by the Secretary.
``(ii) Risk adjustment.--In carrying out
clause (i), the Secretary shall establish and
apply an appropriate risk adjustment
methodology.
``(C) Exemption.--In the case of a hospital that is
paid under section 1814(b)(3), the Secretary may exempt
such hospital from the application of this subsection
if the State which is paid under such section submits
an annual report to the Secretary describing how a
similar program in the State for a participating
hospital or hospitals achieves or surpasses the
measured results in terms of patient health outcomes
and cost savings established under this subsection.
``(3) Hospital acquired conditions.--For purposes of this
subsection, the term `hospital acquired condition' means a
condition identified for purposes of subsection (d)(4)(D)(iv)
and any other condition determined appropriate by the Secretary
that an individual acquires during a stay in an applicable
hospital, as determined by the Secretary.
``(4) Applicable period.--In this subsection, the term
`applicable period' means, with respect to a fiscal year, a
period specified by the Secretary.
``(5) Reporting to hospitals.--Prior to fiscal year 2015
and each subsequent fiscal year, the Secretary shall provide
confidential reports to applicable hospitals with respect to
hospital acquired conditions of the applicable hospital during
the applicable period.
``(6) Reporting hospital specific information.--
``(A) In general.--The Secretary shall make
information available to the public regarding hospital
acquired conditions of each applicable hospital.
``(B) Opportunity to review and submit
corrections.--The Secretary shall ensure that an
applicable hospital has the opportunity to review, and
submit corrections for, the information to be made
public with respect to the hospital under subparagraph
(A) prior to such information being made public.
``(C) Website.--Such information shall be posted on
the Hospital Compare Internet website in an easily
understandable format.
``(7) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) The criteria described in paragraph (2)(A).
``(B) The specification of hospital acquired
conditions under paragraph (3).
``(C) The specification of the applicable period
under paragraph (4).
``(D) The provision of reports to applicable
hospitals under paragraph (5) and the information made
available to the public under paragraph (6).''.
(b) Study and Report on Expansion of Healthcare Acquired Conditions
Policy to Other Providers.--
(1) Study.--The Secretary of Health and Human Services
shall conduct a study on expanding the healthcare acquired
conditions policy under subsection (d)(4)(D) of section 1886 of
the Social Security Act (42 U.S.C. 1395ww) to payments made to
other facilities under the Medicare program under title XVIII
of the Social Security Act, including such payments made to
inpatient rehabilitation facilities, long-term care hospitals
(as described in subsection(d)(1)(B)(iv) of such section),
hospital outpatient departments, and other hospitals excluded
from the inpatient prospective payment system under such
section, skilled nursing facilities, ambulatory surgical
centers, and health clinics. Such study shall include an
analysis of how such policies could impact quality of patient
care, patient safety, and spending under the Medicare program.
(2) Report.--Not later than January 1, 2012, the Secretary
shall submit to Congress a report containing the results of the
study conducted under paragraph (1), together with
recommendations for such legislation and administrative action
as the Secretary determines appropriate.
PART II--NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY
SEC. 3011. NATIONAL STRATEGY.
Title III of the Public Health Service Act (42 U.S.C. 241 et seq.)
is amended by adding at the end the following:
``PART S--HEALTH CARE QUALITY PROGRAMS
``Subpart I--National Strategy for Quality Improvement in Health Care
``SEC. 399HH. NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE.
``(a) Establishment of National Strategy and Priorities.--
``(1) National strategy.--The Secretary, through a
transparent collaborative process, shall establish a national
strategy to improve the delivery of health care services,
patient health outcomes, and population health.
``(2) Identification of priorities.--
``(A) In general.--The Secretary shall identify
national priorities for improvement in developing the
strategy under paragraph (1).
``(B) Requirements.--The Secretary shall ensure
that priorities identified under subparagraph (A)
will--
``(i) have the greatest potential for
improving the health outcomes, efficiency, and
patient-centeredness of health care for all
populations, including children and vulnerable
populations;
``(ii) identify areas in the delivery of
health care services that have the potential
for rapid improvement in the quality and
efficiency of patient care;
``(iii) address gaps in quality,
efficiency, comparative effectiveness
information, and health outcomes measures and
data aggregation techniques;
``(iv) improve Federal payment policy to
emphasize quality and efficiency;
``(v) enhance the use of health care data
to improve quality, efficiency, transparency,
and outcomes;
``(vi) address the health care provided to
patients with high-cost chronic diseases;
``(vii) improve research and dissemination
of strategies and best practices to improve
patient safety and reduce medical errors,
preventable admissions and readmissions, and
health care-associated infections;
``(viii) reduce health disparities across
health disparity populations (as defined in
section 485E) and geographic areas; and
``(ix) address other areas as determined
appropriate by the Secretary.
``(C) Considerations.--In identifying priorities
under subparagraph (A), the Secretary shall take into
consideration the recommendations submitted by the
entity with a contract under section 1890(a) of the
Social Security Act and other stakeholders.
``(D) Coordination with state agencies.--The
Secretary shall collaborate, coordinate, and consult
with State agencies responsible for administering the
Medicaid program under title XIX of the Social Security
Act and the Children's Health Insurance Program under
title XXI of such Act with respect to developing and
disseminating strategies, goals, models, and timetables
that are consistent with the national priorities
identified under subparagraph (A).
``(b) Strategic Plan.--
``(1) In general.--The national strategy shall include a
comprehensive strategic plan to achieve the priorities
described in subsection (a).
``(2) Requirements.--The strategic plan shall include
provisions for addressing, at a minimum, the following:
``(A) Coordination among agencies within the
Department, which shall include steps to minimize
duplication of efforts and utilization of common
quality measures, where available. Such common quality
measures shall be measures identified by the Secretary
under section 1139A or 1139B of the Social Security Act
or endorsed under section 1890 of such Act.
``(B) Agency-specific strategic plans to achieve
national priorities.
``(C) Establishment of annual benchmarks for each
relevant agency to achieve national priorities.
``(D) A process for regular reporting by the
agencies to the Secretary on the implementation of the
strategic plan.
``(E) Strategies to align public and private payers
with regard to quality and patient safety efforts.
``(F) Incorporating quality improvement and
measurement in the strategic plan for health
information technology required by the American
Recovery and Reinvestment Act of 2009 (Public Law 111-
5).
``(c) Periodic Update of National Strategy.--The Secretary shall
update the national strategy not less than annually. Any such update
shall include a review of short- and long-term goals.
``(d) Submission and Availability of National Strategy and
Updates.--
``(1) Deadline for initial submission of national
strategy.--Not later than January 1, 2011, the Secretary shall
submit to the relevant committees of Congress the national
strategy described in subsection (a).
``(2) Updates.--
``(A) In general.--The Secretary shall submit to
the relevant committees of Congress an annual update to
the strategy described in paragraph (1).
``(B) Information submitted.--Each update submitted
under subparagraph (A) shall include--
``(i) a review of the short- and long-term
goals of the national strategy and any gaps in
such strategy;
``(ii) an analysis of the progress, or lack
of progress, in meeting such goals and any
barriers to such progress;
``(iii) the information reported under
section 1139A of the Social Security Act,
consistent with the reporting requirements of
such section; and
``(iv) in the case of an update required to
be submitted on or after January 1, 2014, the
information reported under section 1139B(b)(4)
of the Social Security Act, consistent with the
reporting requirements of such section.
``(C) Satisfaction of other reporting
requirements.--Compliance with the requirements of
clauses (iii) and (iv) of subparagraph (B) shall
satisfy the reporting requirements under sections
1139A(a)(6) and 1139B(b)(4), respectively, of the
Social Security Act.
``(e) Health Care Quality Internet Website.--Not later than January
1, 2011, the Secretary shall create an Internet website to make public
information regarding--
``(1) the national priorities for health care quality
improvement established under subsection (a)(2);
``(2) the agency-specific strategic plans for health care
quality described in subsection (b)(2)(B); and
``(3) other information, as the Secretary determines to be
appropriate.''.
SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH CARE QUALITY.
(a) In General.--The President shall convene a working group to be
known as the Interagency Working Group on Health Care Quality (referred
to in this section as the ``Working Group'').
(b) Goals.--The goals of the Working Group shall be to achieve the
following:
(1) Collaboration, cooperation, and consultation between
Federal departments and agencies with respect to developing and
disseminating strategies, goals, models, and timetables that
are consistent with the national priorities identified under
section 399HH(a)(2) of the Public Health Service Act (as added
by section 3011).
(2) Avoidance of inefficient duplication of quality
improvement efforts and resources, where practicable, and a
streamlined process for quality reporting and compliance
requirements.
(3) Assess alignment of quality efforts in the public
sector with private sector initiatives.
(c) Composition.--
(1) In general.--The Working Group shall be composed of
senior level representatives of--
(A) the Department of Health and Human Services;
(B) the Centers for Medicare & Medicaid Services;
(C) the National Institutes of Health;
(D) the Centers for Disease Control and Prevention;
(E) the Food and Drug Administration;
(F) the Health Resources and Services
Administration;
(G) the Agency for Healthcare Research and Quality;
(H) the Office of the National Coordinator for
Health Information Technology;
(I) the Substance Abuse and Mental Health Services
Administration;
(J) the Administration for Children and Families;
(K) the Department of Commerce;
(L) the Office of Management and Budget;
(M) the United States Coast Guard;
(N) the Federal Bureau of Prisons;
(O) the National Highway Traffic Safety
Administration;
(P) the Federal Trade Commission;
(Q) the Social Security Administration;
(R) the Department of Labor;
(S) the United States Office of Personnel
Management;
(T) the Department of Defense;
(U) the Department of Education;
(V) the Department of Veterans Affairs;
(W) the Veterans Health Administration; and
(X) any other Federal agencies and departments with
activities relating to improving health care quality
and safety, as determined by the President.
(2) Chair and vice-chair.--
(A) Chair.--The Working Group shall be chaired by
the Secretary of Health and Human Services.
(B) Vice chair.--Members of the Working Group,
other than the Secretary of Health and Human Services,
shall serve as Vice Chair of the Group on a rotating
basis, as determined by the Group.
(d) Report to Congress.--Not later than December 31, 2010, and
annually thereafter, the Working Group shall submit to the relevant
Committees of Congress, and make public on an Internet website, a
report describing the progress and recommendations of the Working Group
in meeting the goals described in subsection (b).
SEC. 3013. QUALITY MEASURE DEVELOPMENT.
(a) Public Health Service Act.--Title IX of the Public Health
Service Act (42 U.S.C. 299 et seq.) is amended--
(1) by redesignating part D as part E;
(2) by redesignating sections 931 through 938 as sections
941 through 948, respectively;
(3) in section 948(1), as so redesignated, by striking
``931'' and inserting ``941''; and
(4) by inserting after section 926 the following:
``PART D--HEALTH CARE QUALITY IMPROVEMENT
``Subpart I--Quality Measure Development
``SEC. 931. QUALITY MEASURE DEVELOPMENT.
``(a) Quality Measure.--In this subpart, the term `quality measure'
means a standard for measuring the performance and improvement of
population health or of health plans, providers of services, and other
clinicians in the delivery of health care services.
``(b) Identification of Quality Measures.--
``(1) Identification.--The Secretary, in consultation with
the Director of the Agency for Healthcare Research and Quality
and the Administrator of the Centers for Medicare & Medicaid
Services, shall identify, not less often than triennially, gaps
where no quality measures exist and existing quality measures
that need improvement, updating, or expansion, consistent with
the national strategy under section 399HH, to the extent
available, for use in Federal health programs. In identifying
such gaps and existing quality measures that need improvement,
the Secretary shall take into consideration--
``(A) the gaps identified by the entity with a
contract under section 1890(a) of the Social Security
Act and other stakeholders;
``(B) quality measures identified by the pediatric
quality measures program under section 1139A of the
Social Security Act; and
``(C) quality measures identified through the
Medicaid Quality Measurement Program under section
1139B of the Social Security Act.
``(2) Publication.--The Secretary shall make available to
the public on an Internet website a report on any gaps
identified under paragraph (1) and the process used to make
such identification.
``(c) Grants or Contracts for Quality Measure Development.--
``(1) In general.--The Secretary shall award grants,
contracts, or intergovernmental agreements to eligible entities
for purposes of developing, improving, updating, or expanding
quality measures identified under subsection (b).
``(2) Prioritization in the development of quality
measures.--In awarding grants, contracts, or agreements under
this subsection, the Secretary shall give priority to the
development of quality measures that allow the assessment of--
``(A) health outcomes and functional status of
patients;
``(B) the management and coordination of health
care across episodes of care and care transitions for
patients across the continuum of providers, health care
settings, and health plans;
``(C) the experience, quality, and use of
information provided to and used by patients,
caregivers, and authorized representatives to inform
decisionmaking about treatment options, including the
use of shared decisionmaking tools and preference
sensitive care (as defined in section 936);
``(D) the meaningful use of health information
technology;
``(E) the safety, effectiveness, patient-
centeredness, appropriateness, and timeliness of care;
``(F) the efficiency of care;
``(G) the equity of health services and health
disparities across health disparity populations (as
defined in section 485E) and geographic areas;
``(H) patient experience and satisfaction;
``(I) the use of innovative strategies and
methodologies identified under section 933; and
``(J) other areas determined appropriate by the
Secretary.
``(3) Eligible entities.--To be eligible for a grant or
contract under this subsection, an entity shall--
``(A) have demonstrated expertise and capacity in
the development and evaluation of quality measures;
``(B) have adopted procedures to include in the
quality measure development process--
``(i) the views of those providers or
payers whose performance will be assessed by
the measure; and
``(ii) the views of other parties who also
will use the quality measures (such as
patients, consumers, and health care
purchasers);
``(C) collaborate with the entity with a contract
under section 1890(a) of the Social Security Act and
other stakeholders, as practicable, and the Secretary
so that quality measures developed by the eligible
entity will meet the requirements to be considered for
endorsement by the entity with a contract under such
section 1890(a);
``(D) have transparent policies regarding
governance and conflicts of interest; and
``(E) submit an application to the Secretary at
such time and in such manner, as the Secretary may
require.
``(4) Use of funds.--An entity that receives a grant,
contract, or agreement under this subsection shall use such
award to develop quality measures that meet the following
requirements:
``(A) Such measures support measures required to be
reported under the Social Security Act, where
applicable, and in support of gaps and existing quality
measures that need improvement, as described in
subsection (b)(1)(A).
``(B) Such measures support measures developed
under section 1139A of the Social Security Act and the
Medicaid Quality Measurement Program under section
1139B of such Act, where applicable.
``(C) To the extent practicable, data on such
quality measures is able to be collected using health
information technologies.
``(D) Each quality measure is free of charge to
users of such measure.
``(E) Each quality measure is publicly available on
an Internet website.
``(d) Other Activities by the Secretary.--The Secretary may use
amounts available under this section to update and test, where
applicable, quality measures endorsed by the entity with a contract
under section 1890(a) of the Social Security Act or adopted by the
Secretary.
``(e) Coordination of Grants.--The Secretary shall ensure that
grants or contracts awarded under this section are coordinated with
grants and contracts awarded under sections 1139A(5) and 1139B(4)(A) of
the Social Security Act.''.
(b) Social Security Act.--Section 1890A of the Social Security Act,
as added by section 3014(b), is amended by adding at the end the
following new subsection:
``(e) Development of Quality Measures.--The Administrator of the
Center for Medicare & Medicaid Services shall through contracts develop
quality measures (as determined appropriate by the Administrator) for
use under this Act. In developing such measures, the Administrator
shall consult with the Director of the Agency for Healthcare Research
and Quality.''.
(c) Funding.--There are authorized to be appropriated to the
Secretary of Health and Human Services to carry out this section,
$75,000,000 for each of fiscal years 2010 through 2014. Of the amounts
appropriated under the preceding sentence in a fiscal year, not less
than 50 percent of such amounts shall be used pursuant to subsection
(e) of section 1890A of the Social Security Act, as added by subsection
(b), with respect to programs under such Act. Amounts appropriated
under this subsection for a fiscal year shall remain available until
expended.
SEC. 3014. QUALITY MEASUREMENT.
(a) New Duties for Consensus-based Entity.--
(1) Multi-stakeholder group input.--Section 1890(b) of the
Social Security Act (42 U.S.C. 1395aaa(b)), as amended by
section 3003, is amended by adding at the end the following new
paragraphs:
``(7) Convening multi-stakeholder groups.--
``(A) In general.--The entity shall convene multi-
stakeholder groups to provide input on--
``(i) the selection of quality measures
described in subparagraph (B), from among--
``(I) such measures that have been
endorsed by the entity; and
``(II) such measures that have not
been considered for endorsement by such
entity but are used or proposed to be
used by the Secretary for the
collection or reporting of quality
measures; and
``(ii) national priorities (as identified
under section 399HH of the Public Health
Service Act) for improvement in population
health and in the delivery of health care
services for consideration under the national
strategy established under section 399HH of the
Public Health Service Act.
``(B) Quality measures.--
``(i) In general.--Subject to clause (ii),
the quality measures described in this
subparagraph are quality measures--
``(I) for use pursuant to sections
1814(i)(5)(D), 1833(i)(7), 1833(t)(17),
1848(k)(2)(C), 1866(k)(3),
1881(h)(2)(A)(iii),
1886(b)(3)(B)(viii), 1886(j)(7)(D),
1886(m)(5)(D), 1886(o)(2), and
1895(b)(3)(B)(v);
``(II) for use in reporting
performance information to the public;
and
``(III) for use in health care
programs other than for use under this
Act.
``(ii) Exclusion.--Data sets (such as the
outcome and assessment information set for home
health services and the minimum data set for
skilled nursing facility services) that are
used for purposes of classification systems
used in establishing payment rates under this
title shall not be quality measures described
in this subparagraph.
``(C) Requirement for transparency in process.--
``(i) In general.--In convening multi-
stakeholder groups under subparagraph (A) with
respect to the selection of quality measures,
the entity shall provide for an open and
transparent process for the activities
conducted pursuant to such convening.
``(ii) Selection of organizations
participating in multi-stakeholder groups.--The
process described in clause (i) shall ensure
that the selection of representatives
comprising such groups provides for public
nominations for, and the opportunity for public
comment on, such selection.
``(D) Multi-stakeholder group defined.--In this
paragraph, the term `multi-stakeholder group' means,
with respect to a quality measure, a voluntary
collaborative of organizations representing a broad
group of stakeholders interested in or affected by the
use of such quality measure.
``(8) Transmission of multi-stakeholder input.--Not later
than February 1 of each year (beginning with 2012), the entity
shall transmit to the Secretary the input of multi-stakeholder
groups provided under paragraph (7).''.
(2) Annual report.--Section 1890(b)(5)(A) of the Social
Security Act (42 U.S.C. 1395aaa(b)(5)(A)) is amended--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period at the
end and inserting a semicolon; and
(C) by adding at the end the following new clauses:
``(iv) gaps in endorsed quality measures,
which shall include measures that are within
priority areas identified by the Secretary
under the national strategy established under
section 399HH of the Public Health Service Act,
and where quality measures are unavailable or
inadequate to identify or address such gaps;
``(v) areas in which evidence is
insufficient to support endorsement of quality
measures in priority areas identified by the
Secretary under the national strategy
established under section 399HH of the Public
Health Service Act and where targeted research
may address such gaps; and
``(vi) the matters described in clauses (i)
and (ii) of paragraph (7)(A).''.
(b) Multi-stakeholder Group Input Into Selection of Quality
Measures.--Title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) is amended by inserting after section 1890 the following:
``quality measurement
``Sec. 1890A. (a) Multi-stakeholder Group Input Into Selection of
Quality Measures.--The Secretary shall establish a pre-rulemaking
process under which the following steps occur with respect to the
selection of quality measures described in section 1890(b)(7)(B):
``(1) Input.--Pursuant to section 1890(b)(7), the entity
with a contract under section 1890 shall convene multi-
stakeholder groups to provide input to the Secretary on the
selection of quality measures described in subparagraph (B) of
such paragraph.
``(2) Public availability of measures considered for
selection.--Not later than December 1 of each year (beginning
with 2011), the Secretary shall make available to the public a
list of quality measures described in section 1890(b)(7)(B)
that the Secretary is considering under this title.
``(3) Transmission of multi-stakeholder input.--Pursuant to
section 1890(b)(8), not later than February 1 of each year
(beginning with 2012), the entity shall transmit to the
Secretary the input of multi-stakeholder groups described in
paragraph (1).
``(4) Consideration of multi-stakeholder input.--The
Secretary shall take into consideration the input from multi-
stakeholder groups described in paragraph (1) in selecting
quality measures described in section 1890(b)(7)(B) that have
been endorsed by the entity with a contract under section 1890
and measures that have not been endorsed by such entity.
``(5) Rationale for use of quality measures.--The Secretary
shall publish in the Federal Register the rationale for the use
of any quality measure described in section 1890(b)(7)(B) that
has not been endorsed by the entity with a contract under
section 1890.
``(6) Assessment of impact.--Not later than March 1, 2012,
and at least once every three years thereafter, the Secretary
shall--
``(A) conduct an assessment of the quality impact
of the use of endorsed measures described in section
1890(b)(7)(B); and
``(B) make such assessment available to the public.
``(b) Process for Dissemination of Measures Used by the
Secretary.--
``(1) In general.--The Secretary shall establish a process
for disseminating quality measures used by the Secretary. Such
process shall include the following:
``(A) The incorporation of such measures, where
applicable, in workforce programs, training curricula,
and any other means of dissemination determined
appropriate by the Secretary.
``(B) The dissemination of such quality measures
through the national strategy developed under section
399HH of the Public Health Service Act.
``(2) Existing methods.--To the extent practicable, the
Secretary shall utilize and expand existing dissemination
methods in disseminating quality measures under the process
established under paragraph (1).
``(c) Review of Quality Measures Used by the Secretary.--
``(1) In general.--The Secretary shall--
``(A) periodically (but in no case less often than
once every 3 years) review quality measures described
in section 1890(b)(7)(B); and
``(B) with respect to each such measure, determine
whether to--
``(i) maintain the use of such measure; or
``(ii) phase out such measure.
``(2) Considerations.--In conducting the review under
paragraph (1), the Secretary shall take steps to--
``(A) seek to avoid duplication of measures used;
and
``(B) take into consideration current innovative
methodologies and strategies for quality improvement
practices in the delivery of health care services that
represent best practices for such quality improvement
and measures endorsed by the entity with a contract
under section 1890 since the previous review by the
Secretary.
``(d) Rule of Construction.--Nothing in this section shall preclude
a State from using the quality measures identified under sections 1139A
and 1139B.''.
(c) Funding.--For purposes of carrying out the amendments made by
this section, the Secretary shall provide for the transfer, from the
Federal Hospital Insurance Trust Fund under section 1817 of the Social
Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t),
in such proportion as the Secretary determines appropriate, of
$20,000,000, to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2010 through 2014. Amounts
transferred under the preceding sentence shall remain available until
expended.
SEC. 3015. DATA COLLECTION; PUBLIC REPORTING.
Title III of the Public Health Service Act (42 U.S.C. 241 et seq.),
as amended by section 3011, is further amended by adding at the end the
following:
``SEC. 399II. COLLECTION AND ANALYSIS OF DATA FOR QUALITY AND RESOURCE
USE MEASURES.
``(a) In General.--The Secretary shall collect and aggregate
consistent data on quality and resource use measures from information
systems used to support health care delivery to implement the public
reporting of performance information, as described in section 399JJ,
and may award grants or contracts for this purpose. The Secretary shall
ensure that such collection, aggregation, and analysis systems span an
increasingly broad range of patient populations, providers, and
geographic areas over time.
``(b) Grants or Contracts for Data Collection.--
``(1) In general.--The Secretary may award grants or
contracts to eligible entities to support new, or improve
existing, efforts to collect and aggregate quality and resource
use measures described under subsection (c).
``(2) Eligible entities.--To be eligible for a grant or
contract under this subsection, an entity shall--
``(A) be--
``(i) a multi-stakeholder entity that
coordinates the development of methods and
implementation plans for the consistent
reporting of summary quality and cost
information;
``(ii) an entity capable of submitting such
summary data for a particular population and
providers, such as a disease registry, regional
collaboration, health plan collaboration, or
other population-wide source; or
``(iii) a Federal Indian Health Service
program or a health program operated by an
Indian tribe (as defined in section 4 of the
Indian Health Care Improvement Act);
``(B) promote the use of the systems that provide
data to improve and coordinate patient care;
``(C) support the provision of timely, consistent
quality and resource use information to health care
providers, and other groups and organizations as
appropriate, with an opportunity for providers to
correct inaccurate measures; and
``(D) agree to report, as determined by the
Secretary, measures on quality and resource use to the
public in accordance with the public reporting process
established under section 399JJ.
``(c) Consistent Data Aggregation.--The Secretary may award grants
or contracts under this section only to entities that enable summary
data that can be integrated and compared across multiple sources. The
Secretary shall provide standards for the protection of the security
and privacy of patient data.
``(d) Matching Funds.--The Secretary may not award a grant or
contract under this section to an entity unless the entity agrees that
it will make available (directly or through contributions from other
public or private entities) non-Federal contributions toward the
activities to be carried out under the grant or contract in an amount
equal to $1 for each $5 of Federal funds provided under the grant or
contract. Such non-Federal matching funds may be provided directly or
through donations from public or private entities and may be in cash or
in-kind, fairly evaluated, including plant, equipment, or services.
``(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for fiscal years 2010 through 2014.
``SEC. 399JJ. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
``(a) Development of Performance Websites.--The Secretary shall
make available to the public, through standardized Internet websites,
performance information summarizing data on quality measures. Such
information shall be tailored to respond to the differing needs of
hospitals and other institutional health care providers, physicians and
other clinicians, patients, consumers, researchers, policymakers,
States, and other stakeholders, as the Secretary may specify.
``(b) Information on Conditions.--The performance information made
publicly available on an Internet website, as described in subsection
(a), shall include information regarding clinical conditions to the
extent such information is available, and the information shall, where
appropriate, be provider-specific and sufficiently disaggregated and
specific to meet the needs of patients with different clinical
conditions.
``(c) Consultation.--
``(1) In general.--In carrying out this section, the
Secretary shall consult with the entity with a contract under
section 1890(a) of the Social Security Act, and other entities,
as appropriate, to determine the type of information that is
useful to stakeholders and the format that best facilitates use
of the reports and of performance reporting Internet websites.
``(2) Consultation with stakeholders.--The entity with a
contract under section 1890(a) of the Social Security Act shall
convene multi-stakeholder groups, as described in such section,
to review the design and format of each Internet website made
available under subsection (a) and shall transmit to the
Secretary the views of such multi-stakeholder groups with
respect to each such design and format.
``(d) Coordination.--Where appropriate, the Secretary shall
coordinate the manner in which data are presented through Internet
websites described in subsection (a) and for public reporting of other
quality measures by the Secretary, including such quality measures
under title XVIII of the Social Security Act.
``(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for fiscal years 2010 through 2014.''.
PART III--ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS
SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID INNOVATION
WITHIN CMS.
(a) In General.--Title XI of the Social Security Act is amended by
inserting after section 1115 the following new section:
``center for medicare and medicaid innovation
``Sec. 1115A. (a) Center for Medicare and Medicaid Innovation
Established.--
``(1) In general.--There is created within the Centers for
Medicare & Medicaid Services a Center for Medicare and Medicaid
Innovation (in this section referred to as the `CMI') to carry
out the duties described in this section. The purpose of the
CMI is to test innovative payment and service delivery models
to reduce program expenditures under the applicable titles
while preserving or enhancing the quality of care furnished to
individuals under such titles. In selecting such models, the
Secretary shall give preference to models that also improve the
coordination, quality, and efficiency of health care services
furnished to applicable individuals defined in paragraph
(4)(A).
``(2) Deadline.--The Secretary shall ensure that the CMI is
carrying out the duties described in this section by not later
than January 1, 2011.
``(3) Consultation.--In carrying out the duties under this
section, the CMI shall consult representatives of relevant
Federal agencies, and clinical and analytical experts with
expertise in medicine and health care management. The CMI shall
use open door forums or other mechanisms to seek input from
interested parties.
``(4) Definitions.--In this section:
``(A) Applicable individual.--The term `applicable
individual' means--
``(i) an individual who is entitled to, or
enrolled for, benefits under part A of title
XVIII or enrolled for benefits under part B of
such title;
``(ii) an individual who is eligible for
medical assistance under title XIX, under a
State plan or waiver; or
``(iii) an individual who meets the
criteria of both clauses (i) and (ii).
``(B) Applicable title.--The term `applicable
title' means title XVIII, title XIX, or both.
``(b) Testing of Models (Phase I).--
``(1) In general.--The CMI shall test payment and service
delivery models in accordance with selection criteria under
paragraph (2) to determine the effect of applying such models
under the applicable title (as defined in subsection (a)(4)(B))
on program expenditures under such titles and the quality of
care received by individuals receiving benefits under such
title.
``(2) Selection of models to be tested.--
``(A) In general.--The Secretary shall select
models to be tested from models where the Secretary
determines that there is evidence that the model
addresses a defined population for which there are
deficits in care leading to poor clinical outcomes or
potentially avoidable expenditures. The models selected
under the preceding sentence may include the models
described in subparagraph (B).
``(B) Opportunities.--The models described in this
subparagraph are the following models:
``(i) Promoting broad payment and practice
reform in primary care, including patient-
centered medical home models for high-need
applicable individuals, medical homes that
address women's unique health care needs, and
models that transition primary care practices
away from fee-for-service based reimbursement
and toward comprehensive payment or salary-
based payment.
``(ii) Contracting directly with groups of
providers of services and suppliers to promote
innovative care delivery models, such as
through risk-based comprehensive payment or
salary-based payment.
``(iii) Utilizing geriatric assessments and
comprehensive care plans to coordinate the care
(including through interdisciplinary teams) of
applicable individuals with multiple chronic
conditions and at least one of the following:
``(I) An inability to perform 2 or
more activities of daily living.
``(II) Cognitive impairment,
including dementia.
``(iv) Promote care coordination between
providers of services and suppliers that
transition health care providers away from fee-
for-service based reimbursement and toward
salary-based payment.
``(v) Supporting care coordination for
chronically-ill applicable individuals at high
risk of hospitalization through a health
information technology-enabled provider network
that includes care coordinators, a chronic
disease registry, and home tele-health
technology.
``(vi) Varying payment to physicians who
order advanced diagnostic imaging services (as
defined in section 1834(e)(1)(B)) according to
the physician's adherence to appropriateness
criteria for the ordering of such services, as
determined in consultation with physician
specialty groups and other relevant
stakeholders.
``(vii) Utilizing medication therapy
management services, such as those described in
section 935 of the Public Health Service Act.
``(viii) Establishing community-based
health teams to support small-practice medical
homes by assisting the primary care
practitioner in chronic care management,
including patient self-management, activities.
``(ix) Assisting applicable individuals in
making informed health care choices by paying
providers of services and suppliers for using
patient decision-support tools, including tools
that meet the standards developed and
identified under section 936(c)(2)(A) of the
Public Health Service Act, that improve
applicable individual and caregiver
understanding of medical treatment options.
``(x) Allowing States to test and evaluate
fully integrating care for dual eligible
individuals in the State, including the
management and oversight of all funds under the
applicable titles with respect to such
individuals.
``(xi) Allowing States to test and evaluate
systems of all-payer payment reform for the
medical care of residents of the State,
including dual eligible individuals.
``(xii) Aligning nationally recognized,
evidence-based guidelines of cancer care with
payment incentives under title XVIII in the
areas of treatment planning and follow-up care
planning for applicable individuals described
in clause (i) or (iii) of subsection (a)(4)(A)
with cancer, including the identification of
gaps in applicable quality measures.
``(xiii) Improving post-acute care through
continuing care hospitals that offer inpatient
rehabilitation, long-term care hospitals, and
home health or skilled nursing care during an
inpatient stay and the 30 days immediately
following discharge.
``(xiv) Funding home health providers who
offer chronic care management services to
applicable individuals in cooperation with
interdisciplinary teams.
``(xv) Promoting improved quality and
reduced cost by developing a collaborative of
high-quality, low-cost health care institutions
that is responsible for--
``(I) developing, documenting, and
disseminating best practices and proven
care methods;
``(II) implementing such best
practices and proven care methods
within such institutions to demonstrate
further improvements in quality and
efficiency; and
``(III) providing assistance to
other health care institutions on how
best to employ such best practices and
proven care methods to improve health
care quality and lower costs.
``(xvi) Facilitate inpatient care,
including intensive care, of hospitalized
applicable individuals at their local hospital
through the use of electronic monitoring by
specialists, including intensivists and
critical care specialists, based at integrated
health systems.
``(xvii) Promoting greater efficiencies and
timely access to outpatient services (such as
outpatient physical therapy services) through
models that do not require a physician or other
health professional to refer the service or be
involved in establishing the plan of care for
the service, when such service is furnished by
a health professional who has the authority to
furnish the service under existing State law.
``(xviii) Establishing comprehensive
payments to Healthcare Innovation Zones,
consisting of groups of providers that include
a teaching hospital, physicians, and other
clinical entities, that, through their
structure, operations, and joint-activity
deliver a full spectrum of integrated and
comprehensive health care services to
applicable individuals while also incorporating
innovative methods for the clinical training of
future health care professionals.
``(C) Additional factors for consideration.--In
selecting models for testing under subparagraph (A),
the CMI may consider the following additional factors:
``(i) Whether the model includes a regular
process for monitoring and updating patient
care plans in a manner that is consistent with
the needs and preferences of applicable
individuals.
``(ii) Whether the model places the
applicable individual, including family members
and other informal caregivers of the applicable
individual, at the center of the care team of
the applicable individual.
``(iii) Whether the model provides for in-
person contact with applicable individuals.
``(iv) Whether the model utilizes
technology, such as electronic health records
and patient-based remote monitoring systems, to
coordinate care over time and across settings.
``(v) Whether the model provides for the
maintenance of a close relationship between
care coordinators, primary care practitioners,
specialist physicians, community-based
organizations, and other providers of services
and suppliers.
``(vi) Whether the model relies on a team-
based approach to interventions, such as
comprehensive care assessments, care planning,
and self-management coaching.
``(vii) Whether, under the model, providers
of services and suppliers are able to share
information with patients, caregivers, and
other providers of services and suppliers on a
real time basis.
``(3) Budget neutrality.--
``(A) Initial period.--The Secretary shall not
require, as a condition for testing a model under
paragraph (1), that the design of such model ensure
that such model is budget neutral initially with
respect to expenditures under the applicable title.
``(B) Termination or modification.--The Secretary
shall terminate or modify the design and implementation
of a model unless the Secretary determines (and the
Chief Actuary of the Centers for Medicare & Medicaid
Services, with respect to program spending under the
applicable title, certifies), after testing has begun,
that the model is expected to--
``(i) improve the quality of care (as
determined by the Administrator of the Centers
for Medicare & Medicaid Services) without
increasing spending under the applicable title;
``(ii) reduce spending under the applicable
title without reducing the quality of care; or
``(iii) improve the quality of care and
reduce spending.
Such termination may occur at any time after such
testing has begun and before completion of the testing.
``(4) Evaluation.--
``(A) In general.--The Secretary shall conduct an
evaluation of each model tested under this subsection.
Such evaluation shall include an analysis of--
``(i) the quality of care furnished under
the model, including the measurement of
patient-level outcomes and patient-centeredness
criteria determined appropriate by the
Secretary; and
``(ii) the changes in spending under the
applicable titles by reason of the model.
``(B) Information.--The Secretary shall make the
results of each evaluation under this paragraph
available to the public in a timely fashion and may
establish requirements for States and other entities
participating in the testing of models under this
section to collect and report information that the
Secretary determines is necessary to monitor and
evaluate such models.
``(c) Expansion of Models (Phase II).--Taking into account the
evaluation under subsection (b)(4), the Secretary may, through
rulemaking, expand (including implementation on a nationwide basis) the
duration and the scope of a model that is being tested under subsection
(b) or a demonstration project under section 1866C, to the extent
determined appropriate by the Secretary, if--
``(1) the Secretary determines that such expansion is
expected to--
``(A) reduce spending under applicable title
without reducing the quality of care; or
``(B) improve the quality of care and reduce
spending; and
``(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under applicable titles.
``(d) Implementation.--
``(1) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII and of sections 1902(a)(1),
1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary solely
for purposes of carrying out this section with respect to
testing models described in subsection (b).
``(2) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the selection of models for testing or
expansion under this section;
``(B) the selection of organizations, sites, or
participants to test those models selected;
``(C) the elements, parameters, scope, and duration
of such models for testing or dissemination;
``(D) determinations regarding budget neutrality
under subsection (b)(3);
``(E) the termination or modification of the design
and implementation of a model under subsection
(b)(3)(B); and
``(F) determinations about expansion of the
duration and scope of a model under subsection (c),
including the determination that a model is not
expected to meet criteria described in paragraph (1) or
(2) of such subsection.
``(3) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the testing and evaluation of
models or expansion of such models under this section.
``(e) Application to CHIP.--The Center may carry out activities
under this section with respect to title XXI in the same manner as
provided under this section with respect to the program under the
applicable titles.
``(f) Funding.--
``(1) In general.--There are appropriated, from amounts in
the Treasury not otherwise appropriated--
``(A) $5,000,000 for the design, implementation,
and evaluation of models under subsection (b) for
fiscal year 2010;
``(B) $10,000,000,000 for the activities initiated
under this section for the period of fiscal years 2011
through 2019; and
``(C) the amount described in subparagraph (B) for
the activities initiated under this section for each
subsequent 10-year fiscal period (beginning with the
10-year fiscal period beginning with fiscal year 2020).
Amounts appropriated under the preceding sentence shall remain
available until expended.
``(2) Use of certain funds.--Out of amounts appropriated
under subparagraphs (B) and (C) of paragraph (1), not less than
$25,000,000 shall be made available each such fiscal year to
design, implement, and evaluate models under subsection (b).
``(g) Report to Congress.--Beginning in 2012, and not less than
once every other year thereafter, the Secretary shall submit to
Congress a report on activities under this section. Each such report
shall describe the models tested under subsection (b), including the
number of individuals described in subsection (a)(4)(A)(i) and of
individuals described in subsection (a)(4)(A)(ii) participating in such
models and payments made under applicable titles for services on behalf
of such individuals, any models chosen for expansion under subsection
(c), and the results from evaluations under subsection (b)(4). In
addition, each such report shall provide such recommendations as the
Secretary determines are appropriate for legislative action to
facilitate the development and expansion of successful payment
models.''.
(b) Medicaid Conforming Amendment.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)), as amended by section 8002(b), is
amended--
(1) in paragraph (81), by striking ``and'' at the end;
(2) in paragraph (82), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (82) the following new
paragraph:
``(83) provide for implementation of the payment models
specified by the Secretary under section 1115A(c) for
implementation on a nationwide basis unless the State
demonstrates to the satisfaction of the Secretary that
implementation would not be administratively feasible or
appropriate to the health care delivery system of the State.''.
(c) Revisions to Health Care Quality Demonstration Program.--
Subsections (b) and (f) of section 1866C of the Social Security Act (42
U.S.C. 1395cc-3) are amended by striking ``5-year'' each place it
appears.
SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is
amended by adding at the end the following new section:
``shared savings program
``Sec. 1899. (a) Establishment.--
``(1) In general.--Not later than January 1, 2012, the
Secretary shall establish a shared savings program (in this
section referred to as the `program') that promotes
accountability for a patient population and coordinates items
and services under parts A and B, and encourages investment in
infrastructure and redesigned care processes for high quality
and efficient service delivery. Under such program--
``(A) groups of providers of services and suppliers
meeting criteria specified by the Secretary may work
together to manage and coordinate care for Medicare
fee-for-service beneficiaries through an accountable
care organization (referred to in this section as an
`ACO'); and
``(B) ACOs that meet quality performance standards
established by the Secretary are eligible to receive
payments for shared savings under subsection (d)(2).
``(b) Eligible ACOs.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, as determined appropriate by the Secretary,
the following groups of providers of services and suppliers
which have established a mechanism for shared governance are
eligible to participate as ACOs under the program under this
section:
``(A) ACO professionals in group practice
arrangements.
``(B) Networks of individual practices of ACO
professionals.
``(C) Partnerships or joint venture arrangements
between hospitals and ACO professionals.
``(D) Hospitals employing ACO professionals.
``(E) Such other groups of providers of services
and suppliers as the Secretary determines appropriate.
``(2) Requirements.--An ACO shall meet the following
requirements:
``(A) The ACO shall be willing to become
accountable for the quality, cost, and overall care of
the Medicare fee-for-service beneficiaries assigned to
it.
``(B) The ACO shall enter into an agreement with
the Secretary to participate in the program for not
less than a 3-year period (referred to in this section
as the `agreement period').
``(C) The ACO shall have a formal legal structure
that would allow the organization to receive and
distribute payments for shared savings under subsection
(d)(2) to participating providers of services and
suppliers.
``(D) The ACO shall include primary care ACO
professionals that are sufficient for the number of
Medicare fee-for-service beneficiaries assigned to the
ACO under subsection (c). At a minimum, the ACO shall
have at least 5,000 such beneficiaries assigned to it
under subsection (c) in order to be eligible to
participate in the ACO program.
``(E) The ACO shall provide the Secretary with such
information regarding ACO professionals participating
in the ACO as the Secretary determines necessary to
support the assignment of Medicare fee-for-service
beneficiaries to an ACO, the implementation of quality
and other reporting requirements under paragraph (3),
and the determination of payments for shared savings
under subsection (d)(2).
``(F) The ACO shall have in place a leadership and
management structure that includes clinical and
administrative systems.
``(G) The ACO shall define processes to promote
evidence-based medicine and patient engagement, report
on quality and cost measures, and coordinate care, such
as through the use of telehealth, remote patient
monitoring, and other such enabling technologies.
``(H) The ACO shall demonstrate to the Secretary
that it meets patient-centeredness criteria specified
by the Secretary, such as the use of patient and
caregiver assessments or the use of individualized care
plans.
``(3) Quality and other reporting requirements.--
``(A) In general.--The Secretary shall determine
appropriate measures to assess the quality of care
furnished by the ACO, such as measures of--
``(i) clinical processes and outcomes;
``(ii) patient and, where practicable,
caregiver experience of care; and
``(iii) utilization (such as rates of
hospital admissions for ambulatory care
sensitive conditions).
``(B) Reporting requirements.--An ACO shall submit
data in a form and manner specified by the Secretary on
measures the Secretary determines necessary for the ACO
to report in order to evaluate the quality of care
furnished by the ACO. Such data may include care
transitions across health care settings, including
hospital discharge planning and post-hospital discharge
follow-up by ACO professionals, as the Secretary
determines appropriate.
``(C) Quality performance standards.--The Secretary
shall establish quality performance standards to assess
the quality of care furnished by ACOs. The Secretary
shall seek to improve the quality of care furnished by
ACOs over time by specifying higher standards, new
measures, or both for purposes of assessing such
quality of care.
``(D) Other reporting requirements.--The Secretary
may, as the Secretary determines appropriate,
incorporate reporting requirements and incentive
payments related to the physician quality reporting
initiative (PQRI) under section 1848, including such
requirements and such payments related to electronic
prescribing, electronic health records, and other
similar initiatives under section 1848, and may use
alternative criteria than would otherwise apply under
such section for determining whether to make such
payments. The incentive payments described in the
preceding sentence shall not be taken into
consideration when calculating any payments otherwise
made under subsection (d).
``(4) No duplication in participation in shared savings
programs.--A provider of services or supplier that participates
in any of the following shall not be eligible to participate in
an ACO under this section:
``(A) A model tested or expanded under section
1115A that involves shared savings under this title, or
any other program or demonstration project that
involves such shared savings.
``(B) The independence at home medical practice
pilot program under section 1866E.
``(c) Assignment of Medicare Fee-for-service Beneficiaries to
ACOs.--The Secretary shall determine an appropriate method to assign
Medicare fee-for-service beneficiaries to an ACO based on their
utilization of primary care services provided under this title by an
ACO professional described in subsection (h)(1)(A).
``(d) Payments and Treatment of Savings.--
``(1) Payments.--
``(A) In general.--Under the program, subject to
paragraph (3), payments shall continue to be made to
providers of services and suppliers participating in an
ACO under the original Medicare fee-for-service program
under parts A and B in the same manner as they would
otherwise be made except that a participating ACO is
eligible to receive payment for shared savings under
paragraph (2) if--
``(i) the ACO meets quality performance
standards established by the Secretary under
subsection (b)(3); and
``(ii) the ACO meets the requirement under
subparagraph (B)(i).
``(B) Savings requirement and benchmark.--
``(i) Determining savings.--In each year of
the agreement period, an ACO shall be eligible
to receive payment for shared savings under
paragraph (2) only if the estimated average per
capita Medicare expenditures under the ACO for
Medicare fee-for-service beneficiaries for
parts A and B services, adjusted for
beneficiary characteristics, is at least the
percent specified by the Secretary below the
applicable benchmark under clause (ii). The
Secretary shall determine the appropriate
percent described in the preceding sentence to
account for normal variation in expenditures
under this title, based upon the number of
Medicare fee-for-service beneficiaries assigned
to an ACO.
``(ii) Establish and update benchmark.--The
Secretary shall estimate a benchmark for each
agreement period for each ACO using the most
recent available 3 years of per-beneficiary
expenditures for parts A and B services for
Medicare fee-for-service beneficiaries assigned
to the ACO. Such benchmark shall be adjusted
for beneficiary characteristics and such other
factors as the Secretary determines appropriate
and updated by the projected absolute amount of
growth in national per capita expenditures for
parts A and B services under the original
Medicare fee-for-service program, as estimated
by the Secretary. Such benchmark shall be reset
at the start of each agreement period.
``(2) Payments for shared savings.--Subject to performance
with respect to the quality performance standards established
by the Secretary under subsection (b)(3), if an ACO meets the
requirements under paragraph (1), a percent (as determined
appropriate by the Secretary) of the difference between such
estimated average per capita Medicare expenditures in a year,
adjusted for beneficiary characteristics, under the ACO and
such benchmark for the ACO may be paid to the ACO as shared
savings and the remainder of such difference shall be retained
by the program under this title. The Secretary shall establish
limits on the total amount of shared savings that may be paid
to an ACO under this paragraph.
``(3) Monitoring avoidance of at-risk patients.--If the
Secretary determines that an ACO has taken steps to avoid
patients at risk in order to reduce the likelihood of
increasing costs to the ACO the Secretary may impose an
appropriate sanction on the ACO, including termination from the
program.
``(4) Termination.--The Secretary may terminate an
agreement with an ACO if it does not meet the quality
performance standards established by the Secretary under
subsection (b)(3).
``(e) Administration.--Chapter 35 of title 44, United States Code,
shall not apply to the program.
``(f) Waiver Authority.--The Secretary may waive such requirements
of sections 1128A and 1128B and title XVIII of this Act as may be
necessary to carry out the provisions of this section.
``(g) Limitations on Review.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise of--
``(1) the specification of criteria under subsection
(a)(1)(B);
``(2) the assessment of the quality of care furnished by an
ACO and the establishment of performance standards under
subsection (b)(3);
``(3) the assignment of Medicare fee-for-service
beneficiaries to an ACO under subsection (c);
``(4) the determination of whether an ACO is eligible for
shared savings under subsection (d)(2) and the amount of such
shared savings, including the determination of the estimated
average per capita Medicare expenditures under the ACO for
Medicare fee-for-service beneficiaries assigned to the ACO and
the average benchmark for the ACO under subsection (d)(1)(B);
``(5) the percent of shared savings specified by the
Secretary under subsection (d)(2) and any limit on the total
amount of shared savings established by the Secretary under
such subsection; and
``(6) the termination of an ACO under subsection (d)(4).
``(h) Definitions.--In this section:
``(1) ACO professional.--The term `ACO professional'
means--
``(A) a physician (as defined in section
1861(r)(1)); and
``(B) a practitioner described in section
1842(b)(18)(C)(i).
``(2) Hospital.--The term `hospital' means a subsection (d)
hospital (as defined in section 1886(d)(1)(B)).
``(3) Medicare fee-for-service beneficiary.--The term
`Medicare fee-for-service beneficiary' means an individual who
is enrolled in the original Medicare fee-for-service program
under parts A and B and is not enrolled in an MA plan under
part C, an eligible organization under section 1876, or a PACE
program under section 1894.''.
SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.
Title XVIII of the Social Security Act, as amended by section 3021,
is amended by inserting after section 1886C the following new section:
``national pilot program on payment bundling
``Sec. 1866D. (a) Implementation.--
``(1) In general.--The Secretary shall establish a pilot
program for integrated care during an episode of care provided
to an applicable beneficiary around a hospitalization in order
to improve the coordination, quality, and efficiency of health
care services under this title.
``(2) Definitions.--In this section:
``(A) Applicable beneficiary.--The term `applicable
beneficiary' means an individual who--
``(i) is entitled to, or enrolled for,
benefits under part A and enrolled for benefits
under part B of such title, but not enrolled
under part C or a PACE program under section
1894; and
``(ii) is admitted to a hospital for an
applicable condition.
``(B) Applicable condition.--The term `applicable
condition' means 1 or more of 8 conditions selected by
the Secretary. In selecting conditions under the
preceding sentence, the Secretary shall take into
consideration the following factors:
``(i) Whether the conditions selected
include a mix of chronic and acute conditions.
``(ii) Whether the conditions selected
include a mix of surgical and medical
conditions.
``(iii) Whether a condition is one for
which there is evidence of an opportunity for
providers of services and suppliers to improve
the quality of care furnished while reducing
total expenditures under this title.
``(iv) Whether a condition has significant
variation in--
``(I) the number of readmissions;
and
``(II) the amount of expenditures
for post-acute care spending under this
title.
``(v) Whether a condition is high-volume
and has high post-acute care expenditures under
this title.
``(vi) Which conditions the Secretary
determines are most amenable to bundling across
the spectrum of care given practice patterns
under this title.
``(C) Applicable services.--The term `applicable
services' means the following:
``(i) Acute care inpatient services.
``(ii) Physicians' services delivered in
and outside of an acute care hospital setting.
``(iii) Outpatient hospital services,
including emergency department services.
``(iv) Post-acute care services, including
home health services, skilled nursing services,
inpatient rehabilitation services, and
inpatient hospital services furnished by a
long-term care hospital.
``(v) Other services the Secretary
determines appropriate.
``(D) Episode of care.--
``(i) In general.--Subject to clause (ii),
the term `episode of care' means, with respect
to an applicable condition and an applicable
beneficiary, the period that includes--
``(I) the 3 days prior to the
admission of the applicable beneficiary
to a hospital for the applicable
condition;
``(II) the length of stay of the
applicable beneficiary in such
hospital; and
``(III) the 30 days following the
discharge of the applicable beneficiary
from such hospital.
``(ii) Establishment of period by the
secretary.--The Secretary, as appropriate, may
establish a period (other than the period
described in clause (i)) for an episode of care
under the pilot program.
``(E) Physicians' services.--The term `physicians'
services' has the meaning given such term in section
1861(q).
``(F) Pilot program.--The term `pilot program'
means the pilot program under this section.
``(G) Provider of services.--The term `provider of
services' has the meaning given such term in section
1861(u).
``(H) Readmission.--The term `readmission' has the
meaning given such term in section 1886(q)(5)(E).
``(I) Supplier.--The term `supplier' has the
meaning given such term in section 1861(d).
``(3) Deadline for implementation.--The Secretary shall
establish the pilot program not later than January 1, 2013.
``(b) Developmental Phase.--
``(1) Determination of patient assessment instrument.--The
Secretary shall determine which patient assessment instrument
(such as the Continuity Assessment Record and Evaluation (CARE)
tool) shall be used under the pilot program to evaluate the
applicable condition of an applicable beneficiary for purposes
of determining the most clinically appropriate site for the
provision of post-acute care to the applicable beneficiary.
``(2) Development of quality measures for an episode of
care and for post-acute care.--
``(A) In general.--The Secretary, in consultation
with the Agency for Healthcare Research and Quality and
the entity with a contract under section 1890(a) of the
Social Security Act, shall develop quality measures for
use in the pilot program--
``(i) for episodes of care; and
``(ii) for post-acute care.
``(B) Site-neutral post-acute care quality
measures.--Any quality measures developed under
subparagraph (A)(ii) shall be site-neutral.
``(C) Coordination with quality measure development
and endorsement procedures.--The Secretary shall ensure
that the development of quality measures under
subparagraph (A) is done in a manner that is consistent
with the measures developed and endorsed under section
1890 and 1890A that are applicable to all post-acute
care settings.
``(c) Details.--
``(1) Duration.--
``(A) In general.--Subject to subparagraph (B), the
pilot program shall be conducted for a period of 5
years.
``(B) Extension.--The Secretary may extend the
duration of the pilot program for providers of services
and suppliers participating in the pilot program as of
the day before the end of the 5-year period described
in subparagraph (A), for a period determined
appropriate by the Secretary, if the Secretary
determines that such extension will result in improving
or not reducing the quality of patient care and
reducing spending under this title.
``(2) Participating providers of services and suppliers.--
``(A) In general.--An entity comprised of providers
of services and suppliers, including a hospital, a
physician group, a skilled nursing facility, and a home
health agency, who are otherwise participating under
this title, may submit an application to the Secretary
to provide applicable services to applicable
individuals under this section.
``(B) Requirements.--The Secretary shall develop
requirements for entities to participate in the pilot
program under this section. Such requirements shall
ensure that applicable beneficiaries have an adequate
choice of providers of services and suppliers under the
pilot program.
``(3) Payment methodology.--
``(A) In general.--
``(i) Establishment of payment methods.--
The Secretary shall develop payment methods for
the pilot program for entities participating in
the pilot program. Such payment methods may
include bundled payments and bids from entities
for episodes of care. The Secretary shall make
payments to the entity for services covered
under this section.
``(ii) No additional program
expenditures.--Payments under this section for
applicable items and services under this title
(including payment for services described in
subparagraph (B)) for applicable beneficiaries
for a year shall be established in a manner
that does not result in spending more for such
entity for such beneficiaries than would
otherwise be expended for such entity for such
beneficiaries for such year if the pilot
program were not implemented, as estimated by
the Secretary.
``(B) Inclusion of certain services.--A payment
methodology tested under the pilot program shall
include payment for the furnishing of applicable
services and other appropriate services, such as care
coordination, medication reconciliation, discharge
planning, transitional care services, and other
patient-centered activities as determined appropriate
by the Secretary.
``(C) Bundled payments.--
``(i) In general.--A bundled payment under
the pilot program shall--
``(I) be comprehensive, covering
the costs of applicable services and
other appropriate services furnished to
an individual during an episode of care
(as determined by the Secretary); and
``(II) be made to the entity which
is participating in the pilot program.
``(ii) Requirement for provision of
applicable services and other appropriate
services.--Applicable services and other
appropriate services for which payment is made
under this subparagraph shall be furnished or
directed by the entity which is participating
in the pilot program.
``(D) Payment for post-acute care services after
the episode of care.--The Secretary shall establish
procedures, in the case where an applicable beneficiary
requires continued post-acute care services after the
last day of the episode of care, under which payment
for such services shall be made.
``(4) Quality measures.--
``(A) In general.--The Secretary shall establish
quality measures (including quality measures of
process, outcome, and structure) related to care
provided by entities participating in the pilot
program. Quality measures established under the
preceding sentence shall include measures of the
following:
``(i) Functional status improvement.
``(ii) Reducing rates of avoidable hospital
readmissions.
``(iii) Rates of discharge to the
community.
``(iv) Rates of admission to an emergency
room after a hospitalization.
``(v) Incidence of health care acquired
infections.
``(vi) Efficiency measures.
``(vii) Measures of patient-centeredness of
care.
``(viii) Measures of patient perception of
care.
``(ix) Other measures, including measures
of patient outcomes, determined appropriate by
the Secretary.
``(B) Reporting on quality measures.--
``(i) In general.--A entity shall submit
data to the Secretary on quality measures
established under subparagraph (A) during each
year of the pilot program (in a form and
manner, subject to clause (iii), specified by
the Secretary).
``(ii) Submission of data through
electronic health record.--To the extent
practicable, the Secretary shall specify that
data on measures be submitted under clause (i)
through the use of an qualified electronic
health record (as defined in section 3000(13)
of the Public Health Service Act (42 U.S.C.
300jj-11(13)) in a manner specified by the
Secretary.
``(d) Waiver.--The Secretary may waive such provisions of this
title and title XI as may be necessary to carry out the pilot program.
``(e) Independent Evaluation and Reports on Pilot Program.--
``(1) Independent evaluation.--The Secretary shall conduct
an independent evaluation of the pilot program, including the
extent to which the pilot program has--
``(A) improved quality measures established under
subsection (c)(4)(A);
``(B) improved health outcomes;
``(C) improved applicable beneficiary access to
care; and
``(D) reduced spending under this title.
``(2) Reports.--
``(A) Interim report.--Not later than 2 years after
the implementation of the pilot program, the Secretary
shall submit to Congress a report on the initial
results of the independent evaluation conducted under
paragraph (1).
``(B) Final report.--Not later than 3 years after
the implementation of the pilot program, the Secretary
shall submit to Congress a report on the final results
of the independent evaluation conducted under paragraph
(1).
``(f) Consultation.--The Secretary shall consult with
representatives of small rural hospitals, including critical access
hospitals (as defined in section 1861(mm)(1)), regarding their
participation in the pilot program. Such consultation shall include
consideration of innovative methods of implementing bundled payments in
hospitals described in the preceding sentence, taking into
consideration any difficulties in doing so as a result of the low
volume of services provided by such hospitals.
``(g) Implementation Plan.--
``(1) In general.--Not later than January 1, 2016, the
Secretary shall submit a plan for the implementation of an
expansion of the pilot program if the Secretary determines that
such expansion will result in improving or not reducing the
quality of patient care and reducing spending under this title.
``(h) Administration.--Chapter 35 of title 44, United States Code,
shall not apply to the selection, testing, and evaluation of models or
the expansion of such models under this section.''.
SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.
Title XVIII of the Social Security Act is amended by inserting
after section 1866D, as inserted by section 3023, the following new
section:
``independence at home medical practice demonstration program
``Sec. 1866D. (a) Establishment.--
``(1) In general.--The Secretary shall conduct a
demonstration program (in this section referred to as the
`demonstration program') to test a payment incentive and
service delivery model that utilizes physician and nurse
practitioner directed home-based primary care teams designed to
reduce expenditures and improve health outcomes in the
provision of items and services under this title to applicable
beneficiaries (as defined in subsection (d)).
``(2) Requirement.--The demonstration program shall test
whether a model described in paragraph (1), which is
accountable for providing comprehensive, coordinated,
continuous, and accessible care to high-need populations at
home and coordinating health care across all treatment
settings, results in--
``(A) reducing preventable hospitalizations;
``(B) preventing hospital readmissions;
``(C) reducing emergency room visits;
``(D) improving health outcomes commensurate with
the beneficiaries' stage of chronic illness;
``(E) improving the efficiency of care, such as by
reducing duplicative diagnostic and laboratory tests;
``(F) reducing the cost of health care services
covered under this title; and
``(G) achieving beneficiary and family caregiver
satisfaction.
``(b) Independence at Home Medical Practice.--
``(1) Independence at home medical practice defined.--In
this section:
``(A) In general.--The term `independence at home
medical practice' means a legal entity that--
``(i) is comprised of an individual
physician or nurse practitioner or group of
physicians and nurse practitioners that
provides care as part of a team that includes
physicians, nurses, physician assistants,
pharmacists, and other health and social
services staff as appropriate who have
experience providing home-based primary care to
applicable beneficiaries, make in-home visits,
and are available 24 hours per day, 7 days per
week to carry out plans of care that are
tailored to the individual beneficiary's
chronic conditions and designed to achieve the
results in subsection (a);
``(ii) is organized at least in part for
the purpose of providing physicians' services;
``(iii) has documented experience in
providing home-based primary care services to
high-cost chronically ill beneficiaries, as
determined appropriate by the Secretary;
``(iv) furnishes services to at least 200
applicable beneficiaries (as defined in
subsection (d)) during each year of the
demonstration program;
``(v) has entered into an agreement with
the Secretary;
``(vi) uses electronic health information
systems, remote monitoring, and mobile
diagnostic technology; and
``(vii) meets such other criteria as the
Secretary determines to be appropriate to
participate in the demonstration program.
The entity shall report on quality measures (in such
form, manner, and frequency as specified by the
Secretary, which may be for the group, for providers of
services and suppliers, or both) and report to the
Secretary (in a form, manner, and frequency as
specified by the Secretary) such data as the Secretary
determines appropriate to monitor and evaluate the
demonstration program.
``(B) Physician.--The term `physician' includes,
except as the Secretary may otherwise provide, any
individual who furnishes services for which payment may
be made as physicians' services and has the medical
training or experience to fulfill the physician's role
described in subparagraph (A)(i).
``(2) Participation of nurse practitioners and physician
assistants.--Nothing in this section shall be construed to
prevent a nurse practitioner or physician assistant from
participating in, or leading, a home-based primary care team as
part of an independence at home medical practice if--
``(A) all the requirements of this section are met;
``(B) the nurse practitioner or physician
assistant, as the case may be, is acting consistent
with State law; and
``(C) the nurse practitioner or physician assistant
has the medical training or experience to fulfill the
nurse practitioner or physician assistant role
described in paragraph (1)(A)(i).
``(3) Inclusion of providers and practitioners.--Nothing in
this subsection shall be construed as preventing an
independence at home medical practice from including a provider
of services or a participating practitioner described in
section 1842(b)(18)(C) that is affiliated with the practice
under an arrangement structured so that such provider of
services or practitioner participates in the demonstration
program and shares in any savings under the demonstration
program.
``(4) Quality and performance standards.--The Secretary
shall develop quality performance standards for independence at
home medical practices participating in the demonstration
program.
``(c) Payment Methodology.--
``(1) Establishment of target spending level.--The
Secretary shall establish an estimated annual spending target,
for the amount the Secretary estimates would have been spent in
the absence of the demonstration, for items and services
covered under parts A and B furnished to applicable
beneficiaries for each qualifying independence at home medical
practice under this section. Such spending targets shall be
determined on a per capita basis. Such spending targets shall
include a risk corridor that takes into account normal
variation in expenditures for items and services covered under
parts A and B furnished to such beneficiaries with the size of
the corridor being related to the number of applicable
beneficiaries furnished services by each independence at home
medical practice. The spending targets may also be adjusted for
other factors as the Secretary determines appropriate.
``(2) Incentive payments.--Subject to performance on
quality measures, a qualifying independence at home medical
practice is eligible to receive an incentive payment under this
section if actual expenditures for a year for the applicable
beneficiaries it enrolls are less than the estimated spending
target established under paragraph (1) for such year. An
incentive payment for such year shall be equal to a portion (as
determined by the Secretary) of the amount by which actual
expenditures (including incentive payments under this
paragraph) for applicable beneficiaries under parts A and B for
such year are estimated to be less than 5 percent less than the
estimated spending target for such year, as determined under
paragraph (1).
``(d) Applicable Beneficiaries.--
``(1) Definition.--In this section, the term `applicable
beneficiary' means, with respect to a qualifying independence
at home medical practice, an individual who the practice has
determined--
``(A) is entitled to benefits under part A and
enrolled for benefits under part B;
``(B) is not enrolled in a Medicare Advantage plan
under part C or a PACE program under section 1894;
``(C) has 2 or more chronic illnesses, such as
congestive heart failure, diabetes, other dementias
designated by the Secretary, chronic obstructive
pulmonary disease, ischemic heart disease, stroke,
Alzheimer's Disease and neurodegenerative diseases, and
other diseases and conditions designated by the
Secretary which result in high costs under this title;
``(D) within the past 12 months has had a
nonelective hospital admission;
``(E) within the past 12 months has received acute
or subacute rehabilitation services;
``(F) has 2 or more functional dependencies
requiring the assistance of another person (such as
bathing, dressing, toileting, walking, or feeding); and
``(G) meets such other criteria as the Secretary
determines appropriate.
``(2) Patient election to participate.--The Secretary shall
determine an appropriate method of ensuring that applicable
beneficiaries have agreed to enroll in an independence at home
medical practice under the demonstration program. Enrollment in
the demonstration program shall be voluntary.
``(3) Beneficiary access to services.--Nothing in this
section shall be construed as encouraging physicians or nurse
practitioners to limit applicable beneficiary access to
services covered under this title and applicable beneficiaries
shall not be required to relinquish access to any benefit under
this title as a condition of receiving services from an
independence at home medical practice.
``(e) Implementation.--
``(1) Starting date.--The demonstration program shall begin
no later than January 1, 2012. An agreement with an
independence at home medical practice under the demonstration
program may cover not more than a 3-year period.
``(2) No physician duplication in demonstration
participation.--The Secretary shall not pay an independence at
home medical practice under this section that participates in
section 1899.
``(3) No beneficiary duplication in demonstration
participation.--The Secretary shall ensure that no applicable
beneficiary enrolled in an independence at home medical
practice under this section is participating in the programs
under section 1899.
``(4) Preference.--In approving an independence at home
medical practice, the Secretary shall give preference to
practices that are--
``(A) located in high-cost areas of the country;
``(B) have experience in furnishing health care
services to applicable beneficiaries in the home; and
``(C) use electronic medical records, health
information technology, and individualized plans of
care.
``(5) Limitation on number of practices.--In selecting
qualified independence at home medical practices to participate
under the demonstration program, the Secretary shall limit the
number of such practices so that the number of applicable
beneficiaries that may participate in the demonstration program
does not exceed 10,000.
``(6) Waiver.--The Secretary may waive such provisions of
this title and title XI as the Secretary determines necessary
in order to implement the demonstration program.
``(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(f) Evaluation and Monitoring.--
``(1) In general.--The Secretary shall evaluate each
independence at home medical practice under the demonstration
program to assess whether the practice achieved the results
described in subsection (a).
``(2) Monitoring applicable beneficiaries.--The Secretary
may monitor data on expenditures and quality of services under
this title after an applicable beneficiary discontinues
receiving services under this title through a qualifying
independence at home medical practice.
``(g) Reports to Congress.--The Secretary shall conduct an
independent evaluation of the demonstration program and submit to
Congress a final report, including best practices under the
demonstration program. Such report shall include an analysis of the
demonstration program on coordination of care, expenditures under this
title, applicable beneficiary access to services, and the quality of
health care services provided to applicable beneficiaries.
``(h) Funding.--For purposes of administering and carrying out the
demonstration program, other than for payments for items and services
furnished under this title and incentive payments under subsection (c),
in addition to funds otherwise appropriated, there shall be transferred
to the Secretary for the Center for Medicare & Medicaid Services
Program Management Account from the Federal Hospital Insurance Trust
Fund under section 1817 and the Federal Supplementary Medical Insurance
Trust Fund under section 1841 (in proportions determined appropriate by
the Secretary) $5,000,000 for each of fiscal years 2010 through 2015.
Amounts transferred under this subsection for a fiscal year shall be
available until expended.
``(i) Termination.--
``(1) Mandatory termination.--The Secretary shall terminate
an agreement with an independence at home medical practice if--
``(A) the Secretary estimates or determines that
such practice will not receive an incentive payment for
the second of 2 consecutive years under the
demonstration program; or
``(B) such practice fails to meet quality standards
during any year of the demonstration program.
``(2) Permissive termination.--The Secretary may terminate
an agreement with an independence at home medical practice for
such other reasons determined appropriate by the Secretary.''.
SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM.
(a) In General.--Section 1886 of the Social Security Act (42 U.S.C.
1395ww), as amended by sections 3001 and 3008, is amended by adding at
the end the following new subsection:
``(q) Hospital Readmissions Reduction Program.--
``(1) In general.--With respect to payment for discharges
from an applicable hospital (as defined in paragraph (5)(C))
occurring during a fiscal year beginning on or after October 1,
2012, in order to account for excess readmissions in the
hospital, the Secretary shall reduce the payments that would
otherwise be made to such hospital under subsection (d) (or
section 1814(b)(3), as the case may be) for such a discharge by
an amount equal to the product of--
``(A) the base operating DRG payment amount (as
defined in paragraph (2)) for the discharge; and
``(B) the adjustment factor (described in paragraph
(3)(A)) for the hospital for the fiscal year.
``(2) Base operating drg payment amount defined.--
``(A) In general.--Except as provided in
subparagraph (B), in this subsection, the term `base
operating DRG payment amount' means, with respect to a
hospital for a fiscal year--
``(i) the payment amount that would
otherwise be made under subsection (d)
(determined without regard to subsection (o))
for a discharge if this subsection did not
apply; reduced by
``(ii) any portion of such payment amount
that is attributable to payments under
paragraphs (5)(A), (5)(B), (5)(F), and (12) of
subsection (d).
``(B) Special rules for certain hospitals.--
``(i) Sole community hospitals and
medicare-dependent, small rural hospitals.--In
the case of a medicare-dependent, small rural
hospital (with respect to discharges occurring
during fiscal years 2012 and 2013) or a sole
community hospital, in applying subparagraph
(A)(i), the payment amount that would otherwise
be made under subsection (d) shall be
determined without regard to subparagraphs (I)
and (L) of subsection (b)(3) and subparagraphs
(D) and (G) of subsection (d)(5).
``(ii) Hospitals paid under section 1814.--
In the case of a hospital that is paid under
section 1814(b)(3), the Secretary may exempt
such hospitals provided that States paid under
such section submit an annual report to the
Secretary describing how a similar program in
the State for a participating hospital or
hospitals achieves or surpasses the measured
results in terms of patient health outcomes and
cost savings established herein with respect to
this section.
``(3) Adjustment factor.--
``(A) In general.--For purposes of paragraph (1),
the adjustment factor under this paragraph for an
applicable hospital for a fiscal year is equal to the
greater of--
``(i) the ratio described in subparagraph
(B) for the hospital for the applicable period
(as defined in paragraph (5)(D)) for such
fiscal year; or
``(ii) the floor adjustment factor
specified in subparagraph (C).
``(B) Ratio.--The ratio described in this
subparagraph for a hospital for an applicable period is
equal to 1 minus the ratio of--
``(i) the aggregate payments for excess
readmissions (as defined in paragraph (4)(A))
with respect to an applicable hospital for the
applicable period; and
``(ii) the aggregate payments for all
discharges (as defined in paragraph (4)(B))
with respect to such applicable hospital for
such applicable period.
``(C) Floor adjustment factor.--For purposes of
subparagraph (A), the floor adjustment factor specified
in this subparagraph for--
``(i) fiscal year 2013 is 0.99;
``(ii) fiscal year 2014 is 0.98; or
``(iii) fiscal year 2015 and subsequent
fiscal years is 0.97.
``(4) Aggregate payments, excess readmission ratio
defined.--For purposes of this subsection:
``(A) Aggregate payments for excess readmissions.--
The term `aggregate payments for excess readmissions'
means, for a hospital for an applicable period, the
sum, for applicable conditions (as defined in paragraph
(5)(A)), of the product, for each applicable condition,
of--
``(i) the base operating DRG payment amount
for such hospital for such applicable period
for such condition;
``(ii) the number of admissions for such
condition for such hospital for such applicable
period; and
``(iii) the excess readmissions ratio (as
defined in subparagraph (C)) for such hospital
for such applicable period minus 1.
``(B) Aggregate payments for all discharges.--The
term `aggregate payments for all discharges' means, for
a hospital for an applicable period, the sum of the
base operating DRG payment amounts for all discharges
for all conditions from such hospital for such
applicable period.
``(C) Excess readmission ratio.--
``(i) In general.--Subject to clause (ii),
the term `excess readmissions ratio' means,
with respect to an applicable condition for a
hospital for an applicable period, the ratio
(but not less than 1.0) of--
``(I) the risk adjusted
readmissions based on actual
readmissions, as determined consistent
with a readmission measure methodology
that has been endorsed under paragraph
(5)(A)(ii)(I), for an applicable
hospital for such condition with
respect to such applicable period; to
``(II) the risk adjusted expected
readmissions (as determined consistent
with such a methodology) for such
hospital for such condition with
respect to such applicable period.
``(ii) Exclusion of certain readmissions.--
For purposes of clause (i), with respect to a
hospital, excess readmissions shall not include
readmissions for an applicable condition for
which there are fewer than a minimum number (as
determined by the Secretary) of discharges for
such applicable condition for the applicable
period and such hospital.
``(5) Definitions.--For purposes of this subsection:
``(A) Applicable condition.--The term `applicable
condition' means, subject to subparagraph (B), a
condition or procedure selected by the Secretary among
conditions and procedures for which--
``(i) readmissions (as defined in
subparagraph (E)) that represent conditions or
procedures that are high volume or high
expenditures under this title (or other
criteria specified by the Secretary); and
``(ii) measures of such readmissions--
``(I) have been endorsed by the
entity with a contract under section
1890(a); and
``(II) such endorsed measures have
exclusions for readmissions that are
unrelated to the prior discharge (such
as a planned readmission or transfer to
another applicable hospital).
``(B) Expansion of applicable conditions.--
Beginning with fiscal year 2015, the Secretary shall,
to the extent practicable, expand the applicable
conditions beyond the 3 conditions for which measures
have been endorsed as described in subparagraph
(A)(ii)(I) as of the date of the enactment of this
subsection to the additional 4 conditions that have
been identified by the Medicare Payment Advisory
Commission in its report to Congress in June 2007 and
to other conditions and procedures as determined
appropriate by the Secretary. In expanding such
applicable conditions, the Secretary shall seek the
endorsement described in subparagraph (A)(ii)(I) but
may apply such measures without such an endorsement in
the case of a specified area or medical topic
determined appropriate by the Secretary for which a
feasible and practical measure has not been endorsed by
the entity with a contract under section 1890(a) as
long as due consideration is given to measures that
have been endorsed or adopted by a consensus
organization identified by the Secretary.
``(C) Applicable hospital.--The term `applicable
hospital' means a subsection (d) hospital or a hospital
that is paid under section 1814(b)(3), as the case may
be.
``(D) Applicable period.--The term `applicable
period' means, with respect to a fiscal year, such
period as the Secretary shall specify.
``(E) Readmission.--The term `readmission' means,
in the case of an individual who is discharged from an
applicable hospital, the admission of the individual to
the same or another applicable hospital within a time
period specified by the Secretary from the date of such
discharge. Insofar as the discharge relates to an
applicable condition for which there is an endorsed
measure described in subparagraph (A)(ii)(I), such time
period (such as 30 days) shall be consistent with the
time period specified for such measure.
``(6) Reporting hospital specific information.--
``(A) In general.--The Secretary shall make
information available to the public regarding
readmission rates of each subsection (d) hospital under
the program.
``(B) Opportunity to review and submit
corrections.--The Secretary shall ensure that a
subsection (d) hospital has the opportunity to review,
and submit corrections for, the information to be made
public with respect to the hospital under subparagraph
(A) prior to such information being made public.
``(C) Website.--Such information shall be posted on
the Hospital Compare Internet website in an easily
understandable format.
``(7) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) The determination of base operating DRG
payment amounts.
``(B) The methodology for determining the
adjustment factor under paragraph (3), including excess
readmissions ratio under paragraph (4)(C), aggregate
payments for excess readmissions under paragraph
(4)(A), and aggregate payments for all discharges under
paragraph (4)(B), and applicable periods and applicable
conditions under paragraph (5).
``(C) The measures of readmissions as described in
paragraph (5)(A)(ii).
``(8) Readmission rates for all patients.--
``(A) Calculation of readmission.--The Secretary
shall calculate readmission rates for all patients (as
defined in subparagraph (D)) for a specified hospital
(as defined in subparagraph (D)(ii)) for an applicable
condition (as defined in paragraph (5)(B)) and other
conditions deemed appropriate by the Secretary for an
applicable period (as defined in paragraph (5)(D)) in
the same manner as used to calculate such readmission
rates for hospitals with respect to this title and
posted on the CMS Hospital Compare website.
``(B) Posting of hospital specific all patient
readmission rates.--The Secretary shall make
information on all patient readmission rates calculated
under subparagraph (A) available on the CMS Hospital
Compare website in a form and manner determined
appropriate by the Secretary. The Secretary may also
make other information determined appropriate by the
Secretary available on such website.
``(C) Hospital submission of all patient data.--
``(i) Except as provided for in clause
(ii), each specified hospital (as defined in
subparagraph (D)(ii)) shall submit to the
Secretary, in a form, manner and time specified
by the Secretary, data and information
determined necessary by the Secretary for the
Secretary to calculate the all patient
readmission rates described in subparagraph
(A).
``(ii) Instead of a specified hospital
submitting to the Secretary the data and
information described in clause (i), such data
and information may be submitted to the
Secretary, on behalf of such a specified
hospital, by a state or an entity determined
appropriate by the Secretary.
``(D) Definitions.--For purposes of this paragraph:
``(i) The term `all patients' means
patients who are treated on an inpatient basis
and discharged from a specified hospital (as
defined in clause (ii)).
``(ii) The term `specified hospital' means
a subsection (d) hospital, hospitals described
in clauses (i) through (v) of subsection
(d)(1)(B) and, as determined feasible and
appropriate by the Secretary, other hospitals
not otherwise described in this
subparagraph.''.
(b) Quality Improvement.--Part S of title III of the Public Health
Service Act, as amended by section 3015, is further amended by adding
at the end the following:
``SEC. 399KK. QUALITY IMPROVEMENT PROGRAM FOR HOSPITALS WITH A HIGH
SEVERITY ADJUSTED READMISSION RATE.
``(a) Establishment.--
``(1) In general.--Not later than 2 years after the date of
enactment of this section, the Secretary shall make available a
program for eligible hospitals to improve their readmission
rates through the use of patient safety organizations (as
defined in section 921(4)).
``(2) Eligible hospital defined.--In this subsection, the
term `eligible hospital' means a hospital that the Secretary
determines has a high rate of risk adjusted readmissions for
the conditions described in section 1886(q)(8)(A) of the Social
Security Act and has not taken appropriate steps to reduce such
readmissions and improve patient safety as evidenced through
historically high rates of readmissions, as determined by the
Secretary.
``(3) Risk adjustment.--The Secretary shall utilize
appropriate risk adjustment measures to determine eligible
hospitals.
``(b) Report to the Secretary.--As determined appropriate by the
Secretary, eligible hospitals and patient safety organizations working
with those hospitals shall report to the Secretary on the processes
employed by the hospital to improve readmission rates and the impact of
such processes on readmission rates.''.
SEC. 3026. COMMUNITY-BASED CARE TRANSITIONS PROGRAM.
(a) In General.--The Secretary shall establish a Community-Based
Care Transitions Program under which the Secretary provides funding to
eligible entities that furnish improved care transition services to
high-risk Medicare beneficiaries.
(b) Definitions.--In this section:
(1) Eligible entity.--The term ``eligible entity'' means
the following:
(A) A subsection (d) hospital (as defined in
section 1886(d)(1)(B) of the Social Security Act (42
U.S.C. 1395ww(d)(1)(B))) identified by the Secretary as
having a high readmission rate, such as under section
1886(q) of the Social Security Act, as added by section
3025.
(B) An appropriate community-based organization
that provides care transition services under this
section across a continuum of care through arrangements
with subsection (d) hospitals (as so defined) to
furnish the services described in subsection
(c)(2)(B)(i) and whose governing body includes
sufficient representation of multiple health care
stakeholders (including consumers).
(2) High-risk medicare beneficiary.--The term ``high-risk
Medicare beneficiary'' means a Medicare beneficiary who has
attained a minimum hierarchical condition category score, as
determined by the Secretary, based on a diagnosis of multiple
chronic conditions or other risk factors associated with a
hospital readmission or substandard transition into post-
hospitalization care, which may include 1 or more of the
following:
(A) Cognitive impairment.
(B) Depression.
(C) A history of multiple readmissions.
(D) Any other chronic disease or risk factor as
determined by the Secretary.
(3) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual who is entitled to benefits
under part A of title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) and enrolled under part B of such title,
but not enrolled under part C of such title.
(4) Program.--The term ``program'' means the program
conducted under this section.
(5) Readmission.--The term ``readmission'' has the meaning
given such term in section 1886(q)(5)(E) of the Social Security
Act, as added by section 3025.
(6) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(c) Requirements.--
(1) Duration.--
(A) In general.--The program shall be conducted for
a 5-year period, beginning January 1, 2011.
(B) Expansion.--The Secretary may expand the
duration and the scope of the program, to the extent
determined appropriate by the Secretary, if the
Secretary determines (and the Chief Actuary of the
Centers for Medicare & Medicaid Services, with respect
to spending under this title, certifies) that such
expansion would reduce spending under this title
without reducing quality.
(2) Application; participation.--
(A) In general.--
(i) Application.--An eligible entity
seeking to participate in the program shall
submit an application to the Secretary at such
time, in such manner, and containing such
information as the Secretary may require.
(ii) Partnership.--If an eligible entity is
a hospital, such hospital shall enter into a
partnership with a community-based organization
to participate in the program.
(B) Intervention proposal.--Subject to subparagraph
(C), an application submitted under subparagraph (A)(i)
shall include a detailed proposal for at least 1 care
transition intervention, which may include the
following:
(i) Initiating care transition services for
a high-risk Medicare beneficiary not later than
24 hours prior to the discharge of the
beneficiary from the eligible entity.
(ii) Arranging timely post-discharge
follow-up services to the high-risk Medicare
beneficiary to provide the beneficiary (and, as
appropriate, the primary caregiver of the
beneficiary) with information regarding
responding to symptoms that may indicate
additional health problems or a deteriorating
condition.
(iii) Providing the high-risk Medicare
beneficiary (and, as appropriate, the primary
caregiver of the beneficiary) with assistance
to ensure productive and timely interactions
between patients and post-acute and outpatient
providers.
(iv) Assessing and actively engaging with a
high-risk Medicare beneficiary (and, as
appropriate, the primary caregiver of the
beneficiary) through the provision of self-
management support and relevant information
that is specific to the beneficiary's
condition.
(v) Conducting comprehensive medication
review and management (including, if
appropriate, counseling and self-management
support).
(C) Limitation.--A care transition intervention
proposed under subparagraph (B) may not include payment
for services required under the discharge planning
process described in section 1861(ee) of the Social
Security Act (42 U.S.C. 1395x(ee)).
(3) Selection.--In selecting eligible entities to
participate in the program, the Secretary shall give priority
to eligible entities that--
(A) participate in a program administered by the
Administration on Aging to provide concurrent care
transitions interventions with multiple hospitals and
practitioners; or
(B) provide services to medically underserved
populations, small communities, and rural areas.
(d) Implementation.--Notwithstanding any other provision of law,
the Secretary may implement the provisions of this section by program
instruction or otherwise.
(e) Waiver Authority.--The Secretary may waive such requirements of
titles XI and XVIII of the Social Security Act as may be necessary to
carry out the program.
(f) Funding.--For purposes of carrying out this section, the
Secretary of Health and Human Services shall provide for the transfer,
from the Federal Hospital Insurance Trust Fund under section 1817 of
the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary
Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C.
1395t), in such proportion as the Secretary determines appropriate, of
$500,000,000, to the Centers for Medicare & Medicaid Services Program
Management Account for the period of fiscal years 2011 through 2015.
Amounts transferred under the preceding sentence shall remain available
until expended.
SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION.
(a) In General.--Subsection (d)(3) of section 5007 of the Deficit
Reduction Act of 2005 (Public Law 109-171) is amended by inserting
``(or September 30, 2011, in the case of a demonstration project in
operation as of October 1, 2008)'' after ``December 31, 2009''.
(b) Funding.--
(1) In general.--Subsection (f)(1) of such section is
amended by inserting ``and for fiscal year 2010, $1,600,000,''
after ``$6,000,000,''.
(2) Availability.--Subsection (f)(2) of such section is
amended by striking ``2010'' and inserting ``2014 or until
expended''.
(c) Reports.--
(1) Quality improvement and savings.--Subsection (e)(3) of
such section is amended by striking ``December 1, 2008'' and
inserting ``March 31, 2011''.
(2) Final report.--Subsection (e)(4) of such section is
amended by striking ``May 1, 2010'' and inserting ``March 31,
2013''.
Subtitle B--Improving Medicare for Patients and Providers
PART I--ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER
SERVICES
SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE.
Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d))
is amended by adding at the end the following new paragraph:
``(10) Update for 2010.--
``(A) In general.--Subject to paragraphs (7)(B),
(8)(B), and (9)(B), in lieu of the update to the single
conversion factor established in paragraph (1)(C) that
would otherwise apply for 2010, the update to the
single conversion factor shall be 0.5 percent.
``(B) No effect on computation of conversion factor
for 2011 and subsequent years.--The conversion factor
under this subsection shall be computed under paragraph
(1)(A) for 2011 and subsequent years as if subparagraph
(A) had never applied.''.
SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND REVISIONS
TO THE PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT UNDER THE
MEDICARE PHYSICIAN FEE SCHEDULE.
(a) Extension of Work GPCI Floor.--Section 1848(e)(1)(E) of the
Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is amended by striking
``before January 1, 2010'' and inserting ``before January 1, 2011''.
(b) Practice Expense Geographic Adjustment for 2010 and Subsequent
Years.--Section 1848(e)(1) of the Social Security Act (42 U.S.C.
1395w4(e)(1)) is amended--
(1) in subparagraph (A), by striking ``and (G)'' and
inserting ``(G), and (H)''; and
(2) by adding at the end the following new subparagraph:
``(H) Practice expense geographic adjustment for
2010 and subsequent years.--
``(i) For 2010.--Subject to clause (iii),
for services furnished during 2010, the
employee wage and rent portions of the practice
expense geographic index described in
subparagraph (A)(i) shall reflect \3/4\ of the
difference between the relative costs of
employee wages and rents in each of the
different fee schedule areas and the national
average of such employee wages and rents.
``(ii) For 2011.--Subject to clause (iii),
for services furnished during 2011, the
employee wage and rent portions of the practice
expense geographic index described in
subparagraph (A)(i) shall reflect \1/2\ of the
difference between the relative costs of
employee wages and rents in each of the
different fee schedule areas and the national
average of such employee wages and rents.
``(iii) Hold harmless.--The practice
expense portion of the geographic adjustment
factor applied in a fee schedule area for
services furnished in 2010 or 2011 shall not,
as a result of the application of clause (i) or
(ii), be reduced below the practice expense
portion of the geographic adjustment factor
under subparagraph (A)(i) (as calculated prior
to the application of such clause (i) or (ii),
respectively) for such area for such year.
``(iv) Analysis.--The Secretary shall
analyze current methods of establishing
practice expense geographic adjustments under
subparagraph (A)(i) and evaluate data that
fairly and reliably establishes distinctions in
the costs of operating a medical practice in
the different fee schedule areas. Such analysis
shall include an evaluation of the following:
``(I) The feasibility of using
actual data or reliable survey data
developed by medical organizations on
the costs of operating a medical
practice, including office rents and
non-physician staff wages, in different
fee schedule areas.
``(II) The office expense portion
of the practice expense geographic
adjustment described in subparagraph
(A)(i), including the extent to which
types of office expenses are determined
in local markets instead of national
markets.
``(III) The weights assigned to
each of the categories within the
practice expense geographic adjustment
described in subparagraph (A)(i).
``(v) Revision for 2012 and subsequent
years.--As a result of the analysis described
in clause (iv), the Secretary shall, not later
than January 1, 2012, make appropriate
adjustments to the practice expense geographic
adjustment described in subparagraph (A)(i) to
ensure accurate geographic adjustments across
fee schedule areas, including--
``(I) basing the office rents
component and its weight on office
expenses that vary among fee schedule
areas; and
``(II) considering a representative
range of professional and non-
professional personnel employed in a
medical office based on the use of the
American Community Survey data or other
reliable data for wage adjustments.
Such adjustments shall be made without regard
to adjustments made pursuant to clauses (i) and
(ii) and shall be made in a budget neutral
manner.''.
SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE THERAPY CAPS.
Section 1833(g)(5) of the Social Security Act (42 U.S.C.
1395l(g)(5)) is amended by striking ``December 31, 2009'' and inserting
``December 31, 2010''.
SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN
PHYSICIAN PATHOLOGY SERVICES.
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000 (as enacted into law by section
1(a)(6) of Public Law 106-554), as amended by section 732 of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), and section 136 of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275), is amended by striking
``and 2009'' and inserting ``2009, and 2010''.
SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended--
(1) in the matter preceding clause (i)--
(A) by striking ``2007, and for'' and inserting
``2007, for''; and
(B) by striking ``2010'' and inserting ``2010, and
for such services furnished on or after April 1, 2010,
and before January 1, 2011,''; and
(2) in each of clauses (i) and (ii), by inserting ``, and
on or after April 1, 2010, and before January 1, 2011'' after
``January 1, 2010'' each place it appears.
(b) Air Ambulance.--Section 146(b)(1) of the Medicare Improvements
for Patients and Providers Act of 2008 (Public Law 110-275) is amended
by striking ``December 31, 2009'' and inserting ``December 31, 2009,
and during the period beginning on April 1, 2010, and ending on January
1, 2011''.
(c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by striking
``2010'' and inserting ``2010, and on or after April 1, 2010, and
before January 1, 2011''.
SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM CARE
HOSPITAL SERVICES AND OF MORATORIUM ON THE ESTABLISHMENT
OF CERTAIN HOSPITALS AND FACILITIES.
(a) Extension of Certain Payment Rules.--Section 114(c) of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww
note), as amended by section 4302(a) of the American Recovery and
Reinvestment Act (Public Law 111-5), is further amended by striking
``3-year period'' each place it appears and inserting ``4-year
period''.
(b) Extension of Moratorium.--Section 114(d)(1) of such Act (42
U.S.C. 1395ww note), in the matter preceding subparagraph (A), is
amended by striking ``3-year period'' and inserting ``4-year period''.
SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON.
Section 138(a)(1) of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275) is amended by striking
``December 31, 2009'' and inserting ``December 31, 2010''.
SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL
EXTENDED CARE SERVICES.
(a) Ordering Post-Hospital Extended Care Services.--
(1) In general.--Section 1814(a)(2) of the Social Security
Act (42 U.S.C. 1395f(a)(2)), in the matter preceding
subparagraph (A), is amended by striking ``or clinical nurse
specialist'' and inserting ``, a clinical nurse specialist, or
a physician assistant (as those terms are defined in section
1861(aa)(5))'' after ``nurse practitioner''.
(2) Conforming amendment.--Section 1814(a) of the Social
Security Act (42 U.S.C. 1395f(a)) is amended, in the second
sentence, by striking ``or clinical nurse specialist'' and
inserting ``clinical nurse specialist, or physician assistant''
after ``nurse practitioner,''.
(b) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2011.
SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION
REQUIREMENTS.
(a) In General.--Section 1834(a)(20) of the Social Security Act (42
U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public Law 100-
275), is amended--
(1) in subparagraph (F)(i)--
(A) by inserting ``and subparagraph (G)'' after
``clause (ii)''; and
(B) by inserting ``, except that the Secretary
shall not require a pharmacy to have submitted to the
Secretary such evidence of accreditation prior to
January 1, 2011'' before the semicolon at the end; and
(2) by adding at the end the following new subparagraph:
``(G) Application of accreditation requirement to
certain pharmacies.--
``(i) In general.--With respect to items
and services furnished on or after January 1,
2011, in implementing quality standards under
this paragraph--
``(I) subject to subclause (II), in
applying such standards and the
accreditation requirement of
subparagraph (F)(i) with respect to
pharmacies described in clause (ii)
furnishing such items and services,
such standards and accreditation
requirement shall not apply to such
pharmacies; and
``(II) the Secretary may apply to
such pharmacies an alternative
accreditation requirement established
by the Secretary if the Secretary
determines such alternative
accreditation requirement is more
appropriate for such pharmacies.
``(ii) Pharmacies described.--A pharmacy
described in this clause is a pharmacy that
meets each of the following criteria:
``(I) The total billings by the
pharmacy for such items and services
under this title are less than 5
percent of total pharmacy sales, as
determined based on the average total
pharmacy sales for the previous 3
calendar years, 3 fiscal years, or
other yearly period specified by the
Secretary.
``(II) The pharmacy has been
enrolled under section 1866(j) as a
supplier of durable medical equipment,
prosthetics, orthotics, and supplies,
has been issued (which may include the
renewal of) a provider number for at
least 5 years, and for which a final
adverse action (as defined in section
424.57(a) of title 42, Code of Federal
Regulations) has not been imposed in
the past 5 years.
``(III) The pharmacy submits to the
Secretary an attestation, in a form and
manner, and at a time, specified by the
Secretary, that the pharmacy meets the
criteria described in subclauses (I)
and (II). Such attestation shall be
subject to section 1001 of title 18,
United States Code.
``(IV) The pharmacy agrees to
submit materials as requested by the
Secretary, or during the course of an
audit conducted on a random sample of
pharmacies selected annually, to verify
that the pharmacy meets the criteria
described in subclauses (I) and (II).
Materials submitted under the preceding
sentence shall include a certification
by an accountant on behalf of the
pharmacy or the submission of tax
returns filed by the pharmacy during
the relevant periods, as requested by
the Secretary.''.
(b) Administration.--Notwithstanding any other provision of law,
the Secretary may implement the amendments made by subsection (a) by
program instruction or otherwise.
(c) Rule of Construction.--Nothing in the provisions of or
amendments made by this section shall be construed as affecting the
application of an accreditation requirement for pharmacies to qualify
for bidding in a competitive acquisition area under section 1847 of the
Social Security Act (42 U.S.C. 1395w-3).
SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED TRICARE
BENEFICIARIES.
(a) In General.--
(1) In general.--Section 1837 of the Social Security Act
(42 U.S.C. 1395p) is amended by adding at the end the following
new subsection:
``(l)(1) In the case of any individual who is a covered beneficiary
(as defined in section 1072(5) of title 10, United States Code) at the
time the individual is entitled to part A under section 226(b) or
section 226A and who is eligible to enroll but who has elected not to
enroll (or to be deemed enrolled) during the individual's initial
enrollment period, there shall be a special enrollment period described
in paragraph (2).
``(2) The special enrollment period described in this paragraph,
with respect to an individual, is the 12-month period beginning on the
day after the last day of the initial enrollment period of the
individual or, if later, the 12-month period beginning with the month
the individual is notified of enrollment under this section.
``(3) In the case of an individual who enrolls during the special
enrollment period provided under paragraph (1), the coverage period
under this part shall begin on the first day of the month in which the
individual enrolls, or, at the option of the individual, the first
month after the end of the individual's initial enrollment period.
``(4) An individual may only enroll during the special enrollment
period provided under paragraph (1) one time during the individual's
lifetime.
``(5) The Secretary shall ensure that the materials relating to
coverage under this part that are provided to an individual described
in paragraph (1) prior to the individual's initial enrollment period
contain information concerning the impact of not enrolling under this
part, including the impact on health care benefits under the TRICARE
program under chapter 55 of title 10, United States Code.
``(6) The Secretary of Defense shall collaborate with the Secretary
of Health and Human Services and the Commissioner of Social Security to
provide for the accurate identification of individuals described in
paragraph (1). The Secretary of Defense shall provide such individuals
with notification with respect to this subsection. The Secretary of
Defense shall collaborate with the Secretary of Health and Human
Services and the Commissioner of Social Security to ensure appropriate
follow up pursuant to any notification provided under the preceding
sentence.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to elections made with respect to initial
enrollment periods that end after the date of the enactment of
this Act.
(b) Waiver of Increase of Premium.--Section 1839(b) of the Social
Security Act (42 U.S.C. 1395r(b)) is amended by striking ``section
1837(i)(4)'' and inserting ``subsection (i)(4) or (l) of section
1837''.
SEC. 3111. PAYMENT FOR BONE DENSITY TESTS.
(a) Payment.--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4) is amended--
(A) in subsection (b)--
(i) in paragraph (4)(B), by inserting ``,
and for 2010 and 2011, dual-energy x-ray
absorptiometry services (as described in
paragraph (6))'' before the period at the end;
and
(ii) by adding at the end the following new
paragraph:
``(6) Treatment of bone mass scans.--For dual-energy x-ray
absorptiometry services (identified in 2006 by HCPCS codes
76075 and 76077 (and any succeeding codes)) furnished during
2010 and 2011, instead of the payment amount that would
otherwise be determined under this section for such years, the
payment amount shall be equal to 70 percent of the product of--
``(A) the relative value for the service (as
determined in subsection (c)(2)) for 2006;
``(B) the conversion factor (established under
subsection (d)) for 2006; and
``(C) the geographic adjustment factor (established
under subsection (e)(2)) for the service for the fee
schedule area for 2010 and 2011, respectively.''; and
(B) in subsection (c)(2)(B)(iv)--
(i) in subclause (II), by striking ``and''
at the end;
(ii) in subclause (III), by striking the
period at the end and inserting ``; and''; and
(iii) by adding at the end the following
new subclause:
``(IV) subsection (b)(6) shall not
be taken into account in applying
clause (ii)(II) for 2010 or 2011.''.
(2) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement the amendments made by
paragraph (1) by program instruction or otherwise.
(b) Study and Report by the Institute of Medicine.--
(1) In general.--The Secretary of Health and Human Services
is authorized to enter into an agreement with the Institute of
Medicine of the National Academies to conduct a study on the
ramifications of Medicare payment reductions for dual-energy x-
ray absorptiometry (as described in section 1848(b)(6) of the
Social Security Act, as added by subsection (a)(1)) during
2007, 2008, and 2009 on beneficiary access to bone mass density
tests.
(2) Report.--An agreement entered into under paragraph (1)
shall provide for the Institute of Medicine to submit to the
Secretary and to Congress a report containing the results of
the study conducted under such paragraph.
SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND.
Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C.
1395iii) is amended by striking ``$22,290,000,000'' and inserting
``$0''.
SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORATORY TESTS.
(a) Demonstration Project.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a demonstration project under part B title XVIII of the
Social Security Act under which separate payments are made
under such part for complex diagnostic laboratory tests
provided to individuals under such part. Under the
demonstration project, the Secretary shall establish
appropriate payment rates for such tests.
(2) Covered complex diagnostic laboratory test defined.--In
this section, the term ``complex diagnostic laboratory test''
means a diagnostic laboratory test--
(A) that is an analysis of gene protein expression,
topographic genotyping, or a cancer chemotherapy
sensitivity assay;
(B) that is determined by the Secretary to be a
laboratory test for which there is not an alternative
test having equivalent performance characteristics;
(C) which is billed using a Health Care Procedure
Coding System (HCPCS) code other than a not otherwise
classified code under such Coding System;
(D) which is approved or cleared by the Food and
Drug Administration or is covered under title XVIII of
the Social Security Act; and
(E) is described in section 1861(s)(3) of the
Social Security Act (42 U.S.C. 1395x(s)(3)).
(3) Separate payment defined.--In this section, the term
``separate payment'' means direct payment to a laboratory
(including a hospital-based or independent laboratory) that
performs a complex diagnostic laboratory test with respect to a
specimen collected from an individual during a period in which
the individual is a patient of a hospital if the test is
performed after such period of hospitalization and if separate
payment would not otherwise be made under title XVIII of the
Social Security Act by reason of sections 1862(a)(14) and
1866(a)(1)(H)(i) of the such Act (42 U.S.C. 1395y(a)(14); 42
U.S.C. 1395cc(a)(1)(H)(i)).
(b) Duration.--Subject to subsection (c)(2), the Secretary shall
conduct the demonstration project under this section for the 2-year
period beginning on July 1, 2011.
(c) Payments and Limitation.--Payments under the demonstration
project under this section shall--
(1) be made from the Federal Supplemental Medical Insurance
Trust Fund under section 1841 of the Social Security Act (42
U.S.C. 1395t); and
(2) may not exceed $100,000,000.
(d) Report.--Not later than 2 years after the completion of the
demonstration project under this section, the Secretary shall submit to
Congress a report on the project. Such report shall include--
(1) an assessment of the impact of the demonstration
project on access to care, quality of care, health outcomes,
and expenditures under title XVIII of the Social Security Act
(including any savings under such title); and
(2) such recommendations as the Secretary determines
appropriate.
(e) Implementation Funding.--For purposes of administering this
section (including preparing and submitting the report under subsection
(d)), the Secretary shall provide for the transfer, from the Federal
Supplemental Medical Insurance Trust Fund under section 1841 of the
Social Security Act (42 U.S.C. 1395t), to the Centers for Medicare &
Medicaid Services Program Management Account, of $5,000,000. Amounts
transferred under the preceding sentence shall remain available until
expended.
SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERVICES.
Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C.
1395l(a)(1)(K)) is amended by inserting ``(or 100 percent for services
furnished on or after January 1, 2011)'' after ``1992, 65 percent''.
PART II--RURAL PROTECTIONS
SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.
(a) In General.--Section 1833(t)(7)(D)(i) of the Social Security
Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended--
(1) in subclause (II)--
(A) in the first sentence, by striking ``2010''and
inserting ``2011''; and
(B) in the second sentence, by striking ``or 2009''
and inserting ``, 2009, or 2010''; and
(2) in subclause (III), by striking ``January 1, 2010'' and
inserting ``January 1, 2011''.
(b) Permitting All Sole Community Hospitals To Be Eligible for Hold
Harmless.--Section 1833(t)(7)(D)(i)(III) of the Social Security Act (42
U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by adding at the end the
following new sentence: ``In the case of covered OPD services furnished
on or after January 1, 2010, and before January 1, 2011, the preceding
sentence shall be applied without regard to the 100-bed limitation.''.
SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR CERTAIN
CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO
HOSPITAL PATIENTS IN CERTAIN RURAL AREAS.
Section 416(b) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (42 U.S.C. 1395l-4), as amended by section
105 of division B of the Tax Relief and Health Care Act of 2006 (42
U.S.C. 1395l note) and section 107 of the Medicare, Medicaid, and SCHIP
Extension Act of 2007 (42 U.S.C. 1395l note), is amended by inserting
``or during the 1-year period beginning on July 1, 2010'' before the
period at the end.
SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL DEMONSTRATION
PROGRAM.
(a) One-year Extension.--Section 410A of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173;
117 Stat. 2272) is amended by adding at the end the following new
subsection:
``(g) One-Year Extension of Demonstration Program.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall conduct the demonstration
program under this section for an additional 1-year period (in
this section referred to as the `1-year extension period') that
begins on the date immediately following the last day of the
initial 5-year period under subsection (a)(5).
``(2) Expansion of demonstration states.--Notwithstanding
subsection (a)(2), during the 1-year extension period, the
Secretary shall expand the number of States with low population
densities determined by the Secretary under such subsection to
20. In determining which States to include in such expansion,
the Secretary shall use the same criteria and data that the
Secretary used to determine the States under such subsection
for purposes of the initial 5-year period.
``(3) Increase in maximum number of hospitals participating
in the demonstration program.--Notwithstanding subsection
(a)(4), during the 1-year extension period, not more than 30
rural community hospitals may participate in the demonstration
program under this section.
``(4) No affect on hospitals in demonstration program on
date of enactment.--In the case of a rural community hospital
that is participating in the demonstration program under this
section as of the last day of the initial 5-year period, the
Secretary shall provide for the continued participation of such
rural community hospital in the demonstration program during
the 1-year extension period unless the rural community hospital
makes an election, in such form and manner as the Secretary may
specify, to discontinue such participation.''.
(b) Conforming Amendments.--Subsection (a)(5) of section 410A of
the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (Public Law 108-173; 117 Stat. 2272) is amended by inserting ``(in
this section referred to as the `initial 5-year period') and, as
provided in subsection (g), for the 1-year extension period'' after
``5-year period''.
(c) Technical Amendments.--
(1) Subsection (b) of section 410A of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173; 117 Stat. 2272) is amended--
(A) in paragraph (1)(B)(ii), by striking ``2)'' and
inserting ``2))''; and
(B) in paragraph (2), by inserting ``cost'' before
``reporting period'' the first place such term appears
in each of subparagraphs (A) and (B).
(2) Subsection (f)(1) of section 410A of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173; 117 Stat. 2272) is amended--
(A) in subparagraph (A)(ii), by striking
``paragraph (2)'' and inserting ``subparagraph (B)'';
and
(B) in subparagraph (B), by striking ``paragraph
(1)(B)'' and inserting ``subparagraph (A)(ii)''.
SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.
(a) Extension of Payment Methodology.--Section 1886(d)(5)(G) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``October 1, 2011'' and
inserting ``October 1, 2012''; and
(2) in clause (ii)(II), by striking ``October 1, 2011'' and
inserting ``October 1, 2012''.
(b) Conforming Amendments.--
(1) Extension of target amount.--Section 1886(b)(3)(D) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is
amended--
(A) in the matter preceding clause (i), by striking
``October 1, 2011'' and inserting ``October 1, 2012'';
and
(B) in clause (iv), by striking ``through fiscal
year 2011'' and inserting ``through fiscal year 2012''.
(2) Permitting hospitals to decline reclassification.--
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of
1993 (42 U.S.C. 1395ww note) is amended by striking ``through
fiscal year 2011'' and inserting ``through fiscal year 2012''.
SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT HOSPITAL
PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12)) is amended--
(1) in subparagraph (A), by inserting ``or (D)'' after
``subparagraph (B)'';
(2) in subparagraph (B), in the matter preceding clause
(i), by striking ``The Secretary'' and inserting ``For
discharges occurring in fiscal years 2005 through 2010 and for
discharges occurring in fiscal year 2013 and subsequent fiscal
years, the Secretary'';
(3) in subparagraph (C)(i)--
(A) by inserting ``(or, with respect to fiscal
years 2011 and 2012, 15 road miles)'' after ``25 road
miles''; and
(B) by inserting ``(or, with respect to fiscal
years 2011 and 2012, 1,500 discharges of individuals
entitled to, or enrolled for, benefits under part A)''
after ``800 discharges''; and
(4) by adding at the end the following new subparagraph:
``(D) Temporary applicable percentage increase.--
For discharges occurring in fiscal years 2011 and 2012,
the Secretary shall determine an applicable percentage
increase for purposes of subparagraph (A) using a
continuous linear sliding scale ranging from 25 percent
for low-volume hospitals with 200 or fewer discharges
of individuals entitled to, or enrolled for, benefits
under part A in the fiscal year to 0 percent for low-
volume hospitals with greater than 1,500 discharges of
such individuals in the fiscal year.''.
SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON COMMUNITY
HEALTH INTEGRATION MODELS IN CERTAIN RURAL COUNTIES.
(a) Removal of Limitation on Number of Eligible Counties
Selected.--Subsection (d)(3) of section 123 of the Medicare
Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395i-4
note) is amended by striking ``not more than 6''.
(b) Removal of References to Rural Health Clinic Services and
Inclusion of Physicians' Services in Scope of Demonstration Project.--
Such section 123 is amended--
(1) in subsection (d)(4)(B)(i)(3), by striking subclause
(III); and
(2) in subsection (j)--
(A) in paragraph (8), by striking subparagraph (B)
and inserting the following:
``(B) Physicians' services (as defined in section
1861(q) of the Social Security Act (42 U.S.C.
1395x(q)).'';
(B) by striking paragraph (9); and
(C) by redesignating paragraph (10) as paragraph
(9).
SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS FOR HEALTH
CARE PROVIDERS SERVING IN RURAL AREAS.
(a) Study.--The Medicare Payment Advisory Commission shall conduct
a study on the adequacy of payments for items and services furnished by
providers of services and suppliers in rural areas under the Medicare
program under title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.). Such study shall include an analysis of--
(1) any adjustments in payments to providers of services
and suppliers that furnish items and services in rural areas;
(2) access by Medicare beneficiaries to items and services
in rural areas;
(3) the adequacy of payments to providers of services and
suppliers that furnish items and services in rural areas; and
(4) the quality of care furnished in rural areas.
(b) Report.--Not later than January 1, 2011, the Medicare Payment
Advisory Commission shall submit to Congress a report containing the
results of the study conducted under subsection (a). Such report shall
include recommendations on appropriate modifications to any adjustments
in payments to providers of services and suppliers that furnish items
and services in rural areas, together with recommendations for such
legislation and administrative action as the Medicare Payment Advisory
Commission determines appropriate.
SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS HOSPITAL
SERVICES.
(a) In General.--Subsections (g)(2)(A) and (l)(8) of section 1834
of the Social Security Act (42 U.S.C. 1395m) are each amended by
inserting ``101 percent of'' before ``the reasonable costs''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect as if included in the enactment of section 405(a) of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173; 117 Stat. 2266).
SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL HOSPITAL
FLEXIBILITY PROGRAM.
(a) Authorization.--Section 1820(j) of the Social Security Act (42
U.S.C. 1395i-4(j)) is amended--
(1) by striking ``2010, and for'' and inserting ``2010,
for''; and
(2) by inserting ``and for making grants to all States
under subsection (g), such sums as may be necessary in each of
fiscal years 2011 and 2012, to remain available until
expended'' before the period at the end.
(b) Use of Funds.--Section 1820(g)(3) of the Social Security Act
(42 U.S.C. 1395i-4(g)(3)) is amended--
(1) in subparagraph (A), by inserting ``and to assist such
hospitals in participating in delivery system reforms under the
provisions of and amendments made by the Patient Protection and
Affordable Care Act, such as value-based purchasing programs,
accountable care organizations under section 1899, the National
pilot program on payment bundling under section 1866D, and
other delivery system reform programs determined appropriate by
the Secretary'' before the period at the end; and
(2) in subparagraph (E)--
(A) by striking ``, and to offset'' and inserting
``, to offset''; and
(B) by inserting ``and to participate in delivery
system reforms under the provisions of and amendments
made by the Patient Protection and Affordable Care Act,
such as value-based purchasing programs, accountable
care organizations under section 1899, the National
pilot program on payment bundling under section 1866D,
and other delivery system reform programs determined
appropriate by the Secretary'' before the period at the
end.
(c) Effective Date.--The amendments made by this section shall
apply to grants made on or after January 1, 2010.
PART III--IMPROVING PAYMENT ACCURACY
SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.
(a) Rebasing Home Health Prospective Payment Amount.--
(1) In general.--Section 1895(b)(3)(A) of the Social
Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended--
(A) in clause (i)(III), by striking ``For periods''
and inserting ``Subject to clause (iii), for periods'';
and
(B) by adding at the end the following new clause:
``(iii) Adjustment for 2013 and subsequent
years.--
``(I) In general.--Subject to
subclause (II), for 2013 and subsequent
years, the amount (or amounts) that
would otherwise be applicable under
clause (i)(III) shall be adjusted by a
percentage determined appropriate by
the Secretary to reflect such factors
as changes in the number of visits in
an episode, the mix of services in an
episode, the level of intensity of
services in an episode, the average
cost of providing care per episode, and
other factors that the Secretary
considers to be relevant. In conducting
the analysis under the preceding
sentence, the Secretary may consider
differences between hospital-based and
freestanding agencies, between for-
profit and nonprofit agencies, and
between the resource costs of urban and
rural agencies. Such adjustment shall
be made before the update under
subparagraph (B) is applied for the
year.
``(II) Transition.--The Secretary
shall provide for a 4-year phase-in (in
equal increments) of the adjustment
under subclause (I), with such
adjustment being fully implemented for
2016. During each year of such phase-
in, the amount of any adjustment under
subclause (I) for the year may not
exceed 3.5 percent of the amount (or
amounts) applicable under clause
(i)(III) as of the date of enactment of
the Patient Protection and Affordable
Care Act.''.
(2) MedPAC study and report.--
(A) Study.--The Medicare Payment Advisory
Commission shall conduct a study on the implementation
of the amendments made by paragraph (1). Such study
shall include an analysis of the impact of such
amendments on--
(i) access to care;
(ii) quality outcomes;
(iii) the number of home health agencies;
and
(iv) rural agencies, urban agencies, for-
profit agencies, and nonprofit agencies.
(B) Report.--Not later than January 1, 2015, the
Medicare Payment Advisory Commission shall submit to
Congress a report on the study conducted under
subparagraph (A), together with recommendations for
such legislation and administrative action as the
Commission determines appropriate.
(b) Program-specific Outlier Cap.--Section 1895(b) of the Social
Security Act (42 U.S.C. 1395fff(b)) is amended--
(1) in paragraph (3)(C), by striking ``the aggregate'' and
all that follows through the period at the end and inserting
``5 percent of the total payments estimated to be made based on
the prospective payment system under this subsection for the
period.''; and
(2) in paragraph (5)--
(A) by striking ``Outliers.--The Secretary'' and
inserting the following: ``Outliers.--
``(A) In general.--Subject to subparagraph (B), the
Secretary'';
(B) in subparagraph (A), as added by subparagraph
(A), by striking ``5 percent'' and inserting ``2.5
percent''; and
(C) by adding at the end the following new
subparagraph:
``(B) Program specific outlier cap.--The estimated
total amount of additional payments or payment
adjustments made under subparagraph (A) with respect to
a home health agency for a year (beginning with 2011)
may not exceed an amount equal to 10 percent of the
estimated total amount of payments made under this
section (without regard to this paragraph) with respect
to the home health agency for the year.''.
(c) Application of the Medicare Rural Home Health Add-on Policy.--
Section 421 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2283), as
amended by section 5201(b) of the Deficit Reduction Act of 2005 (Public
Law 109-171; 120 Stat. 46), is amended--
(1) in the section heading, by striking ``one-year'' and
inserting ``temporary''; and
(2) in subsection (a)--
(A) by striking ``, and episodes'' and inserting
``, episodes'';
(B) by inserting ``and episodes and visits ending
on or after April 1, 2010, and before January 1,
2016,'' after ``January 1, 2007,''; and
(C) by inserting ``(or, in the case of episodes and
visits ending on or after April 1, 2010, and before
January 1, 2016, 3 percent)'' before the period at the
end.
(d) Study and Report on the Development of Home Health Payment
Reforms in Order To Ensure Access to Care and Quality Services.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a study to evaluate the costs and quality of care among
efficient home health agencies relative to other such agencies
in providing ongoing access to care and in treating Medicare
beneficiaries with varying severity levels of illness. Such
study shall include an analysis of the following:
(A) Methods to revise the home health prospective
payment system under section 1895 of the Social
Security Act (42 U.S.C. 1395fff) to more accurately
account for the costs related to patient severity of
illness or to improving beneficiary access to care,
including--
(i) payment adjustments for services that
may be under- or over-valued;
(ii) necessary changes to reflect the
resource use relative to providing home health
services to low-income Medicare beneficiaries
or Medicare beneficiaries living in medically
underserved areas;
(iii) ways the outlier payment may be
improved to more accurately reflect the cost of
treating Medicare beneficiaries with high
severity levels of illness;
(iv) the role of quality of care incentives
and penalties in driving provider and patient
behavior;
(v) improvements in the application of a
wage index; and
(vi) other areas determined appropriate by
the Secretary.
(B) The validity and reliability of responses on
the OASIS instrument with particular emphasis on
questions that relate to higher payment under the home
health prospective payment system and higher outcome
scores under Home Care Compare.
(C) Additional research or payment revisions under
the home health prospective payment system that may be
necessary to set the payment rates for home health
services based on costs of high-quality and efficient
home health agencies or to improve Medicare beneficiary
access to care.
(D) A timetable for implementation of any
appropriate changes based on the analysis of the
matters described in subparagraphs (A), (B), and (C).
(E) Other areas determined appropriate by the
Secretary.
(2) Considerations.--In conducting the study under
paragraph (1), the Secretary shall consider whether certain
factors should be used to measure patient severity of illness
and access to care, such as--
(A) population density and relative patient access
to care;
(B) variations in service costs for providing care
to individuals who are dually eligible under the
Medicare and Medicaid programs;
(C) the presence of severe or chronic diseases, as
evidenced by multiple, discontinuous home health
episodes;
(D) poverty status, as evidenced by the receipt of
Supplemental Security Income under title XVI of the
Social Security Act;
(E) the absence of caregivers;
(F) language barriers;
(G) atypical transportation costs;
(H) security costs; and
(I) other factors determined appropriate by the
Secretary.
(3) Report.--Not later than March 1, 2011, the Secretary
shall submit to Congress a report on the study conducted under
paragraph (1), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(4) Consultations.--In conducting the study under paragraph
(1) and preparing the report under paragraph (3), the Secretary
shall consult with--
(A) stakeholders representing home health agencies;
(B) groups representing Medicare beneficiaries;
(C) the Medicare Payment Advisory Commission;
(D) the Inspector General of the Department of
Health and Human Services; and
(E) the Comptroller General of the United States.
SEC. 3132. HOSPICE REFORM.
(a) Hospice Care Payment Reforms.--
(1) In general.--Section 1814(i) of the Social Security Act
(42 U.S.C. 1395f(i)), as amended by section 3004(c), is
amended--
(A) by redesignating paragraph (6) as paragraph
(7); and
(B) by inserting after paragraph (5) the following
new paragraph:
``(6)(A) The Secretary shall collect additional data and
information as the Secretary determines appropriate to revise
payments for hospice care under this subsection pursuant to
subparagraph (D) and for other purposes as determined
appropriate by the Secretary. The Secretary shall begin to
collect such data by not later than January 1, 2011.
``(B) The additional data and information to be collected
under subparagraph (A) may include data and information on--
``(i) charges and payments;
``(ii) the number of days of hospice care which are
attributable to individuals who are entitled to, or
enrolled for, benefits under part A; and
``(iii) with respect to each type of service
included in hospice care--
``(I) the number of days of hospice care
attributable to the type of service;
``(II) the cost of the type of service; and
``(III) the amount of payment for the type
of service;
``(iv) charitable contributions and other revenue
of the hospice program;
``(v) the number of hospice visits;
``(vi) the type of practitioner providing the
visit; and
``(vii) the length of the visit and other basic
information with respect to the visit.
``(C) The Secretary may collect the additional data and
information under subparagraph (A) on cost reports, claims, or
other mechanisms as the Secretary determines to be appropriate.
``(D)(i) Notwithstanding the preceding paragraphs of this
subsection, not earlier than October 1, 2013, the Secretary
shall, by regulation, implement revisions to the methodology
for determining the payment rates for routine home care and
other services included in hospice care under this part, as the
Secretary determines to be appropriate. Such revisions may be
based on an analysis of data and information collected under
subparagraph (A). Such revisions may include adjustments to per
diem payments that reflect changes in resource intensity in
providing such care and services during the course of the
entire episode of hospice care.
``(ii) Revisions in payment implemented pursuant to clause
(i) shall result in the same estimated amount of aggregate
expenditures under this title for hospice care furnished in the
fiscal year in which such revisions in payment are implemented
as would have been made under this title for such care in such
fiscal year if such revisions had not been implemented.
``(E) The Secretary shall consult with hospice programs and
the Medicare Payment Advisory Commission regarding the
additional data and information to be collected under
subparagraph (A) and the payment revisions under subparagraph
(D).''.
(2) Conforming amendments.--Section 1814(i)(1)(C) of the
Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended--
(A) in clause (ii)--
(i) in the matter preceding subclause (I),
by inserting ``(before the first fiscal year in
which the payment revisions described in
paragraph (6)(D) are implemented)'' after
``subsequent fiscal year''; and
(ii) in subclause (VII), by inserting
``(before the first fiscal year in which the
payment revisions described in paragraph (6)(D)
are implemented), subject to clause (iv),''
after ``subsequent fiscal year''; and
(B) by adding at the end the following new clause:
``(iii) With respect to routine home care
and other services included in hospice care
furnished during fiscal years subsequent to the
first fiscal year in which payment revisions
described in paragraph (6)(D) are implemented,
the payment rates for such care and services
shall be the payment rates in effect under this
clause during the preceding fiscal year
increased by, subject to clause (iv), the
market basket percentage increase (as defined
in section 1886(b)(3)(B)(iii)) for the fiscal
year.''.
(b) Adoption of MedPAC Hospice Program Eligibility Recertification
Recommendations.--Section 1814(a)(7) of the Social Security Act (42
U.S.C. 1395f(a)(7)) is amended--
(1) in subparagraph (B), by striking ``and'' at the end;
and
(2) by adding at the end the following new subparagraph:
``(D) on and after January 1, 2011--
``(i) a hospice physician or nurse
practitioner has a face-to-face encounter with
the individual to determine continued
eligibility of the individual for hospice care
prior to the 180th-day recertification and each
subsequent recertification under subparagraph
(A)(ii) and attests that such visit took place
(in accordance with procedures established by
the Secretary); and
``(ii) in the case of hospice care provided
an individual for more than 180 days by a
hospice program for which the number of such
cases for such program comprises more than a
percent (specified by the Secretary) of the
total number of such cases for all programs
under this title, the hospice care provided to
such individual is medically reviewed (in
accordance with procedures established by the
Secretary); and''.
SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE HOSPITAL
(DSH) PAYMENTS.
Section 1886 of the Social Security Act (42 U.S.C. 1395ww), as
amended by sections 3001, 3008, and 3025, is amended--
(1) in subsection (d)(5)(F)(i), by striking ``For'' and
inserting ``Subject to subsection (r), for''; and
(2) by adding at the end the following new subsection:
``(r) Adjustments to Medicare DSH Payments.--
``(1) Empirically justified dsh payments.--For fiscal year
2015 and each subsequent fiscal year, instead of the amount of
disproportionate share hospital payment that would otherwise be
made under subsection (d)(5)(F) to a subsection (d) hospital
for the fiscal year, the Secretary shall pay to the subsection
(d) hospital 25 percent of such amount (which represents the
empirically justified amount for such payment, as determined by
the Medicare Payment Advisory Commission in its March 2007
Report to the Congress).
``(2) Additional payment.--In addition to the payment made
to a subsection (d) hospital under paragraph (1), for fiscal
year 2015 and each subsequent fiscal year, the Secretary shall
pay to such subsection (d) hospitals an additional amount equal
to the product of the following factors:
``(A) Factor one.--A factor equal to the difference
between--
``(i) the aggregate amount of payments that
would be made to subsection (d) hospitals under
subsection (d)(5)(F) if this subsection did not
apply for such fiscal year (as estimated by the
Secretary); and
``(ii) the aggregate amount of payments
that are made to subsection (d) hospitals under
paragraph (1) for such fiscal year (as so
estimated).
``(B) Factor two.--
``(i) Fiscal years 2015, 2016, and 2017.--
For each of fiscal years 2015, 2016, and 2017,
a factor equal to 1 minus the percent change
(divided by 100) in the percent of individuals
under the age of 65 who are uninsured, as
determined by comparing the percent of such
individuals--
``(I) who are uninsured in 2012,
the last year before coverage expansion
under the Patient Protection and
Affordable Care Act (as calculated by
the Secretary based on the most recent
estimates available from the Director
of the Congressional Budget Office
before a vote in either House on such
Act that, if determined in the
affirmative, would clear such Act for
enrollment); and
``(II) who are uninsured in the
most recent period for which data is
available (as so calculated).
``(ii) 2018 and subsequent years.--For
fiscal year 2018 and each subsequent fiscal
year, a factor equal to 1 minus the percent
change (divided by 100) in the percent of
individuals who are uninsured, as determined by
comparing the percent of individuals--
``(I) who are uninsured in 2012 (as
estimated by the Secretary, based on
data from the Census Bureau or other
sources the Secretary determines
appropriate, and certified by the Chief
Actuary of the Centers for Medicare &
Medicaid Services); and
``(II) who are uninsured in the
most recent period for which data is
available (as so estimated and
certified).
``(C) Factor three.--A factor equal to the percent,
for each subsection (d) hospital, that represents the
quotient of--
``(i) the amount of uncompensated care for
such hospital for a period selected by the
Secretary (as estimated by the Secretary, based
on appropriate data (including, in the case
where the Secretary determines that alternative
data is available which is a better proxy for
the costs of subsection (d) hospitals for
treating the uninsured, the use of such
alternative data)); and
``(ii) the aggregate amount of
uncompensated care for all subsection (d)
hospitals that receive a payment under this
subsection for such period (as so estimated,
based on such data).
``(3) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) Any estimate of the Secretary for purposes of
determining the factors described in paragraph (2).
``(B) Any period selected by the Secretary for such
purposes.''.
SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.
(a) In General.--Section 1848(c)(2) of the Social Security Act (42
U.S.C. 1395w-4(c)(2)) is amended by adding at the end the following new
subparagraphs:
``(K) Potentially misvalued codes.--
``(i) In general.--The Secretary shall--
``(I) periodically identify
services as being potentially misvalued
using criteria specified in clause
(ii); and
``(II) review and make appropriate
adjustments to the relative values
established under this paragraph for
services identified as being
potentially misvalued under subclause
(I).
``(ii) Identification of potentially
misvalued codes.--For purposes of identifying
potentially misvalued services pursuant to
clause (i)(I), the Secretary shall examine (as
the Secretary determines to be appropriate)
codes (and families of codes as appropriate)
for which there has been the fastest growth;
codes (and families of codes as appropriate)
that have experienced substantial changes in
practice expenses; codes for new technologies
or services within an appropriate period (such
as 3 years) after the relative values are
initially established for such codes; multiple
codes that are frequently billed in conjunction
with furnishing a single service; codes with
low relative values, particularly those that
are often billed multiple times for a single
treatment; codes which have not been subject to
review since the implementation of the RBRVS
(the so-called `Harvard-valued codes'); and
such other codes determined to be appropriate
by the Secretary.
``(iii) Review and adjustments.--
``(I) The Secretary may use
existing processes to receive
recommendations on the review and
appropriate adjustment of potentially
misvalued services described in clause
(i)(II).
``(II) The Secretary may conduct
surveys, other data collection
activities, studies, or other analyses
as the Secretary determines to be
appropriate to facilitate the review
and appropriate adjustment described in
clause (i)(II).
``(III) The Secretary may use
analytic contractors to identify and
analyze services identified under
clause (i)(I), conduct surveys or
collect data, and make recommendations
on the review and appropriate
adjustment of services described in
clause (i)(II).
``(IV) The Secretary may coordinate
the review and appropriate adjustment
described in clause (i)(II) with the
periodic review described in
subparagraph (B).
``(V) As part of the review and
adjustment described in clause (i)(II),
including with respect to codes with
low relative values described in clause
(ii), the Secretary may make
appropriate coding revisions (including
using existing processes for
consideration of coding changes) which
may include consolidation of individual
services into bundled codes for payment
under the fee schedule under subsection
(b).
``(VI) The provisions of
subparagraph (B)(ii)(II) shall apply to
adjustments to relative value units
made pursuant to this subparagraph in
the same manner as such provisions
apply to adjustments under subparagraph
(B)(ii)(II).
``(L) Validating relative value units.--
``(i) In general.--The Secretary shall
establish a process to validate relative value
units under the fee schedule under subsection
(b).
``(ii) Components and elements of work.--
The process described in clause (i) may include
validation of work elements (such as time,
mental effort and professional judgment,
technical skill and physical effort, and stress
due to risk) involved with furnishing a service
and may include validation of the pre-, post-,
and intra-service components of work.
``(iii) Scope of codes.--The validation of
work relative value units shall include a
sampling of codes for services that is the same
as the codes listed under subparagraph (K)(ii).
``(iv) Methods.--The Secretary may conduct
the validation under this subparagraph using
methods described in subclauses (I) through (V)
of subparagraph (K)(iii) as the Secretary
determines to be appropriate.
``(v) Adjustments.--The Secretary shall
make appropriate adjustments to the work
relative value units under the fee schedule
under subsection (b). The provisions of
subparagraph (B)(ii)(II) shall apply to
adjustments to relative value units made
pursuant to this subparagraph in the same
manner as such provisions apply to adjustments
under subparagraph (B)(ii)(II).''.
(b) Implementation.--
(1) Administration.--
(A) Chapter 35 of title 44, United States Code and
the provisions of the Federal Advisory Committee Act (5
U.S.C. App.) shall not apply to this section or the
amendment made by this section.
(B) Notwithstanding any other provision of law, the
Secretary may implement subparagraphs (K) and (L) of
1848(c)(2) of the Social Security Act, as added by
subsection (a), by program instruction or otherwise.
(C) Section 4505(d) of the Balanced Budget Act of
1997 is repealed.
(D) Except for provisions related to
confidentiality of information, the provisions of the
Federal Acquisition Regulation shall not apply to this
section or the amendment made by this section.
(2) Focusing cms resources on potentially overvalued
codes.--Section 1868(a) of the Social Security Act (42 U.S.C.
1395ee(a)) is repealed.
SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR ADVANCED
IMAGING SERVICES.
(a) Adjustment in Practice Expense To Reflect Higher Presumed
Utilization.--Section 1848 of the Social Security Act (42 U.S.C. 1395w-
4) is amended--
(1) in subsection (b)(4)--
(A) in subparagraph (B), by striking ``subparagraph
(A)'' and inserting ``this paragraph''; and
(B) by adding at the end the following new
subparagraph:
``(C) Adjustment in practice expense to reflect
higher presumed utilization.--Consistent with the
methodology for computing the number of practice
expense relative value units under subsection
(c)(2)(C)(ii) with respect to advanced diagnostic
imaging services (as defined in section 1834(e)(1)(B))
furnished on or after January 1, 2010, the Secretary
shall adjust such number of units so it reflects--
``(i) in the case of services furnished on
or after January 1, 2010, and before January 1,
2013, a 65 percent (rather than 50 percent)
presumed rate of utilization of imaging
equipment;
``(ii) in the case of services furnished on
or after January 1, 2013, and before January 1,
2014, a 70 percent (rather than 50 percent)
presumed rate of utilization of imaging
equipment; and
``(iii) in the case of services furnished
on or after January 1, 2014, a 75 percent
(rather than 50 percent) presumed rate of
utilization of imaging equipment.''; and
(2) in subsection (c)(2)(B)(v), by adding at the end the
following new subclauses:
``(III) Change in presumed
utilization level of certain advanced
diagnostic imaging services for 2010
through 2012.--Effective for fee
schedules established beginning with
2010 and ending with 2012, reduced
expenditures attributable to the
presumed rate of utilization of imaging
equipment of 65 percent under
subsection (b)(4)(C)(i) instead of a
presumed rate of utilization of such
equipment of 50 percent.
``(IV) Change in presumed
utilization level of certain advanced
diagnostic imaging services for 2013.--
Effective for fee schedules established
for 2013, reduced expenditures
attributable to the presumed rate of
utilization of imaging equipment of 70
percent under subsection (b)(4)(C)(ii)
instead of a presumed rate of
utilization of such equipment of 50
percent.
``(V) Change in presumed
utilization level of certain advanced
diagnostic imaging services for 2014
and subsequent years.--Effective for
fee schedules established beginning
with 2014, reduced expenditures
attributable to the presumed rate of
utilization of imaging equipment of 75
percent under subsection (b)(4)(C)(iii)
instead of a presumed rate of
utilization of such equipment of 50
percent.''.
(b) Adjustment in Technical Component ``discount'' on Single-
session Imaging to Consecutive Body Parts.--Section 1848 of the Social
Security Act (42 U.S.C. 1395w-4), as amended by subsection (a), is
amended--
(1) in subsection (b)(4), by adding at the end the
following new subparagraph:
``(D) Adjustment in technical component discount on
single-session imaging involving consecutive body
parts.--For services furnished on or after July 1,
2010, the Secretary shall increase the reduction in
payments attributable to the multiple procedure payment
reduction applicable to the technical component for
imaging under the final rule published by the Secretary
in the Federal Register on November 21, 2005 (part 405
of title 42, Code of Federal Regulations) from 25
percent to 50 percent.''; and
(2) in subsection (c)(2)(B)(v), by adding at the end the
following new subclause:
``(VI) Additional reduced payment
for multiple imaging procedures.--
Effective for fee schedules established
beginning with 2010 (but not applied
for services furnished prior to July 1,
2010), reduced expenditures
attributable to the increase in the
multiple procedure payment reduction
from 25 to 50 percent (as described in
subsection (b)(4)(D)).''.
(c) Analysis by the Chief Actuary of the Centers for Medicare &
Medicaid Services.--Not later than January 1, 2013, the Chief Actuary
of the Centers for Medicare & Medicaid Services shall make publicly
available an analysis of whether, for the period of 2010 through 2019,
the cumulative expenditure reductions under title XVIII of the Social
Security Act that are attributable to the adjustments under the
amendments made by this section are projected to exceed $3,000,000,000.
SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS.
(a) In General.--Section 1834(a)(7)(A) of the Social Security Act
(42 U.S.C. 1395m(a)(7)(A)) is amended--
(1) in clause (i)--
(A) in subclause (II), by inserting ``subclause
(III) and'' after ``Subject to''; and
(B) by adding at the end the following new
subclause:
``(III) Special rule for power-
driven wheelchairs.--For purposes of
payment for power-driven wheelchairs,
subclause (II) shall be applied by
substituting `15 percent' and `6
percent' for `10 percent' and `7.5
percent', respectively.''; and
(2) in clause (iii)--
(A) in the heading, by inserting ``complex,
rehabilitative'' before ``power-driven''; and
(B) by inserting ``complex, rehabilitative'' before
``power-driven''.
(b) Technical Amendment.--Section 1834(a)(7)(C)(ii)(II) of the
Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended by
striking ``(A)(ii) or''.
(c) Effective Date.--
(1) In general.--Subject to paragraph (2), the amendments
made by subsection (a) shall take effect on January 1, 2011,
and shall apply to power-driven wheelchairs furnished on or
after such date.
(2) Application to competitive bidding.--The amendments
made by subsection (a) shall not apply to payment made for
items and services furnished pursuant to contracts entered into
under section 1847 of the Social Security Act (42 U.S.C. 1395w-
3) prior to January 1, 2011, pursuant to the implementation of
subsection (a)(1)(B)(i)(I) of such section 1847.
SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT.
(a) Extension of Section 508 Hospital Reclassifications.--
(1) In general.--Subsection (a) of section 106 of division
B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395
note), as amended by section 117 of the Medicare, Medicaid, and
SCHIP Extension Act of 2007 (Public Law 110-173) and section
124 of the Medicare Improvements for Patients and Providers Act
of 2008 (Public Law 110-275), is amended by striking
``September 30, 2009'' and inserting ``September 30, 2010''.
(2) Use of particular wage index in fiscal year 2010.--For
purposes of implementation of the amendment made by this
subsection during fiscal year 2010, the Secretary shall use the
hospital wage index that was promulgated by the Secretary in
the Federal Register on August 27, 2009 (74 Fed. Reg. 43754),
and any subsequent corrections.
(b) Plan for Reforming the Medicare Hospital Wage Index System.--
(1) In general.--Not later than December 31, 2011, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall submit to Congress a
report that includes a plan to reform the hospital wage index
system under section 1886 of the Social Security Act.
(2) Details.--In developing the plan under paragraph (1),
the Secretary shall take into account the goals for reforming
such system set forth in the Medicare Payment Advisory
Commission June 2007 report entitled ``Report to Congress:
Promoting Greater Efficiency in Medicare'', including
establishing a new hospital compensation index system that--
(A) uses Bureau of Labor Statistics data, or other
data or methodologies, to calculate relative wages for
each geographic area involved;
(B) minimizes wage index adjustments between and
within metropolitan statistical areas and statewide
rural areas;
(C) includes methods to minimize the volatility of
wage index adjustments that result from implementation
of policy, while maintaining budget neutrality in
applying such adjustments;
(D) takes into account the effect that
implementation of the system would have on health care
providers and on each region of the country;
(E) addresses issues related to occupational mix,
such as staffing practices and ratios, and any evidence
on the effect on quality of care or patient safety as a
result of the implementation of the system; and
(F) provides for a transition.
(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall consult with relevant affected
parties.
(c) Use of Particular Criteria for Determining Reclassifications.--
Notwithstanding any other provision of law, in making decisions on
applications for reclassification of a subsection (d) hospital (as
defined in paragraph (1)(B) of section 1886(d) of the Social Security
Act (42 U.S.C. 1395ww(d)) for the purposes described in paragraph
(10)(D)(v) of such section for fiscal year 2011 and each subsequent
fiscal year (until the first fiscal year beginning on or after the date
that is 1 year after the Secretary of Health and Human Services submits
the report to Congress under subsection (b)), the Geographic
Classification Review Board established under paragraph (10) of such
section shall use the average hourly wage comparison criteria used in
making such decisions as of September 30, 2008. The preceding sentence
shall be effected in a budget neutral manner.
SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS.
Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is
amended by adding at the end the following new paragraph:
``(18) Authorization of adjustment for cancer hospitals.--
``(A) Study.--The Secretary shall conduct a study
to determine if, under the system under this
subsection, costs incurred by hospitals described in
section 1886(d)(1)(B)(v) with respect to ambulatory
payment classification groups exceed those costs
incurred by other hospitals furnishing services under
this subsection (as determined appropriate by the
Secretary). In conducting the study under this
subparagraph, the Secretary shall take into
consideration the cost of drugs and biologicals
incurred by such hospitals.
``(B) Authorization of adjustment.--Insofar as the
Secretary determines under subparagraph (A) that costs
incurred by hospitals described in section
1886(d)(1)(B)(v) exceed those costs incurred by other
hospitals furnishing services under this subsection,
the Secretary shall provide for an appropriate
adjustment under paragraph (2)(E) to reflect those
higher costs effective for services furnished on or
after January 1, 2011.''.
SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.
(a) In General.--Section 1847A of the Social Security Act (42
U.S.C. 1395w-3a) is amended--
(1) in subsection (b)--
(A) in paragraph (1)--
(i) in subparagraph (A), by striking ``or''
at the end;
(ii) in subparagraph (B), by striking the
period at the end and inserting ``; or''; and
(iii) by adding at the end the following
new subparagraph:
``(C) in the case of a biosimilar biological
product (as defined in subsection (c)(6)(H)), the
amount determined under paragraph (8).''; and
(B) by adding at the end the following new
paragraph:
``(8) Biosimilar biological product.--The amount specified
in this paragraph for a biosimilar biological product described
in paragraph (1)(C) is the sum of--
``(A) the average sales price as determined using
the methodology described under paragraph (6) applied
to a biosimilar biological product for all National
Drug Codes assigned to such product in the same manner
as such paragraph is applied to drugs described in such
paragraph; and
``(B) 6 percent of the amount determined under
paragraph (4) for the reference biological product (as
defined in subsection (c)(6)(I)).''; and
(2) in subsection (c)(6), by adding at the end the
following new subparagraph:
``(H) Biosimilar biological product.--The term
`biosimilar biological product' means a biological
product approved under an abbreviated application for a
license of a biological product that relies in part on
data or information in an application for another
biological product licensed under section 351 of the
Public Health Service Act.
``(I) Reference biological product.--The term
`reference biological product' means the biological
product licensed under such section 351 that is
referred to in the application described in
subparagraph (H) of the biosimilar biological
product.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to payments for biosimilar biological products beginning with the
first day of the second calendar quarter after enactment of legislation
providing for a biosimilar pathway (as determined by the Secretary).
SEC. 3140. MEDICARE HOSPICE CONCURRENT CARE DEMONSTRATION PROGRAM.
(a) Establishment.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a Medicare Hospice Concurrent Care demonstration
program at participating hospice programs under which Medicare
beneficiaries are furnished, during the same period, hospice
care and any other items or services covered under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.) from funds
otherwise paid under such title to such hospice programs.
(2) Duration.--The demonstration program under this section
shall be conducted for a 3-year period.
(3) Sites.--The Secretary shall select not more than 15
hospice programs at which the demonstration program under this
section shall be conducted. Such hospice programs shall be
located in urban and rural areas.
(b) Independent Evaluation and Reports.--
(1) Independent evaluation.--The Secretary shall provide
for the conduct of an independent evaluation of the
demonstration program under this section. Such independent
evaluation shall determine whether the demonstration program
has improved patient care, quality of life, and cost-
effectiveness for Medicare beneficiaries participating in the
demonstration program.
(2) Reports.--The Secretary shall submit to Congress a
report containing the results of the evaluation conducted under
paragraph (1), together with such recommendations as the
Secretary determines appropriate.
(c) Budget Neutrality.--With respect to the 3-year period of the
demonstration program under this section, the Secretary shall ensure
that the aggregate expenditures under title XVIII for such period shall
not exceed the aggregate expenditures that would have been expended
under such title if the demonstration program under this section had
not been implemented.
SEC. 3141. APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL BASIS IN THE
CALCULATION OF THE MEDICARE HOSPITAL WAGE INDEX FLOOR.
In the case of discharges occurring on or after October 1, 2010,
for purposes of applying section 4410 of the Balanced Budget Act of
1997 (42 U.S.C. 1395ww note) and paragraph (h)(4) of section 412.64 of
title 42, Code of Federal Regulations, the Secretary of Health and
Human Services shall administer subsection (b) of such section 4410 and
paragraph (e) of such section 412.64 in the same manner as the
Secretary administered such subsection (b) and paragraph (e) for
discharges occurring during fiscal year 2008 (through a uniform,
national adjustment to the area wage index).
SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS.
(a) Study.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a study on the need for an additional payment for urban
Medicare-dependent hospitals for inpatient hospital services
under section 1886 of the Social Security Act (42 U.S.C.
1395ww). Such study shall include an analysis of--
(A) the Medicare inpatient margins of urban
Medicare-dependent hospitals, as compared to other
hospitals which receive 1 or more additional payments
or adjustments under such section (including those
payments or adjustments described in paragraph (2)(A));
and
(B) whether payments to medicare-dependent, small
rural hospitals under subsection (d)(5)(G) of such
section should be applied to urban Medicare-dependent
hospitals.
(2) Urban medicare-dependent hospital defined.--For
purposes of this section, the term ``urban Medicare-dependent
hospital'' means a subsection (d) hospital (as defined in
subsection (d)(1)(B) of such section) that--
(A) does not receive any additional payment or
adjustment under such section, such as payments for
indirect medical education costs under subsection
(d)(5)(B) of such section, disproportionate share
payments under subsection (d)(5)(A) of such section,
payments to a rural referral center under subsection
(d)(5)(C) of such section, payments to a critical
access hospital under section 1814(l) of such Act (42
U.S.C. 1395f(l)), payments to a sole community hospital
under subsection (d)(5)(D) of such section 1886, or
payments to a medicare-dependent, small rural hospital
under subsection (d)(5)(G) of such section 1886; and
(B) for which more than 60 percent of its inpatient
days or discharges during 2 of the 3 most recently
audited cost reporting periods for which the Secretary
has a settled cost report were attributable to
inpatients entitled to benefits under part A of title
XVIII of such Act.
(b) Report.--Not later than 9 months after the date of enactment of
this Act, the Secretary shall submit to Congress a report containing
the results of the study conducted under subsection (a), together with
recommendations for such legislation and administrative action as the
Secretary determines appropriate.
SEC. 3143. PROTECTING HOME HEALTH BENEFITS.
Nothing in the provisions of, or amendments made by, this Act shall
result in the reduction of guaranteed home health benefits under title
XVIII of the Social Security Act.
Subtitle C--Provisions Relating to Part C
SEC. 3201. MEDICARE ADVANTAGE PAYMENT.
(a) MA Benchmark Based on Plan's Competitive Bids.--
(1) In general.--Section 1853(j) of the Social Security Act
(42 U.S.C. 1395w-23(j)) is amended--
(A) by striking ``Amounts.--For purposes'' and
inserting ``Amounts.--
``(1) In general.--For purposes'';
(B) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B), respectively, and indenting
the subparagraphs appropriately;
(C) in subparagraph (A), as redesignated by
subparagraph (B)--
(i) by redesignating subparagraphs (A) and
(B) as clauses (i) and (ii), respectively, and
indenting the clauses appropriately; and
(ii) in clause (i), as redesignated by
clause (i), by striking ``an amount equal to''
and all that follows through the end and
inserting ``an amount equal to--
``(I) for years before 2007, \1/12\
of the annual MA capitation rate under
section 1853(c)(1) for the area for the
year, adjusted as appropriate for the
purpose of risk adjustment;
``(II) for 2007 through 2011, \1/
12\ of the applicable amount determined
under subsection (k)(1) for the area
for the year;
``(III) for 2012, the sum of--
``(aa) \2/3\ of the
quotient of--
``(AA) the
applicable amount
determined under
subsection (k)(1) for
the area for the year;
and
``(BB) 12; and
``(bb) \1/3\ of the MA
competitive benchmark amount
(determined under paragraph
(2)) for the area for the
month;
``(IV) for 2013, the sum of--
``(aa) \1/3\ of the
quotient of--
``(AA) the
applicable amount
determined under
subsection (k)(1) for
the area for the year;
and
``(BB) 12; and
``(bb) \2/3\ of the MA
competitive benchmark amount
(as so determined) for the area
for the month;
``(V) for 2014, the MA competitive
benchmark amount for the area for a
month in 2013 (as so determined),
increased by the national per capita MA
growth percentage, described in
subsection (c)(6) for 2014, but not
taking into account any adjustment
under subparagraph (C) of such
subsection for a year before 2004; and
``(VI) for 2015 and each subsequent
year, the MA competitive benchmark
amount (as so determined) for the area
for the month; or'';
(iii) in clause (ii), as redesignated by
clause (i), by striking ``subparagraph (A)''
and inserting ``clause (i)'';
(D) by adding at the end the following new
paragraphs:
``(2) Computation of ma competitive benchmark amount.--
``(A) In general.--Subject to subparagraph (B) and
paragraph (3), for months in each year (beginning with
2012) for each MA payment area the Secretary shall
compute an MA competitive benchmark amount equal to the
weighted average of the unadjusted MA statutory non-
drug monthly bid amount (as defined in section
1854(b)(2)(E)) for each MA plan in the area, with the
weight for each plan being equal to the average number
of beneficiaries enrolled under such plan in the
reference month (as defined in section 1858(f)(4),
except that, in applying such definition for purposes
of this paragraph, `to compute the MA competitive
benchmark amount under section 1853(j)(2)' shall be
substituted for `to compute the percentage specified in
subparagraph (A) and other relevant percentages under
this part').
``(B) Weighting rules.--
``(i) Single plan rule.--In the case of an
MA payment area in which only a single MA plan
is being offered, the weight under subparagraph
(A) shall be equal to 1.
``(ii) Use of simple average among multiple
plans if no plans offered in previous year.--In
the case of an MA payment area in which no MA
plan was offered in the previous year and more
than 1 MA plan is offered in the current year,
the Secretary shall use a simple average of the
unadjusted MA statutory non-drug monthly bid
amount (as so defined) for purposes of
computing the MA competitive benchmark amount
under subparagraph (A).
``(3) Cap on ma competitive benchmark amount.--In no case
shall the MA competitive benchmark amount for an area for a
month in a year be greater than the applicable amount that
would (but for the application of this subsection) be
determined under subsection (k)(1) for the area for the month
in the year.''; and
(E) in subsection (k)(2)(B)(ii)(III), by striking
``(j)(1)(A)'' and inserting ``(j)(1)(A)(i)''.
(2) Conforming amendments.--
(A) Section 1853(k)(2) of the Social Security Act
(42 U.S.C. 1395w-23(k)(2)) is amended--
(i) in subparagraph (A), by striking
``through 2010'' and inserting ``and subsequent
years''; and
(ii) in subparagraph (C)--
(I) in clause (iii), by striking
``and'' at the end;
(II) in clause (iv), by striking
the period at the end and inserting ``;
and''; and
(III) by adding at the end the
following new clause:
``(v) for 2011 and subsequent years,
0.00.''.
(B) Section 1854(b) of the Social Security Act (42
U.S.C. 1395w-24(b)) is amended--
(i) in paragraph (3)(B)(i), by striking
``1853(j)(1)'' and inserting ``1853(j)(1)(A)'';
and
(ii) in paragraph (4)(B)(i), by striking
``1853(j)(2)'' and inserting ``1853(j)(1)(B)''.
(C) Section 1858(f) of the Social Security Act (42
U.S.C. 1395w-27(f)) is amended--
(i) in paragraph (1), by striking
``1853(j)(2)'' and inserting ``1853(j)(1)(B)'';
and
(ii) in paragraph (3)(A), by striking
``1853(j)(1)(A)'' and inserting
``1853(j)(1)(A)(i)''.
(D) Section 1860C-1(d)(1)(A) of the Social Security
Act (42 U.S.C. 1395w-29(d)(1)(A)) is amended by
striking ``1853(j)(1)(A)'' and inserting
``1853(j)(1)(A)(i)''.
(b) Reduction of National Per Capita Growth Percentage for 2011.--
Section 1853(c)(6) of the Social Security Act (42 U.S.C. 1395w-
23(c)(6)) is amended--
(1) in clause (v), by striking ``and'' at the end;
(2) in clause (vi)--
(A) by striking ``for a year after 2002'' and
inserting ``for 2003 through 2010''; and
(B) by striking the period at the end and inserting
a comma; and
(C) by adding at the end the following new clauses:
``(vii) for 2011, 3 percentage points; and
``(viii) for a year after 2011, 0
percentage points.''.
(c) Enhancement of Beneficiary Rebates.--Section 1854(b)(1)(C)(i)
of the Social Security Act (42 U.S.C. 1395w-24(b)(1)(C)(i)) is amended
by inserting ``(or 100 percent in the case of plan years beginning on
or after January 1, 2014)'' after ``75 percent''.
(d) Bidding Rules.--
(1) Requirements for information submitted.--Section
1854(a)(6)(A) of the Social Security Act (42 U.S.C. 1395w-
24(a)(6)(A)) is amended, in the flush matter following clause
(v), by adding at the end the following sentence: ``Information
to be submitted under this paragraph shall be certified by a
qualified member of the American Academy of Actuaries and shall
meet actuarial guidelines and rules established by the
Secretary under subparagraph (B)(v).''.
(2) Establishment of actuarial guidelines.--Section
1854(a)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
24(a)(6)(B)) is amended--
(A) in clause (i), by striking ``(iii) and (iv)''
and inserting ``(iii), (iv), and (v)''; and
(B) by adding at the end the following new clause:
``(v) Establishment of actuarial
guidelines.--
``(I) In general.--In order to
establish fair MA competitive
benchmarks under section
1853(j)(1)(A)(i), the Secretary, acting
through the Chief Actuary of the
Centers for Medicare & Medicaid
Services (in this clause referred to as
the `Chief Actuary'), shall establish--
``(aa) actuarial guidelines
for the submission of bid
information under this
paragraph; and
``(bb) bidding rules that
are appropriate to ensure
accurate bids and fair
competition among MA plans.
``(II) Denial of bid amounts.--The
Secretary shall deny monthly bid
amounts submitted under subparagraph
(A) that do not meet the actuarial
guidelines and rules established under
subclause (I).
``(III) Refusal to accept certain
bids due to misrepresentations and
failures to adequately meet
requirements.--In the case where the
Secretary determines that information
submitted by an MA organization under
subparagraph (A) contains consistent
misrepresentations and failures to
adequately meet requirements of the
organization, the Secretary may refuse
to accept any additional such bid
amounts from the organization for the
plan year and the Chief Actuary shall,
if the Chief Actuary determines that
the actuaries of the organization were
complicit in those misrepresentations
and failures, report those actuaries to
the Actuarial Board for Counseling and
Discipline.''.
(3) Effective date.--The amendments made by this subsection
shall apply to bid amounts submitted on or after January 1,
2012.
(e) MA Local Plan Service Areas.--
(1) In general.--Section 1853(d) of the Social Security Act
(42 U.S.C. 1395w-23(d)) is amended--
(A) in the subsection heading, by striking ``MA
Region'' and inserting ``MA Region; MA Local Plan
Service Area'';
(B) in paragraph (1), by striking subparagraph (A)
and inserting the following:
``(A) with respect to an MA local plan--
``(i) for years before 2012, an MA local
area (as defined in paragraph (2)); and
``(ii) for 2012 and succeeding years, a
service area that is an entire urban or rural
area, as applicable (as described in paragraph
(5)); and''; and
(C) by adding at the end the following new
paragraph:
``(5) MA local plan service area.--For 2012 and succeeding
years, the service area for an MA local plan shall be an entire
urban or rural area in each State as follows:
``(A) Urban areas.--
``(i) In general.--Subject to clause (ii)
and subparagraphs (C) and (D), the service area
for an MA local plan in an urban area shall be
the Core Based Statistical Area (in this
paragraph referred to as a `CBSA') or, if
applicable, a conceptually similar alternative
classification, as defined by the Director of
the Office of Management and Budget.
``(ii) CBSA covering more than one state.--
In the case of a CBSA (or alternative
classification) that covers more than one
State, the Secretary shall divide the CBSA (or
alternative classification) into separate
service areas with respect to each State
covered by the CBSA (or alternative
classification).
``(B) Rural areas.--Subject to subparagraphs (C)
and (D), the service area for an MA local plan in a
rural area shall be a county that does not qualify for
inclusion in a CBSA (or alternative classification), as
defined by the Director of the Office of Management and
Budget.
``(C) Refinements to service areas.--For 2015 and
succeeding years, in order to reflect actual patterns
of health care service utilization, the Secretary may
adjust the boundaries of service areas for MA local
plans in urban areas and rural areas under
subparagraphs (A) and (B), respectively, but may only
do so based on recent analyses of actual patterns of
care.
``(D) Additional authority to make limited
exceptions to service area requirements for ma local
plans.--The Secretary may, in addition to any
adjustments under subparagraph (C), make limited
exceptions to service area requirements otherwise
applicable under this part for MA local plans that have
in effect (as of the date of enactment of the Patient
Protection and Affordable Care Act)--
``(i) agreements with another MA
organization or MA plan that preclude the
offering of benefits throughout an entire
service area; or
``(ii) limitations in their structural
capacity to support adequate networks
throughout an entire service area as a result
of the delivery system model of the MA local
plan.''.
(2) Conforming amendments.--
(A) In general.--
(i) Section 1851(b)(1) of the Social
Security Act (42 U.S.C. 1395w-21(b)(1)) is
amended by striking subparagraph (C).
(ii) Section 1853(b)(1)(B)(i) of such Act
(42 U.S.C. 1395w-23(b)(1)(B)(i))--
(I) in the matter preceding
subclause (I), by striking ``MA payment
area'' and inserting ``MA local area
(as defined in subsection (d)(2))'';
and
(II) in subclause (I), by striking
``MA payment area'' and inserting ``MA
local area (as so defined)''.
(iii) Section 1853(b)(4) of such Act (42
U.S.C. 1395w-23(b)(4)) is amended by striking
``Medicare Advantage payment area'' and
inserting ``MA local area (as so defined)''.
(iv) Section 1853(c)(1) of such Act (42
U.S.C. 1395w-23(c)(1)) is amended--
(I) in the matter preceding
subparagraph (A), by striking ``a
Medicare Advantage payment area that
is''; and
(II) in subparagraph (D)(i), by
striking ``MA payment area'' and
inserting ``MA local area (as defined
in subsection (d)(2))''.
(v) Section 1854 of such Act (42 U.S.C.
1395w-24) is amended by striking subsection
(h).
(B) Effective date.--The amendments made by this
paragraph shall take effect on January 1, 2012.
(f) Performance Bonuses.--
(1) MA plans.--
(A) In general.--Section 1853 of the Social
Security Act (42 U.S.C. 1395w-23) is amended by adding
at the end the following new subsection:
``(n) Performance Bonuses.--
``(1) Care coordination and management performance bonus.--
``(A) In general.--For years beginning with 2014,
subject to subparagraph (B), in the case of an MA plan
that conducts 1 or more programs described in
subparagraph (C) with respect to the year, the
Secretary shall, in addition to any other payment
provided under this part, make monthly payments, with
respect to coverage of an individual under this part,
to the MA plan in an amount equal to the product of--
``(i) 0.5 percent of the national monthly
per capita cost for expenditures for
individuals enrolled under the original
medicare fee-for-service program for the year;
and
``(ii) the total number of programs
described in clauses (i) through (ix) of
subparagraph (C) that the Secretary determines
the plan is conducting for the year under such
subparagraph.
``(B) Limitation.--In no case may the total amount
of payment with respect to a year under subparagraph
(A) be greater than 2 percent of the national monthly
per capita cost for expenditures for individuals
enrolled under the original medicare fee-for-service
program for the year, as determined prior to the
application of risk adjustment under paragraph (4).
``(C) Programs described.--The following programs
are described in this paragraph:
``(i) Care management programs that--
``(I) target individuals with 1 or
more chronic conditions;
``(II) identify gaps in care; and
``(III) facilitate improved care by
using additional resources like nurses,
nurse practitioners, and physician
assistants.
``(ii) Programs that focus on patient
education and self-management of health
conditions, including interventions that--
``(I) help manage chronic
conditions;
``(II) reduce declines in health
status; and
``(III) foster patient and provider
collaboration.
``(iii) Transitional care interventions
that focus on care provided around a hospital
inpatient episode, including programs that
target post-discharge patient care in order to
reduce unnecessary health complications and
readmissions.
``(iv) Patient safety programs, including
provisions for hospital-based patient safety
programs in contracts that the Medicare
Advantage organization offering the MA plan has
with hospitals.
``(v) Financial policies that promote
systematic coordination of care by primary care
physicians across the full spectrum of
specialties and sites of care, such as medical
homes, capitation arrangements, or pay-for-
performance programs.
``(vi) Programs that address, identify, and
ameliorate health care disparities among
principal at-risk subpopulations.
``(vii) Medication therapy management
programs that are more extensive than is
required under section 1860D-4(c) (as
determined by the Secretary).
``(viii) Health information technology
programs, including clinical decision support
and other tools to facilitate data collection
and ensure patient-centered, appropriate care.
``(ix) Such other care management and
coordination programs as the Secretary
determines appropriate.
``(D) Conduct of program in urban and rural
areas.--An MA plan may conduct a program described in
subparagraph (C) in a manner appropriate for an urban
or rural area, as applicable.
``(E) Reporting of data.--Each Medicare Advantage
organization shall provide to the Secretary the
information needed to determine whether they are
eligible for a care coordination and management
performance bonus at a time and in a manner specified
by the Secretary.
``(F) Periodic auditing.--The Secretary shall
provide for the annual auditing of programs described
in subparagraph (C) for which an MA plan receives a
care coordination and management performance bonus
under this paragraph. The Comptroller General shall
monitor auditing activities conducted under this
subparagraph.
``(2) Quality performance bonuses.--
``(A) Quality bonus.--For years beginning with
2014, the Secretary shall, in addition to any other
payment provided under this part, make monthly
payments, with respect to coverage of an individual
under this part, to an MA plan that achieves at least a
3 star rating (or comparable rating) on a rating system
described in subparagraph (C) in an amount equal to--
``(i) in the case of a plan that achieves a
3 star rating (or comparable rating) on such
system 2 percent of the national monthly per
capita cost for expenditures for individuals
enrolled under the original medicare fee-for-
service program for the year; and
``(ii) in the case of a plan that achieves
a 4 or 5 star rating (or comparable rating on
such system, 4 percent of such national monthly
per capita cost for the year.
``(B) Improved quality bonus.--For years beginning
with 2014, in the case of an MA plan that does not
receive a quality bonus under subparagraph (A) and is
an improved quality MA plan with respect to the year
(as identified by the Secretary), the Secretary shall,
in addition to any other payment provided under this
part, make monthly payments, with respect to coverage
of an individual under this part, to the MA plan in an
amount equal to 1 percent of such national monthly per
capita cost for the year.
``(C) Use of rating system.--For purposes of
subparagraph (A), a rating system described in this
paragraph is--
``(i) a rating system that uses up to 5
stars to rate clinical quality and enrollee
satisfaction and performance at the Medicare
Advantage contract or MA plan level; or
``(ii) such other system established by the
Secretary that provides for the determination
of a comparable quality performance rating to
the rating system described in clause (i).
``(D) Data used in determining score.--
``(i) In general.--The rating of an MA plan
under the rating system described in
subparagraph (C) with respect to a year shall
be based on based on the most recent data
available.
``(ii) Plans that fail to report data.--An
MA plan which does not report data that enables
the Secretary to rate the plan for purposes of
subparagraph (A) or identify the plan for
purposes of subparagraph (B) shall be counted,
for purposes of such rating or identification,
as having the lowest plan performance rating
and the lowest percentage improvement,
respectively.
``(3) Quality bonus for new and low enrollment ma plans.--
``(A) New ma plans.--For years beginning with 2014,
in the case of an MA plan that first submits a bid
under section 1854(a)(1)(A) for 2012 or a subsequent
year, only receives enrollments made during the
coverage election periods described in section 1851(e),
and is not able to receive a bonus under subparagraph
(A) or (B) of paragraph (2) for the year, the Secretary
shall, in addition to any other payment provided under
this part, make monthly payments, with respect to
coverage of an individual under this part, to the MA
plan in an amount equal to 2 percent of national
monthly per capita cost for expenditures for
individuals enrolled under the original medicare fee-
for-service program for the year. In its fourth year of
operation, the MA plan shall be paid in the same manner
as other MA plans with comparable enrollment.
``(B) Low enrollment plans.--For years beginning
with 2014, in the case of an MA plan that has low
enrollment (as defined by the Secretary) and would not
otherwise be able to receive a bonus under subparagraph
(A) or (B) of paragraph (2) or subparagraph (A) of this
paragraph for the year (referred to in this
subparagraph as a `low enrollment plan'), the Secretary
shall use a regional or local mean of the rating of all
MA plans in the region or local area, as determined
appropriate by the Secretary, on measures used to
determine whether MA plans are eligible for a quality
or an improved quality bonus, as applicable, to
determine whether the low enrollment plan is eligible
for a bonus under such a subparagraph.
``(4) Risk adjustment.--The Secretary shall risk adjust a
performance bonus under this subsection in the same manner as
the Secretary risk adjusts beneficiary rebates described in
section 1854(b)(1)(C).
``(5) Notification.--The Secretary, in the annual
announcement required under subsection (b)(1)(B) for 2014 and
each succeeding year, shall notify the Medicare Advantage
organization of any performance bonus (including a care
coordination and management performance bonus under paragraph
(1), a quality performance bonus under paragraph (2), and a
quality bonus for new and low enrollment plans under paragraph
(3)) that the organization will receive under this subsection
with respect to the year. The Secretary shall provide for the
publication of the information described in the previous
sentence on the Internet website of the Centers for Medicare &
Medicaid Services.''
(B) Conforming amendment.--Section 1853(a)(1)(B) of
the Social Security Act (42 U.S.C. 1395w-23(a)(1)(B))
is amended--
(i) in clause (i), by inserting ``and any
performance bonus under subsection (n)'' before
the period at the end; and
(ii) in clause (ii), by striking ``(G)''
and inserting ``(G), plus the amount (if any)
of any performance bonus under subsection
(n)''.
(2) Application of performance bonuses to ma regional
plans.--Section 1858 of the Social Security Act (42 U.S.C.
1395w-27a) is amended--
(A) in subsection (f)(1), by striking ``subsection
(e)'' and inserting ``subsections (e) and (i)''; and
(B) by adding at the end the following new
subsection:
``(i) Application of Performance Bonuses to MA Regional Plans.--For
years beginning with 2014, the Secretary shall apply the performance
bonuses under section 1853(n) (relating to bonuses for care
coordination and management, quality performance, and new and low
enrollment MA plans) to MA regional plans in a similar manner as such
performance bonuses apply to MA plans under such subsection.''.
(g) Grandfathering Supplemental Benefits for Current Enrollees
After Implementation of Competitive Bidding.--Section 1853 of the
Social Security Act (42 U.S.C. 1395w-23), as amended by subsection (f),
is amended by adding at the end the following new subsection:
``(o) Grandfathering Supplemental Benefits for Current Enrolles
After Implementation of Competitive Bidding.--
``(1) Identification of areas.--The Secretary shall
identify MA local areas in which, with respect to 2009, average
bids submitted by an MA organization under section 1854(a) for
MA local plans in the area are not greater than 75 percent of
the adjusted average per capita cost for the year involved,
determined under section 1876(a)(4), for the area for
individuals who are not enrolled in an MA plan under this part
for the year, but adjusted to exclude costs attributable to
payments under section 1848(o), 1886(n), and 1886(h).
``(2) Election to provide rebates to grandfathered
enrollees.--
``(A) In general.--For years beginning with 2012,
each Medicare Advantage organization offering an MA
local plan in an area identified by the Secretary under
paragraph (1) may elect to provide rebates to
grandfathered enrollees under section 1854(b)(1)(C). In
the case where an MA organization makes such an
election, the monthly per capita dollar amount of such
rebates shall not exceed the applicable amount for the
year (as defined in subparagraph (B)).
``(B) Applicable amount.--For purposes of this
subsection, the term `applicable amount' means--
``(i) for 2012, the monthly per capita
dollar amount of such rebates provided to
enrollees under the MA local plan with respect
to 2011; and
``(ii) for a subsequent year, 95 percent of
the amount determined under this subparagraph
for the preceding year.
``(3) Special rules for plans in identified areas.--
Notwithstanding any other provision of this part, the following
shall apply with respect to each Medicare Advantage
organization offering an MA local plan in an area identified by
the Secretary under paragraph (1) that makes an election
described in paragraph (2):
``(A) Payments.--The amount of the monthly payment
under this section to the Medicare Advantage
organization, with respect to coverage of a
grandfathered enrollee under this part in the area for
a month, shall be equal to--
``(i) for 2012 and 2013, the sum of--
``(I) the bid amount under section
1854(a) for the MA local plan; and
``(II) the applicable amount (as
defined in paragraph (2)(B)) for the MA
local plan for the year.
``(ii) for 2014 and subsequent years, the
sum of--
``(I) the MA competitive benchmark
amount under subsection (j)(1)(A)(i)
for the area for the month, adjusted,
only to the extent the Secretary
determines necessary, to account for
induced utilization as a result of
rebates provided to grandfathered
enrollees (except that such adjustment
shall not exceed 0.5 percent of such MA
competitive benchmark amount); and
``(II) the applicable amount (as so
defined) for the MA local plan for the
year.
``(B) Requirement to submit bids under competitive
bidding.--The Medicare Advantage organization shall
submit a single bid amount under section 1854(a) for
the MA local plan. The Medicare Advantage organization
shall remove from such bid amount any effects of
induced demand for care that may result from the higher
rebates available to grandfathered enrollees under this
subsection.
``(C) Nonapplication of bonus payments and any
other rebates.--The Medicare Advantage organization
offering the MA local plan shall not be eligible for
any bonus payment under subsection (n) or any rebate
under this part (other than as provided under this
subsection) with respect to grandfathered enrollees.
``(D) Nonapplication of uniform bid and premium
amounts to grandfathered enrollees.--Section 1854(c)
shall not apply with respect to the MA local plan.
``(E) Nonapplication of limitation on application
of plan rebates toward payment of part b premium.--
Notwithstanding clause (iii) of section 1854(b)(1)(C),
in the case of a grandfathered enrollee, a rebate under
such section may be used for the purpose described in
clause (ii)(III) of such section.
``(F) Risk adjustment.--The Secretary shall risk
adjust rebates to grandfathered enrollees under this
subsection in the same manner as the Secretary risk
adjusts beneficiary rebates described in section
1854(b)(1)(C).
``(4) Definition of grandfathered enrollee.--In this
subsection, the term `grandfathered enrollee' means an
individual who is enrolled (effective as of the date of
enactment of this subsection) in an MA local plan in an area
that is identified by the Secretary under paragraph (1).''.
(h) Transitional Extra Benefits.--Section 1853 of the Social
Security Act (42 U.S.C. 1395w-23), as amended by subsections (f) and
(g), is amended by adding at the end the following new subsection:
``(p) Transitional Extra Benefits.--
``(1) In general.--For years beginning with 2012, the
Secretary shall provide transitional rebates under section
1854(b)(1)(C) for the provision of extra benefits (as specified
by the Secretary) to enrollees described in paragraph (2).
``(2) Enrollees described.--An enrollee described in this
paragraph is an individual who--
``(A) enrolls in an MA local plan in an applicable
area; and
``(B) experiences a significant reduction in extra
benefits described in clause (ii) of section
1854(b)(1)(C) as a result of competitive bidding under
this part (as determined by the Secretary).
``(3) Applicable areas.--In this subsection, the term
`applicable area' means the following:
``(A) The 2 largest metropolitan statistical areas,
if the Secretary determines that the total amount of
such extra benefits for each enrollee for the month in
those areas is greater than $100.
``(B) A county where--
``(i) the MA area-specific non-drug monthly
benchmark amount for a month in 2011 is equal
to the legacy urban floor amount (as described
in subsection (c)(1)(B)(iii)), as determined by
the Secretary for the area for 2011;
``(ii) the percentage of Medicare Advantage
eligible beneficiaries in the county who are
enrolled in an MA plan for 2009 is greater than
30 percent (as determined by the Secretary);
and
``(iii) average bids submitted by an MA
organization under section 1854(a) for MA local
plans in the county for 2011 are not greater
than the adjusted average per capita cost for
the year involved, determined under section
1876(a)(4), for the county for individuals who
are not enrolled in an MA plan under this part
for the year, but adjusted to exclude costs
attributable to payments under section 1848(o),
1886(n), and 1886(h).
``(C) If the Secretary determines appropriate, a
county contiguous to an area or county described in
subparagraph (A) or (B), respectively.
``(4) Review of plan bids.--In the case of a bid submitted
by an MA organization under section 1854(a) for an MA local
plan in an applicable area, the Secretary shall review such bid
in order to ensure that extra benefits (as specified by the
Secretary) are provided to enrollees described in paragraph
(2).
``(5) Funding.--The Secretary shall provide for the
transfer from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance
Trust Fund established under section 1841, in such proportion
as the Secretary determines appropriate, of an amount not to
exceed $5,000,000,000 for the period of fiscal years 2012
through 2019 for the purpose of providing transitional rebates
under section 1854(b)(1)(C) for the provision of extra benefits
under this subsection.''.
(i) Nonapplication of Competitive Bidding and Related Provisions
and Clarification of MA Payment Area for PACE Programs.--
(1) Nonapplication of competitive bidding and related
provisions for pace programs.--Section 1894 of the Social
Security Act (42 U.S.C. 1395eee) is amended--
(A) by redesignating subsections (h) and (i) as
subsections (i) and (j), respectively;
(B) by inserting after subsection (g) the following
new subsection:
``(h) Nonapplication of Competitive Bidding and Related Provisions
Under Part C.--With respect to a PACE program under this section, the
following provisions (and regulations relating to such provisions)
shall not apply:
``(1) Section 1853(j)(1)(A)(i), relating to MA area-
specific non-drug monthly benchmark amount being based on
competitive bids.
``(2) Section 1853(d)(5), relating to the establishment of
MA local plan service areas.
``(3) Section 1853(n), relating to the payment of
performance bonuses.
``(4) Section 1853(o), relating to grandfathering
supplemental benefits for current enrollees after
implementation of competitive bidding.
``(5) Section 1853(p), relating to transitional extra
benefits.''.
(2) Special rule for ma payment area for pace programs.--
Section 1853(d) of the Social Security Act (42 U.S.C. 1395w-
23(d)), as amended by subsection (e), is amended by adding at
the end the following new paragraph:
``(6) Special rule for ma payment area for pace programs.--
For years beginning with 2012, in the case of a PACE program
under section 1894, the MA payment area shall be the MA local
area (as defined in paragraph (2)).''.
SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION.
(a) Limitation on Variation of Cost Sharing for Certain Benefits.--
(1) In general.--Section 1852(a)(1)(B) of the Social
Security Act (42 U.S.C. 1395w-22(a)(1)(B)) is amended--
(A) in clause (i), by inserting ``, subject to
clause (iii),'' after ``and B or''; and
(B) by adding at the end the following new clauses:
``(iii) Limitation on variation of cost
sharing for certain benefits.--Subject to
clause (v), cost-sharing for services described
in clause (iv) shall not exceed the cost-
sharing required for those services under parts
A and B.
``(iv) Services described.--The following
services are described in this clause:
``(I) Chemotherapy administration
services.
``(II) Renal dialysis services (as
defined in section 1881(b)(14)(B)).
``(III) Skilled nursing care.
``(IV) Such other services that the
Secretary determines appropriate
(including services that the Secretary
determines require a high level of
predictability and transparency for
beneficiaries).
``(v) Exception.--In the case of services
described in clause (iv) for which there is no
cost-sharing required under parts A and B,
cost-sharing may be required for those services
in accordance with clause (i).''.
(2) Effective date.--The amendments made by this subsection
shall apply to plan years beginning on or after January 1,
2011.
(b) Application of Rebates, Performance Bonuses, and Premiums.--
(1) Application of rebates.--Section 1854(b)(1)(C) of the
Social Security Act (42 U.S.C. 1395w-24(b)(1)(C)) is amended--
(A) in clause (ii), by striking ``rebate.--A
rebate'' and inserting ``rebate for plan years before
2012.--For plan years before 2012, a rebate'';
(B) by redesignating clauses (iii) and (iv) as
clauses (iv) and (v); and
(C) by inserting after clause (ii) the following
new clause:
``(iii) Form of rebate for plan year 2012
and subsequent plan years.--For plan years
beginning on or after January 1, 2012, a rebate
required under this subparagraph may not be
used for the purpose described in clause
(ii)(III) and shall be provided through the
application of the amount of the rebate in the
following priority order:
``(I) First, to use the most
significant share to meaningfully
reduce cost-sharing otherwise
applicable for benefits under the
original medicare fee-for-service
program under parts A and B and for
qualified prescription drug coverage
under part D, including the reduction
of any deductibles, copayments, and
maximum limitations on out-of-pocket
expenses otherwise applicable. Any
reduction of maximum limitations on
out-of-pocket expenses under the
preceding sentence shall apply to all
benefits under the original medicare
fee-for-service program option. The
Secretary may provide guidance on
meaningfully reducing cost-sharing
under this subclause, except that such
guidance may not require a particular
amount of cost-sharing or reduction in
cost-sharing.
``(II) Second, to use the next most
significant share to meaningfully
provide coverage of preventive and
wellness health care benefits (as
defined by the Secretary) which are not
benefits under the original medicare
fee-for-service program, such as
smoking cessation, a free flu shot, and
an annual physical examination.
``(III) Third, to use the remaining
share to meaningfully provide coverage
of other health care benefits which are
not benefits under the original
medicare fee-for-service program, such
as eye examinations and dental
coverage, and are not benefits
described in subclause (II).''.
(2) Application of performance bonuses.--Section 1853(n) of
the Social Security Act, as added by section 3201(f), is
amended by adding at the end the following new paragraph:
``(6) Application of performance bonuses.--For plan years
beginning on or after January 1, 2014, any performance bonus
paid to an MA plan under this subsection shall be used for the
purposes, and in the priority order, described in subclauses
(I) through (III) of section 1854(b)(1)(C)(iii).''.
(3) Application of ma monthly supplementary beneficiary
premium.--Section 1854(b)(2)(C) of the Social Security Act (42
U.S.C. 1395w-24(b)(2)(C)) is amended--
(A) by striking ``Premium.--The term'' and
inserting ``premium.--
``(i) In general.--The term''; and
(B) by adding at the end the following new clause:
``(ii) Application of ma monthly
supplementary beneficiary premium.--For plan
years beginning on or after January 1, 2012,
any MA monthly supplementary beneficiary
premium charged to an individual enrolled in an
MA plan shall be used for the purposes, and in
the priority order, described in subclauses (I)
through (III) of paragraph (1)(C)(iii).''.
SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING MA PAYMENT
TRANSITION.
Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w-
23(a)(1)(C)) is amended by adding at the end the following new clause:
``(iii) Application of coding intensity
adjustment for 2011 and subsequent years.--
``(I) Requirement to apply in 2011
through 2013.--In order to ensure
payment accuracy, the Secretary shall
conduct an analysis of the differences
described in clause (ii)(I). The
Secretary shall ensure that the results
of such analysis are incorporated into
the risk scores for 2011, 2012, and
2013.
``(II) Authority to apply in 2014
and subsequent years.--The Secretary
may, as appropriate, incorporate the
results of such analysis into the risk
scores for 2014 and subsequent
years.''.
SEC. 3204. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS.
(a) Annual 45-day Period for Disenrollment From MA Plans To Elect
To Receive Benefits Under the Original Medicare Fee-for-service
Program.--
(1) In general.--Section 1851(e)(2)(C) of the Social
Security Act (42 U.S.C. 1395w-1(e)(2)(C)) is amended to read as
follows:
``(C) Annual 45-day period for disenrollment from
ma plans to elect to receive benefits under the
original medicare fee-for-service program.--Subject to
subparagraph (D), at any time during the first 45 days
of a year (beginning with 2011), an individual who is
enrolled in a Medicare Advantage plan may change the
election under subsection (a)(1), but only with respect
to coverage under the original medicare fee-for-service
program under parts A and B, and may elect qualified
prescription drug coverage in accordance with section
1860D-1.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to 2011 and succeeding years.
(b) Timing of the Annual, Coordinated Election Period Under Parts C
and D.--Section 1851(e)(3)(B) of the Social Security Act (42 U.S.C.
1395w-1(e)(3)(B)) is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) in clause (iv)--
(A) by striking ``and succeeding years'' and
inserting ``, 2008, 2009, and 2010''; and
(B) by striking the period at the end and inserting
``; and''; and
(3) by adding at the end the following new clause:
``(v) with respect to 2012 and succeeding
years, the period beginning on October 15 and
ending on December 7 of the year before such
year.''.
SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS
INDIVIDUALS.
(a) Extension of SNP Authority.--Section 1859(f)(1) of the Social
Security Act (42 U.S.C. 1395w-28(f)(1)), as amended by section 164(a)
of the Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275), is amended by striking ``2011'' and inserting
``2014''.
(b) Authority To Apply Frailty Adjustment Under PACE Payment
Rules.--Section 1853(a)(1)(B) of the Social Security Act (42 U.S.C.
1395w-23(a)(1)(B)) is amended by adding at the end the following new
clause:
``(iv) Authority to apply frailty
adjustment under pace payment rules for certain
specialized ma plans for special needs
individuals.--
``(I) In general.--Notwithstanding
the preceding provisions of this
paragraph, for plan year 2011 and
subsequent plan years, in the case of a
plan described in subclause (II), the
Secretary may apply the payment rules
under section 1894(d) (other than
paragraph (3) of such section) rather
than the payment rules that would
otherwise apply under this part, but
only to the extent necessary to reflect
the costs of treating high
concentrations of frail individuals.
``(II) Plan described.--A plan
described in this subclause is a
specialized MA plan for special needs
individuals described in section
1859(b)(6)(B)(ii) that is fully
integrated with capitated contracts
with States for Medicaid benefits,
including long-term care, and that have
similar average levels of frailty (as
determined by the Secretary) as the
PACE program.''.
(c) Transition and Exception Regarding Restriction on Enrollment.--
Section 1859(f) of the Social Security Act (42 U.S.C. 1395w-28(f)) is
amended by adding at the end the following new paragraph:
``(6) Transition and exception regarding restriction on
enrollment.--
``(A) In general.--Subject to subparagraph (C), the
Secretary shall establish procedures for the transition
of applicable individuals to--
``(i) a Medicare Advantage plan that is not
a specialized MA plan for special needs
individuals (as defined in subsection (b)(6));
or
``(ii) the original medicare fee-for-
service program under parts A and B.
``(B) Applicable individuals.--For purposes of
clause (i), the term `applicable individual' means an
individual who--
``(i) is enrolled under a specialized MA
plan for special needs individuals (as defined
in subsection (b)(6)); and
``(ii) is not within the 1 or more of the
classes of special needs individuals to which
enrollment under the plan is restricted to.
``(C) Exception.--The Secretary shall provide for
an exception to the transition described in
subparagraph (A) for a limited period of time for
individuals enrolled under a specialized MA plan for
special needs individuals described in subsection
(b)(6)(B)(ii) who are no longer eligible for medical
assistance under title XIX.
``(D) Timeline for initial transition.--The
Secretary shall ensure that applicable individuals
enrolled in a specialized MA plan for special needs
individuals (as defined in subsection (b)(6)) prior to
January 1, 2010, are transitioned to a plan or the
program described in subparagraph (A) by not later than
January 1, 2013.''.
(d) Temporary Extension of Authority To Operate but No Service Area
Expansion for Dual Special Needs Plans That Do Not Meet Certain
Requirements.--Section 164(c)(2) of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275) is amended by
striking ``December 31, 2010'' and inserting ``December 31, 2012''.
(e) Authority To Require Special Needs Plans Be NCQA Approved.--
Section 1859(f) of the Social Security Act (42 U.S.C. 1395w-28(f)), as
amended by subsections (a) and (c), is amended--
(1) in paragraph (2), by adding at the end the following
new subparagraph:
``(C) If applicable, the plan meets the requirement
described in paragraph (7).'';
(2) in paragraph (3), by adding at the end the following
new subparagraph:
``(E) If applicable, the plan meets the requirement
described in paragraph (7).'';
(3) in paragraph (4), by adding at the end the following
new subparagraph:
``(C) If applicable, the plan meets the requirement
described in paragraph (7).''; and
(4) by adding at the end the following new paragraph:
``(7) Authority to require special needs plans be ncqa
approved.--For 2012 and subsequent years, the Secretary shall
require that a Medicare Advantage organization offering a
specialized MA plan for special needs individuals be approved
by the National Committee for Quality Assurance (based on
standards established by the Secretary).''.
(f) Risk Adjustment.--Section 1853(a)(1)(C) of the Social Security
Act (42 U.S.C. 1395i-23(a)(1)(C)) is amended by adding at the end the
following new clause:
``(iii) Improvements to risk adjustment for
special needs individuals with chronic health
conditions.--
``(I) In general.--For 2011 and
subsequent years, for purposes of the
adjustment under clause (i) with
respect to individuals described in
subclause (II), the Secretary shall use
a risk score that reflects the known
underlying risk profile and chronic
health status of similar individuals.
Such risk score shall be used instead
of the default risk score for new
enrollees in Medicare Advantage plans
that are not specialized MA plans for
special needs individuals (as defined
in section 1859(b)(6)).
``(II) Individuals described.--An
individual described in this subclause
is a special needs individual described
in subsection (b)(6)(B)(iii) who
enrolls in a specialized MA plan for
special needs individuals on or after
January 1, 2011.
``(III) Evaluation.--For 2011 and
periodically thereafter, the Secretary
shall evaluate and revise the risk
adjustment system under this
subparagraph in order to, as accurately
as possible, account for higher medical
and care coordination costs associated
with frailty, individuals with
multiple, comorbid chronic conditions,
and individuals with a diagnosis of
mental illness, and also to account for
costs that may be associated with
higher concentrations of beneficiaries
with those conditions.
``(IV) Publication of evaluation
and revisions.--The Secretary shall
publish, as part of an announcement
under subsection (b), a description of
any evaluation conducted under
subclause (III) during the preceding
year and any revisions made under such
subclause as a result of such
evaluation.''.
(g) Technical Correction.--Section 1859(f)(5) of the Social
Security Act (42 U.S.C. 1395w-28(f)(5)) is amended, in the matter
preceding subparagraph (A), by striking ``described in subsection
(b)(6)(B)(i)''.
SEC. 3206. EXTENSION OF REASONABLE COST CONTRACTS.
Section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)(ii)) is amended, in the matter preceding subclause (I),
by striking ``January 1, 2010'' and inserting ``January 1, 2013''.
SEC. 3207. TECHNICAL CORRECTION TO MA PRIVATE FEE-FOR-SERVICE PLANS.
For plan year 2011 and subsequent plan years, to the extent that
the Secretary of Health and Human Services is applying the 2008 service
area extension waiver policy (as modified in the April 11, 2008,
Centers for Medicare & Medicaid Services' memorandum with the subject
``2009 Employer Group Waiver-Modification of the 2008 Service Area
Extension Waiver Granted to Certain MA Local Coordinated Care Plans'')
to Medicare Advantage coordinated care plans, the Secretary shall
extend the application of such waiver policy to employers who contract
directly with the Secretary as a Medicare Advantage private fee-for-
service plan under section 1857(i)(2) of the Social Security Act (42
U.S.C. 1395w-27(i)(2)) and that had enrollment as of October 1, 2009.
SEC. 3208. MAKING SENIOR HOUSING FACILITY DEMONSTRATION PERMANENT.
(a) In General.--Section 1859 of the Social Security Act (42 U.S.C.
1395w-28) is amended by adding at the end the following new subsection:
``(g) Special Rules for Senior Housing Facility Plans.--
``(1) In general.--In the case of a Medicare Advantage
senior housing facility plan described in paragraph (2),
notwithstanding any other provision of this part to the
contrary and in accordance with regulations of the Secretary,
the service area of such plan may be limited to a senior
housing facility in a geographic area.
``(2) Medicare advantage senior housing facility plan
described.--For purposes of this subsection, a Medicare
Advantage senior housing facility plan is a Medicare Advantage
plan that--
``(A) restricts enrollment of individuals under
this part to individuals who reside in a continuing
care retirement community (as defined in section
1852(l)(4)(B));
``(B) provides primary care services onsite and has
a ratio of accessible physicians to beneficiaries that
the Secretary determines is adequate;
``(C) provides transportation services for
beneficiaries to specialty providers outside of the
facility; and
``(D) has participated (as of December 31, 2009) in
a demonstration project established by the Secretary
under which such a plan was offered for not less than 1
year.''.
(b) Effective Date.--The amendment made by this section shall take
effect on January 1, 2010, and shall apply to plan years beginning on
or after such date.
SEC. 3209. AUTHORITY TO DENY PLAN BIDS.
(a) In General.--Section 1854(a)(5) of the Social Security Act (42
U.S.C. 1395w-24(a)(5)) is amended by adding at the end the following
new subparagraph:
``(C) Rejection of bids.--
``(i) In general.--Nothing in this section
shall be construed as requiring the Secretary
to accept any or every bid submitted by an MA
organization under this subsection.
``(ii) Authority to deny bids that propose
significant increases in cost sharing or
decreases in benefits.--The Secretary may deny
a bid submitted by an MA organization for an MA
plan if it proposes significant increases in
cost sharing or decreases in benefits offered
under the plan.''.
(b) Application Under Part D.--Section 1860D-11(d) of such Act (42
U.S.C. 1395w-111(d)) is amended by adding at the end the following new
paragraph:
``(3) Rejection of bids.--Paragraph (5)(C) of section
1854(a) shall apply with respect to bids submitted by a PDP
sponsor under subsection (b) in the same manner as such
paragraph applies to bids submitted by an MA organization under
such section 1854(a).''.
(c) Effective Date.--The amendments made by this section shall
apply to bids submitted for contract years beginning on or after
January 1, 2011.
SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP PLANS.
(a) In General.--Section 1882 of the Social Security Act (42 U.S.C.
1395ss) is amended by adding at the end the following new subsection:
``(y) Development of New Standards for Certain Medicare
Supplemental Policies.--
``(1) In general.--The Secretary shall request the National
Association of Insurance Commissioners to review and revise the
standards for benefit packages described in paragraph (2) under
subsection (p)(1), to otherwise update standards to include
requirements for nominal cost sharing to encourage the use of
appropriate physicians' services under part B. Such revisions
shall be based on evidence published in peer-reviewed journals
or current examples used by integrated delivery systems and
made consistent with the rules applicable under subsection
(p)(1)(E) with the reference to the `1991 NAIC Model
Regulation' deemed a reference to the NAIC Model Regulation as
published in the Federal Register on December 4, 1998, and as
subsequently updated by the National Association of Insurance
Commissioners to reflect previous changes in law and the
reference to `date of enactment of this subsection' deemed a
reference to the date of enactment of the Patient Protection
and Affordable Care Act. To the extent practicable, such
revision shall provide for the implementation of revised
standards for benefit packages as of January 1, 2015.
``(2) Benefit packages described.--The benefit packages
described in this paragraph are benefit packages classified as
`C' and `F'.''.
(b) Conforming Amendment.--Section 1882(o)(1) of the Social
Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking ``, and
(w)'' and inserting ``(w), and (y)''.
Subtitle D--Medicare Part D Improvements for Prescription Drug Plans
and MA-PD Plans
SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM.
(a) Condition for Coverage of Drugs Under Part D.--Part D of Title
XVIII of the Social Security Act (42 U.S.C. 1395w-101 et seq.), is
amended by adding at the end the following new section:
``condition for coverage of drugs under this part
``Sec. 1860D-43. (a) In General.--In order for coverage to be
available under this part for covered part D drugs (as defined in
section 1860D-2(e)) of a manufacturer, the manufacturer must--
``(1) participate in the Medicare coverage gap discount
program under section 1860D-14A;
``(2) have entered into and have in effect an agreement
described in subsection (b) of such section with the Secretary;
and
``(3) have entered into and have in effect, under terms and
conditions specified by the Secretary, a contract with a third
party that the Secretary has entered into a contract with under
subsection (d)(3) of such section.
``(b) Effective Date.--Subsection (a) shall apply to covered part D
drugs dispensed under this part on or after July 1, 2010.
``(c) Authorizing Coverage for Drugs Not Covered Under
Agreements.--Subsection (a) shall not apply to the dispensing of a
covered part D drug if--
``(1) the Secretary has made a determination that the
availability of the drug is essential to the health of
beneficiaries under this part; or
``(2) the Secretary determines that in the period beginning
on July 1, 2010, and ending on December 31, 2010, there were
extenuating circumstances.
``(d) Definition of Manufacturer.--In this section, the term
`manufacturer' has the meaning given such term in section 1860D-
14A(g)(5).''.
(b) Medicare Coverage Gap Discount Program.--Part D of title XVIII
of the Social Security Act (42 U.S.C. 1395w-101) is amended by
inserting after section 1860D-14 the following new section:
``medicare coverage gap discount program
``Sec. 1860D-14A. (a) Establishment.--The Secretary shall
establish a Medicare coverage gap discount program (in this section
referred to as the `program') by not later than July 1, 2010. Under the
program, the Secretary shall enter into agreements described in
subsection (b) with manufacturers and provide for the performance of
the duties described in subsection (c)(1). The Secretary shall
establish a model agreement for use under the program by not later than
April 1, 2010, in consultation with manufacturers, and allow for
comment on such model agreement.
``(b) Terms of Agreement.--
``(1) In general.--
``(A) Agreement.--An agreement under this section
shall require the manufacturer to provide applicable
beneficiaries access to discounted prices for
applicable drugs of the manufacturer.
``(B) Provision of discounted prices at the point-
of-sale.--Except as provided in subsection
(c)(1)(A)(iii), such discounted prices shall be
provided to the applicable beneficiary at the pharmacy
or by the mail order service at the point-of-sale of an
applicable drug.
``(C) Timing of agreement.--
``(i) Special rule for 2010 and 2011.--In
order for an agreement with a manufacturer to
be in effect under this section with respect to
the period beginning on July 1, 2010, and
ending on December 31, 2011, the manufacturer
shall enter into such agreement not later than
May 1, 2010.
``(ii) 2012 and subsequent years.--In order
for an agreement with a manufacturer to be in
effect under this section with respect to plan
year 2012 or a subsequent plan year, the
manufacturer shall enter into such agreement
(or such agreement shall be renewed under
paragraph (4)(A)) not later than January 30 of
the preceding year.
``(2) Provision of appropriate data.--Each manufacturer
with an agreement in effect under this section shall collect
and have available appropriate data, as determined by the
Secretary, to ensure that it can demonstrate to the Secretary
compliance with the requirements under the program.
``(3) Compliance with requirements for administration of
program.--Each manufacturer with an agreement in effect under
this section shall comply with requirements imposed by the
Secretary or a third party with a contract under subsection
(d)(3), as applicable, for purposes of administering the
program, including any determination under clause (i) of
subsection (c)(1)(A) or procedures established under such
subsection (c)(1)(A).
``(4) Length of agreement.--
``(A) In general.--An agreement under this section
shall be effective for an initial period of not less
than 18 months and shall be automatically renewed for a
period of not less than 1 year unless terminated under
subparagraph (B).
``(B) Termination.--
``(i) By the secretary.--The Secretary may
provide for termination of an agreement under
this section for a knowing and willful
violation of the requirements of the agreement
or other good cause shown. Such termination
shall not be effective earlier than 30 days
after the date of notice to the manufacturer of
such termination. The Secretary shall provide,
upon request, a manufacturer with a hearing
concerning such a termination, and such hearing
shall take place prior to the effective date of
the termination with sufficient time for such
effective date to be repealed if the Secretary
determines appropriate.
``(ii) By a manufacturer.--A manufacturer
may terminate an agreement under this section
for any reason. Any such termination shall be
effective, with respect to a plan year--
``(I) if the termination occurs
before January 30 of a plan year, as of
the day after the end of the plan year;
and
``(II) if the termination occurs on
or after January 30 of a plan year, as
of the day after the end of the
succeeding plan year.
``(iii) Effectiveness of termination.--Any
termination under this subparagraph shall not
affect discounts for applicable drugs of the
manufacturer that are due under the agreement
before the effective date of its termination.
``(iv) Notice to third party.--The
Secretary shall provide notice of such
termination to a third party with a contract
under subsection (d)(3) within not less than 30
days before the effective date of such
termination.
``(c) Duties Described and Special Rule for Supplemental
Benefits.--
``(1) Duties described.--The duties described in this
subsection are the following:
``(A) Administration of program.--Administering the
program, including--
``(i) the determination of the amount of
the discounted price of an applicable drug of a
manufacturer;
``(ii) except as provided in clause (iii),
the establishment of procedures under which
discounted prices are provided to applicable
beneficiaries at pharmacies or by mail order
service at the point-of-sale of an applicable
drug;
``(iii) in the case where, during the
period beginning on July 1, 2010, and ending on
December 31, 2011, it is not practicable to
provide such discounted prices at the point-of-
sale (as described in clause (ii)), the
establishment of procedures to provide such
discounted prices as soon as practicable after
the point-of-sale;
``(iv) the establishment of procedures to
ensure that, not later than the applicable
number of calendar days after the dispensing of
an applicable drug by a pharmacy or mail order
service, the pharmacy or mail order service is
reimbursed for an amount equal to the
difference between--
``(I) the negotiated price of the
applicable drug; and
``(II) the discounted price of the
applicable drug;
``(v) the establishment of procedures to
ensure that the discounted price for an
applicable drug under this section is applied
before any coverage or financial assistance
under other health benefit plans or programs
that provide coverage or financial assistance
for the purchase or provision of prescription
drug coverage on behalf of applicable
beneficiaries as the Secretary may specify;
``(vi) the establishment of procedures to
implement the special rule for supplemental
benefits under paragraph (2); and
``(vii) providing a reasonable dispute
resolution mechanism to resolve disagreements
between manufacturers, applicable
beneficiaries, and the third party with a
contract under subsection (d)(3).
``(B) Monitoring compliance.--
``(i) In general.--The Secretary shall
monitor compliance by a manufacturer with the
terms of an agreement under this section.
``(ii) Notification.--If a third party with
a contract under subsection (d)(3) determines
that the manufacturer is not in compliance with
such agreement, the third party shall notify
the Secretary of such noncompliance for
appropriate enforcement under subsection (e).
``(C) Collection of data from prescription drug
plans and ma-pd plans.--The Secretary may collect
appropriate data from prescription drug plans and MA-PD
plans in a timeframe that allows for discounted prices
to be provided for applicable drugs under this section.
``(2) Special rule for supplemental benefits.--For plan
year 2010 and each subsequent plan year, in the case where an
applicable beneficiary has supplemental benefits with respect
to applicable drugs under the prescription drug plan or MA-PD
plan that the applicable beneficiary is enrolled in, the
applicable beneficiary shall not be provided a discounted price
for an applicable drug under this section until after such
supplemental benefits have been applied with respect to the
applicable drug.
``(d) Administration.--
``(1) In general.--Subject to paragraph (2), the Secretary
shall provide for the implementation of this section, including
the performance of the duties described in subsection (c)(1).
``(2) Limitation.--
``(A) In general.--Subject to subparagraph (B), in
providing for such implementation, the Secretary shall
not receive or distribute any funds of a manufacturer
under the program.
``(B) Exception.--The limitation under subparagraph
(A) shall not apply to the Secretary with respect to
drugs dispensed during the period beginning on July 1,
2010, and ending on December 31, 2010, but only if the
Secretary determines that the exception to such
limitation under this subparagraph is necessary in
order for the Secretary to begin implementation of this
section and provide applicable beneficiaries timely
access to discounted prices during such period.
``(3) Contract with third parties.--The Secretary shall
enter into a contract with 1 or more third parties to
administer the requirements established by the Secretary in
order to carry out this section. At a minimum, the contract
with a third party under the preceding sentence shall require
that the third party--
``(A) receive and transmit information between the
Secretary, manufacturers, and other individuals or
entities the Secretary determines appropriate;
``(B) receive, distribute, or facilitate the
distribution of funds of manufacturers to appropriate
individuals or entities in order to meet the
obligations of manufacturers under agreements under
this section;
``(C) provide adequate and timely information to
manufacturers, consistent with the agreement with the
manufacturer under this section, as necessary for the
manufacturer to fulfill its obligations under this
section; and
``(D) permit manufacturers to conduct periodic
audits, directly or through contracts, of the data and
information used by the third party to determine
discounts for applicable drugs of the manufacturer
under the program.
``(4) Performance requirements.--The Secretary shall
establish performance requirements for a third party with a
contract under paragraph (3) and safeguards to protect the
independence and integrity of the activities carried out by the
third party under the program under this section.
``(5) Implementation.--The Secretary may implement the
program under this section by program instruction or otherwise.
``(6) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the program under this section.
``(e) Enforcement.--
``(1) Audits.--Each manufacturer with an agreement in
effect under this section shall be subject to periodic audit by
the Secretary.
``(2) Civil money penalty.--
``(A) In general.--The Secretary shall impose a
civil money penalty on a manufacturer that fails to
provide applicable beneficiaries discounts for
applicable drugs of the manufacturer in accordance with
such agreement for each such failure in an amount the
Secretary determines is commensurate with the sum of--
``(i) the amount that the manufacturer
would have paid with respect to such discounts
under the agreement, which will then be used to
pay the discounts which the manufacturer had
failed to provide; and
``(ii) 25 percent of such amount.
``(B) Application.--The provisions of section 1128A
(other than subsections (a) and (b)) shall apply to a
civil money penalty under this paragraph in the same
manner as such provisions apply to a penalty or
proceeding under section 1128A(a).
``(f) Clarification Regarding Availability of Other Covered Part D
Drugs.--Nothing in this section shall prevent an applicable beneficiary
from purchasing a covered part D drug that is not an applicable drug
(including a generic drug or a drug that is not on the formulary of the
prescription drug plan or MA-PD plan that the applicable beneficiary is
enrolled in).
``(g) Definitions.--In this section:
``(1) Applicable beneficiary.--The term `applicable
beneficiary' means an individual who, on the date of dispensing
an applicable drug--
``(A) is enrolled in a prescription drug plan or an
MA-PD plan;
``(B) is not enrolled in a qualified retiree
prescription drug plan;
``(C) is not entitled to an income-related subsidy
under section 1860D-14(a);
``(D) is not subject to a reduction in premium
subsidy under section 1839(i); and
``(E) who--
``(i) has reached or exceeded the initial
coverage limit under section 1860D-2(b)(3)
during the year; and
``(ii) has not incurred costs for covered
part D drugs in the year equal to the annual
out-of-pocket threshold specified in section
1860D-2(b)(4)(B).
``(2) Applicable drug.--The term `applicable drug' means,
with respect to an applicable beneficiary, a covered part D
drug--
``(A) approved under a new drug application under
section 505(b) of the Federal Food, Drug, and Cosmetic
Act or, in the case of a biologic product, licensed
under section 351 of the Public Health Service Act
(other than a product licensed under subsection (k) of
such section 351); and
``(B)(i) if the PDP sponsor of the prescription
drug plan or the MA organization offering the MA-PD
plan uses a formulary, which is on the formulary of the
prescription drug plan or MA-PD plan that the
applicable beneficiary is enrolled in;
``(ii) if the PDP sponsor of the prescription drug
plan or the MA organization offering the MA-PD plan
does not use a formulary, for which benefits are
available under the prescription drug plan or MA-PD
plan that the applicable beneficiary is enrolled in; or
``(iii) is provided through an exception or appeal.
``(3) Applicable number of calendar days.--The term
`applicable number of calendar days' means--
``(A) with respect to claims for reimbursement
submitted electronically, 14 days; and
``(B) with respect to claims for reimbursement
submitted otherwise, 30 days.
``(4) Discounted price.--
``(A) In general.--The term `discounted price'
means 50 percent of the negotiated price of the
applicable drug of a manufacturer.
``(B) Clarification.--Nothing in this section shall
be construed as affecting the responsibility of an
applicable beneficiary for payment of a dispensing fee
for an applicable drug.
``(C) Special case for certain claims.--In the case
where the entire amount of the negotiated price of an
individual claim for an applicable drug with respect to
an applicable beneficiary does not fall at or above the
initial coverage limit under section 1860D-2(b)(3) and
below the annual out-of-pocket threshold specified in
section 1860D-2(b)(4)(B) for the year, the manufacturer
of the applicable drug shall provide the discounted
price under this section on only the portion of the
negotiated price of the applicable drug that falls at
or above such initial coverage limit and below such
annual out-of-pocket threshold.
``(5) Manufacturer.--The term `manufacturer' means any
entity which is engaged in the production, preparation,
propagation, compounding, conversion, or processing of
prescription drug products, either directly or indirectly by
extraction from substances of natural origin, or independently
by means of chemical synthesis, or by a combination of
extraction and chemical synthesis. Such term does not include a
wholesale distributor of drugs or a retail pharmacy licensed
under State law.
``(6) Negotiated price.--The term `negotiated price' has
the meaning given such term in section 423.100 of title 42,
Code of Federal Regulations (as in effect on the date of
enactment of this section), except that such negotiated price
shall not include any dispensing fee for the applicable drug.
``(7) Qualified retiree prescription drug plan.--The term
`qualified retiree prescription drug plan' has the meaning
given such term in section 1860D-22(a)(2).''.
(c) Inclusion in Incurred Costs.--
(1) In general.--Section 1860D-2(b)(4) of the Social
Security Act (42 U.S.C. 1395w-102(b)(4)) is amended--
(A) in subparagraph (C), in the matter preceding
clause (i), by striking ``In applying'' and inserting
``Except as provided in subparagraph (E), in
applying''; and
(B) by adding at the end the following new
subparagraph:
``(E) Inclusion of costs of applicable drugs under
medicare coverage gap discount program.--In applying
subparagraph (A), incurred costs shall include the
negotiated price (as defined in paragraph (6) of
section 1860D-14A(g)) of an applicable drug (as defined
in paragraph (2) of such section) of a manufacturer
that is furnished to an applicable beneficiary (as
defined in paragraph (1) of such section) under the
Medicare coverage gap discount program under section
1860D-14A, regardless of whether part of such costs
were paid by a manufacturer under such program.''.
(2) Effective date.--The amendments made by this subsection
shall apply to costs incurred on or after July 1, 2010.
(d) Conforming Amendment Permitting Prescription Drug Discounts.--
(1) In general.--Section 1128B(b)(3) of the Social Security
Act (42 U.S.C. 1320a-7b(b)(3)) is amended--
(A) by striking ``and'' at the end of subparagraph
(G);
(B) in the subparagraph (H) added by section 237(d)
of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117
Stat. 2213)--
(i) by moving such subparagraph 2 ems to
the left; and
(ii) by striking the period at the end and
inserting a semicolon;
(C) in the subparagraph (H) added by section 431(a)
of such Act (117 Stat. 2287)--
(i) by redesignating such subparagraph as
subparagraph (I);
(ii) by moving such subparagraph 2 ems to
the left; and
(iii) by striking the period at the end and
inserting ``; and''; and
(D) by adding at the end the following new
subparagraph:
``(J) a discount in the price of an applicable drug
(as defined in paragraph (2) of section 1860D-14A(g))
of a manufacturer that is furnished to an applicable
beneficiary (as defined in paragraph (1) of such
section) under the Medicare coverage gap discount
program under section 1860D-14A.''.
(2) Conforming amendment to definition of best price under
medicaid.--Section 1927(c)(1)(C)(i)(VI) of the Social Security
Act (42 U.S.C. 1396r-8(c)(1)(C)(i)(VI)) is amended by inserting
``, or any discounts provided by manufacturers under the
Medicare coverage gap discount program under section 1860D-
14A'' before the period at the end.
(3) Effective date.--The amendments made by this subsection
shall apply to drugs dispensed on or after July 1, 2010.
SEC. 3302. IMPROVEMENT IN DETERMINATION OF MEDICARE PART D LOW-INCOME
BENCHMARK PREMIUM.
(a) In General.--Section 1860D-14(b)(2)(B)(iii) of the Social
Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is amended by
inserting ``, determined without regard to any reduction in such
premium as a result of any beneficiary rebate under section
1854(b)(1)(C) or bonus payment under section 1853(n)'' before the
period at the end.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to premiums for months beginning on or after January 1, 2011.
SEC. 3303. VOLUNTARY DE MINIMIS POLICY FOR SUBSIDY ELIGIBLE INDIVIDUALS
UNDER PRESCRIPTION DRUG PLANS AND MA-PD PLANS.
(a) In General.--Section 1860D-14(a) of the Social Security Act (42
U.S.C. 1395w-114(a)) is amended by adding at the end the following new
paragraph:
``(5) Waiver of de minimis premiums.--The Secretary shall,
under procedures established by the Secretary, permit a
prescription drug plan or an MA-PD plan to waive the monthly
beneficiary premium for a subsidy eligible individual if the
amount of such premium is de minimis. If such premium is waived
under the plan, the Secretary shall not reassign subsidy
eligible individuals enrolled in the plan to other plans based
on the fact that the monthly beneficiary premium under the plan
was greater than the low-income benchmark premium amount.''.
(b) Authorizing the Secretary To Auto-enroll Subsidy Eligible
Individuals in Plans That Waive De Minimis Premiums.--Section 1860D-
1(b)(1) of the Social Security Act (42 U.S.C. 1395w-101(b)(1)) is
amended--
(1) in subparagraph (C), by inserting ``except as provided
in subparagraph (D),'' after ``shall include,''
(2) by adding at the end the following new subparagraph:
``(D) Special rule for plans that waive de minimis
premiums.--The process established under subparagraph
(A) may include, in the case of a part D eligible
individual who is a subsidy eligible individual (as
defined in section 1860D-14(a)(3)) who has failed to
enroll in a prescription drug plan or an MA-PD plan,
for the enrollment in a prescription drug plan or MA-PD
plan that has waived the monthly beneficiary premium
for such subsidy eligible individual under section
1860D-14(a)(5). If there is more than one such plan
available, the Secretary shall enroll such an
individual under the preceding sentence on a random
basis among all such plans in the PDP region. Nothing
in the previous sentence shall prevent such an
individual from declining or changing such
enrollment.''.
(c) Effective Date.--The amendments made by this subsection shall
apply to premiums for months, and enrollments for plan years, beginning
on or after January 1, 2011.
SEC. 3304. SPECIAL RULE FOR WIDOWS AND WIDOWERS REGARDING ELIGIBILITY
FOR LOW-INCOME ASSISTANCE.
(a) In General.--Section 1860D-14(a)(3)(B) of the Social Security
Act (42 U.S.C. 1395w-114(a)(3)(B)) is amended by adding at the end the
following new clause:
``(vi) Special rule for widows and
widowers.--Notwithstanding the preceding
provisions of this subparagraph, in the case of
an individual whose spouse dies during the
effective period for a determination or
redetermination that has been made under this
subparagraph, such effective period shall be
extended through the date that is 1 year after
the date on which the determination or
redetermination would (but for the application
of this clause) otherwise cease to be
effective.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on January 1, 2011.
SEC. 3305. IMPROVED INFORMATION FOR SUBSIDY ELIGIBLE INDIVIDUALS
REASSIGNED TO PRESCRIPTION DRUG PLANS AND MA-PD PLANS.
Section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114)
is amended--
(1) by redesignating subsection (d) as subsection (e); and
(2) by inserting after subsection (c) the following new
subsection:
``(d) Facilitation of Reassignments.--Beginning not later than
January 1, 2011, the Secretary shall, in the case of a subsidy eligible
individual who is enrolled in one prescription drug plan and is
subsequently reassigned by the Secretary to a new prescription drug
plan, provide the individual, within 30 days of such reassignment,
with--
``(1) information on formulary differences between the
individual's former plan and the plan to which the individual
is reassigned with respect to the individual's drug regimens;
and
``(2) a description of the individual's right to request a
coverage determination, exception, or reconsideration under
section 1860D-4(g), bring an appeal under section 1860D-4(h),
or resolve a grievance under section 1860D-4(f).''.
SEC. 3306. FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B) of section 119 of the Medicare Improvements for
Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note) is amended
by striking ``(42 U.S.C. 1395w-23(f))'' and all that follows through
the period at the end and inserting ``(42 U.S.C. 1395w-23(f)), to the
Centers for Medicare & Medicaid Services Program Management Account--
``(i) for fiscal year 2009, of $7,500,000;
and
``(ii) for the period of fiscal years 2010
through 2012, of $15,000,000.
Amounts appropriated under this subparagraph shall
remain available until expended.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119 is amended by striking ``(42 U.S.C.
1395w-23(f))'' and all that follows through the period at the end and
inserting ``(42 U.S.C. 1395w-23(f)), to the Administration on Aging--
``(i) for fiscal year 2009, of $7,500,000;
and
``(ii) for the period of fiscal years 2010
through 2012, of $15,000,000.
Amounts appropriated under this subparagraph shall
remain available until expended.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119 is amended by striking ``(42
U.S.C. 1395w-23(f))'' and all that follows through the period at the
end and inserting ``(42 U.S.C. 1395w-23(f)), to the Administration on
Aging--
``(i) for fiscal year 2009, of $5,000,000;
and
``(ii) for the period of fiscal years 2010
through 2012, of $10,000,000.
Amounts appropriated under this subparagraph shall
remain available until expended.''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2) of such section
119 is amended by striking ``(42 U.S.C. 1395w-23(f))'' and all that
follows through the period at the end and inserting ``(42 U.S.C. 1395w-
23(f)), to the Administration on Aging--
``(i) for fiscal year 2009, of $5,000,000;
and
``(ii) for the period of fiscal years 2010
through 2012, of $5,000,000.
Amounts appropriated under this subparagraph shall
remain available until expended.''.
(e) Secretarial Authority To Enlist Support in Conducting Certain
Outreach Activities.--Such section 119 is amended by adding at the end
the following new subsection:
``(g) Secretarial Authority To Enlist Support in Conducting Certain
Outreach Activities.--The Secretary may request that an entity awarded
a grant under this section support the conduct of outreach activities
aimed at preventing disease and promoting wellness. Notwithstanding any
other provision of this section, an entity may use a grant awarded
under this subsection to support the conduct of activities described in
the preceding sentence.''.
SEC. 3307. IMPROVING FORMULARY REQUIREMENTS FOR PRESCRIPTION DRUG PLANS
AND MA-PD PLANS WITH RESPECT TO CERTAIN CATEGORIES OR
CLASSES OF DRUGS.
(a) Improving Formulary Requirements.--Section 1860D-4(b)(3)(G) of
the Social Security Act is amended to read as follows:
``(G) Required inclusion of drugs in certain
categories and classes.--
``(i) Formulary requirements.--
``(I) In general.--Subject to
subclause (II), a PDP sponsor offering
a prescription drug plan shall be
required to include all covered part D
drugs in the categories and classes
identified by the Secretary under
clause (ii)(I).
``(II) Exceptions.--The Secretary
may establish exceptions that permit a
PDP sponsor offering a prescription
drug plan to exclude from its formulary
a particular covered part D drug in a
category or class that is otherwise
required to be included in the
formulary under subclause (I) (or to
otherwise limit access to such a drug,
including through prior authorization
or utilization management).
``(ii) Identification of drugs in certain
categories and classes.--
``(I) In general.--Subject to
clause (iv), the Secretary shall
identify, as appropriate, categories
and classes of drugs for which the
Secretary determines are of clinical
concern.
``(II) Criteria.--The Secretary
shall use criteria established by the
Secretary in making any determination
under subclause (I).
``(iii) Implementation.--The Secretary
shall establish the criteria under clause
(ii)(II) and any exceptions under clause
(i)(II) through the promulgation of a
regulation which includes a public notice and
comment period.
``(iv) Requirement for certain categories
and classes until criteria established.--Until
such time as the Secretary establishes the
criteria under clause (ii)(II) the following
categories and classes of drugs shall be
identified under clause (ii)(I):
``(I) Anticonvulsants.
``(II) Antidepressants.
``(III) Antineoplastics.
``(IV) Antipsychotics.
``(V) Antiretrovirals.
``(VI) Immunosuppressants for the
treatment of transplant rejection.''.
(b) Effective Date.--The amendments made by this section shall
apply to plan year 2011 and subsequent plan years.
SEC. 3308. REDUCING PART D PREMIUM SUBSIDY FOR HIGH-INCOME
BENEFICIARIES.
(a) Income-Related Increase in Part D Premium.--
(1) In general.--Section 1860D-13(a) of the Social Security
Act (42 U.S.C. 1395w-113(a)) is amended by adding at the end
the following new paragraph:
``(7) Increase in base beneficiary premium based on
income.--
``(A) In general.--In the case of an individual
whose modified adjusted gross income exceeds the
threshold amount applicable under paragraph (2) of
section 1839(i) (including application of paragraph (5)
of such section) for the calendar year, the monthly
amount of the beneficiary premium applicable under this
section for a month after December 2010 shall be
increased by the monthly adjustment amount specified in
subparagraph (B).
``(B) Monthly adjustment amount.--The monthly
adjustment amount specified in this subparagraph for an
individual for a month in a year is equal to the
product of--
``(i) the quotient obtained by dividing--
``(I) the applicable percentage
determined under paragraph (3)(C) of
section 1839(i) (including application
of paragraph (5) of such section) for
the individual for the calendar year
reduced by 25.5 percent; by
``(II) 25.5 percent; and
``(ii) the base beneficiary premium (as
computed under paragraph (2)).
``(C) Modified adjusted gross income.--For purposes
of this paragraph, the term `modified adjusted gross
income' has the meaning given such term in subparagraph
(A) of section 1839(i)(4), determined for the taxable
year applicable under subparagraphs (B) and (C) of such
section.
``(D) Determination by commissioner of social
security.--The Commissioner of Social Security shall
make any determination necessary to carry out the
income-related increase in the base beneficiary premium
under this paragraph.
``(E) Procedures to assure correct income-related
increase in base beneficiary premium.--
``(i) Disclosure of base beneficiary
premium.--Not later than September 15 of each
year beginning with 2010, the Secretary shall
disclose to the Commissioner of Social Security
the amount of the base beneficiary premium (as
computed under paragraph (2)) for the purpose
of carrying out the income-related increase in
the base beneficiary premium under this
paragraph with respect to the following year.
``(ii) Additional disclosure.--Not later
than October 15 of each year beginning with
2010, the Secretary shall disclose to the
Commissioner of Social Security the following
information for the purpose of carrying out the
income-related increase in the base beneficiary
premium under this paragraph with respect to
the following year:
``(I) The modified adjusted gross
income threshold applicable under
paragraph (2) of section 1839(i)
(including application of paragraph (5)
of such section).
``(II) The applicable percentage
determined under paragraph (3)(C) of
section 1839(i) (including application
of paragraph (5) of such section).
``(III) The monthly adjustment
amount specified in subparagraph (B).
``(IV) Any other information the
Commissioner of Social Security
determines necessary to carry out the
income-related increase in the base
beneficiary premium under this
paragraph.
``(F) Rule of construction.--The formula used to
determine the monthly adjustment amount specified under
subparagraph (B) shall only be used for the purpose of
determining such monthly adjustment amount under such
subparagraph.''.
(2) Collection of monthly adjustment amount.--Section
1860D-13(c) of the Social Security Act (42 U.S.C. 1395w-113(c))
is amended--
(A) in paragraph (1), by striking ``(2) and (3)''
and inserting ``(2), (3), and (4)''; and
(B) by adding at the end the following new
paragraph:
``(4) Collection of monthly adjustment amount.--
``(A) In general.--Notwithstanding any provision of
this subsection or section 1854(d)(2), subject to
subparagraph (B), the amount of the income-related
increase in the base beneficiary premium for an
individual for a month (as determined under subsection
(a)(7)) shall be paid through withholding from benefit
payments in the manner provided under section 1840.
``(B) Agreements.--In the case where the monthly
benefit payments of an individual that are withheld
under subparagraph (A) are insufficient to pay the
amount described in such subparagraph, the Commissioner
of Social Security shall enter into agreements with the
Secretary, the Director of the Office of Personnel
Management, and the Railroad Retirement Board as
necessary in order to allow other agencies to collect
the amount described in subparagraph (A) that was not
withheld under such subparagraph.''.
(b) Conforming Amendments.--
(1) Medicare.--Section 1860D-13(a)(1) of the Social
Security Act (42 U.S.C. 1395w-113(a)(1)) is amended--
(A) by redesignating subparagraph (F) as
subparagraph (G);
(B) in subparagraph (G), as redesignated by
subparagraph (A), by striking ``(D) and (E)'' and
inserting ``(D), (E), and (F)''; and
(C) by inserting after subparagraph (E) the
following new subparagraph:
``(F) Increase based on income.--The monthly
beneficiary premium shall be increased pursuant to
paragraph (7).''.
(2) Internal revenue code.--Section 6103(l)(20) of the
Internal Revenue Code of 1986 (relating to disclosure of return
information to carry out Medicare part B premium subsidy
adjustment) is amended--
(A) in the heading, by inserting ``and part d base
beneficiary premium increase'' after ``part b premium
subsidy adjustment'';
(B) in subparagraph (A)--
(i) in the matter preceding clause (i), by
inserting ``or increase under section 1860D-
13(a)(7)'' after ``1839(i)''; and
(ii) in clause (vii), by inserting after
``subsection (i) of such section'' the
following: ``or increase under section 1860D-
13(a)(7) of such Act''; and
(C) in subparagraph (B)--
(i) by striking ``Return information'' and
inserting the following:
``(i) In general.--Return information'';
(ii) by inserting ``or increase under such
section 1860D-13(a)(7)'' before the period at
the end;
(iii) as amended by clause (i), by
inserting ``or for the purpose of resolving
taxpayer appeals with respect to any such
premium adjustment or increase'' before the
period at the end; and
(iv) by adding at the end the following new
clause:
``(ii) Disclosure to other agencies.--
Officers, employees, and contractors of the
Social Security Administration may disclose--
``(I) the taxpayer identity
information and the amount of the
premium subsidy adjustment or premium
increase with respect to a taxpayer
described in subparagraph (A) to
officers, employees, and contractors of
the Centers for Medicare and Medicaid
Services, to the extent that such
disclosure is necessary for the
collection of the premium subsidy
amount or the increased premium amount,
``(II) the taxpayer identity
information and the amount of the
premium subsidy adjustment or the
increased premium amount with respect
to a taxpayer described in subparagraph
(A) to officers and employees of the
Office of Personnel Management and the
Railroad Retirement Board, to the
extent that such disclosure is
necessary for the collection of the
premium subsidy amount or the increased
premium amount,
``(III) return information with
respect to a taxpayer described in
subparagraph (A) to officers and
employees of the Department of Health
and Human Services to the extent
necessary to resolve administrative
appeals of such premium subsidy
adjustment or increased premium, and
``(IV) return information with
respect to a taxpayer described in
subparagraph (A) to officers and
employees of the Department of Justice
for use in judicial proceedings to the
extent necessary to carry out the
purposes described in clause (i).''.
SEC. 3309. ELIMINATION OF COST SHARING FOR CERTAIN DUAL ELIGIBLE
INDIVIDUALS.
Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42 U.S.C.
1395w-114(a)(1)(D)(i)) is amended by inserting ``or, effective on a
date specified by the Secretary (but in no case earlier than January 1,
2012), who would be such an institutionalized individual or couple, if
the full-benefit dual eligible individual were not receiving services
under a home and community-based waiver authorized for a State under
section 1115 or subsection (c) or (d) of section 1915 or under a State
plan amendment under subsection (i) of such section or services
provided through enrollment in a medicaid managed care organization
with a contract under section 1903(m) or under section 1932'' after
``1902(q)(1)(B))''.
SEC. 3310. REDUCING WASTEFUL DISPENSING OF OUTPATIENT PRESCRIPTION
DRUGS IN LONG-TERM CARE FACILITIES UNDER PRESCRIPTION
DRUG PLANS AND MA-PD PLANS.
(a) In General.--Section 1860D-4(c) of the Social Security Act (42
U.S.C. 1395w-104(c)) is amended by adding at the end the following new
paragraph:
``(3) Reducing wasteful dispensing of outpatient
prescription drugs in long-term care facilities.--The Secretary
shall require PDP sponsors of prescription drug plans to
utilize specific, uniform dispensing techniques, as determined
by the Secretary, in consultation with relevant stakeholders
(including representatives of nursing facilities, residents of
nursing facilities, pharmacists, the pharmacy industry
(including retail and long-term care pharmacy), prescription
drug plans, MA-PD plans, and any other stakeholders the
Secretary determines appropriate), such as weekly, daily, or
automated dose dispensing, when dispensing covered part D drugs
to enrollees who reside in a long-term care facility in order
to reduce waste associated with 30-day fills.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to plan years beginning on or after January 1, 2012.
SEC. 3311. IMPROVED MEDICARE PRESCRIPTION DRUG PLAN AND MA-PD PLAN
COMPLAINT SYSTEM.
(a) In General.--The Secretary shall develop and maintain a
complaint system, that is widely known and easy to use, to collect and
maintain information on MA-PD plan and prescription drug plan
complaints that are received (including by telephone, letter, e-mail,
or any other means) by the Secretary (including by a regional office of
the Department of Health and Human Services, the Medicare Beneficiary
Ombudsman, a subcontractor, a carrier, a fiscal intermediary, and a
Medicare administrative contractor under section 1874A of the Social
Security Act (42 U.S.C. 1395kk)) through the date on which the
complaint is resolved. The system shall be able to report and initiate
appropriate interventions and monitoring based on substantial
complaints and to guide quality improvement.
(b) Model Electronic Complaint Form.--The Secretary shall develop a
model electronic complaint form to be used for reporting plan
complaints under the system. Such form shall be prominently displayed
on the front page of the Medicare.gov Internet website and on the
Internet website of the Medicare Beneficiary Ombudsman.
(c) Annual Reports by the Secretary.--The Secretary shall submit to
Congress annual reports on the system. Such reports shall include an
analysis of the number and types of complaints reported in the system,
geographic variations in such complaints, the timeliness of agency or
plan responses to such complaints, and the resolution of such
complaints.
(d) Definitions.--In this section:
(1) MA-PD plan.--The term ``MA-PD plan'' has the meaning
given such term in section 1860D-41(a)(9) of such Act (42
U.S.C. 1395w-151(a)(9)).
(2) Prescription drug plan.--The term ``prescription drug
plan'' has the meaning given such term in section 1860D-
41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14)).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(4) System.--The term ``system'' means the plan complaint
system developed and maintained under subsection (a).
SEC. 3312. UNIFORM EXCEPTIONS AND APPEALS PROCESS FOR PRESCRIPTION DRUG
PLANS AND MA-PD PLANS.
(a) In General.--Section 1860D-4(b)(3) of the Social Security Act
(42 U.S.C. 1395w-104(b)(3)) is amended by adding at the end the
following new subparagraph:
``(H) Use of single, uniform exceptions and appeals
process.--Notwithstanding any other provision of this
part, each PDP sponsor of a prescription drug plan
shall--
``(i) use a single, uniform exceptions and
appeals process (including, to the extent the
Secretary determines feasible, a single,
uniform model form for use under such process)
with respect to the determination of
prescription drug coverage for an enrollee
under the plan; and
``(ii) provide instant access to such
process by enrollees through a toll-free
telephone number and an Internet website.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to exceptions and appeals on or after January 1, 2012.
SEC. 3313. OFFICE OF THE INSPECTOR GENERAL STUDIES AND REPORTS.
(a) Study and Annual Report on Part D Formularies' Inclusion of
Drugs Commonly Used by Dual Eligibles.--
(1) Study.--The Inspector General of the Department of
Health and Human Services shall conduct a study of the extent
to which formularies used by prescription drug plans and MA-PD
plans under part D include drugs commonly used by full-benefit
dual eligible individuals (as defined in section 1935(c)(6) of
the Social Security Act (42 U.S.C. 1396u-5(c)(6))).
(2) Annual reports.--Not later than July 1 of each year
(beginning with 2011), the Inspector General shall submit to
Congress a report on the study conducted under paragraph (1),
together with such recommendations as the Inspector General
determines appropriate.
(b) Study and Report on Prescription Drug Prices Under Medicare
Part D and Medicaid.--
(1) Study.--
(A) In general.--The Inspector General of the
Department of Health and Human Services shall conduct a
study on prices for covered part D drugs under the
Medicare prescription drug program under part D of
title XVIII of the Social Security Act and for covered
outpatient drugs under title XIX. Such study shall
include the following:
(i) A comparison, with respect to the 200
most frequently dispensed covered part D drugs
under such program and covered outpatient drugs
under such title (as determined by the
Inspector General based on volume and
expenditures), of--
(I) the prices paid for covered
part D drugs by PDP sponsors of
prescription drug plans and Medicare
Advantage organizations offering MA-PD
plans; and
(II) the prices paid for covered
outpatient drugs by a State plan under
title XIX.
(ii) An assessment of--
(I) the financial impact of any
discrepancies in such prices on the
Federal Government; and
(II) the financial impact of any
such discrepancies on enrollees under
part D or individuals eligible for
medical assistance under a State plan
under title XIX.
(B) Price.--For purposes of subparagraph (A), the
price of a covered part D drug or a covered outpatient
drug shall include any rebate or discount under such
program or such title, respectively, including any
negotiated price concession described in section 1860D-
2(d)(1)(B) of the Social Security Act (42 U.S.C. 1395w-
102(d)(1)(B)) or rebate under an agreement under
section 1927 of the Social Security Act (42 U.S.C.
1396r-8).
(C) Authority to collect any necessary
information.--Notwithstanding any other provision of
law, the Inspector General of the Department of Health
and Human Services shall be able to collect any
information related to the prices of covered part D
drugs under such program and covered outpatient drugs
under such title XIX necessary to carry out the
comparison under subparagraph (A).
(2) Report.--
(A) In general.--Not later than October 1, 2011,
subject to subparagraph (B), the Inspector General
shall submit to Congress a report containing the
results of the study conducted under paragraph (1),
together with recommendations for such legislation and
administrative action as the Inspector General
determines appropriate.
(B) Limitation on information contained in
report.--The report submitted under subparagraph (A)
shall not include any information that the Inspector
General determines is proprietary or is likely to
negatively impact the ability of a PDP sponsor or a
State plan under title XIX to negotiate prices for
covered part D drugs or covered outpatient drugs,
respectively.
(3) Definitions.--In this section:
(A) Covered part d drug.--The term ``covered part D
drug'' has the meaning given such term in section
1860D-2(e) of the Social Security Act (42 U.S.C. 1395w-
102(e)).
(B) Covered outpatient drug.--The term ``covered
outpatient drug'' has the meaning given such term in
section 1927(k) of such Act (42 U.S.C. 1396r(k)).
(C) MA-PD plan.--The term ``MA-PD plan'' has the
meaning given such term in section 1860D-41(a)(9) of
such Act (42 U.S.C. 1395w-151(a)(9)).
(D) Medicare advantage organization.--The term
``Medicare Advantage organization'' has the meaning
given such term in section 1859(a)(1) of such Act (42
U.S.C. 1395w-28)(a)(1)).
(E) PDP sponsor.--The term ``PDP sponsor'' has the
meaning given such term in section 1860D-41(a)(13) of
such Act (42 U.S.C. 1395w-151(a)(13)).
(F) Prescription drug plan.--The term
``prescription drug plan'' has the meaning given such
term in section 1860D-41(a)(14) of such Act (42 U.S.C.
1395w-151(a)(14)).
SEC. 3314. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE PROGRAMS
AND INDIAN HEALTH SERVICE IN PROVIDING PRESCRIPTION DRUGS
TOWARD THE ANNUAL OUT-OF-POCKET THRESHOLD UNDER PART D.
(a) In General.--Section 1860D-2(b)(4)(C) of the Social Security
Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by striking ``such costs shall be treated as
incurred only if'' and inserting ``subject to clause
(iii), such costs shall be treated as incurred only
if'';
(B) by striking ``, under section 1860D-14, or
under a State Pharmaceutical Assistance Program''; and
(C) by striking the period at the end and inserting
``; and''; and
(3) by inserting after clause (ii) the following new
clause:
``(iii) such costs shall be treated as
incurred and shall not be considered to be
reimbursed under clause (ii) if such costs are
borne or paid--
``(I) under section 1860D-14;
``(II) under a State Pharmaceutical
Assistance Program;
``(III) by the Indian Health
Service, an Indian tribe or tribal
organization, or an urban Indian
organization (as defined in section 4
of the Indian Health Care Improvement
Act); or
``(IV) under an AIDS Drug
Assistance Program under part B of
title XXVI of the Public Health Service
Act.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to costs incurred on or after January 1, 2011.
SEC. 3315. IMMEDIATE REDUCTION IN COVERAGE GAP IN 2010.
Section 1860D-2(b) of the Social Security Act (42 U.S.C. 1395w-
102(b)) is amended--
(1) in paragraph (3)(A), by striking ``paragraph (4)'' and
inserting ``paragraphs (4) and (7)''; and
(2) by adding at the end the following new paragraph:
``(7) Increase in initial coverage limit in 2010.--
``(A) In general.--For the plan year beginning on
January 1, 2010, the initial coverage limit described
in paragraph (3)(B) otherwise applicable shall be
increased by $500.
``(B) Application.--In applying subparagraph (A)--
``(i) except as otherwise provided in this
subparagraph, there shall be no change in the
premiums, bids, or any other parameters under
this part or part C;
``(ii) costs that would be treated as
incurred costs for purposes of applying
paragraph (4) but for the application of
subparagraph (A) shall continue to be treated
as incurred costs;
``(iii) the Secretary shall establish
procedures, which may include a reconciliation
process, to fully reimburse PDP sponsors with
respect to prescription drug plans and MA
organizations with respect to MA-PD plans for
the reduction in beneficiary cost sharing
associated with the application of subparagraph
(A);
``(iv) the Secretary shall develop an
estimate of the additional increased costs
attributable to the application of this
paragraph for increased drug utilization and
financing and administrative costs and shall
use such estimate to adjust payments to PDP
sponsors with respect to prescription drug
plans under this part and MA organizations with
respect to MA-PD plans under part C; and
``(v) the Secretary shall establish
procedures for retroactive reimbursement of
part D eligible individuals who are covered
under such a plan for costs which are incurred
before the date of initial implementation of
subparagraph (A) and which would be reimbursed
under such a plan if such implementation
occurred as of January 1, 2010.
``(C) No effect on subsequent years.--The increase
under subparagraph (A) shall only apply with respect to
the plan year beginning on January 1, 2010, and the
initial coverage limit for plan years beginning on or
after January 1, 2011, shall be determined as if
subparagraph (A) had never applied.''.
Subtitle E--Ensuring Medicare Sustainability
SEC. 3401. REVISION OF CERTAIN MARKET BASKET UPDATES AND INCORPORATION
OF PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET UPDATES
THAT DO NOT ALREADY INCORPORATE SUCH IMPROVEMENTS.
(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of the Social
Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended by section
3001(a)(3), is further amended--
(1) in clause (i)(XX), by striking ``clause (viii)'' and
inserting ``clauses (viii), (ix), (xi), and (xii)'';
(2) in the first sentence of clause (viii), by inserting
``of such applicable percentage increase (determined without
regard to clause (ix), (xi), or (xii))'' after ``one-quarter'';
(3) in the first sentence of clause (ix)(I), by inserting
``(determined without regard to clause (viii), (xi), or
(xii))'' after ``clause (i)'' the second time it appears; and
(4) by adding at the end the following new clauses:
``(xi)(I) For 2012 and each subsequent fiscal year, after
determining the applicable percentage increase described in clause (i)
and after application of clauses (viii) and (ix), such percentage
increase shall be reduced by the productivity adjustment described in
subclause (II).
``(II) The productivity adjustment described in this subclause,
with respect to a percentage, factor, or update for a fiscal year,
year, cost reporting period, or other annual period, is a productivity
adjustment equal to the 10-year moving average of changes in annual
economy-wide private nonfarm business multi-factor productivity (as
projected by the Secretary for the 10-year period ending with the
applicable fiscal year, year, cost reporting period, or other annual
period).
``(III) The application of subclause (I) may result in the
applicable percentage increase described in clause (i) being less than
0.0 for a fiscal year, and may result in payment rates under this
section for a fiscal year being less than such payment rates for the
preceding fiscal year.
``(xii) After determining the applicable percentage increase
described in clause (i), and after application of clauses (viii), (ix),
and (xi), the Secretary shall reduce such applicable percentage
increase--
``(I) for each of fiscal years 2010 and 2011, by 0.25
percentage point; and
``(II) subject to clause (xiii), for each of fiscal years
2012 through 2019, by 0.2 percentage point.
The application of this clause may result in the applicable percentage
increase described in clause (i) being less than 0.0 for a fiscal year,
and may result in payment rates under this section for a fiscal year
being less than such payment rates for the preceding fiscal year.
``(xiii) Clause (xii) shall be applied with respect to any of
fiscal years 2014 through 2019 by substituting `0.0 percentage points'
for `0.2 percentage point', if for such fiscal year--
``(I) the excess (if any) of--
``(aa) the total percentage of the non-elderly
insured population for the preceding fiscal year (based
on the most recent estimates available from the
Director of the Congressional Budget Office before a
vote in either House on the Patient Protection and
Affordable Care Act that, if determined in the
affirmative, would clear such Act for enrollment); over
``(bb) the total percentage of the non-elderly
insured population for such preceding fiscal year (as
estimated by the Secretary); exceeds
``(II) 5 percentage points.''.
(b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of the
Social Security Act (42 U.S.C. 1395yy(e)(5)(B)) is amended--
(1) by striking ``percentage.--The term'' and inserting
``percentage.--
``(i) In general.--Subject to clause (ii),
the term''; and
(2) by adding at the end the following new clause:
``(ii) Adjustment.--For fiscal year 2012
and each subsequent fiscal year, after
determining the percentage described in clause
(i), the Secretary shall reduce such percentage
by the productivity adjustment described in
section 1886(b)(3)(B)(xi)(II). The application
of the preceding sentence may result in such
percentage being less than 0.0 for a fiscal
year, and may result in payment rates under
this subsection for a fiscal year being less
than such payment rates for the preceding
fiscal year.''.
(c) Long-term Care Hospitals.--Section 1886(m) of the Social
Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the
following new paragraphs:
``(3) Implementation for rate year 2010 and subsequent
years.--
``(A) In general.--In implementing the system
described in paragraph (1) for rate year 2010 and each
subsequent rate year, any annual update to a standard
Federal rate for discharges for the hospital during the
rate year, shall be reduced--
``(i) for rate year 2012 and each
subsequent rate year, by the productivity
adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(ii) for each of rate years 2010 through
2019, by the other adjustment described in
paragraph (4).
``(B) Special rule.--The application of this
paragraph may result in such annual update being less
than 0.0 for a rate year, and may result in payment
rates under the system described in paragraph (1) for a
rate year being less than such payment rates for the
preceding rate year.
``(4) Other adjustment.--
``(A) In general.--For purposes of paragraph
(3)(A)(ii), the other adjustment described in this
paragraph is--
``(i) for each of rate years 2010 and 2011,
0.25 percentage point; and
``(ii) subject to subparagraph (B), for
each of rate years 2012 through 2019, 0.2
percentage point.
``(B) Reduction of other adjustment.--Subparagraph
(A)(ii) shall be applied with respect to any of rate
years 2014 through 2019 by substituting `0.0 percentage
points' for `0.2 percentage point', if for such rate
year--
``(i) the excess (if any) of--
``(I) the total percentage of the
non-elderly insured population for the
preceding rate year (based on the most
recent estimates available from the
Director of the Congressional Budget
Office before a vote in either House on
the Patient Protection and Affordable
Care Act that, if determined in the
affirmative, would clear such Act for
enrollment); over
``(II) the total percentage of the
non-elderly insured population for such
preceding rate year (as estimated by
the Secretary); exceeds
``(ii) 5 percentage points.''.
(d) Inpatient Rehabilitation Facilities.--Section 1886(j)(3) of the
Social Security Act (42 U.S.C. 1395ww(j)(3)) is amended--
(1) in subparagraph (C)--
(A) by striking ``factor.--For purposes'' and
inserting ``factor.--
``(i) In general.--For purposes'';
(B) by inserting ``subject to clause (ii)'' before
the period at the end of the first sentence of clause
(i), as added by paragraph (1); and
(C) by adding at the end the following new clause:
``(ii) Productivity and other adjustment.--
After establishing the increase factor
described in clause (i) for a fiscal year, the
Secretary shall reduce such increase factor--
``(I) for fiscal year 2012 and each
subsequent fiscal year, by the
productivity adjustment described in
section 1886(b)(3)(B)(xi)(II); and
``(II) for each of fiscal years
2010 through 2019, by the other
adjustment described in subparagraph
(D).
The application of this clause may result in
the increase factor under this subparagraph
being less than 0.0 for a fiscal year, and may
result in payment rates under this subsection
for a fiscal year being less than such payment
rates for the preceding fiscal year.''; and
(2) by adding at the end the following new subparagraph:
``(D) Other adjustment.--
``(i) In general.--For purposes of
subparagraph (C)(ii)(II), the other adjustment
described in this subparagraph is--
``(I) for each of fiscal years 2010
and 2011, 0.25 percentage point; and
``(II) subject to clause (ii), for
each of fiscal years 2012 through 2019,
0.2 percentage point.
``(ii) Reduction of other adjustment.--
Clause (i)(II) shall be applied with respect to
any of fiscal years 2014 through 2019 by
substituting `0.0 percentage points' for `0.2
percentage point', if for such fiscal year--
``(I) the excess (if any) of--
``(aa) the total percentage
of the non-elderly insured
population for the preceding
fiscal year (based on the most
recent estimates available from
the Director of the
Congressional Budget Office
before a vote in either House
on the Patient Protection and
Affordable Care Act that, if
determined in the affirmative,
would clear such Act for
enrollment); over
``(bb) the total percentage
of the non-elderly insured
population for such preceding
fiscal year (as estimated by
the Secretary); exceeds
``(II) 5 percentage points.''.
(e) Home Health Agencies.--Section 1895(b)(3)(B) of the Social
Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended--
(1) in clause (ii)(V), by striking ``clause (v)'' and
inserting ``clauses (v) and (vi)''; and
(2) by adding at the end the following new clause:
``(vi) Adjustments.--After determining the
home health market basket percentage increase
under clause (iii), and after application of
clause (v), the Secretary shall reduce such
percentage--
``(I) for 2015 and each subsequent
year, by the productivity adjustment
described in section
1886(b)(3)(B)(xi)(II); and
``(II) for each of 2011 and 2012,
by 1 percentage point.
The application of this clause may result in
the home health market basket percentage
increase under clause (iii) being less than 0.0
for a year, and may result in payment rates
under the system under this subsection for a
year being less than such payment rates for the
preceding year.''.
(f) Psychiatric Hospitals.--Section 1886 of the Social Security
Act, as amended by sections 3001, 3008, 3025, and 3133, is amended by
adding at the end the following new subsection:
``(s) Prospective Payment for Psychiatric Hospitals.--
``(1) Reference to establishment and implementation of
system.--For provisions related to the establishment and
implementation of a prospective payment system for payments
under this title for inpatient hospital services furnished by
psychiatric hospitals (as described in clause (i) of subsection
(d)(1)(B)) and psychiatric units (as described in the matter
following clause (v) of such subsection), see section 124 of
the Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 1999.
``(2) Implementation for rate year beginning in 2010 and
subsequent rate years.--
``(A) In general.--In implementing the system
described in paragraph (1) for the rate year beginning
in 2010 and any subsequent rate year, any update to a
base rate for days during the rate year for a
psychiatric hospital or unit, respectively, shall be
reduced--
``(i) for the rate year beginning in 2012
and each subsequent rate year, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(ii) for each of the rate years beginning
in 2010 through 2019, by the other adjustment
described in paragraph (3).
``(B) Special rule.--The application of this
paragraph may result in such update being less than 0.0
for a rate year, and may result in payment rates under
the system described in paragraph (1) for a rate year
being less than such payment rates for the preceding
rate year.
``(3) Other adjustment.--
``(A) In general.--For purposes of paragraph
(2)(A)(ii), the other adjustment described in this
paragraph is--
``(i) for each of the rate years beginning
in 2010 and 2011, 0.25 percentage point; and
``(ii) subject to subparagraph (B), for
each of the rate years beginning in 2012
through 2019, 0.2 percentage point.
``(B) Reduction of other adjustment.--Subparagraph
(A)(ii) shall be applied with respect to any of rate
years 2014 through 2019 by substituting `0.0 percentage
points' for `0.2 percentage point', if for such rate
year--
``(i) the excess (if any) of--
``(I) the total percentage of the
non-elderly insured population for the
preceding rate year (based on the most
recent estimates available from the
Director of the Congressional Budget
Office before a vote in either House on
the Patient Protection and Affordable
Care Act that, if determined in the
affirmative, would clear such Act for
enrollment); over
``(II) the total percentage of the
non-elderly insured population for such
preceding rate year (as estimated by
the Secretary); exceeds
``(ii) 5 percentage points.''.
(g) Hospice Care.--Section 1814(i)(1)(C) of the Social Security Act
(42 U.S.C. 1395f(i)(1)(C)), as amended by section 3132, is amended by
adding at the end the following new clauses:
``(iv) After determining the market basket percentage increase
under clause (ii)(VII) or (iii), as applicable, with respect to fiscal
year 2013 and each subsequent fiscal year, the Secretary shall reduce
such percentage--
``(I) for 2013 and each subsequent fiscal year, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(II) subject to clause (v), for each of fiscal years 2013
through 2019, by 0.5 percentage point.
The application of this clause may result in the market basket
percentage increase under clause (ii)(VII) or (iii), as applicable,
being less than 0.0 for a fiscal year, and may result in payment rates
under this subsection for a fiscal year being less than such payment
rates for the preceding fiscal year.
``(v) Clause (iv)(II) shall be applied with respect to any of
fiscal years 2014 through 2019 by substituting `0.0 percentage points'
for `0.5 percentage point', if for such fiscal year--
``(I) the excess (if any) of--
``(aa) the total percentage of the non-elderly
insured population for the preceding fiscal year (based
on the most recent estimates available from the
Director of the Congressional Budget Office before a
vote in either House on the Patient Protection and
Affordable Care Act that, if determined in the
affirmative, would clear such Act for enrollment); over
``(bb) the total percentage of the non-elderly
insured population for such preceding fiscal year (as
estimated by the Secretary); exceeds
``(II) 5 percentage points.''.
(h) Dialysis.--Section 1881(b)(14)(F) of the Social Security Act
(42 U.S.C. 1395rr(b)(14)(F)) is amended--
(1) in clause (i)--
(A) by inserting ``(I)'' after ``(F)(i)''
(B) in subclause (I), as inserted by subparagraph
(A)--
(i) by striking ``clause (ii)'' and
inserting ``subclause (II) and clause (ii)'';
and
(ii) by striking ``minus 1.0 percentage
point''; and
(C) by adding at the end the following new
subclause:
``(II) For 2012 and each subsequent year, after determining the
increase factor described in subclause (I), the Secretary shall reduce
such increase factor by the productivity adjustment described in
section 1886(b)(3)(B)(xi)(II). The application of the preceding
sentence may result in such increase factor being less than 0.0 for a
year, and may result in payment rates under the payment system under
this paragraph for a year being less than such payment rates for the
preceding year.''; and
(2) in clause (ii)(II)--
(A) by striking ``The'' and inserting ``Subject to
clause (i)(II), the''; and
(B) by striking ``clause (i) minus 1.0 percentage
point'' and inserting ``clause (i)(I)''.
(i) Outpatient Hospitals.--Section 1833(t)(3) of the Social
Security Act (42 U.S.C. 1395l(t)(3)) is amended--
(1) in subparagraph (C)(iv), by inserting ``and
subparagraph (F) of this paragraph'' after ``(17)''; and
(2) by adding at the end the following new subparagraphs:
``(F) Productivity and other adjustment.--After
determining the OPD fee schedule increase factor under
subparagraph (C)(iv), the Secretary shall reduce such
increase factor--
``(i) for 2012 and subsequent years, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(ii) for each of 2010 through 2019, by
the adjustment described in subparagraph (G).
The application of this subparagraph may result in the
increase factor under subparagraph (C)(iv) being less
than 0.0 for a year, and may result in payment rates
under the payment system under this subsection for a
year being less than such payment rates for the
preceding year.
``(G) Other adjustment.--
``(i) Adjustment.--For purposes of
subparagraph (F)(ii), the adjustment described
in this subparagraph is--
``(I) for each of 2010 and 2011,
0.25 percentage point; and
``(II) subject to clause (ii), for
each of 2012 through 2019, 0.2
percentage point.
``(ii) Reduction of other adjustment.--
Clause (i)(II) shall be applied with respect to
any of 2014 through 2019 by substituting `0.0
percentage points' for `0.2 percentage point',
if for such year--
``(I) the excess (if any) of--
``(aa) the total percentage
of the non-elderly insured
population for the preceding
year (based on the most recent
estimates available from the
Director of the Congressional
Budget Office before a vote in
either House on the Patient
Protection and Affordable Care
Act that, if determined in the
affirmative, would clear such
Act for enrollment); over
``(bb) the total percentage
of the non-elderly insured
population for such preceding
year (as estimated by the
Secretary); exceeds
``(II) 5 percentage points.''.
(j) Ambulance Services.--Section 1834(l)(3) of the Social Security
Act (42 U.S.C. 1395m(l)(3)) is amended--
(1) in subparagraph (A), by striking ``and'' at the end;
(2) in subparagraph (B)--
(A) by inserting ``, subject to subparagraph (C)
and the succeeding sentence of this paragraph,'' after
``increased''; and
(B) by striking the period at the end and inserting
``; and'';
(3) by adding at the end the following new subparagraph:
``(C) for 2011 and each subsequent year, after
determining the percentage increase under subparagraph
(B) for the year, reduce such percentage increase by
the productivity adjustment described in section
1886(b)(3)(B)(xi)(II).''; and
(4) by adding at the end the following flush sentence:
``The application of subparagraph (C) may result in the
percentage increase under subparagraph (B) being less than 0.0
for a year, and may result in payment rates under the fee
schedule under this subsection for a year being less than such
payment rates for the preceding year.''.
(k) Ambulatory Surgical Center Services.--Section 1833(i)(2)(D) of
the Social Security Act (42 U.S.C. 1395l(i)(2)(D)) is amended--
(1) by redesignating clause (v) as clause (vi); and
(2) by inserting after clause (iv) the following new
clause:
``(v) In implementing the system described
in clause (i) for 2011 and each subsequent
year, any annual update under such system for
the year, after application of clause (iv),
shall be reduced by the productivity adjustment
described in section 1886(b)(3)(B)(xi)(II). The
application of the preceding sentence may
result in such update being less than 0.0 for a
year, and may result in payment rates under the
system described in clause (i) for a year being
less than such payment rates for the preceding
year.''.
(l) Laboratory Services.--Section 1833(h)(2)(A) of the Social
Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended--
(1) in clause (i)--
(A) by inserting ``, subject to clause (iv),''
after ``year) by''; and
(B) by striking ``through 2013'' and inserting
``and 2010''; and
(2) by adding at the end the following new clause:
``(iv) After determining the adjustment to
the fee schedules under clause (i), the
Secretary shall reduce such adjustment--
``(I) for 2011 and each subsequent
year, by the productivity adjustment
described in section
1886(b)(3)(B)(xi)(II); and
``(II) for each of 2011 through
2015, by 1.75 percentage points.
Subclause (I) shall not apply in a year where
the adjustment to the fee schedules determined
under clause (i) is 0.0 or a percentage
decrease for a year. The application of the
productivity adjustment under subclause (I)
shall not result in an adjustment to the fee
schedules under clause (i) being less than 0.0
for a year. The application of subclause (II)
may result in an adjustment to the fee
schedules under clause (i) being less than 0.0
for a year, and may result in payment rates for
a year being less than such payment rates for
the preceding year.''.
(m) Certain Durable Medical Equipment.--Section 1834(a)(14) of the
Social Security Act (42 U.S.C. 1395m(a)(14)) is amended--
(1) in subparagraph (K)--
(A) by striking ``2011, 2012, and 2013,''; and
(B) by inserting ``and'' after the semicolon at the
end;
(2) by striking subparagraphs (L) and (M) and inserting the
following new subparagraph:
``(L) for 2011 and each subsequent year--
``(i) the percentage increase in the
consumer price index for all urban consumers
(United States city average) for the 12-month
period ending with June of the previous year,
reduced by--
``(ii) the productivity adjustment
described in section 1886(b)(3)(B)(xi)(II).'';
and
(3) by adding at the end the following flush sentence:
``The application of subparagraph (L)(ii) may result in the
covered item update under this paragraph being less than 0.0
for a year, and may result in payment rates under this
subsection for a year being less than such payment rates for
the preceding year.''.
(n) Prosthetic Devices, Orthotics, and Prosthetics.--Section
1834(h)(4) of the Social Security Act (42 U.S.C. 1395m(h)(4)) is
amended--
(1) in subparagraph (A)--
(A) in clause (ix), by striking ``and'' at the end;
(B) in clause (x)--
(i) by striking ``a subsequent year'' and
inserting ``for each of 2007 through 2010'';
and
(ii) by inserting ``and'' after the
semicolon at the end;
(C) by adding at the end the following new clause:
``(xi) for 2011 and each subsequent year--
``(I) the percentage increase in
the consumer price index for all urban
consumers (United States city average)
for the 12-month period ending with
June of the previous year, reduced by--
``(II) the productivity adjustment
described in section
1886(b)(3)(B)(xi)(II).''; and
(D) by adding at the end the following flush
sentence:
``The application of subparagraph (A)(xi)(II) may result in the
applicable percentage increase under subparagraph (A) being
less than 0.0 for a year, and may result in payment rates under
this subsection for a year being less than such payment rates
for the preceding year.''.
(o) Other Items.--Section 1842(s)(1) of the Social Security Act (42
U.S.C. 1395u(s)(1)) is amended--
(1) in the first sentence, by striking ``Subject to'' and
inserting ``(A) Subject to'';
(2) by striking the second sentence and inserting the
following new subparagraph:
``(B) Any fee schedule established under this
paragraph for such item or service shall be updated--
``(i) for years before 2011--
``(I) subject to subclause (II), by
the percentage increase in the consumer
price index for all urban consumers
(United States city average) for the
12-month period ending with June of the
preceding year; and
``(II) for items and services
described in paragraph (2)(D) for 2009,
section 1834(a)(14)(J) shall apply
under this paragraph instead of the
percentage increase otherwise
applicable; and
``(ii) for 2011 and subsequent years--
``(I) the percentage increase in
the consumer price index for all urban
consumers (United States city average)
for the 12-month period ending with
June of the previous year, reduced by--
``(II) the productivity adjustment
described in section
1886(b)(3)(B)(xi)(II).''; and
(3) by adding at the end the following flush sentence:
``The application of subparagraph (B)(ii)(II) may result in the
update under this paragraph being less than 0.0 for a year, and
may result in payment rates under any fee schedule established
under this paragraph for a year being less than such payment
rates for the preceding year.''.
(p) No Application Prior to April 1, 2010.--Notwithstanding the
preceding provisions of this section, the amendments made by
subsections (a), (c), and (d) shall not apply to discharges occurring
before April 1, 2010.
SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART B PREMIUMS.
Section 1839(i) of the Social Security Act (42 U.S.C. 1395r(i)) is
amended--
(1) in paragraph (2), in the matter preceding subparagraph
(A), by inserting ``subject to paragraph (6),'' after
``subsection,'';
(2) in paragraph (3)(A)(i), by striking ``The applicable''
and inserting ``Subject to paragraph (6), the applicable'';
(3) by redesignating paragraph (6) as paragraph (7); and
(4) by inserting after paragraph (5) the following new
paragraph:
``(6) Temporary adjustment to income thresholds.--
Notwithstanding any other provision of this subsection, during
the period beginning on January 1, 2011, and ending on December
31, 2019--
``(A) the threshold amount otherwise applicable
under paragraph (2) shall be equal to such amount for
2010; and
``(B) the dollar amounts otherwise applicable under
paragraph (3)(C)(i) shall be equal to such dollar
amounts for 2010.''.
SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD.
(a) Board.--
(1) In general.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), as amended by section 3022, is amended by
adding at the end the following new section:
``independent medicare advisory board
``Sec. 1899A. (a) Establishment.--There is established an
independent board to be known as the `Independent Medicare Advisory
Board'.
``(b) Purpose.--It is the purpose of this section to, in accordance
with the following provisions of this section, reduce the per capita
rate of growth in Medicare spending--
``(1) by requiring the Chief Actuary of the Centers for
Medicare & Medicaid Services to determine in each year to which
this section applies (in this section referred to as `a
determination year') the projected per capita growth rate under
Medicare for the second year following the determination year
(in this section referred to as `an implementation year');
``(2) if the projection for the implementation year exceeds
the target growth rate for that year, by requiring the Board to
develop and submit during the first year following the
determination year (in this section referred to as `a proposal
year') a proposal containing recommendations to reduce the
Medicare per capita growth rate to the extent required by this
section; and
``(3) by requiring the Secretary to implement such
proposals unless Congress enacts legislation pursuant to this
section.
``(c) Board Proposals.--
``(1) Development.--
``(A) In general.--The Board shall develop detailed
and specific proposals related to the Medicare program
in accordance with the succeeding provisions of this
section.
``(B) Advisory reports.--Beginning January 15,
2014, the Board may develop and submit to Congress
advisory reports on matters related to the Medicare
program, regardless of whether or not the Board
submitted a proposal for such year. Such a report may,
for years prior to 2020, include recommendations
regarding improvements to payment systems for providers
of services and suppliers who are not otherwise subject
to the scope of the Board's recommendations in a
proposal under this section. Any advisory report
submitted under this subparagraph shall not be subject
to the rules for congressional consideration under
subsection (d).
``(2) Proposals.--
``(A) Requirements.--Each proposal submitted under
this section in a proposal year shall meet each of the
following requirements:
``(i) If the Chief Actuary of the Centers
for Medicare & Medicaid Services has made a
determination under paragraph (7)(A) in the
determination year, the proposal shall include
recommendations so that the proposal as a whole
(after taking into account recommendations
under clause (v)) will result in a net
reduction in total Medicare program spending in
the implementation year that is at least equal
to the applicable savings target established
under paragraph (7)(B) for such implementation
year. In determining whether a proposal meets
the requirement of the preceding sentence,
reductions in Medicare program spending during
the 3-month period immediately preceding the
implementation year shall be counted to the
extent that such reductions are a result of the
implementation of recommendations contained in
the proposal for a change in the payment rate
for an item or service that was effective
during such period pursuant to subsection
(e)(2)(A).
``(ii) The proposal shall not include any
recommendation to ration health care, raise
revenues or Medicare beneficiary premiums under
section 1818, 1818A, or 1839, increase Medicare
beneficiary cost-sharing (including
deductibles, coinsurance, and copayments), or
otherwise restrict benefits or modify
eligibility criteria.
``(iii) In the case of proposals submitted
prior to December 31, 2018, the proposal shall
not include any recommendation that would
reduce payment rates for items and services
furnished, prior to December 31, 2019, by
providers of services (as defined in section
1861(u)) and suppliers (as defined in section
1861(d)) scheduled, pursuant to the amendments
made by section 3401 of the Patient Protection
and Affordable Care Act, to receive a reduction
to the inflationary payment updates of such
providers of services and suppliers in excess
of a reduction due to productivity in a year in
which such recommendations would take effect.
``(iv) As appropriate, the proposal shall
include recommendations to reduce Medicare
payments under parts C and D, such as
reductions in direct subsidy payments to
Medicare Advantage and prescription drug plans
specified under paragraph (1) and (2) of
section 1860D-15(a) that are related to
administrative expenses (including profits) for
basic coverage, denying high bids or removing
high bids for prescription drug coverage from
the calculation of the national average monthly
bid amount under section 1860D-13(a)(4), and
reductions in payments to Medicare Advantage
plans under clauses (i) and (ii) of section
1853(a)(1)(B) that are related to
administrative expenses (including profits) and
performance bonuses for Medicare Advantage
plans under section 1853(n). Any such
recommendation shall not affect the base
beneficiary premium percentage specified under
1860D-13(a).
``(v) The proposal shall include
recommendations with respect to administrative
funding for the Secretary to carry out the
recommendations contained in the proposal.
``(vi) The proposal shall only include
recommendations related to the Medicare
program.
``(B) Additional considerations.--In developing and
submitting each proposal under this section in a
proposal year, the Board shall, to the extent
feasible--
``(i) give priority to recommendations that
extend Medicare solvency;
``(ii) include recommendations that--
``(I) improve the health care
delivery system and health outcomes,
including by promoting integrated care,
care coordination, prevention and
wellness, and quality and efficiency
improvement; and
``(II) protect and improve Medicare
beneficiaries' access to necessary and
evidence-based items and services,
including in rural and frontier areas;
``(iii) include recommendations that target
reductions in Medicare program spending to
sources of excess cost growth;
``(iv) consider the effects on Medicare
beneficiaries of changes in payments to
providers of services (as defined in section
1861(u)) and suppliers (as defined in section
1861(d));
``(v) consider the effects of the
recommendations on providers of services and
suppliers with actual or projected negative
cost margins or payment updates; and
``(vi) consider the unique needs of
Medicare beneficiaries who are dually eligible
for Medicare and the Medicaid program under
title XIX.
``(C) No increase in total medicare program
spending.--Each proposal submitted under this section
shall be designed in such a manner that implementation
of the recommendations contained in the proposal would
not be expected to result, over the 10-year period
starting with the implementation year, in any increase
in the total amount of net Medicare program spending
relative to the total amount of net Medicare program
spending that would have occurred absent such
implementation.
``(D) Consultation with medpac.--The Board shall
submit a draft copy of each proposal to be submitted
under this section to the Medicare Payment Advisory
Commission established under section 1805 for its
review. The Board shall submit such draft copy by not
later than September 1 of the determination year.
``(E) Review and comment by the secretary.--The
Board shall submit a draft copy of each proposal to be
submitted to Congress under this section to the
Secretary for the Secretary's review and comment. The
Board shall submit such draft copy by not later than
September 1 of the determination year. Not later than
March 1 of the submission year, the Secretary shall
submit a report to Congress on the results of such
review, unless the Secretary submits a proposal under
paragraph (5)(A) in that year.
``(F) Consultations.--In carrying out its duties
under this section, the Board shall engage in regular
consultations with the Medicaid and CHIP Payment and
Access Commission under section 1900.
``(3) Transmission of board proposal to president.--
``(A) In general.--
``(i) In general.--Except as provided in
clause (ii) and subsection (f)(3)(B), the Board
shall transmit a proposal under this section to
the President on January 15 of each year
(beginning with 2014).
``(ii) Exception.--The Board shall not
submit a proposal under clause (i) in a
proposal year if the year is--
``(I) a year for which the Chief
Actuary of the Centers for Medicare &
Medicaid Services makes a determination
in the determination year under
paragraph (6)(A) that the growth rate
described in clause (i) of such
paragraph does not exceed the growth
rate described in clause (ii) of such
paragraph;
``(II) a year in which the Chief
Actuary of the Centers for Medicare &
Medicaid Services makes a determination
in the determination year that the
projected percentage increase (if any)
for the medical care expenditure
category of the Consumer Price Index
for All Urban Consumers (United States
city average) for the implementation
year is less than the projected
percentage increase (if any) in the
Consumer Price Index for All Urban
Consumers (all items; United States
city average) for such implementation
year; or
``(III) for proposal year 2019 and
subsequent proposal years, a year in
which the Chief Actuary of the Centers
for Medicare & Medicaid Services makes
a determination in the determination
year that the growth rate described in
paragraph (8) exceeds the growth rate
described in paragraph (6)(A)(i).
``(iii) Start-up period.--The Board may not
submit a proposal under clause (i) prior to
January 15, 2014.
``(B) Required information.--Each proposal
submitted by the Board under subparagraph (A)(i) shall
include--
``(i) the recommendations described in
paragraph (2)(A)(i);
``(ii) an explanation of each
recommendation contained in the proposal and
the reasons for including such recommendation;
``(iii) an actuarial opinion by the Chief
Actuary of the Centers for Medicare & Medicaid
Services certifying that the proposal meets the
requirements of subparagraphs (A)(i) and (C) of
paragraph (2);
``(iv) a legislative proposal that
implements the recommendations; and
``(v) other information determined
appropriate by the Board.
``(4) Presidential submission to congress.--Upon receiving
a proposal from the Board under paragraph (3)(A)(i) or the
Secretary under paragraph (5), the President shall immediately
submit such proposal to Congress.
``(5) Contingent secretarial development of proposal.--If,
with respect to a proposal year, the Board is required, to but
fails, to submit a proposal to the President by the deadline
applicable under paragraph (3)(A)(i), the Secretary shall
develop a detailed and specific proposal that satisfies the
requirements of subparagraphs (A) and (C) (and, to the extent
feasible, subparagraph (B)) of paragraph (2) and contains the
information required paragraph (3)(B)). By not later than
January 25 of the year, the Secretary shall transmit--
``(A) such proposal to the President; and
``(B) a copy of such proposal to the Medicare
Payment Advisory Commission for its review.
``(6) Per capita growth rate projections by chief
actuary.--
``(A) In general.--Subject to subsection (f)(3)(A),
not later than April 30, 2013, and annually thereafter,
the Chief Actuary of the Centers for Medicare &
Medicaid Services shall determine in each such year
whether--
``(i) the projected Medicare per capita
growth rate for the implementation year (as
determined under subparagraph (B)); exceeds
``(ii) the projected Medicare per capita
target growth rate for the implementation year
(as determined under subparagraph (C)).
``(B) Medicare per capita growth rate.--
``(i) In general.--For purposes of this
section, the Medicare per capita growth rate
for an implementation year shall be calculated
as the projected 5-year average (ending with
such year) of the growth in Medicare program
spending per unduplicated enrollee.
``(ii) Requirement.--The projection under
clause (i) shall--
``(I) to the extent that there is
projected to be a negative update to
the single conversion factor applicable
to payments for physicians' services
under section 1848(d) furnished in the
proposal year or the implementation
year, assume that such update for such
services is 0 percent rather than the
negative percent that would otherwise
apply; and
``(II) take into account any
delivery system reforms or other
payment changes that have been enacted
or published in final rules but not yet
implemented as of the making of such
calculation.
``(C) Medicare per capita target growth rate.--For
purposes of this section, the Medicare per capita
target growth rate for an implementation year shall be
calculated as the projected 5-year average (ending with
such year) percentage increase in--
``(i) with respect to a determination year
that is prior to 2018, the average of the
projected percentage increase (if any) in--
``(I) the Consumer Price Index for
All Urban Consumers (all items; United
States city average); and
``(II) the medical care expenditure
category of the Consumer Price Index
for All Urban Consumers (United States
city average); and
``(ii) with respect to a determination year
that is after 2017, the nominal gross domestic
product per capita plus 1.0 percentage point.
``(7) Savings requirement.--
``(A) In general.--If, with respect to a
determination year, the Chief Actuary of the Centers
for Medicare & Medicaid Services makes a determination
under paragraph (6)(A) that the growth rate described
in clause (i) of such paragraph exceeds the growth rate
described in clause (ii) of such paragraph, the Chief
Actuary shall establish an applicable savings target
for the implementation year.
``(B) Applicable savings target.--For purposes of
this section, the applicable savings target for an
implementation year shall be an amount equal to the
product of--
``(i) the total amount of projected
Medicare program spending for the proposal
year; and
``(ii) the applicable percent for the
implementation year.
``(C) Applicable percent.--For purposes of
subparagraph (B), the applicable percent for an
implementation year is the lesser of--
``(i) in the case of--
``(I) implementation year 2015, 0.5
percent;
``(II) implementation year 2016,
1.0 percent;
``(III) implementation year 2017,
1.25 percent; and
``(IV) implementation year 2018 or
any subsequent implementation year, 1.5
percent; and
``(ii) the projected excess for the
implementation year (expressed as a percent)
determined under subparagraph (A).
``(8) Per capita rate of growth in national health
expenditures.--In each determination year (beginning in 2018),
the Chief Actuary of the Centers for Medicare & Medicaid
Services shall project the per capita rate of growth in
national health expenditures for the implementation year. Such
rate of growth for an implementation year shall be calculated
as the projected 5-year average (ending with such year)
percentage increase in national health care expenditures.
``(d) Congressional Consideration.--
``(1) Introduction.--
``(A) In general.--On the day on which a proposal
is submitted by the President to the House of
Representatives and the Senate under subsection (c)(4),
the legislative proposal (described in subsection
(c)(3)(B)(iv)) contained in the proposal shall be
introduced (by request) in the Senate by the majority
leader of the Senate or by Members of the Senate
designated by the majority leader of the Senate and
shall be introduced (by request) in the House by the
majority leader of the House or by Members of the House
designated by the majority leader of the House.
``(B) Not in session.--If either House is not in
session on the day on which such legislative proposal
is submitted, the legislative proposal shall be
introduced in that House, as provided in subparagraph
(A), on the first day thereafter on which that House is
in session.
``(C) Any member.--If the legislative proposal is
not introduced in either House within 5 days on which
that House is in session after the day on which the
legislative proposal is submitted, then any Member of
that House may introduce the legislative proposal.
``(D) Referral.--The legislation introduced under
this paragraph shall be referred by the Presiding
Officers of the respective Houses to the Committee on
Finance in the Senate and to the Committee on Energy
and Commerce and the Committee on Ways and Means in the
House of Representatives.
``(2) Committee consideration of proposal.--
``(A) Reporting bill.--Not later than April 1 of
any proposal year in which a proposal is submitted by
the President to Congress under this section, the
Committee on Ways and Means and the Committee on Energy
and Commerce of the House of Representatives and the
Committee on Finance of the Senate may report the bill
referred to the Committee under paragraph (1)(D) with
committee amendments related to the Medicare program.
``(B) Calculations.--In determining whether a
committee amendment meets the requirement of
subparagraph (A), the reductions in Medicare program
spending during the 3-month period immediately
preceding the implementation year shall be counted to
the extent that such reductions are a result of the
implementation provisions in the committee amendment
for a change in the payment rate for an item or service
that was effective during such period pursuant to such
amendment.
``(C) Committee jurisdiction.--Notwithstanding rule
XV of the Standing Rules of the Senate, a committee
amendment described in subparagraph (A) may include
matter not within the jurisdiction of the Committee on
Finance if that matter is relevant to a proposal
contained in the bill submitted under subsection
(c)(3).
``(D) Discharge.--If, with respect to the House
involved, the committee has not reported the bill by
the date required by subparagraph (A), the committee
shall be discharged from further consideration of the
proposal.
``(3) Limitation on changes to the board recommendations.--
``(A) In general.--It shall not be in order in the
Senate or the House of Representatives to consider any
bill, resolution, or amendment, pursuant to this
subsection or conference report thereon, that fails to
satisfy the requirements of subparagraphs (A)(i) and
(C) of subsection (c)(2).
``(B) Limitation on changes to the board
recommendations in other legislation.--It shall not be
in order in the Senate or the House of Representatives
to consider any bill, resolution, amendment, or
conference report (other than pursuant to this section)
that would repeal or otherwise change the
recommendations of the Board if that change would fail
to satisfy the requirements of subparagraphs (A)(i) and
(C) of subsection (c)(2).
``(C) Limitation on changes to this subsection.--It
shall not be in order in the Senate or the House of
Representatives to consider any bill, resolution,
amendment, or conference report that would repeal or
otherwise change this subsection.
``(D) Waiver.--This paragraph may be waived or
suspended in the Senate only by the affirmative vote of
three-fifths of the Members, duly chosen and sworn.
``(E) Appeals.--An affirmative vote of three-fifths
of the Members of the Senate, duly chosen and sworn,
shall be required in the Senate to sustain an appeal of
the ruling of the Chair on a point of order raised
under this paragraph.
``(4) Expedited procedure.--
``(A) Consideration.--A motion to proceed to the
consideration of the bill in the Senate is not
debatable.
``(B) Amendment.--
``(i) Time limitation.--Debate in the
Senate on any amendment to a bill under this
section shall be limited to 1 hour, to be
equally divided between, and controlled by, the
mover and the manager of the bill, and debate
on any amendment to an amendment, debatable
motion, or appeal shall be limited to 30
minutes, to be equally divided between, and
controlled by, the mover and the manager of the
bill, except that in the event the manager of
the bill is in favor of any such amendment,
motion, or appeal, the time in opposition
thereto shall be controlled by the minority
leader or such leader's designee.
``(ii) Germane.--No amendment that is not
germane to the provisions of such bill shall be
received.
``(iii) Additional time.--The leaders, or
either of them, may, from the time under their
control on the passage of the bill, allot
additional time to any Senator during the
consideration of any amendment, debatable
motion, or appeal.
``(iv) Amendment not in order.--It shall
not be in order to consider an amendment that
would cause the bill to result in a net
reduction in total Medicare program spending in
the implementation year that is less than the
applicable savings target established under
subsection (c)(7)(B) for such implementation
year.
``(v) Waiver and appeals.--This paragraph
may be waived or suspended in the Senate only
by the affirmative vote of three-fifths of the
Members, duly chosen and sworn. An affirmative
vote of three-fifths of the Members of the
Senate, duly chosen and sworn, shall be
required in the Senate to sustain an appeal of
the ruling of the Chair on a point of order
raised under this section.
``(C) Consideration by the other house.--
``(i) In general.--The expedited procedures
provided in this subsection for the
consideration of a bill introduced pursuant to
paragraph (1) shall not apply to such a bill
that is received by one House from the other
House if such a bill was not introduced in the
receiving House.
``(ii) Before passage.--If a bill that is
introduced pursuant to paragraph (1) is
received by one House from the other House,
after introduction but before disposition of
such a bill in the receiving House, then the
following shall apply:
``(I) The receiving House shall
consider the bill introduced in that
House through all stages of
consideration up to, but not including,
passage.
``(II) The question on passage
shall be put on the bill of the other
House as amended by the language of the
receiving House.
``(iii) After passage.--If a bill
introduced pursuant to paragraph (1) is
received by one House from the other House,
after such a bill is passed by the receiving
House, then the vote on passage of the bill
that originates in the receiving House shall be
considered to be the vote on passage of the
bill received from the other House as amended
by the language of the receiving House.
``(iv) Disposition.--Upon disposition of a
bill introduced pursuant to paragraph (1) that
is received by one House from the other House,
it shall no longer be in order to consider the
bill that originates in the receiving House.
``(v) Limitation.--Clauses (ii), (iii), and
(iv) shall apply only to a bill received by one
House from the other House if the bill--
``(I) is related only to the
program under this title; and
``(II) satisfies the requirements
of subparagraphs (A)(i) and (C) of
subsection (c)(2).
``(D) Senate limits on debate.--
``(i) In general.--In the Senate,
consideration of the bill and on all debatable
motions and appeals in connection therewith
shall not exceed a total of 30 hours, which
shall be divided equally between the majority
and minority leaders or their designees.
``(ii) Motion to further limit debate.--A
motion to further limit debate on the bill is
in order and is not debatable.
``(iii) Motion or appeal.--Any debatable
motion or appeal is debatable for not to exceed
1 hour, to be divided equally between those
favoring and those opposing the motion or
appeal.
``(iv) Final disposition.--After 30 hours
of consideration, the Senate shall proceed,
without any further debate on any question, to
vote on the final disposition thereof to the
exclusion of all amendments not then pending
before the Senate at that time and to the
exclusion of all motions, except a motion to
table, or to reconsider and one quorum call on
demand to establish the presence of a quorum
(and motions required to establish a quorum)
immediately before the final vote begins.
``(E) Consideration in conference.--
``(i) In general.--Consideration in the
Senate and the House of Representatives on the
conference report or any messages between
Houses shall be limited to 10 hours, equally
divided and controlled by the majority and
minority leaders of the Senate or their
designees and the Speaker of the House of
Representatives and the minority leader of the
House of Representatives or their designees.
``(ii) Time limitation.--Debate in the
Senate on any amendment under this subparagraph
shall be limited to 1 hour, to be equally
divided between, and controlled by, the mover
and the manager of the bill, and debate on any
amendment to an amendment, debatable motion, or
appeal shall be limited to 30 minutes, to be
equally divided between, and controlled by, the
mover and the manager of the bill, except that
in the event the manager of the bill is in
favor of any such amendment, motion, or appeal,
the time in opposition thereto shall be
controlled by the minority leader or such
leader's designee.
``(iii) Final disposition.--After 10 hours
of consideration, the Senate shall proceed,
without any further debate on any question, to
vote on the final disposition thereof to the
exclusion of all motions not then pending
before the Senate at that time or necessary to
resolve the differences between the Houses and
to the exclusion of all other motions, except a
motion to table, or to reconsider and one
quorum call on demand to establish the presence
of a quorum (and motions required to establish
a quorum) immediately before the final vote
begins.
``(iv) Limitation.--Clauses (i) through
(iii) shall only apply to a conference report,
message or the amendments thereto if the
conference report, message, or an amendment
thereto--
``(I) is related only to the
program under this title; and
``(II) satisfies the requirements
of subparagraphs (A)(i) and (C) of
subsection (c)(2).
``(F) Veto.--If the President vetoes the bill
debate on a veto message in the Senate under this
subsection shall be 1 hour equally divided between the
majority and minority leaders or their designees.
``(5) Rules of the senate and house of representatives.--
This subsection and subsection (f)(2) are enacted by Congress--
``(A) as an exercise of the rulemaking power of the
Senate and the House of Representatives, respectively,
and is deemed to be part of the rules of each House,
respectively, but applicable only with respect to the
procedure to be followed in that House in the case of
bill under this section, and it supersedes other rules
only to the extent that it is inconsistent with such
rules; and
``(B) with full recognition of the constitutional
right of either House to change the rules (so far as
they relate to the procedure of that House) at any
time, in the same manner, and to the same extent as in
the case of any other rule of that House.
``(e) Implementation of Proposal.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall, except as provided in paragraph (3),
implement the recommendations contained in a proposal submitted
by the President to Congress pursuant to this section on August
15 of the year in which the proposal is so submitted.
``(2) Application.--
``(A) In general.--A recommendation described in
paragraph (1) shall apply as follows:
``(i) In the case of a recommendation that
is a change in the payment rate for an item or
service under Medicare in which payment rates
change on a fiscal year basis (or a cost
reporting period basis that relates to a fiscal
year), on a calendar year basis (or a cost
reporting period basis that relates to a
calendar year), or on a rate year basis (or a
cost reporting period basis that relates to a
rate year), such recommendation shall apply to
items and services furnished on the first day
of the first fiscal year, calendar year, or
rate year (as the case may be) that begins
after such August 15.
``(ii) In the case of a recommendation
relating to payments to plans under parts C and
D, such recommendation shall apply to plan
years beginning on the first day of the first
calendar year that begins after such August 15.
``(iii) In the case of any other
recommendation, such recommendation shall be
addressed in the regular regulatory process
timeframe and shall apply as soon as
practicable.
``(B) Interim final rulemaking.--The Secretary may
use interim final rulemaking to implement any
recommendation described in paragraph (1).
``(3) Exception.--The Secretary shall not be required to
implement the recommendations contained in a proposal submitted
in a proposal year by the President to Congress pursuant to
this section if--
``(A) prior to August 15 of the proposal year,
Federal legislation is enacted that includes the
following provision: `This Act supercedes the
recommendations of the Board contained in the proposal
submitted, in the year which includes the date of
enactment of this Act, to Congress under section 1899A
of the Social Security Act.'; and
``(B) in the case of implementation year 2020 and
subsequent implementation years, a joint resolution
described in subsection (f)(1) is enacted not later
than August 15, 2017.
``(4) No affect on authority to implement certain
provisions.--Nothing in paragraph (3) shall be construed to
affect the authority of the Secretary to implement any
recommendation contained in a proposal or advisory report under
this section to the extent that the Secretary otherwise has the
authority to implement such recommendation administratively.
``(5) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the implementation by the Secretary under
this subsection of the recommendations contained in a proposal.
``(f) Joint Resolution Required To Discontinue the Board.--
``(1) In general.--For purposes of subsection (e)(3)(B), a
joint resolution described in this paragraph means only a joint
resolution--
``(A) that is introduced in 2017 by not later than
February 1 of such year;
``(B) which does not have a preamble;
``(C) the title of which is as follows: `Joint
resolution approving the discontinuation of the process
for consideration and automatic implementation of the
annual proposal of the Independent Medicare Advisory
Board under section 1899A of the Social Security Act';
and
``(D) the matter after the resolving clause of
which is as follows: `That Congress approves the
discontinuation of the process for consideration and
automatic implementation of the annual proposal of the
Independent Medicare Advisory Board under section 1899A
of the Social Security Act.'.
``(2) Procedure.--
``(A) Referral.--A joint resolution described in
paragraph (1) shall be referred to the Committee on
Ways and Means and the Committee on Energy and Commerce
of the House of Representatives and the Committee on
Finance of the Senate.
``(B) Discharge.--In the Senate, if the committee
to which is referred a joint resolution described in
paragraph (1) has not reported such joint resolution
(or an identical joint resolution) at the end of 20
days after the joint resolution described in paragraph
(1) is introduced, such committee may be discharged
from further consideration of such joint resolution
upon a petition supported in writing by 30 Members of
the Senate, and such joint resolution shall be placed
on the calendar.
``(C) Consideration.--
``(i) In general.--In the Senate, when the
committee to which a joint resolution is
referred has reported, or when a committee is
discharged (under subparagraph (C)) from
further consideration of a joint resolution
described in paragraph (1), it is at any time
thereafter in order (even though a previous
motion to the same effect has been disagreed
to) for a motion to proceed to the
consideration of the joint resolution to be
made, and all points of order against the joint
resolution (and against consideration of the
joint resolution) are waived, except for points
of order under the Congressional Budget act of
1974 or under budget resolutions pursuant to
that Act. The motion is not debatable. A motion
to reconsider the vote by which the motion is
agreed to or disagreed to shall not be in
order. If a motion to proceed to the
consideration of the joint resolution is agreed
to, the joint resolution shall remain the
unfinished business of the Senate until
disposed of.
``(ii) Debate limitation.--In the Senate,
consideration of the joint resolution, and on
all debatable motions and appeals in connection
therewith, shall be limited to not more than 10
hours, which shall be divided equally between
the majority leader and the minority leader, or
their designees. A motion further to limit
debate is in order and not debatable. An
amendment to, or a motion to postpone, or a
motion to proceed to the consideration of other
business, or a motion to recommit the joint
resolution is not in order.
``(iii) Passage.--In the Senate,
immediately following the conclusion of the
debate on a joint resolution described in
paragraph (1), and a single quorum call at the
conclusion of the debate if requested in
accordance with the rules of the Senate, the
vote on passage of the joint resolution shall
occur.
``(iv) Appeals.--Appeals from the decisions
of the Chair relating to the application of the
rules of the Senate to the procedure relating
to a joint resolution described in paragraph
(1) shall be decided without debate.
``(D) Other house acts first.--If, before the
passage by 1 House of a joint resolution of that House
described in paragraph (1), that House receives from
the other House a joint resolution described in
paragraph (1), then the following procedures shall
apply:
``(i) The joint resolution of the other
House shall not be referred to a committee.
``(ii) With respect to a joint resolution
described in paragraph (1) of the House
receiving the joint resolution--
``(I) the procedure in that House
shall be the same as if no joint
resolution had been received from the
other House; but
``(II) the vote on final passage
shall be on the joint resolution of the
other House.
``(E) Excluded days.--For purposes of determining
the period specified in subparagraph (B), there shall
be excluded any days either House of Congress is
adjourned for more than 3 days during a session of
Congress.
``(F) Majority required for adoption.--A joint
resolution considered under this subsection shall
require an affirmative vote of three-fifths of the
Members, duly chosen and sworn, for adoption.
``(3) Termination.--If a joint resolution described in
paragraph (1) is enacted not later than August 15, 2017--
``(A) the Chief Actuary of the Medicare & Medicaid
Services shall not--
``(i) make any determinations under
subsection (c)(6) after May 1, 2017; or
``(ii) provide any opinion pursuant to
subsection (c)(3)(B)(iii) after January 16,
2018;
``(B) the Board shall not submit any proposals or
advisory reports to Congress under this section after
January 16, 2018; and
``(C) the Board and the consumer advisory council
under subsection (k) shall terminate on August 16,
2018.
``(g) Board Membership; Terms of Office; Chairperson; Removal.--
``(1) Membership.--
``(A) In general.--The Board shall be composed of--
``(i) 15 members appointed by the
President, by and with the advice and consent
of the Senate; and
``(ii) the Secretary, the Administrator of
the Center for Medicare & Medicaid Services,
and the Administrator of the Health Resources
and Services Administration, all of whom shall
serve ex officio as nonvoting members of the
Board.
``(B) Qualifications.--
``(i) In general.--The appointed membership
of the Board shall include individuals with
national recognition for their expertise in
health finance and economics, actuarial
science, health facility management, health
plans and integrated delivery systems,
reimbursement of health facilities, allopathic
and osteopathic physicians, and other providers
of health services, and other related fields,
who provide a mix of different professionals,
broad geographic representation, and a balance
between urban and rural representatives.
``(ii) Inclusion.--The appointed membership
of the Board shall include (but not be limited
to) physicians and other health professionals,
experts in the area of pharmaco-economics or
prescription drug benefit programs, employers,
third-party payers, individuals skilled in the
conduct and interpretation of biomedical,
health services, and health economics research
and expertise in outcomes and effectiveness
research and technology assessment. Such
membership shall also include representatives
of consumers and the elderly.
``(iii) Majority nonproviders.--Individuals
who are directly involved in the provision or
management of the delivery of items and
services covered under this title shall not
constitute a majority of the appointed
membership of the Board.
``(C) Ethical disclosure.--The President shall
establish a system for public disclosure by appointed
members of the Board of financial and other potential
conflicts of interest relating to such members.
Appointed members of the Board shall be treated as
officers in the executive branch for purposes of
applying title I of the Ethics in Government Act of
1978 (Public Law 95-521).
``(D) Conflicts of interest.--No individual may
serve as an appointed member if that individual engages
in any other business, vocation, or employment.
``(E) Consultation with congress.--In selecting
individuals for nominations for appointments to the
Board, the President shall consult with--
``(i) the majority leader of the Senate
concerning the appointment of 3 members;
``(ii) the Speaker of the House of
Representatives concerning the appointment of 3
members;
``(iii) the minority leader of the Senate
concerning the appointment of 3 members; and
``(iv) the minority leader of the House of
Representatives concerning the appointment of 3
members.
``(2) Term of office.--Each appointed member shall hold
office for a term of 6 years except that--
``(A) a member may not serve more than 2 full
consecutive terms (but may be reappointed to 2 full
consecutive terms after being appointed to fill a
vacancy on the Board);
``(B) a member appointed to fill a vacancy
occurring prior to the expiration of the term for which
that member's predecessor was appointed shall be
appointed for the remainder of such term;
``(C) a member may continue to serve after the
expiration of the member's term until a successor has
taken office; and
``(D) of the members first appointed under this
section, 5 shall be appointed for a term of 1 year, 5
shall be appointed for a term of 3 years, and 5 shall
be appointed for a term of 6 years, the term of each to
be designated by the President at the time of
nomination.
``(3) Chairperson.--
``(A) In general.--The Chairperson shall be
appointed by the President, by and with the advice and
consent of the Senate, from among the members of the
Board.
``(B) Duties.--The Chairperson shall be the
principal executive officer of the Board, and shall
exercise all of the executive and administrative
functions of the Board, including functions of the
Board with respect to--
``(i) the appointment and supervision of
personnel employed by the Board;
``(ii) the distribution of business among
personnel appointed and supervised by the
Chairperson and among administrative units of
the Board; and
``(iii) the use and expenditure of funds.
``(C) Governance.--In carrying out any of the
functions under subparagraph (B), the Chairperson shall
be governed by the general policies established by the
Board and by the decisions, findings, and
determinations the Board shall by law be authorized to
make.
``(D) Requests for appropriations.--Requests or
estimates for regular, supplemental, or deficiency
appropriations on behalf of the Board may not be
submitted by the Chairperson without the prior approval
of a majority vote of the Board.
``(4) Removal.--Any appointed member may be removed by the
President for neglect of duty or malfeasance in office, but for
no other cause.
``(h) Vacancies; Quorum; Seal; Vice Chairperson; Voting on
Reports.--
``(1) Vacancies.--No vacancy on the Board shall impair the
right of the remaining members to exercise all the powers of
the Board.
``(2) Quorum.--A majority of the appointed members of the
Board shall constitute a quorum for the transaction of
business, but a lesser number of members may hold hearings.
``(3) Seal.--The Board shall have an official seal, of
which judicial notice shall be taken.
``(4) Vice chairperson.--The Board shall annually elect a
Vice Chairperson to act in the absence or disability of the
Chairperson or in case of a vacancy in the office of the
Chairperson.
``(5) Voting on proposals.--Any proposal of the Board must
be approved by the majority of appointed members present.
``(i) Powers of the Board.--
``(1) Hearings.--The Board may hold such hearings, sit and
act at such times and places, take such testimony, and receive
such evidence as the Board considers advisable to carry out
this section.
``(2) Authority to inform research priorities for data
collection.--The Board may advise the Secretary on priorities
for health services research, particularly as such priorities
pertain to necessary changes and issues regarding payment
reforms under Medicare.
``(3) Obtaining official data.--The Board may secure
directly from any department or agency of the United States
information necessary to enable it to carry out this section.
Upon request of the Chairperson, the head of that department or
agency shall furnish that information to the Board on an agreed
upon schedule.
``(4) Postal services.--The Board may use the United States
mails in the same manner and under the same conditions as other
departments and agencies of the Federal Government.
``(5) Gifts.--The Board may accept, use, and dispose of
gifts or donations of services or property.
``(6) Offices.--The Board shall maintain a principal office
and such field offices as it determines necessary, and may meet
and exercise any of its powers at any other place.
``(j) Personnel Matters.--
``(1) Compensation of members and chairperson.--Each
appointed member, other than the Chairperson, shall be
compensated at a rate equal to the annual rate of basic pay
prescribed for level III of the Executive Schedule under
section 5315 of title 5, United States Code. The Chairperson
shall be compensated at a rate equal to the daily equivalent of
the annual rate of basic pay prescribed for level II of the
Executive Schedule under section 5315 of title 5, United States
Code.
``(2) Travel expenses.--The appointed members shall be
allowed travel expenses, including per diem in lieu of
subsistence, at rates authorized for employees of agencies
under subchapter I of chapter 57 of title 5, United States
Code, while away from their homes or regular places of business
in the performance of services for the Board.
``(3) Staff.--
``(A) In general.--The Chairperson may, without
regard to the civil service laws and regulations,
appoint and terminate an executive director and such
other additional personnel as may be necessary to
enable the Board to perform its duties. The employment
of an executive director shall be subject to
confirmation by the Board.
``(B) Compensation.--The Chairperson may fix the
compensation of the executive director and other
personnel without regard to chapter 51 and subchapter
III of chapter 53 of title 5, United States Code,
relating to classification of positions and General
Schedule pay rates, except that the rate of pay for the
executive director and other personnel may not exceed
the rate payable for level V of the Executive Schedule
under section 5316 of such title.
``(4) Detail of government employees.--Any Federal
Government employee may be detailed to the Board without
reimbursement, and such detail shall be without interruption or
loss of civil service status or privilege.
``(5) Procurement of temporary and intermittent services.--
The Chairperson may procure temporary and intermittent services
under section 3109(b) of title 5, United States Code, at rates
for individuals which do not exceed the daily equivalent of the
annual rate of basic pay prescribed for level V of the
Executive Schedule under section 5316 of such title.
``(k) Consumer Advisory Council.--
``(1) In general.--There is established a consumer advisory
council to advise the Board on the impact of payment policies
under this title on consumers.
``(2) Membership.--
``(A) Number and appointment.--The consumer
advisory council shall be composed of 10 consumer
representatives appointed by the Comptroller General of
the United States, 1 from among each of the 10 regions
established by the Secretary as of the date of
enactment of this section.
``(B) Qualifications.--The membership of the
council shall represent the interests of consumers and
particular communities.
``(3) Duties.--The consumer advisory council shall, subject
to the call of the Board, meet not less frequently than 2 times
each year in the District of Columbia.
``(4) Open meetings.--Meetings of the consumer advisory
council shall be open to the public.
``(5) Election of officers.--Members of the consumer
advisory council shall elect their own officers.
``(6) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.) shall apply to the consumer advisory
council except that section 14 of such Act shall not apply.
``(l) Definitions.--In this section:
``(1) Board; chairperson; member.--The terms `Board',
`Chairperson', and `Member' mean the Independent Medicare
Advisory Board established under subsection (a) and the
Chairperson and any Member thereof, respectively.
``(2) Medicare.--The term `Medicare' means the program
established under this title, including parts A, B, C, and D.
``(3) Medicare beneficiary.--The term `Medicare
beneficiary' means an individual who is entitled to, or
enrolled for, benefits under part A or enrolled for benefits
under part B.
``(4) Medicare program spending.--The term `Medicare
program spending' means program spending under parts A, B, and
D net of premiums.
``(m) Funding.--
``(1) In general.--There are appropriated to the Board to
carry out its duties and functions--
``(A) for fiscal year 2012, $15,000,000; and
``(B) for each subsequent fiscal year, the amount
appropriated under this paragraph for the previous
fiscal year increased by the annual percentage increase
in the Consumer Price Index for All Urban Consumers
(all items; United States city average) as of June of
the previous fiscal year.
``(2) From trust funds.--Sixty percent of amounts
appropriated under paragraph (1) shall be derived by transfer
from the Federal Hospital Insurance Trust Fund under section
1817 and 40 percent of amounts appropriated under such
paragraph shall be derived by transfer from the Federal
Supplementary Medical Insurance Trust Fund under section
1841.''.
(2) Lobbying cooling-off period for members of the
independent medicare advisory board.--Section 207(c) of title
18, United States Code, is amended by inserting at the end the
following:
``(3) Members of the independent medicare advisory board.--
``(A) In general.--Paragraph (1) shall apply to a
member of the Independent Medicare Advisory Board under
section 1899A.
``(B) Agencies and congress.--For purposes of
paragraph (1), the agency in which the individual
described in subparagraph (A) served shall be
considered to be the Independent Medicare Advisory
Board, the Department of Health and Human Services, and
the relevant committees of jurisdiction of Congress,
including the Committee on Ways and Means and the
Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the
Senate.''.
(b) GAO Study and Report on Determination and Implementation of
Payment and Coverage Policies Under the Medicare Program.--
(1) Initial study and report.--
(A) Study.--The Comptroller General of the United
States (in this section referred to as the
``Comptroller General'') shall conduct a study on
changes to payment policies, methodologies, and rates
and coverage policies and methodologies under the
Medicare program under title XVIII of the Social
Security Act as a result of the recommendations
contained in the proposals made by the Independent
Medicare Advisory Board under section 1899A of such Act
(as added by subsection (a)), including an analysis of
the effect of such recommendations on--
(i) Medicare beneficiary access to
providers and items and services;
(ii) the affordability of Medicare premiums
and cost-sharing (including deductibles,
coinsurance, and copayments);
(iii) the potential impact of changes on
other government or private-sector purchasers
and payers of care; and
(iv) quality of patient care, including
patient experience, outcomes, and other
measures of care.
(B) Report.--Not later than July 1, 2015, the
Comptroller General shall submit to Congress a report
containing the results of the study conducted under
subparagraph (A), together with recommendations for
such legislation and administrative action as the
Comptroller General determines appropriate.
(2) Subsequent studies and reports.--The Comptroller
General shall periodically conduct such additional studies and
submit reports to Congress on changes to Medicare payments
policies, methodologies, and rates and coverage policies and
methodologies as the Comptroller General determines
appropriate, in consultation with the Committee on Ways and
Means and the Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the Senate.
(c) Conforming Amendments.--Section 1805(b) of the Social Security
Act (42 U.S.C. 1395b-6(b)) is amended--
(1) by redesignating paragraphs (4) through (8) as
paragraphs (5) through (9), respectively; and
(2) by inserting after paragraph (3) the following:
``(4) Review and comment on the independent medicare
advisory board or secretarial proposal.--If the Independent
Medicare Advisory Board (as established under subsection (a) of
section 1899A) or the Secretary submits a proposal to the
Commission under such section in a year, the Commission shall
review the proposal and, not later than March 1 of that year,
submit to the Committee on Ways and Means and the Committee on
Energy and Commerce of the House of Representatives and the
Committee on Finance of the Senate written comments on such
proposal. Such comments may include such recommendations as the
Commission deems appropriate.''.
Subtitle F--Health Care Quality Improvements
SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY IMPROVEMENT
TECHNICAL ASSISTANCE.
Part D of title IX of the Public Health Service Act, as amended by
section 3013, is further amended by adding at the end the following:
``Subpart II--Health Care Quality Improvement Programs
``SEC. 933. HEALTH CARE DELIVERY SYSTEM RESEARCH.
``(a) Purpose.--The purposes of this section are to--
``(1) enable the Director to identify, develop, evaluate,
disseminate, and provide training in innovative methodologies
and strategies for quality improvement practices in the
delivery of health care services that represent best practices
(referred to as `best practices') in health care quality,
safety, and value; and
``(2) ensure that the Director is accountable for
implementing a model to pursue such research in a collaborative
manner with other related Federal agencies.
``(b) General Functions of the Center.--The Center for Quality
Improvement and Patient Safety of the Agency for Healthcare Research
and Quality (referred to in this section as the `Center'), or any other
relevant agency or department designated by the Director, shall--
``(1) carry out its functions using research from a variety
of disciplines, which may include epidemiology, health
services, sociology, psychology, human factors engineering,
biostatistics, health economics, clinical research, and health
informatics;
``(2) conduct or support activities consistent with the
purposes described in subsection (a), and for--
``(A) best practices for quality improvement
practices in the delivery of health care services; and
``(B) that include changes in processes of care and
the redesign of systems used by providers that will
reliably result in intended health outcomes, improve
patient safety, and reduce medical errors (such as
skill development for health care providers in team-
based health care delivery and rapid cycle process
improvement) and facilitate adoption of improved
workflow;
``(3) identify health care providers, including health care
systems, single institutions, and individual providers, that--
``(A) deliver consistently high-quality, efficient
health care services (as determined by the Secretary);
and
``(B) employ best practices that are adaptable and
scalable to diverse health care settings or effective
in improving care across diverse settings;
``(4) assess research, evidence, and knowledge about what
strategies and methodologies are most effective in improving
health care delivery;
``(5) find ways to translate such information rapidly and
effectively into practice, and document the sustainability of
those improvements;
``(6) create strategies for quality improvement through the
development of tools, methodologies, and interventions that can
successfully reduce variations in the delivery of health care;
``(7) identify, measure, and improve organizational, human,
or other causative factors, including those related to the
culture and system design of a health care organization, that
contribute to the success and sustainability of specific
quality improvement and patient safety strategies;
``(8) provide for the development of best practices in the
delivery of health care services that--
``(A) have a high likelihood of success, based on
structured review of empirical evidence;
``(B) are specified with sufficient detail of the
individual processes, steps, training, skills, and
knowledge required for implementation and incorporation
into workflow of health care practitioners in a variety
of settings;
``(C) are designed to be readily adapted by health
care providers in a variety of settings; and
``(D) where applicable, assist health care
providers in working with other health care providers
across the continuum of care and in engaging patients
and their families in improving the care and patient
health outcomes;
``(9) provide for the funding of the activities of
organizations with recognized expertise and excellence in
improving the delivery of health care services, including
children's health care, by involving multiple disciplines,
managers of health care entities, broad development and
training, patients, caregivers and families, and frontline
health care workers, including activities for the examination
of strategies to share best quality improvement practices and
to promote excellence in the delivery of health care services;
and
``(10) build capacity at the State and community level to
lead quality and safety efforts through education, training,
and mentoring programs to carry out the activities under
paragraphs (1) through (9).
``(c) Research Functions of Center.--
``(1) In general.--The Center shall support, such as
through a contract or other mechanism, research on health care
delivery system improvement and the development of tools to
facilitate adoption of best practices that improve the quality,
safety, and efficiency of health care delivery services. Such
support may include establishing a Quality Improvement Network
Research Program for the purpose of testing, scaling, and
disseminating of interventions to improve quality and
efficiency in health care. Recipients of funding under the
Program may include national, State, multi-State, or multi-site
quality improvement networks.
``(2) Research requirements.--The research conducted
pursuant to paragraph (1) shall--
``(A) address the priorities identified by the
Secretary in the national strategic plan established
under section 399HH;
``(B) identify areas in which evidence is
insufficient to identify strategies and methodologies,
taking into consideration areas of insufficient
evidence identified by the entity with a contract under
section 1890(a) of the Social Security Act in the
report required under section 399JJ;
``(C) address concerns identified by health care
institutions and providers and communicated through the
Center pursuant to subsection (d);
``(D) reduce preventable morbidity, mortality, and
associated costs of morbidity and mortality by building
capacity for patient safety research;
``(E) support the discovery of processes for the
reliable, safe, efficient, and responsive delivery of
health care, taking into account discoveries from
clinical research and comparative effectiveness
research;
``(F) allow communication of research findings and
translate evidence into practice recommendations that
are adaptable to a variety of settings, and which, as
soon as practicable after the establishment of the
Center, shall include--
``(i) the implementation of a national
application of Intensive Care Unit improvement
projects relating to the adult (including
geriatric), pediatric, and neonatal patient
populations;
``(ii) practical methods for addressing
health care associated infections, including
Methicillin-Resistant Staphylococcus Aureus and
Vancomycin-Resistant Entercoccus infections and
other emerging infections; and
``(iii) practical methods for reducing
preventable hospital admissions and
readmissions;
``(G) expand demonstration projects for improving
the quality of children's health care and the use of
health information technology, such as through
Pediatric Quality Improvement Collaboratives and
Learning Networks, consistent with provisions of
section 1139A of the Social Security Act for assessing
and improving quality, where applicable;
``(H) identify and mitigate hazards by--
``(i) analyzing events reported to patient
safety reporting systems and patient safety
organizations; and
``(ii) using the results of such analyses
to develop scientific methods of response to
such events;
``(I) include the conduct of systematic reviews of
existing practices that improve the quality, safety,
and efficiency of health care delivery, as well as new
research on improving such practices; and
``(J) include the examination of how to measure and
evaluate the progress of quality and patient safety
activities.
``(d) Dissemination of Research Findings.--
``(1) Public availability.--The Director shall make the
research findings of the Center available to the public through
multiple media and appropriate formats to reflect the varying
needs of health care providers and consumers and diverse levels
of health literacy.
``(2) Linkage to health information technology.--The
Secretary shall ensure that research findings and results
generated by the Center are shared with the Office of the
National Coordinator of Health Information Technology and used
to inform the activities of the health information technology
extension program under section 3012, as well as any relevant
standards, certification criteria, or implementation
specifications.
``(e) Prioritization.--The Director shall identify and regularly
update a list of processes or systems on which to focus research and
dissemination activities of the Center, taking into account--
``(1) the cost to Federal health programs;
``(2) consumer assessment of health care experience;
``(3) provider assessment of such processes or systems and
opportunities to minimize distress and injury to the health
care workforce;
``(4) the potential impact of such processes or systems on
health status and function of patients, including vulnerable
populations including children;
``(5) the areas of insufficient evidence identified under
subsection (c)(2)(B); and
``(6) the evolution of meaningful use of health information
technology, as defined in section 3000.
``(f) Coordination.--The Center shall coordinate its activities
with activities conducted by the Center for Medicare and Medicaid
Innovation established under section 1115A of the Social Security Act.
``(g) Funding.--There is authorized to be appropriated to carry out
this section $20,000,000 for fiscal years 2010 through 2014.
``SEC. 934. QUALITY IMPROVEMENT TECHNICAL ASSISTANCE AND
IMPLEMENTATION.
``(a) In General.--The Director, through the Center for Quality
Improvement and Patient Safety of the Agency for Healthcare Research
and Quality (referred to in this section as the `Center'), shall
award--
``(1) technical assistance grants or contracts to eligible
entities to provide technical support to institutions that
deliver health care and health care providers (including rural
and urban providers of services and suppliers with limited
infrastructure and financial resources to implement and support
quality improvement activities, providers of services and
suppliers with poor performance scores, and providers of
services and suppliers for which there are disparities in care
among subgroups of patients) so that such institutions and
providers understand, adapt, and implement the models and
practices identified in the research conducted by the Center,
including the Quality Improvement Networks Research Program;
and
``(2) implementation grants or contracts to eligible
entities to implement the models and practices described under
paragraph (1).
``(b) Eligible Entities.--
``(1) Technical assistance award.--To be eligible to
receive a technical assistance grant or contract under
subsection (a)(1), an entity--
``(A) may be a health care provider, health care
provider association, professional society, health care
worker organization, Indian health organization,
quality improvement organization, patient safety
organization, local quality improvement collaborative,
the Joint Commission, academic health center,
university, physician-based research network, primary
care extension program established under section 399W,
a Federal Indian Health Service program or a health
program operated by an Indian tribe (as defined in
section 4 of the Indian Health Care Improvement Act),
or any other entity identified by the Secretary; and
``(B) shall have demonstrated expertise in
providing information and technical support and
assistance to health care providers regarding quality
improvement.
``(2) Implementation award.--To be eligible to receive an
implementation grant or contract under subsection (a)(2), an
entity--
``(A) may be a hospital or other health care
provider or consortium or providers, as determined by
the Secretary; and
``(B) shall have demonstrated expertise in
providing information and technical support and
assistance to health care providers regarding quality
improvement.
``(c) Application.--
``(1) Technical assistance award.--To receive a technical
assistance grant or contract under subsection (a)(1), an
eligible entity shall submit an application to the Secretary at
such time, in such manner, and containing--
``(A) a plan for a sustainable business model that
may include a system of--
``(i) charging fees to institutions and
providers that receive technical support from
the entity; and
``(ii) reducing or eliminating such fees
for such institutions and providers that serve
low-income populations; and
``(B) such other information as the Director may
require.
``(2) Implementation award.--To receive a grant or contract
under subsection (a)(2), an eligible entity shall submit an
application to the Secretary at such time, in such manner, and
containing--
``(A) a plan for implementation of a model or
practice identified in the research conducted by the
Center including--
``(i) financial cost, staffing
requirements, and timeline for implementation;
and
``(ii) pre- and projected post-
implementation quality measure performance data
in targeted improvement areas identified by the
Secretary; and
``(B) such other information as the Director may
require.
``(d) Matching Funds.--The Director may not award a grant or
contract under this section to an entity unless the entity agrees that
it will make available (directly or through contributions from other
public or private entities) non-Federal contributions toward the
activities to be carried out under the grant or contract in an amount
equal to $1 for each $5 of Federal funds provided under the grant or
contract. Such non-Federal matching funds may be provided directly or
through donations from public or private entities and may be in cash or
in-kind, fairly evaluated, including plant, equipment, or services.
``(e) Evaluation.--
``(1) In general.--The Director shall evaluate the
performance of each entity that receives a grant or contract
under this section. The evaluation of an entity shall include a
study of--
``(A) the success of such entity in achieving the
implementation, by the health care institutions and
providers assisted by such entity, of the models and
practices identified in the research conducted by the
Center under section 933;
``(B) the perception of the health care
institutions and providers assisted by such entity
regarding the value of the entity; and
``(C) where practicable, better patient health
outcomes and lower cost resulting from the assistance
provided by such entity.
``(2) Effect of evaluation.--Based on the outcome of the
evaluation of the entity under paragraph (1), the Director
shall determine whether to renew a grant or contract with such
entity under this section.
``(f) Coordination.--The entities that receive a grant or contract
under this section shall coordinate with health information technology
regional extension centers under section 3012(c) and the primary care
extension program established under section 399W regarding the
dissemination of quality improvement, system delivery reform, and best
practices information.''.
SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE PATIENT-
CENTERED MEDICAL HOME.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall establish a
program to provide grants to or enter into contracts with eligible
entities to establish community-based interdisciplinary,
interprofessional teams (referred to in this section as ``health
teams'') to support primary care practices, including obstetrics and
gynecology practices, within the hospital service areas served by the
eligible entities. Grants or contracts shall be used to--
(1) establish health teams to provide support services to
primary care providers; and
(2) provide capitated payments to primary care providers as
determined by the Secretary.
(b) Eligible Entities.--To be eligible to receive a grant or
contract under subsection (a), an entity shall--
(1)(A) be a State or State-designated entity; or
(B) be an Indian tribe or tribal organization, as defined
in section 4 of the Indian Health Care Improvement Act;
(2) submit a plan for achieving long-term financial
sustainability within 3 years;
(3) submit a plan for incorporating prevention initiatives
and patient education and care management resources into the
delivery of health care that is integrated with community-based
prevention and treatment resources, where available;
(4) ensure that the health team established by the entity
includes an interdisciplinary, interprofessional team of health
care providers, as determined by the Secretary; such team may
include medical specialists, nurses, pharmacists,
nutritionists, dieticians, social workers, behavioral and
mental health providers (including substance use disorder
prevention and treatment providers), doctors of chiropractic,
licensed complementary and alternative medicine practitioners,
and physicians' assistants;
(5) agree to provide services to eligible individuals with
chronic conditions, as described in section 1945 of the Social
Security Act (as added by section 2703), in accordance with the
payment methodology established under subsection (c) of such
section; and
(6) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require.
(c) Requirements for Health Teams.--A health team established
pursuant to a grant or contract under subsection (a) shall--
(1) establish contractual agreements with primary care
providers to provide support services;
(2) support patient-centered medical homes, defined as a
mode of care that includes--
(A) personal physicians;
(B) whole person orientation;
(C) coordinated and integrated care;
(D) safe and high-quality care through evidence-
informed medicine, appropriate use of health
information technology, and continuous quality
improvements;
(E) expanded access to care; and
(F) payment that recognizes added value from
additional components of patient-centered care;
(3) collaborate with local primary care providers and
existing State and community based resources to coordinate
disease prevention, chronic disease management, transitioning
between health care providers and settings and case management
for patients, including children, with priority given to those
amenable to prevention and with chronic diseases or conditions
identified by the Secretary;
(4) in collaboration with local health care providers,
develop and implement interdisciplinary, interprofessional care
plans that integrate clinical and community preventive and
health promotion services for patients, including children,
with a priority given to those amenable to prevention and with
chronic diseases or conditions identified by the Secretary;
(5) incorporate health care providers, patients,
caregivers, and authorized representatives in program design
and oversight;
(6) provide support necessary for local primary care
providers to--
(A) coordinate and provide access to high-quality
health care services;
(B) coordinate and provide access to preventive and
health promotion services;
(C) provide access to appropriate specialty care
and inpatient services;
(D) provide quality-driven, cost-effective,
culturally appropriate, and patient- and family-
centered health care;
(E) provide access to pharmacist-delivered
medication management services, including medication
reconciliation;
(F) provide coordination of the appropriate use of
complementary and alternative (CAM) services to those
who request such services;
(G) promote effective strategies for treatment
planning, monitoring health outcomes and resource use,
sharing information, treatment decision support, and
organizing care to avoid duplication of service and
other medical management approaches intended to improve
quality and value of health care services;
(H) provide local access to the continuum of health
care services in the most appropriate setting,
including access to individuals that implement the care
plans of patients and coordinate care, such as
integrative health care practitioners;
(I) collect and report data that permits evaluation
of the success of the collaborative effort on patient
outcomes, including collection of data on patient
experience of care, and identification of areas for
improvement; and
(J) establish a coordinated system of early
identification and referral for children at risk for
developmental or behavioral problems such as through
the use of infolines, health information technology, or
other means as determined by the Secretary;
(7) provide 24-hour care management and support during
transitions in care settings including--
(A) a transitional care program that provides
onsite visits from the care coordinator, assists with
the development of discharge plans and medication
reconciliation upon admission to and discharge from the
hospitals, nursing home, or other institution setting;
(B) discharge planning and counseling support to
providers, patients, caregivers, and authorized
representatives;
(C) assuring that post-discharge care plans include
medication management, as appropriate;
(D) referrals for mental and behavioral health
services, which may include the use of infolines; and
(E) transitional health care needs from adolescence
to adulthood;
(8) serve as a liaison to community prevention and
treatment programs;
(9) demonstrate a capacity to implement and maintain health
information technology that meets the requirements of certified
EHR technology (as defined in section 3000 of the Public Health
Service Act (42 U.S.C. 300jj)) to facilitate coordination among
members of the applicable care team and affiliated primary care
practices; and
(10) where applicable, report to the Secretary information
on quality measures used under section 399JJ of the Public
Health Service Act.
(d) Requirement for Primary Care Providers.--A provider who
contracts with a care team shall--
(1) provide a care plan to the care team for each patient
participant;
(2) provide access to participant health records; and
(3) meet regularly with the care team to ensure integration
of care.
(e) Reporting to Secretary.--An entity that receives a grant or
contract under subsection (a) shall submit to the Secretary a report
that describes and evaluates, as requested by the Secretary, the
activities carried out by the entity under subsection (c).
(f) Definition of Primary Care.--In this section, the term
``primary care'' means the provision of integrated, accessible health
care services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained
partnership with patients, and practicing in the context of family and
community.
SEC. 3503. MEDICATION MANAGEMENT SERVICES IN TREATMENT OF CHRONIC
DISEASE.
Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.),
as amended by section 3501, is further amended by inserting after
section 934 the following:
``SEC. 935. GRANTS OR CONTRACTS TO IMPLEMENT MEDICATION MANAGEMENT
SERVICES IN TREATMENT OF CHRONIC DISEASES.
``(a) In General.--The Secretary, acting through the Patient Safety
Research Center established in section 933 (referred to in this section
as the `Center'), shall establish a program to provide grants or
contracts to eligible entities to implement medication management
(referred to in this section as `MTM') services provided by licensed
pharmacists, as a collaborative, multidisciplinary, inter-professional
approach to the treatment of chronic diseases for targeted individuals,
to improve the quality of care and reduce overall cost in the treatment
of such diseases. The Secretary shall commence the program under this
section not later than May 1, 2010.
``(b) Eligible Entities.--To be eligible to receive a grant or
contract under subsection (a), an entity shall--
``(1) provide a setting appropriate for MTM services, as
recommended by the experts described in subsection (e);
``(2) submit to the Secretary a plan for achieving long-
term financial sustainability;
``(3) where applicable, submit a plan for coordinating MTM
services through local community health teams established in
section 3502 of the Patient Protection and Affordable Care Act
or in collaboration with primary care extension programs
established in section 399W;
``(4) submit a plan for meeting the requirements under
subsection (c); and
``(5) submit to the Secretary such other information as the
Secretary may require.
``(c) MTM Services to Targeted Individuals.--The MTM services
provided with the assistance of a grant or contract awarded under
subsection (a) shall, as allowed by State law including applicable
collaborative pharmacy practice agreements, include--
``(1) performing or obtaining necessary assessments of the
health and functional status of each patient receiving such MTM
services;
``(2) formulating a medication treatment plan according to
therapeutic goals agreed upon by the prescriber and the patient
or caregiver or authorized representative of the patient;
``(3) selecting, initiating, modifying, recommending
changes to, or administering medication therapy;
``(4) monitoring, which may include access to, ordering, or
performing laboratory assessments, and evaluating the response
of the patient to therapy, including safety and effectiveness;
``(5) performing an initial comprehensive medication review
to identify, resolve, and prevent medication-related problems,
including adverse drug events, quarterly targeted medication
reviews for ongoing monitoring, and additional followup
interventions on a schedule developed collaboratively with the
prescriber;
``(6) documenting the care delivered and communicating
essential information about such care, including a summary of
the medication review, and the recommendations of the
pharmacist to other appropriate health care providers of the
patient in a timely fashion;
``(7) providing education and training designed to enhance
the understanding and appropriate use of the medications by the
patient, caregiver, and other authorized representative;
``(8) providing information, support services, and
resources and strategies designed to enhance patient adherence
with therapeutic regimens;
``(9) coordinating and integrating MTM services within the
broader health care management services provided to the
patient; and
``(10) such other patient care services allowed under
pharmacist scopes of practice in use in other Federal programs
that have implemented MTM services.
``(d) Targeted Individuals.--MTM services provided by licensed
pharmacists under a grant or contract awarded under subsection (a)
shall be offered to targeted individuals who--
``(1) take 4 or more prescribed medications (including
over-the-counter medications and dietary supplements);
``(2) take any `high risk' medications;
``(3) have 2 or more chronic diseases, as identified by the
Secretary; or
``(4) have undergone a transition of care, or other
factors, as determined by the Secretary, that are likely to
create a high risk of medication-related problems.
``(e) Consultation With Experts.--In designing and implementing MTM
services provided under grants or contracts awarded under subsection
(a), the Secretary shall consult with Federal, State, private, public-
private, and academic entities, pharmacy and pharmacist organizations,
health care organizations, consumer advocates, chronic disease groups,
and other stakeholders involved with the research, dissemination, and
implementation of pharmacist-delivered MTM services, as the Secretary
determines appropriate. The Secretary, in collaboration with this
group, shall determine whether it is possible to incorporate rapid
cycle process improvement concepts in use in other Federal programs
that have implemented MTM services.
``(f) Reporting to the Secretary.--An entity that receives a grant
or contract under subsection (a) shall submit to the Secretary a report
that describes and evaluates, as requested by the Secretary, the
activities carried out under subsection (c), including quality measures
endorsed by the entity with a contract under section 1890 of the Social
Security Act, as determined by the Secretary.
``(g) Evaluation and Report.--The Secretary shall submit to the
relevant committees of Congress a report which shall--
``(1) assess the clinical effectiveness of pharmacist-
provided services under the MTM services program, as compared
to usual care, including an evaluation of whether enrollees
maintained better health with fewer hospitalizations and
emergency room visits than similar patients not enrolled in the
program;
``(2) assess changes in overall health care resource use by
targeted individuals;
``(3) assess patient and prescriber satisfaction with MTM
services;
``(4) assess the impact of patient-cost sharing
requirements on medication adherence and recommendations for
modifications;
``(5) identify and evaluate other factors that may impact
clinical and economic outcomes, including demographic
characteristics, clinical characteristics, and health services
use of the patient, as well as characteristics of the regimen,
pharmacy benefit, and MTM services provided; and
``(6) evaluate the extent to which participating
pharmacists who maintain a dispensing role have a conflict of
interest in the provision of MTM services, and if such conflict
is found, provide recommendations on how such a conflict might
be appropriately addressed.
``(h) Grants or Contracts To Fund Development of Performance
Measures.--The Secretary may, through the quality measure development
program under section 931 of the Public Health Service Act, award
grants or contracts to eligible entities for the purpose of funding the
development of performance measures that assess the use and
effectiveness of medication therapy management services.''.
SEC. 3504. DESIGN AND IMPLEMENTATION OF REGIONALIZED SYSTEMS FOR
EMERGENCY CARE.
(a) In General.--Title XII of the Public Health Service Act (42
U.S.C. 300d et seq.) is amended--
(1) in section 1203--
(A) in the section heading, by inserting ``for
trauma systems'' after ``grants''; and
(B) in subsection (a), by striking ``Administrator
of the Health Resources and Services Administration''
and inserting ``Assistant Secretary for Preparedness
and Response'';
(2) by inserting after section 1203 the following:
``SEC. 1204. COMPETITIVE GRANTS FOR REGIONALIZED SYSTEMS FOR EMERGENCY
CARE RESPONSE.
``(a) In General.--The Secretary, acting through the Assistant
Secretary for Preparedness and Response, shall award not fewer than 4
multiyear contracts or competitive grants to eligible entities to
support pilot projects that design, implement, and evaluate innovative
models of regionalized, comprehensive, and accountable emergency care
and trauma systems.
``(b) Eligible Entity; Region.--In this section:
``(1) Eligible entity.--The term `eligible entity' means--
``(A) a State or a partnership of 1 or more States
and 1 or more local governments; or
``(B) an Indian tribe (as defined in section 4 of
the Indian Health Care Improvement Act) or a
partnership of 1 or more Indian tribes.
``(2) Region.--The term `region' means an area within a
State, an area that lies within multiple States, or a similar
area (such as a multicounty area), as determined by the
Secretary.
``(3) Emergency services.--The term `emergency services'
includes acute, prehospital, and trauma care.
``(c) Pilot Projects.--The Secretary shall award a contract or
grant under subsection (a) to an eligible entity that proposes a pilot
project to design, implement, and evaluate an emergency medical and
trauma system that--
``(1) coordinates with public health and safety services,
emergency medical services, medical facilities, trauma centers,
and other entities in a region to develop an approach to
emergency medical and trauma system access throughout the
region, including 9-1-1 Public Safety Answering Points and
emergency medical dispatch;
``(2) includes a mechanism, such as a regional medical
direction or transport communications system, that operates
throughout the region to ensure that the patient is taken to
the medically appropriate facility (whether an initial facility
or a higher-level facility) in a timely fashion;
``(3) allows for the tracking of prehospital and hospital
resources, including inpatient bed capacity, emergency
department capacity, trauma center capacity, on-call specialist
coverage, ambulance diversion status, and the coordination of
such tracking with regional communications and hospital
destination decisions; and
``(4) includes a consistent region-wide prehospital,
hospital, and interfacility data management system that--
``(A) submits data to the National EMS Information
System, the National Trauma Data Bank, and others;
``(B) reports data to appropriate Federal and State
databanks and registries; and
``(C) contains information sufficient to evaluate
key elements of prehospital care, hospital destination
decisions, including initial hospital and interfacility
decisions, and relevant health outcomes of hospital
care.
``(d) Application.--
``(1) In general.--An eligible entity that seeks a contract
or grant described in subsection (a) shall submit to the
Secretary an application at such time and in such manner as the
Secretary may require.
``(2) Application information.--Each application shall
include--
``(A) an assurance from the eligible entity that
the proposed system--
``(i) has been coordinated with the
applicable State Office of Emergency Medical
Services (or equivalent State office);
``(ii) includes consistent indirect and
direct medical oversight of prehospital,
hospital, and interfacility transport
throughout the region;
``(iii) coordinates prehospital treatment
and triage, hospital destination, and
interfacility transport throughout the region;
``(iv) includes a categorization or
designation system for special medical
facilities throughout the region that is
integrated with transport and destination
protocols;
``(v) includes a regional medical
direction, patient tracking, and resource
allocation system that supports day-to-day
emergency care and surge capacity and is
integrated with other components of the
national and State emergency preparedness
system; and
``(vi) addresses pediatric concerns related
to integration, planning, preparedness, and
coordination of emergency medical services for
infants, children and adolescents; and
``(B) such other information as the Secretary may
require.
``(e) Requirement of Matching Funds.--
``(1) In general.--The Secretary may not make a grant under
this section unless the State (or consortia of States) involved
agrees, with respect to the costs to be incurred by the State
(or consortia) in carrying out the purpose for which such grant
was made, to make available non-Federal contributions (in cash
or in kind under paragraph (2)) toward such costs in an amount
equal to not less than $1 for each $3 of Federal funds provided
in the grant. Such contributions may be made directly or
through donations from public or private entities.
``(2) Non-federal contributions.--Non-Federal contributions
required in paragraph (1) may be in cash or in kind, fairly
evaluated, including equipment or services (and excluding
indirect or overhead costs). Amounts provided by the Federal
Government, or services assisted or subsidized to any
significant extent by the Federal Government, may not be
included in determining the amount of such non-Federal
contributions.
``(f) Priority.--The Secretary shall give priority for the award of
the contracts or grants described in subsection (a) to any eligible
entity that serves a population in a medically underserved area (as
defined in section 330(b)(3)).
``(g) Report.--Not later than 90 days after the completion of a
pilot project under subsection (a), the recipient of such contract or
grant described in shall submit to the Secretary a report containing
the results of an evaluation of the program, including an
identification of--
``(1) the impact of the regional, accountable emergency
care and trauma system on patient health outcomes for various
critical care categories, such as trauma, stroke, cardiac
emergencies, neurological emergencies, and pediatric
emergencies;
``(2) the system characteristics that contribute to the
effectiveness and efficiency of the program (or lack thereof);
``(3) methods of assuring the long-term financial
sustainability of the emergency care and trauma system;
``(4) the State and local legislation necessary to
implement and to maintain the system;
``(5) the barriers to developing regionalized, accountable
emergency care and trauma systems, as well as the methods to
overcome such barriers; and
``(6) recommendations on the utilization of available
funding for future regionalization efforts.
``(h) Dissemination of Findings.--The Secretary shall, as
appropriate, disseminate to the public and to the appropriate
Committees of the Congress, the information contained in a report made
under subsection (g).''; and
(3) in section 1232--
(A) in subsection (a), by striking ``appropriated''
and all that follows through the period at the end and
inserting ``appropriated $24,000,000 for each of fiscal
years 2010 through 2014.''; and
(B) by inserting after subsection (c) the
following:
``(d) Authority.--For the purpose of carrying out parts A through
C, beginning on the date of enactment of the Patient Protection and
Affordable Care Act, the Secretary shall transfer authority in
administering grants and related authorities under such parts from the
Administrator of the Health Resources and Services Administration to
the Assistant Secretary for Preparedness and Response.''.
(b) Support for Emergency Medicine Research.--Part H of title IV of
the Public Health Service Act (42 U.S.C. 289 et seq.) is amended by
inserting after the section 498C the following:
``SEC. 498D. SUPPORT FOR EMERGENCY MEDICINE RESEARCH.
``(a) Emergency Medical Research.--The Secretary shall support
Federal programs administered by the National Institutes of Health, the
Agency for Healthcare Research and Quality, the Health Resources and
Services Administration, the Centers for Disease Control and
Prevention, and other agencies involved in improving the emergency care
system to expand and accelerate research in emergency medical care
systems and emergency medicine, including--
``(1) the basic science of emergency medicine;
``(2) the model of service delivery and the components of
such models that contribute to enhanced patient health
outcomes;
``(3) the translation of basic scientific research into
improved practice; and
``(4) the development of timely and efficient delivery of
health services.
``(b) Pediatric Emergency Medical Research.--The Secretary shall
support Federal programs administered by the National Institutes of
Health, the Agency for Healthcare Research and Quality, the Health
Resources and Services Administration, the Centers for Disease Control
and Prevention, and other agencies to coordinate and expand research in
pediatric emergency medical care systems and pediatric emergency
medicine, including--
``(1) an examination of the gaps and opportunities in
pediatric emergency care research and a strategy for the
optimal organization and funding of such research;
``(2) the role of pediatric emergency services as an
integrated component of the overall health system;
``(3) system-wide pediatric emergency care planning,
preparedness, coordination, and funding;
``(4) pediatric training in professional education; and
``(5) research in pediatric emergency care, specifically on
the efficacy, safety, and health outcomes of medications used
for infants, children, and adolescents in emergency care
settings in order to improve patient safety.
``(c) Impact Research.--The Secretary shall support research to
determine the estimated economic impact of, and savings that result
from, the implementation of coordinated emergency care systems.
``(d) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary
for each of fiscal years 2010 through 2014.''.
SEC. 3505. TRAUMA CARE CENTERS AND SERVICE AVAILABILITY.
(a) Trauma Care Centers.--
(1) Grants for trauma care centers.--Section 1241 of the
Public Health Service Act (42 U.S.C. 300d-41) is amended by
striking subsections (a) and (b) and inserting the following:
``(a) In General.--The Secretary shall establish 3 programs to
award grants to qualified public, nonprofit Indian Health Service,
Indian tribal, and urban Indian trauma centers--
``(1) to assist in defraying substantial uncompensated care
costs;
``(2) to further the core missions of such trauma centers,
including by addressing costs associated with patient
stabilization and transfer, trauma education and outreach,
coordination with local and regional trauma systems, essential
personnel and other fixed costs, and expenses associated with
employee and non-employee physician services; and
``(3) to provide emergency relief to ensure the continued
and future availability of trauma services.
``(b) Minimum Qualifications of Trauma Centers.--
``(1) Participation in trauma care system operating under
certain professional guidelines.--Except as provided in
paragraph (2), the Secretary may not award a grant to a trauma
center under subsection (a) unless the trauma center is a
participant in a trauma system that substantially complies with
section 1213.
``(2) Exemption.--Paragraph (1) shall not apply to trauma
centers that are located in States with no existing trauma care
system.
``(3) Qualification for substantial uncompensated care
costs.--The Secretary shall award substantial uncompensated
care grants under subsection (a)(1) only to trauma centers
meeting at least 1 of the criteria in 1 of the following 3
categories:
``(A) Category a.--The criteria for category A are
as follows:
``(i) At least 40 percent of the visits in
the emergency department of the hospital in
which the trauma center is located were charity
or self-pay patients.
``(ii) At least 50 percent of the visits in
such emergency department were Medicaid (under
title XIX of the Social Security Act (42 U.S.C.
1396 et seq.)) and charity and self-pay
patients combined.
``(B) Category b.--The criteria for category B are
as follows:
``(i) At least 35 percent of the visits in
the emergency department were charity or self-
pay patients.
``(ii) At least 50 percent of the visits in
the emergency department were Medicaid and
charity and self-pay patients combined.
``(C) Category c.--The criteria for category C are
as follows:
``(i) At least 20 percent of the visits in
the emergency department were charity or self-
pay patients.
``(ii) At least 30 percent of the visits in
the emergency department were Medicaid and
charity and self-pay patients combined.
``(4) Trauma centers in 1115 waiver states.--
Notwithstanding paragraph (3), the Secretary may award a
substantial uncompensated care grant to a trauma center under
subsection (a)(1) if the trauma center qualifies for funds
under a Low Income Pool or Safety Net Care Pool established
through a waiver approved under section 1115 of the Social
Security Act (42 U.S.C. 1315).
``(5) Designation.--The Secretary may not award a grant to
a trauma center unless such trauma center is verified by the
American College of Surgeons or designated by an equivalent
State or local agency.
``(c) Additional Requirements.--The Secretary may not award a grant
to a trauma center under subsection (a)(1) unless such trauma center--
``(1) submits to the Secretary a plan satisfactory to the
Secretary that demonstrates a continued commitment to serving
trauma patients regardless of their ability to pay; and
``(2) has policies in place to assist patients who cannot
pay for part or all of the care they receive, including a
sliding fee scale, and to ensure fair billing and collection
practices.''.
(2) Considerations in making grants.--Section 1242 of the
Public Health Service Act (42 U.S.C. 300d-42) is amended by
striking subsections (a) and (b) and inserting the following:
``(a) Substantial Uncompensated Care Awards.--
``(1) In general.--The Secretary shall establish an award
basis for each eligible trauma center for grants under section
1241(a)(1) according to the percentage described in paragraph
(2), subject to the requirements of section 1241(b)(3).
``(2) Percentages.--The applicable percentages are as
follows:
``(A) With respect to a category A trauma center,
100 percent of the uncompensated care costs.
``(B) With respect to a category B trauma center,
not more than 75 percent of the uncompensated care
costs.
``(C) With respect to a category C trauma center,
not more than 50 percent of the uncompensated care
costs.
``(b) Core Mission Awards.--
``(1) In general.--In awarding grants under section
1241(a)(2), the Secretary shall--
``(A) reserve 25 percent of the amount allocated
for core mission awards for Level III and Level IV
trauma centers; and
``(B) reserve 25 percent of the amount allocated
for core mission awards for large urban Level I and II
trauma centers--
``(i) that have at least 1 graduate medical
education fellowship in trauma or trauma
related specialties for which demand is
exceeding supply;
``(ii) for which--
``(I) annual uncompensated care
costs exceed $10,000,000; or
``(II) at least 20 percent of
emergency department visits are charity
or self-pay or Medicaid patients; and
``(iii) that are not eligible for
substantial uncompensated care awards under
section 1241(a)(1).
``(c) Emergency Awards.--In awarding grants under section
1241(a)(3), the Secretary shall--
``(1) give preference to any application submitted by a
trauma center that provides trauma care in a geographic area in
which the availability of trauma care has significantly
decreased or will significantly decrease if the center is
forced to close or downgrade service or growth in demand for
trauma services exceeds capacity; and
``(2) reallocate any emergency awards funds not obligated
due to insufficient, or a lack of qualified, applications to
the significant uncompensated care award program.''.
(3) Certain agreements.--Section 1243 of the Public Health
Service Act (42 U.S.C. 300d-43) is amended by striking
subsections (a), (b), and (c) and inserting the following:
``(a) Maintenance of Financial Support.--The Secretary may require
a trauma center receiving a grant under section 1241(a) to maintain
access to trauma services at comparable levels to the prior year during
the grant period.
``(b) Trauma Care Registry.--The Secretary may require the trauma
center receiving a grant under section 1241(a) to provide data to a
national and centralized registry of trauma cases, in accordance with
guidelines developed by the American College of Surgeons, and as the
Secretary may otherwise require.''.
(4) General provisions.--Section 1244 of the Public Health
Service Act (42 U.S.C. 300d-44) is amended by striking
subsections (a), (b), and (c) and inserting the following:
``(a) Application.--The Secretary may not award a grant to a trauma
center under section 1241(a) unless such center submits an application
for the grant to the Secretary and the application is in such form, is
made in such manner, and contains such agreements, assurances, and
information as the Secretary determines to be necessary to carry out
this part.
``(b) Limitation on Duration of Support.--The period during which a
trauma center receives payments under a grant under section 1241(a)(3)
shall be for 3 fiscal years, except that the Secretary may waive such
requirement for a center and authorize such center to receive such
payments for 1 additional fiscal year.
``(c) Limitation on Amount of Grant.--Notwithstanding section
1242(a), a grant under section 1241 may not be made in an amount
exceeding $2,000,000 for each fiscal year.
``(d) Eligibility.--Except as provided in section
1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under
section 1241(a) shall not preclude a trauma center from being eligible
for other grants described in such section.
``(e) Funding Distribution.--Of the total amount appropriated for a
fiscal year under section 1245, 70 percent shall be used for
substantial uncompensated care awards under section 1241(a)(1), 20
percent shall be used for core mission awards under section 1241(a)(2),
and 10 percent shall be used for emergency awards under section
1241(a)(3).
``(f) Minimum Allowance.--Notwithstanding subsection (e), if the
amount appropriated for a fiscal year under section 1245 is less than
$25,000,000, all available funding for such fiscal year shall be used
for substantial uncompensated care awards under section 1241(a)(1).
``(g) Substantial Uncompensated Care Award Distribution and
Proportional Share.--Notwithstanding section 1242(a), of the amount
appropriated for substantial uncompensated care grants for a fiscal
year, the Secretary shall--
``(1) make available--
``(A) 50 percent of such funds for category A
trauma center grantees;
``(B) 35 percent of such funds for category B
trauma center grantees; and
``(C) 15 percent of such funds for category C
trauma center grantees; and
``(2) provide available funds within each category in a
manner proportional to the award basis specified in section
1242(a)(2) to each eligible trauma center.
``(h) Report.--Beginning 2 years after the date of enactment of the
Patient Protection and Affordable Care Act, and every 2 years
thereafter, the Secretary shall biennially report to Congress regarding
the status of the grants made under section 1241 and on the overall
financial stability of trauma centers.''.
(5) Authorization of appropriations.--Section 1245 of the
Public Health Service Act (42 U.S.C. 300d-45) is amended to
read as follows:
``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.
``For the purpose of carrying out this part, there are authorized
to be appropriated $100,000,000 for fiscal year 2009, and such sums as
may be necessary for each of fiscal years 2010 through 2015. Such
authorization of appropriations is in addition to any other
authorization of appropriations or amounts that are available for such
purpose.''.
(6) Definition.--Part D of title XII of the Public Health
Service Act (42 U.S.C. 300d-41 et seq.) is amended by adding at
the end the following:
``SEC. 1246. DEFINITION.
``In this part, the term `uncompensated care costs' means
unreimbursed costs from serving self-pay, charity, or Medicaid
patients, without regard to payment under section 1923 of the Social
Security Act, all of which are attributable to emergency care and
trauma care, including costs related to subsequent inpatient admissions
to the hospital.''.
(b) Trauma Service Availability.--Title XII of the Public Health
Service Act (42 U.S.C. 300d et seq.) is amended by adding at the end
the following:
``PART H--TRAUMA SERVICE AVAILABILITY
``SEC. 1281. GRANTS TO STATES.
``(a) Establishment.--To promote universal access to trauma care
services provided by trauma centers and trauma-related physician
specialties, the Secretary shall provide funding to States to enable
such States to award grants to eligible entities for the purposes
described in this section.
``(b) Awarding of Grants by States.--Each State may award grants to
eligible entities within the State for the purposes described in
subparagraph (d).
``(c) Eligibility.--
``(1) In general.--To be eligible to receive a grant under
subsection (b) an entity shall--
``(A) be--
``(i) a public or nonprofit trauma center
or consortium thereof that meets that
requirements of paragraphs (1), (2), and (5) of
section 1241(b);
``(ii) a safety net public or nonprofit
trauma center that meets the requirements of
paragraphs (1) through (5) of section 1241(b);
or
``(iii) a hospital in an underserved area
(as defined by the State) that seeks to
establish new trauma services; and
``(B) submit to the State an application at such
time, in such manner, and containing such information
as the State may require.
``(2) Limitation.--A State shall use at least 40 percent of
the amount available to the State under this part for a fiscal
year to award grants to safety net trauma centers described in
paragraph (1)(A)(ii).
``(d) Use of Funds.--The recipient of a grant under subsection (b)
shall carry out 1 or more of the following activities consistent with
subsection (b):
``(1) Providing trauma centers with funding to support
physician compensation in trauma-related physician specialties
where shortages exist in the region involved, with priority
provided to safety net trauma centers described in subsection
(c)(1)(A)(ii).
``(2) Providing for individual safety net trauma center
fiscal stability and costs related to having service that is
available 24 hours a day, 7 days a week, with priority provided
to safety net trauma centers described in subsection
(c)(1)(A)(ii) located in urban, border, and rural areas.
``(3) Reducing trauma center overcrowding at specific
trauma centers related to throughput of trauma patients.
``(4) Establishing new trauma services in underserved areas
as defined by the State.
``(5) Enhancing collaboration between trauma centers and
other hospitals and emergency medical services personnel
related to trauma service availability.
``(6) Making capital improvements to enhance access and
expedite trauma care, including providing helipads and
associated safety infrastructure.
``(7) Enhancing trauma surge capacity at specific trauma
centers.
``(8) Ensuring expedient receipt of trauma patients
transported by ground or air to the appropriate trauma center.
``(9) Enhancing interstate trauma center collaboration.
``(e) Limitation.--
``(1) In general.--A State may use not more than 20 percent
of the amount available to the State under this part for a
fiscal year for administrative costs associated with awarding
grants and related costs.
``(2) Maintenance of effort.--The Secretary may not provide
funding to a State under this part unless the State agrees that
such funds will be used to supplement and not supplant State
funding otherwise available for the activities and costs
described in this part.
``(f) Distribution of Funds.--The following shall apply with
respect to grants provided in this part:
``(1) Less than $10,000,000.--If the amount of
appropriations for this part in a fiscal year is less than
$10,000,000, the Secretary shall divide such funding evenly
among only those States that have 1 or more trauma centers
eligible for funding under section 1241(b)(3)(A).
``(2) Less than $20,000,000.--If the amount of
appropriations in a fiscal year is less than $20,000,000, the
Secretary shall divide such funding evenly among only those
States that have 1 or more trauma centers eligible for funding
under subparagraphs (A) and (B) of section 1241(b)(3).
``(3) Less than $30,000,000.--If the amount of
appropriations for this part in a fiscal year is less than
$30,000,000, the Secretary shall divide such funding evenly
among only those States that have 1 or more trauma centers
eligible for funding under section 1241(b)(3).
``(4) $30,000,000 or more.--If the amount of appropriations
for this part in a fiscal year is $30,000,000 or more, the
Secretary shall divide such funding evenly among all States.
``SEC. 1282. AUTHORIZATION OF APPROPRIATIONS.
``For the purpose of carrying out this part, there is authorized to
be appropriated $100,000,000 for each of fiscal years 2010 through
2015.''.
SEC. 3506. PROGRAM TO FACILITATE SHARED DECISIONMAKING.
Part D of title IX of the Public Health Service Act, as amended by
section 3503, is further amended by adding at the end the following:
``SEC. 936. PROGRAM TO FACILITATE SHARED DECISIONMAKING.
``(a) Purpose.--The purpose of this section is to facilitate
collaborative processes between patients, caregivers or authorized
representatives, and clinicians that engages the patient, caregiver or
authorized representative in decisionmaking, provides patients,
caregivers or authorized representatives with information about trade-
offs among treatment options, and facilitates the incorporation of
patient preferences and values into the medical plan.
``(b) Definitions.--In this section:
``(1) Patient decision aid.--The term `patient decision
aid' means an educational tool that helps patients, caregivers
or authorized representatives understand and communicate their
beliefs and preferences related to their treatment options, and
to decide with their health care provider what treatments are
best for them based on their treatment options, scientific
evidence, circumstances, beliefs, and preferences.
``(2) Preference sensitive care.--The term `preference
sensitive care' means medical care for which the clinical
evidence does not clearly support one treatment option such
that the appropriate course of treatment depends on the values
of the patient or the preferences of the patient, caregivers or
authorized representatives regarding the benefits, harms and
scientific evidence for each treatment option, the use of such
care should depend on the informed patient choice among
clinically appropriate treatment options.
``(c) Establishment of Independent Standards for Patient Decision
Aids for Preference Sensitive Care.--
``(1) Contract with entity to establish standards and
certify patient decision aids.--
``(A) In general.--For purposes of supporting
consensus-based standards for patient decision aids for
preference sensitive care and a certification process
for patient decision aids for use in the Federal health
programs and by other interested parties, the Secretary
shall have in effect a contract with the entity with a
contract under section 1890 of the Social Security Act.
Such contract shall provide that the entity perform the
duties described in paragraph (2).
``(B) Timing for first contract.--As soon as
practicable after the date of the enactment of this
section, the Secretary shall enter into the first
contract under subparagraph (A).
``(C) Period of contract.--A contract under
subparagraph (A) shall be for a period of 18 months
(except such contract may be renewed after a subsequent
bidding process).
``(2) Duties.--The following duties are described in this
paragraph:
``(A) Develop and identify standards for patient
decision aids.--The entity shall synthesize evidence
and convene a broad range of experts and key
stakeholders to develop and identify consensus-based
standards to evaluate patient decision aids for
preference sensitive care.
``(B) Endorse patient decision aids.--The entity
shall review patient decision aids and develop a
certification process whether patient decision aids
meet the standards developed and identified under
subparagraph (A). The entity shall give priority to the
review and certification of patient decision aids for
preference sensitive care.
``(d) Program To Develop, Update and Patient Decision Aids To
Assist Health Care Providers and Patients.--
``(1) In general.--The Secretary, acting through the
Director, and in coordination with heads of other relevant
agencies, such as the Director of the Centers for Disease
Control and Prevention and the Director of the National
Institutes of Health, shall establish a program to award grants
or contracts--
``(A) to develop, update, and produce patient
decision aids for preference sensitive care to assist
health care providers in educating patients,
caregivers, and authorized representatives concerning
the relative safety, relative effectiveness (including
possible health outcomes and impact on functional
status), and relative cost of treatment or, where
appropriate, palliative care options;
``(B) to test such materials to ensure such
materials are balanced and evidence based in aiding
health care providers and patients, caregivers, and
authorized representatives to make informed decisions
about patient care and can be easily incorporated into
a broad array of practice settings; and
``(C) to educate providers on the use of such
materials, including through academic curricula.
``(2) Requirements for patient decision aids.--Patient
decision aids developed and produced pursuant to a grant or
contract under paragraph (1)--
``(A) shall be designed to engage patients,
caregivers, and authorized representatives in informed
decisionmaking with health care providers;
``(B) shall present up-to-date clinical evidence
about the risks and benefits of treatment options in a
form and manner that is age-appropriate and can be
adapted for patients, caregivers, and authorized
representatives from a variety of cultural and
educational backgrounds to reflect the varying needs of
consumers and diverse levels of health literacy;
``(C) shall, where appropriate, explain why there
is a lack of evidence to support one treatment option
over another; and
``(D) shall address health care decisions across
the age span, including those affecting vulnerable
populations including children.
``(3) Distribution.--The Director shall ensure that patient
decision aids produced with grants or contracts under this
section are available to the public.
``(4) Nonduplication of efforts.--The Director shall ensure
that the activities under this section of the Agency and other
agencies, including the Centers for Disease Control and
Prevention and the National Institutes of Health, are free of
unnecessary duplication of effort.
``(e) Grants To Support Shared Decisionmaking Implementation.--
``(1) In general.--The Secretary shall establish a program
to provide for the phased-in development, implementation, and
evaluation of shared decisionmaking using patient decision aids
to meet the objective of improving the understanding of
patients of their medical treatment options.
``(2) Shared decisionmaking resource centers.--
``(A) In general.--The Secretary shall provide
grants for the establishment and support of Shared
Decisionmaking Resource Centers (referred to in this
subsection as `Centers') to provide technical
assistance to providers and to develop and disseminate
best practices and other information to support and
accelerate adoption, implementation, and effective use
of patient decision aids and shared decisionmaking by
providers.
``(B) Objectives.--The objective of a Center is to
enhance and promote the adoption of patient decision
aids and shared decisionmaking through--
``(i) providing assistance to eligible
providers with the implementation and effective
use of, and training on, patient decision aids;
and
``(ii) the dissemination of best practices
and research on the implementation and
effective use of patient decision aids.
``(3) Shared decisionmaking participation grants.--
``(A) In general.--The Secretary shall provide
grants to health care providers for the development and
implementation of shared decisionmaking techniques and
to assess the use of such techniques.
``(B) Preference.--In order to facilitate the use
of best practices, the Secretary shall provide a
preference in making grants under this subsection to
health care providers who participate in training by
Shared Decisionmaking Resource Centers or comparable
training.
``(C) Limitation.--Funds under this paragraph shall
not be used to purchase or implement use of patient
decision aids other than those certified under the
process identified in subsection (c).
``(4) Guidance.--The Secretary may issue guidance to
eligible grantees under this subsection on the use of patient
decision aids.
``(f) Funding.--For purposes of carrying out this section there are
authorized to be appropriated such sums as may be necessary for fiscal
year 2010 and each subsequent fiscal year.''.
SEC. 3507. PRESENTATION OF PRESCRIPTION DRUG BENEFIT AND RISK
INFORMATION.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting through the
Commissioner of Food and Drugs, shall determine whether the addition of
quantitative summaries of the benefits and risks of prescription drugs
in a standardized format (such as a table or drug facts box) to the
promotional labeling or print advertising of such drugs would improve
health care decisionmaking by clinicians and patients and consumers.
(b) Review and Consultation.--In making the determination under
subsection (a), the Secretary shall review all available scientific
evidence and research on decisionmaking and social and cognitive
psychology and consult with drug manufacturers, clinicians, patients
and consumers, experts in health literacy, representatives of racial
and ethnic minorities, and experts in women's and pediatric health.
(c) Report.--Not later than 1 year after the date of enactment of
this Act, the Secretary shall submit to Congress a report that
provides--
(1) the determination by the Secretary under subsection
(a); and
(2) the reasoning and analysis underlying that
determination.
(d) Authority.--If the Secretary determines under subsection (a)
that the addition of quantitative summaries of the benefits and risks
of prescription drugs in a standardized format (such as a table or drug
facts box) to the promotional labeling or print advertising of such
drugs would improve health care decisionmaking by clinicians and
patients and consumers, then the Secretary, not later than 3 years
after the date of submission of the report under subsection (c), shall
promulgate proposed regulations as necessary to implement such format.
(e) Clarification.--Nothing in this section shall be construed to
restrict the existing authorities of the Secretary with respect to
benefit and risk information.
SEC. 3508. DEMONSTRATION PROGRAM TO INTEGRATE QUALITY IMPROVEMENT AND
PATIENT SAFETY TRAINING INTO CLINICAL EDUCATION OF HEALTH
PROFESSIONALS.
(a) In General.--The Secretary may award grants to eligible
entities or consortia under this section to carry out demonstration
projects to develop and implement academic curricula that integrates
quality improvement and patient safety in the clinical education of
health professionals. Such awards shall be made on a competitive basis
and pursuant to peer review.
(b) Eligibility.--To be eligible to receive a grant under
subsection (a), an entity or consortium shall--
(1) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require;
(2) be or include--
(A) a health professions school;
(B) a school of public health;
(C) a school of social work;
(D) a school of nursing;
(E) a school of pharmacy;
(F) an institution with a graduate medical
education program; or
(G) a school of health care administration;
(3) collaborate in the development of curricula described
in subsection (a) with an organization that accredits such
school or institution;
(4) provide for the collection of data regarding the
effectiveness of the demonstration project; and
(5) provide matching funds in accordance with subsection
(c).
(c) Matching Funds.--
(1) In general.--The Secretary may award a grant to an
entity or consortium under this section only if the entity or
consortium agrees to make available non-Federal contributions
toward the costs of the program to be funded under the grant in
an amount that is not less than $1 for each $5 of Federal funds
provided under the grant.
(2) Determination of amount contributed.--Non-Federal
contributions under paragraph (1) may be in cash or in-kind,
fairly evaluated, including equipment or services. Amounts
provided by the Federal Government, or services assisted or
subsidized to any significant extent by the Federal Government,
may not be included in determining the amount of such
contributions.
(d) Evaluation.--The Secretary shall take such action as may be
necessary to evaluate the projects funded under this section and
publish, make publicly available, and disseminate the results of such
evaluations on as wide a basis as is practicable.
(e) Reports.--Not later than 2 years after the date of enactment of
this section, and annually thereafter, the Secretary shall submit to
the Committee on Health, Education, Labor, and Pensions and the
Committee on Finance of the Senate and the Committee on Energy and
Commerce and the Committee on Ways and Means of the House of
Representatives a report that--
(1) describes the specific projects supported under this
section; and
(2) contains recommendations for Congress based on the
evaluation conducted under subsection (d).
SEC. 3509. IMPROVING WOMEN'S HEALTH.
(a) Health and Human Services Office on Women's Health.--
(1) Establishment.--Part A of title II of the Public Health
Service Act (42 U.S.C. 202 et seq.) is amended by adding at the
end the following:
``SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN'S HEALTH.
``(a) Establishment of Office.--There is established within the
Office of the Secretary, an Office on Women's Health (referred to in
this section as the `Office'). The Office shall be headed by a Deputy
Assistant Secretary for Women's Health who may report to the Secretary.
``(b) Duties.--The Secretary, acting through the Office, with
respect to the health concerns of women, shall--
``(1) establish short-range and long-range goals and
objectives within the Department of Health and Human Services
and, as relevant and appropriate, coordinate with other
appropriate offices on activities within the Department that
relate to disease prevention, health promotion, service
delivery, research, and public and health care professional
education, for issues of particular concern to women throughout
their lifespan;
``(2) provide expert advice and consultation to the
Secretary concerning scientific, legal, ethical, and policy
issues relating to women's health;
``(3) monitor the Department of Health and Human Services'
offices, agencies, and regional activities regarding women's
health and identify needs regarding the coordination of
activities, including intramural and extramural
multidisciplinary activities;
``(4) establish a Department of Health and Human Services
Coordinating Committee on Women's Health, which shall be
chaired by the Deputy Assistant Secretary for Women's Health
and composed of senior level representatives from each of the
agencies and offices of the Department of Health and Human
Services;
``(5) establish a National Women's Health Information
Center to--
``(A) facilitate the exchange of information
regarding matters relating to health information,
health promotion, preventive health services, research
advances, and education in the appropriate use of
health care;
``(B) facilitate access to such information;
``(C) assist in the analysis of issues and problems
relating to the matters described in this paragraph;
and
``(D) provide technical assistance with respect to
the exchange of information (including facilitating the
development of materials for such technical
assistance);
``(6) coordinate efforts to promote women's health programs
and policies with the private sector; and
``(7) through publications and any other means appropriate,
provide for the exchange of information between the Office and
recipients of grants, contracts, and agreements under
subsection (c), and between the Office and health professionals
and the general public.
``(c) Grants and Contracts Regarding Duties.--
``(1) Authority.--In carrying out subsection (b), the
Secretary may make grants to, and enter into cooperative
agreements, contracts, and interagency agreements with, public
and private entities, agencies, and organizations.
``(2) Evaluation and dissemination.--The Secretary shall
directly or through contracts with public and private entities,
agencies, and organizations, provide for evaluations of
projects carried out with financial assistance provided under
paragraph (1) and for the dissemination of information
developed as a result of such projects.
``(d) Reports.--Not later than 1 year after the date of enactment
of this section, and every second year thereafter, the Secretary shall
prepare and submit to the appropriate committees of Congress a report
describing the activities carried out under this section during the
period for which the report is being prepared.
``(e) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2010 through 2014.''.
(2) Transfer of functions.--There are transferred to the
Office on Women's Health (established under section 229 of the
Public Health Service Act, as added by this section), all
functions exercised by the Office on Women's Health of the
Public Health Service prior to the date of enactment of this
section, including all personnel and compensation authority,
all delegation and assignment authority, and all remaining
appropriations. All orders, determinations, rules, regulations,
permits, agreements, grants, contracts, certificates, licenses,
registrations, privileges, and other administrative actions
that--
(A) have been issued, made, granted, or allowed to
become effective by the President, any Federal agency
or official thereof, or by a court of competent
jurisdiction, in the performance of functions
transferred under this paragraph; and
(B) are in effect at the time this section takes
effect, or were final before the date of enactment of
this section and are to become effective on or after
such date,
shall continue in effect according to their terms until
modified, terminated, superseded, set aside, or revoked in
accordance with law by the President, the Secretary, or other
authorized official, a court of competent jurisdiction, or by
operation of law.
(b) Centers for Disease Control and Prevention Office of Women's
Health.--Part A of title III of the Public Health Service Act (42
U.S.C. 241 et seq.) is amended by adding at the end the following:
``SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION OFFICE OF
WOMEN'S HEALTH.
``(a) Establishment.--There is established within the Office of the
Director of the Centers for Disease Control and Prevention, an office
to be known as the Office of Women's Health (referred to in this
section as the `Office'). The Office shall be headed by a director who
shall be appointed by the Director of such Centers.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Director of the Centers for Disease
Control and Prevention on the current level of the Centers'
activity regarding women's health conditions across, where
appropriate, age, biological, and sociocultural contexts, in
all aspects of the Centers' work, including prevention
programs, public and professional education, services, and
treatment;
``(2) establish short-range and long-range goals and
objectives within the Centers for women's health and, as
relevant and appropriate, coordinate with other appropriate
offices on activities within the Centers that relate to
prevention, research, education and training, service delivery,
and policy development, for issues of particular concern to
women;
``(3) identify projects in women's health that should be
conducted or supported by the Centers;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on the policy of the Centers with regard to women;
and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4)).
``(c) Definition.--As used in this section, the term `women's
health conditions', with respect to women of all age, ethnic, and
racial groups, means diseases, disorders, and conditions--
``(1) unique to, significantly more serious for, or
significantly more prevalent in women; and
``(2) for which the factors of medical risk or type of
medical intervention are different for women, or for which
there is reasonable evidence that indicates that such factors
or types may be different for women.
``(d) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2010 through 2014.''.
(c) Office of Women's Health Research.--Section 486(a) of the
Public Health Service Act (42 U.S.C. 287d(a)) is amended by inserting
``and who shall report directly to the Director'' before the period at
the end thereof.
(d) Substance Abuse and Mental Health Services Administration.--
Section 501(f) of the Public Health Service Act (42 U.S.C. 290aa(f)) is
amended--
(1) in paragraph (1), by inserting ``who shall report
directly to the Administrator'' before the period;
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3), the following:
``(4) Office.--Nothing in this subsection shall be
construed to preclude the Secretary from establishing within
the Substance Abuse and Mental Health Administration an Office
of Women's Health.''.
(e) Agency for Healthcare Research and Quality Activities Regarding
Women's Health.--Part C of title IX of the Public Health Service Act
(42 U.S.C. 299c et seq.) is amended--
(1) by redesignating sections 925 and 926 as sections 926
and 927, respectively; and
(2) by inserting after section 924 the following:
``SEC. 925. ACTIVITIES REGARDING WOMEN'S HEALTH.
``(a) Establishment.--There is established within the Office of the
Director, an Office of Women's Health and Gender-Based Research
(referred to in this section as the `Office'). The Office shall be
headed by a director who shall be appointed by the Director of
Healthcare and Research Quality.
``(b) Purpose.--The official designated under subsection (a)
shall--
``(1) report to the Director on the current Agency level of
activity regarding women's health, across, where appropriate,
age, biological, and sociocultural contexts, in all aspects of
Agency work, including the development of evidence reports and
clinical practice protocols and the conduct of research into
patient outcomes, delivery of health care services, quality of
care, and access to health care;
``(2) establish short-range and long-range goals and
objectives within the Agency for research important to women's
health and, as relevant and appropriate, coordinate with other
appropriate offices on activities within the Agency that relate
to health services and medical effectiveness research, for
issues of particular concern to women;
``(3) identify projects in women's health that should be
conducted or supported by the Agency;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on Agency policy with regard to women; and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4)).''.
``(c) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2010 through 2014.''.
(f) Health Resources and Services Administration Office of Women's
Health.--Title VII of the Social Security Act (42 U.S.C. 901 et seq.)
is amended by adding at the end the following:
``SEC. 713. OFFICE OF WOMEN'S HEALTH.
``(a) Establishment.--The Secretary shall establish within the
Office of the Administrator of the Health Resources and Services
Administration, an office to be known as the Office of Women's Health.
The Office shall be headed by a director who shall be appointed by the
Administrator.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Administrator on the current
Administration level of activity regarding women's health
across, where appropriate, age, biological, and sociocultural
contexts;
``(2) establish short-range and long-range goals and
objectives within the Health Resources and Services
Administration for women's health and, as relevant and
appropriate, coordinate with other appropriate offices on
activities within the Administration that relate to health care
provider training, health service delivery, research, and
demonstration projects, for issues of particular concern to
women;
``(3) identify projects in women's health that should be
conducted or supported by the bureaus of the Administration;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on Administration policy with regard to women; and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4) of the Public Health
Service Act).
``(c) Continued Administration of Existing Programs.--The Director
of the Office shall assume the authority for the development,
implementation, administration, and evaluation of any projects carried
out through the Health Resources and Services Administration relating
to women's health on the date of enactment of this section.
``(d) Definitions.--For purposes of this section:
``(1) Administration.--The term `Administration' means the
Health Resources and Services Administration.
``(2) Administrator.--The term `Administrator' means the
Administrator of the Health Resources and Services
Administration.
``(3) Office.--The term `Office' means the Office of
Women's Health established under this section in the
Administration.
``(e) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2010 through 2014.''.
(g) Food and Drug Administration Office of Women's Health.--Chapter
X of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 391 et seq.)
is amended by adding at the end the following:
``SEC. 1011. OFFICE OF WOMEN'S HEALTH.
``(a) Establishment.--There is established within the Office of the
Commissioner, an office to be known as the Office of Women's Health
(referred to in this section as the `Office'). The Office shall be
headed by a director who shall be appointed by the Commissioner of Food
and Drugs.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Commissioner of Food and Drugs on
current Food and Drug Administration (referred to in this
section as the `Administration') levels of activity regarding
women's participation in clinical trials and the analysis of
data by sex in the testing of drugs, medical devices, and
biological products across, where appropriate, age, biological,
and sociocultural contexts;
``(2) establish short-range and long-range goals and
objectives within the Administration for issues of particular
concern to women's health within the jurisdiction of the
Administration, including, where relevant and appropriate,
adequate inclusion of women and analysis of data by sex in
Administration protocols and policies;
``(3) provide information to women and health care
providers on those areas in which differences between men and
women exist;
``(4) consult with pharmaceutical, biologics, and device
manufacturers, health professionals with expertise in women's
issues, consumer organizations, and women's health
professionals on Administration policy with regard to women;
``(5) make annual estimates of funds needed to monitor
clinical trials and analysis of data by sex in accordance with
needs that are identified; and
``(6) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4) of the Public Health
Service Act).
``(c) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2010 through 2014.''.
(h) No New Regulatory Authority.--Nothing in this section and the
amendments made by this section may be construed as establishing
regulatory authority or modifying any existing regulatory authority.
(i) Limitation on Termination.--Notwithstanding any other provision
of law, a Federal office of women's health (including the Office of
Research on Women's Health of the National Institutes of Health) or
Federal appointive position with primary responsibility over women's
health issues (including the Associate Administrator for Women's
Services under the Substance Abuse and Mental Health Services
Administration) that is in existence on the date of enactment of this
section shall not be terminated, reorganized, or have any of it's
powers or duties transferred unless such termination, reorganization,
or transfer is approved by Congress through the adoption of a
concurrent resolution of approval.
(j) Rule of Construction.--Nothing in this section (or the
amendments made by this section) shall be construed to limit the
authority of the Secretary of Health and Human Services with respect to
women's health, or with respect to activities carried out through the
Department of Health and Human Services on the date of enactment of
this section.
SEC. 3510. PATIENT NAVIGATOR PROGRAM.
Section 340A of the Public Health Service Act (42 U.S.C. 256a) is
amended--
(1) by striking subsection (d)(3) and inserting the
following:
``(3) Limitations on grant period.--In carrying out this
section, the Secretary shall ensure that the total period of a
grant does not exceed 4 years.'';
(2) in subsection (e), by adding at the end the following:
``(3) Minimum core proficiencies.--The Secretary shall not
award a grant to an entity under this section unless such
entity provides assurances that patient navigators recruited,
assigned, trained, or employed using grant funds meet minimum
core proficiencies, as defined by the entity that submits the
application, that are tailored for the main focus or
intervention of the navigator involved.''; and
(3) in subsection (m)--
(A) in paragraph (1), by striking ``and $3,500,000
for fiscal year 2010.'' and inserting ``$3,500,000 for
fiscal year 2010, and such sums as may be necessary for
each of fiscal years 2011 through 2015.''; and
(B) in paragraph (2), by striking ``2010'' and
inserting ``2015''.
SEC. 3511. AUTHORIZATION OF APPROPRIATIONS.
Except where otherwise provided in this subtitle (or an amendment
made by this subtitle), there is authorized to be appropriated such
sums as may be necessary to carry out this subtitle (and such
amendments made by this subtitle).
Subtitle G--Protecting and Improving Guaranteed Medicare Benefits
SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE BENEFITS.
(a) Protecting Guaranteed Medicare Benefits.--Nothing in the
provisions of, or amendments made by, this Act shall result in a
reduction of guaranteed benefits under title XVIII of the Social
Security Act.
(b) Ensuring That Medicare Savings Benefit the Medicare Program and
Medicare Beneficiaries.--Savings generated for the Medicare program
under title XVIII of the Social Security Act under the provisions of,
and amendments made by, this Act shall extend the solvency of the
Medicare trust funds, reduce Medicare premiums and other cost-sharing
for beneficiaries, and improve or expand guaranteed Medicare benefits
and protect access to Medicare providers.
December 24, 2009
Ordered to be printed as passed
In the Senate of the United States,
December 24, 2009.
Resolved, That the bill from the House of Representatives (H.R.
3590) entitled ``An Act to amend the Internal Revenue Code of 1986 to
modify the first-time homebuyers credit in the case of members of the
Armed Forces and certain other Federal employees, and for other
purposes.'', do pass with the following
AMENDMENTS:
Strike out all after the enacting clause and insert:
SEC. 3602. NO CUTS IN GUARANTEED BENEFITS.
Nothing in this Act shall result in the reduction or elimination of
any benefits guaranteed by law to participants in Medicare Advantage
plans.
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH
COUNCIL.
(a) Establishment.--The President shall establish, within the
Department of Health and Human Services, a council to be known as the
``National Prevention, Health Promotion and Public Health Council''
(referred to in this section as the ``Council'').
(b) Chairperson.--The President shall appoint the Surgeon General
to serve as the chairperson of the Council.
(c) Composition.--The Council shall be composed of--
(1) the Secretary of Health and Human Services;
(2) the Secretary of Agriculture;
(3) the Secretary of Education;
(4) the Chairman of the Federal Trade Commission;
(5) the Secretary of Transportation;
(6) the Secretary of Labor;
(7) the Secretary of Homeland Security;
(8) the Administrator of the Environmental Protection
Agency;
(9) the Director of the Office of National Drug Control
Policy;
(10) the Director of the Domestic Policy Council;
(11) the Assistant Secretary for Indian Affairs;
(12) the Chairman of the Corporation for National and
Community Service; and
(13) the head of any other Federal agency that the
chairperson determines is appropriate.
(d) Purposes and Duties.--The Council shall--
(1) provide coordination and leadership at the Federal
level, and among all Federal departments and agencies, with
respect to prevention, wellness and health promotion practices,
the public health system, and integrative health care in the
United States;
(2) after obtaining input from relevant stakeholders,
develop a national prevention, health promotion, public health,
and integrative health care strategy that incorporates the most
effective and achievable means of improving the health status
of Americans and reducing the incidence of preventable illness
and disability in the United States;
(3) provide recommendations to the President and Congress
concerning the most pressing health issues confronting the
United States and changes in Federal policy to achieve national
wellness, health promotion, and public health goals, including
the reduction of tobacco use, sedentary behavior, and poor
nutrition;
(4) consider and propose evidence-based models, policies,
and innovative approaches for the promotion of transformative
models of prevention, integrative health, and public health on
individual and community levels across the United States;
(5) establish processes for continual public input,
including input from State, regional, and local leadership
communities and other relevant stakeholders, including Indian
tribes and tribal organizations;
(6) submit the reports required under subsection (g); and
(7) carry out other activities determined appropriate by
the President.
(e) Meetings.--The Council shall meet at the call of the
Chairperson.
(f) Advisory Group.--
(1) In general.--The President shall establish an Advisory
Group to the Council to be known as the ``Advisory Group on
Prevention, Health Promotion, and Integrative and Public
Health'' (hereafter referred to in this section as the
``Advisory Group''). The Advisory Group shall be within the
Department of Health and Human Services and report to the
Surgeon General.
(2) Composition.--
(A) In general.--The Advisory Group shall be
composed of not more than 25 non-Federal members to be
appointed by the President.
(B) Representation.--In appointing members under
subparagraph (A), the President shall ensure that the
Advisory Group includes a diverse group of licensed
health professionals, including integrative health
practitioners who have expertise in--
(i) worksite health promotion;
(ii) community services, including
community health centers;
(iii) preventive medicine;
(iv) health coaching;
(v) public health education;
(vi) geriatrics; and
(vii) rehabilitation medicine.
(3) Purposes and duties.--The Advisory Group shall develop
policy and program recommendations and advise the Council on
lifestyle-based chronic disease prevention and management,
integrative health care practices, and health promotion.
(g) National Prevention and Health Promotion Strategy.--Not later
than 1 year after the date of enactment of this Act, the Chairperson,
in consultation with the Council, shall develop and make public a
national prevention, health promotion and public health strategy, and
shall review and revise such strategy periodically. Such strategy
shall--
(1) set specific goals and objectives for improving the
health of the United States through federally-supported
prevention, health promotion, and public health programs,
consistent with ongoing goal setting efforts conducted by
specific agencies;
(2) establish specific and measurable actions and timelines
to carry out the strategy, and determine accountability for
meeting those timelines, within and across Federal departments
and agencies; and
(3) make recommendations to improve Federal efforts
relating to prevention, health promotion, public health, and
integrative health care practices to ensure Federal efforts are
consistent with available standards and evidence.
(h) Report.--Not later than July 1, 2010, and annually thereafter
through January 1, 2015, the Council shall submit to the President and
the relevant committees of Congress, a report that--
(1) describes the activities and efforts on prevention,
health promotion, and public health and activities to develop a
national strategy conducted by the Council during the period
for which the report is prepared;
(2) describes the national progress in meeting specific
prevention, health promotion, and public health goals defined
in the strategy and further describes corrective actions
recommended by the Council and taken by relevant agencies and
organizations to meet these goals;
(3) contains a list of national priorities on health
promotion and disease prevention to address lifestyle behavior
modification (smoking cessation, proper nutrition, appropriate
exercise, mental health, behavioral health, substance use
disorder, and domestic violence screenings) and the prevention
measures for the 5 leading disease killers in the United
States;
(4) contains specific science-based initiatives to achieve
the measurable goals of Healthy People 2010 regarding
nutrition, exercise, and smoking cessation, and targeting the 5
leading disease killers in the United States;
(5) contains specific plans for consolidating Federal
health programs and Centers that exist to promote healthy
behavior and reduce disease risk (including eliminating
programs and offices determined to be ineffective in meeting
the priority goals of Healthy People 2010);
(6) contains specific plans to ensure that all Federal
health care programs are fully coordinated with science-based
prevention recommendations by the Director of the Centers for
Disease Control and Prevention; and
(7) contains specific plans to ensure that all non-
Department of Health and Human Services prevention programs are
based on the science-based guidelines developed by the Centers
for Disease Control and Prevention under paragraph (4).
(i) Periodic Reviews.--The Secretary and the Comptroller General of
the United States shall jointly conduct periodic reviews, not less than
every 5 years, and evaluations of every Federal disease prevention and
health promotion initiative, program, and agency. Such reviews shall be
evaluated based on effectiveness in meeting metrics-based goals with an
analysis posted on such agencies' public Internet websites.
SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND.
(a) Purpose.--It is the purpose of this section to establish a
Prevention and Public Health Fund (referred to in this section as the
``Fund''), to be administered through the Department of Health and
Human Services, Office of the Secretary, to provide for expanded and
sustained national investment in prevention and public health programs
to improve health and help restrain the rate of growth in private and
public sector health care costs.
(b) Funding.--There are hereby authorized to be appropriated, and
appropriated, to the Fund, out of any monies in the Treasury not
otherwise appropriated--
(1) for fiscal year 2010, $500,000,000;
(2) for fiscal year 2011, $750,000,000;
(3) for fiscal year 2012, $1,000,000,000;
(4) for fiscal year 2013, $1,250,000,000;
(5) for fiscal year 2014, $1,500,000,000; and
(6) for fiscal year 2015, and each fiscal year thereafter,
$2,000,000,000.
(c) Use of Fund.--The Secretary shall transfer amounts in the Fund
to accounts within the Department of Health and Human Services to
increase funding, over the fiscal year 2008 level, for programs
authorized by the Public Health Service Act, for prevention, wellness,
and public health activities including prevention research and health
screenings, such as the Community Transformation grant program, the
Education and Outreach Campaign for Preventive Benefits, and
immunization programs.
(d) Transfer Authority.--The Committee on Appropriations of the
Senate and the Committee on Appropriations of the House of
Representatives may provide for the transfer of funds in the Fund to
eligible activities under this section, subject to subsection (c).
SEC. 4003. CLINICAL AND COMMUNITY PREVENTIVE SERVICES.
(a) Preventive Services Task Force.--Section 915 of the Public
Health Service Act (42 U.S.C. 299b-4) is amended by striking subsection
(a) and inserting the following:
``(a) Preventive Services Task Force.--
``(1) Establishment and purpose.--The Director shall
convene an independent Preventive Services Task Force (referred
to in this subsection as the `Task Force') to be composed of
individuals with appropriate expertise. Such Task Force shall
review the scientific evidence related to the effectiveness,
appropriateness, and cost-effectiveness of clinical preventive
services for the purpose of developing recommendations for the
health care community, and updating previous clinical
preventive recommendations, to be published in the Guide to
Clinical Preventive Services (referred to in this section as
the `Guide'), for individuals and organizations delivering
clinical services, including primary care professionals, health
care systems, professional societies, employers, community
organizations, non-profit organizations, Congress and other
policy-makers, governmental public health agencies, health care
quality organizations, and organizations developing national
health objectives. Such recommendations shall consider clinical
preventive best practice recommendations from the Agency for
Healthcare Research and Quality, the National Institutes of
Health, the Centers for Disease Control and Prevention, the
Institute of Medicine, specialty medical associations, patient
groups, and scientific societies.
``(2) Duties.--The duties of the Task Force shall include--
``(A) the development of additional topic areas for
new recommendations and interventions related to those
topic areas, including those related to specific sub-
populations and age groups;
``(B) at least once during every 5-year period,
review interventions and update recommendations related
to existing topic areas, including new or improved
techniques to assess the health effects of
interventions;
``(C) improved integration with Federal Government
health objectives and related target setting for health
improvement;
``(D) the enhanced dissemination of
recommendations;
``(E) the provision of technical assistance to
those health care professionals, agencies and
organizations that request help in implementing the
Guide recommendations; and
``(F) the submission of yearly reports to Congress
and related agencies identifying gaps in research, such
as preventive services that receive an insufficient
evidence statement, and recommending priority areas
that deserve further examination, including areas
related to populations and age groups not adequately
addressed by current recommendations.
``(3) Role of agency.--The Agency shall provide ongoing
administrative, research, and technical support for the
operations of the Task Force, including coordinating and
supporting the dissemination of the recommendations of the Task
Force, ensuring adequate staff resources, and assistance to
those organizations requesting it for implementation of the
Guide's recommendations.
``(4) Coordination with community preventive services task
force.--The Task Force shall take appropriate steps to
coordinate its work with the Community Preventive Services Task
Force and the Advisory Committee on Immunization Practices,
including the examination of how each task force's
recommendations interact at the nexus of clinic and community.
``(5) Operation.--Operation. In carrying out the duties
under paragraph (2), the Task Force is not subject to the
provisions of Appendix 2 of title 5, United States Code.
``(6) Independence.--All members of the Task Force convened
under this subsection, and any recommendations made by such
members, shall be independent and, to the extent practicable,
not subject to political pressure.
``(7) Authorization of appropriations.--There are
authorized to be appropriated such sums as may be necessary for
each fiscal year to carry out the activities of the Task
Force.''.
(b) Community Preventive Services Task Force.--
(1) In general.--Part P of title III of the Public Health
Service Act, as amended by paragraph (2), is amended by adding
at the end the following:
``SEC. 399U. COMMUNITY PREVENTIVE SERVICES TASK FORCE.
``(a) Establishment and Purpose.--The Director of the Centers for
Disease Control and Prevention shall convene an independent Community
Preventive Services Task Force (referred to in this subsection as the
`Task Force') to be composed of individuals with appropriate expertise.
Such Task Force shall review the scientific evidence related to the
effectiveness, appropriateness, and cost-effectiveness of community
preventive interventions for the purpose of developing recommendations,
to be published in the Guide to Community Preventive Services (referred
to in this section as the `Guide'), for individuals and organizations
delivering population-based services, including primary care
professionals, health care systems, professional societies, employers,
community organizations, non-profit organizations, schools,
governmental public health agencies, Indian tribes, tribal
organizations and urban Indian organizations, medical groups, Congress
and other policy-makers. Community preventive services include any
policies, programs, processes or activities designed to affect or
otherwise affecting health at the population level.
``(b) Duties.--The duties of the Task Force shall include--
``(1) the development of additional topic areas for new
recommendations and interventions related to those topic areas,
including those related to specific populations and age groups,
as well as the social, economic and physical environments that
can have broad effects on the health and disease of populations
and health disparities among sub-populations and age groups;
``(2) at least once during every 5-year period, review
interventions and update recommendations related to existing
topic areas, including new or improved techniques to assess the
health effects of interventions, including health impact
assessment and population health modeling;
``(3) improved integration with Federal Government health
objectives and related target setting for health improvement;
``(4) the enhanced dissemination of recommendations;
``(5) the provision of technical assistance to those health
care professionals, agencies, and organizations that request
help in implementing the Guide recommendations; and
``(6) providing yearly reports to Congress and related
agencies identifying gaps in research and recommending priority
areas that deserve further examination, including areas related
to populations and age groups not adequately addressed by
current recommendations.
``(c) Role of Agency.--The Director shall provide ongoing
administrative, research, and technical support for the operations of
the Task Force, including coordinating and supporting the dissemination
of the recommendations of the Task Force, ensuring adequate staff
resources, and assistance to those organizations requesting it for
implementation of Guide recommendations.
``(d) Coordination With Preventive Services Task Force.--The Task
Force shall take appropriate steps to coordinate its work with the U.S.
Preventive Services Task Force and the Advisory Committee on
Immunization Practices, including the examination of how each task
force's recommendations interact at the nexus of clinic and community.
``(e) Operation.--In carrying out the duties under subsection (b),
the Task Force shall not be subject to the provisions of Appendix 2 of
title 5, United States Code.
``(f) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary for each fiscal year to
carry out the activities of the Task Force.''.
(2) Technical amendments.--
(A) Section 399R of the Public Health Service Act
(as added by section 2 of the ALS Registry Act (Public
Law 110-373; 122 Stat. 4047)) is redesignated as
section 399S.
(B) Section 399R of such Act (as added by section 3
of the Prenatally and Postnatally Diagnosed Conditions
Awareness Act (Public Law 110-374; 122 Stat. 4051)) is
redesignated as section 399T.
SEC. 4004. EDUCATION AND OUTREACH CAMPAIGN REGARDING PREVENTIVE
BENEFITS.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall provide for
the planning and implementation of a national public-private
partnership for a prevention and health promotion outreach and
education campaign to raise public awareness of health improvement
across the life span. Such campaign shall include the dissemination of
information that--
(1) describes the importance of utilizing preventive
services to promote wellness, reduce health disparities, and
mitigate chronic disease;
(2) promotes the use of preventive services recommended by
the United States Preventive Services Task Force and the
Community Preventive Services Task Force;
(3) encourages healthy behaviors linked to the prevention
of chronic diseases;
(4) explains the preventive services covered under health
plans offered through a Gateway;
(5) describes additional preventive care supported by the
Centers for Disease Control and Prevention, the Health
Resources and Services Administration, the Substance Abuse and
Mental Health Services Administration, the Advisory Committee
on Immunization Practices, and other appropriate agencies; and
(6) includes general health promotion information.
(b) Consultation.--In coordinating the campaign under subsection
(a), the Secretary shall consult with the Institute of Medicine to
provide ongoing advice on evidence-based scientific information for
policy, program development, and evaluation.
(c) Media Campaign.--
(1) In general.--Not later than 1 year after the date of
enactment of this Act, the Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish and implement a national science-based media
campaign on health promotion and disease prevention.
(2) Requirement of campaign.--The campaign implemented
under paragraph (1)--
(A) shall be designed to address proper nutrition,
regular exercise, smoking cessation, obesity reduction,
the 5 leading disease killers in the United States, and
secondary prevention through disease screening
promotion;
(B) shall be carried out through competitively bid
contracts awarded to entities providing for the
professional production and design of such campaign;
(C) may include the use of television, radio,
Internet, and other commercial marketing venues and may
be targeted to specific age groups based on peer-
reviewed social research;
(D) shall not be duplicative of any other Federal
efforts relating to health promotion and disease
prevention; and
(E) may include the use of humor and nationally
recognized positive role models.
(3) Evaluation.--The Secretary shall ensure that the
campaign implemented under paragraph (1) is subject to an
independent evaluation every 2 years and shall report every 2
years to Congress on the effectiveness of such campaigns
towards meeting science-based metrics.
(d) Website.--The Secretary, in consultation with private-sector
experts, shall maintain or enter into a contract to maintain an
Internet website to provide science-based information on guidelines for
nutrition, regular exercise, obesity reduction, smoking cessation, and
specific chronic disease prevention. Such website shall be designed to
provide information to health care providers and consumers.
(e) Dissemination of Information Through Providers.--The Secretary,
acting through the Centers for Disease Control and Prevention, shall
develop and implement a plan for the dissemination of health promotion
and disease prevention information consistent with national priorities,
to health care providers who participate in Federal programs, including
programs administered by the Indian Health Service, the Department of
Veterans Affairs, the Department of Defense, and the Health Resources
and Services Administration, and Medicare and Medicaid.
(f) Personalized Prevention Plans.--
(1) Contract.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention, shall enter
into a contract with a qualified entity for the development and
operation of a Federal Internet website personalized prevention
plan tool.
(2) Use.--The website developed under paragraph (1) shall
be designed to be used as a source of the most up-to-date
scientific evidence relating to disease prevention for use by
individuals. Such website shall contain a component that
enables an individual to determine their disease risk (based on
personal health and family history, BMI, and other relevant
information) relating to the 5 leading diseases in the United
States, and obtain personalized suggestions for preventing such
diseases.
(g) Internet Portal.--The Secretary shall establish an Internet
portal for accessing risk-assessment tools developed and maintained by
private and academic entities.
(h) Priority Funding.--Funding for the activities authorized under
this section shall take priority over funding provided through the
Centers for Disease Control and Prevention for grants to States and
other entities for similar purposes and goals as provided for in this
section. Not to exceed $500,000,000 shall be expended on the campaigns
and activities required under this section.
(i) Public Awareness of Preventive and Obesity-related Services.--
(1) Information to states.--The Secretary of Health and
Human Services shall provide guidance and relevant information
to States and health care providers regarding preventive and
obesity-related services that are available to Medicaid
enrollees, including obesity screening and counseling for
children and adults.
(2) Information to enrollees.--Each State shall design a
public awareness campaign to educate Medicaid enrollees
regarding availability and coverage of such services, with the
goal of reducing incidences of obesity.
(3) Report.--Not later than January 1, 2011, and every 3
years thereafter through January 1, 2017, the Secretary of
Health and Human Services shall report to Congress on the
status and effectiveness of efforts under paragraphs (1) and
(2), including summaries of the States' efforts to increase
awareness of coverage of obesity-related services.
(j) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary to carry out this section.
Subtitle B--Increasing Access to Clinical Preventive Services
SEC. 4101. SCHOOL-BASED HEALTH CENTERS.
(a) Grants for the Establishment of School-based Health Centers.--
(1) Program.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish a program to award grants to eligible entities to
support the operation of school-based health centers.
(2) Eligibility.--To be eligible for a grant under this
subsection, an entity shall--
(A) be a school-based health center or a sponsoring
facility of a school-based health center; and
(B) submit an application at such time, in such
manner, and containing such information as the
Secretary may require, including at a minimum an
assurance that funds awarded under the grant shall not
be used to provide any service that is not authorized
or allowed by Federal, State, or local law.
(3) Preference.--In awarding grants under this section, the
Secretary shall give preference to awarding grants for school-
based health centers that serve a large population of children
eligible for medical assistance under the State Medicaid plan
under title XIX of the Social Security Act or under a waiver of
such plan or children eligible for child health assistance
under the State child health plan under title XXI of that Act
(42 U.S.C. 1397aa et seq.).
(4) Limitation on use of funds.--An eligible entity shall
use funds provided under a grant awarded under this subsection
only for expenditures for facilities (including the acquisition
or improvement of land, or the acquisition, construction,
expansion, replacement, or other improvement of any building or
other facility), equipment, or similar expenditures, as
specified by the Secretary. No funds provided under a grant
awarded under this section shall be used for expenditures for
personnel or to provide health services.
(5) Appropriations.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated for each of
fiscal years 2010 through 2013, $50,000,000 for the purpose of
carrying out this subsection. Funds appropriated under this
paragraph shall remain available until expended.
(6) Definitions.--In this subsection, the terms ``school-
based health center'' and ``sponsoring facility'' have the
meanings given those terms in section 2110(c)(9) of the Social
Security Act (42 U.S.C. 1397jj(c)(9)).
(b) Grants for the Operation of School-based Health Centers.--Part
Q of title III of the Public Health Service Act (42 U.S.C. 280h et
seq.) is amended by adding at the end the following:
``SEC. 399Z-1. SCHOOL-BASED HEALTH CENTERS.
``(a) Definitions; Establishment of Criteria.--In this section:
``(1) Comprehensive primary health services.--The term
`comprehensive primary health services' means the core services
offered by school-based health centers, which shall include the
following:
``(A) Physical.--Comprehensive health assessments,
diagnosis, and treatment of minor, acute, and chronic
medical conditions, and referrals to, and follow-up
for, specialty care and oral health services.
``(B) Mental health.--Mental health and substance
use disorder assessments, crisis intervention,
counseling, treatment, and referral to a continuum of
services including emergency psychiatric care,
community support programs, inpatient care, and
outpatient programs.
``(2) Medically underserved children and adolescents.--
``(A) In general.--The term `medically underserved
children and adolescents' means a population of
children and adolescents who are residents of an area
designated as a medically underserved area or a health
professional shortage area by the Secretary.
``(B) Criteria.--The Secretary shall prescribe
criteria for determining the specific shortages of
personal health services for medically underserved
children and adolescents under subparagraph (A) that
shall--
``(i) take into account any comments
received by the Secretary from the chief
executive officer of a State and local
officials in a State; and
``(ii) include factors indicative of the
health status of such children and adolescents
of an area, including the ability of the
residents of such area to pay for health
services, the accessibility of such services,
the availability of health professionals to
such children and adolescents, and other
factors as determined appropriate by the
Secretary.
``(3) School-based health center.--The term `school-based
health center' means a health clinic that--
``(A) meets the definition of a school-based health
center under section 2110(c)(9)(A) of the Social
Security Act and is administered by a sponsoring
facility (as defined in section 2110(c)(9)(B) of the
Social Security Act);
``(B) provides, at a minimum, comprehensive primary
health services during school hours to children and
adolescents by health professionals in accordance with
established standards, community practice, reporting
laws, and other State laws, including parental consent
and notification laws that are not inconsistent with
Federal law; and
``(C) does not perform abortion services.
``(b) Authority To Award Grants.--The Secretary shall award grants
for the costs of the operation of school-based health centers (referred
to in this section as `SBHCs') that meet the requirements of this
section.
``(c) Applications.--To be eligible to receive a grant under this
section, an entity shall--
``(1) be an SBHC (as defined in subsection (a)(3)); and
``(2) submit to the Secretary an application at such time,
in such manner, and containing--
``(A) evidence that the applicant meets all
criteria necessary to be designated an SBHC;
``(B) evidence of local need for the services to be
provided by the SBHC;
``(C) an assurance that--
``(i) SBHC services will be provided to
those children and adolescents for whom
parental or guardian consent has been obtained
in cooperation with Federal, State, and local
laws governing health care service provision to
children and adolescents;
``(ii) the SBHC has made and will continue
to make every reasonable effort to establish
and maintain collaborative relationships with
other health care providers in the catchment
area of the SBHC;
``(iii) the SBHC will provide on-site
access during the academic day when school is
in session and 24-hour coverage through an on-
call system and through its backup health
providers to ensure access to services on a
year-round basis when the school or the SBHC is
closed;
``(iv) the SBHC will be integrated into the
school environment and will coordinate health
services with school personnel, such as
administrators, teachers, nurses, counselors,
and support personnel, as well as with other
community providers co-located at the school;
``(v) the SBHC sponsoring facility assumes
all responsibility for the SBHC administration,
operations, and oversight; and
``(vi) the SBHC will comply with Federal,
State, and local laws concerning patient
privacy and student records, including
regulations promulgated under the Health
Insurance Portability and Accountability Act of
1996 and section 444 of the General Education
Provisions Act; and
``(D) such other information as the Secretary may
require.
``(d) Preferences and Consideration.--In reviewing applications:
``(1) The Secretary may give preference to applicants who
demonstrate an ability to serve the following:
``(A) Communities that have evidenced barriers to
primary health care and mental health and substance use
disorder prevention services for children and
adolescents.
``(B) Communities with high per capita numbers of
children and adolescents who are uninsured,
underinsured, or enrolled in public health insurance
programs.
``(C) Populations of children and adolescents that
have historically demonstrated difficulty in accessing
health and mental health and substance use disorder
prevention services.
``(2) The Secretary may give consideration to whether an
applicant has received a grant under subsection (a) of section
4101 of the Patient Protection and Affordable Care Act.
``(e) Waiver of Requirements.--The Secretary may--
``(1) under appropriate circumstances, waive the
application of all or part of the requirements of this
subsection with respect to an SBHC for not to exceed 2 years;
and
``(2) upon a showing of good cause, waive the requirement
that the SBHC provide all required comprehensive primary health
services for a designated period of time to be determined by
the Secretary.
``(f) Use of Funds.--
``(1) Funds.--Funds awarded under a grant under this
section--
``(A) may be used for--
``(i) acquiring and leasing equipment
(including the costs of amortizing the
principle of, and paying interest on, loans for
such equipment);
``(ii) providing training related to the
provision of required comprehensive primary
health services and additional health services;
``(iii) the management and operation of
health center programs;
``(iv) the payment of salaries for
physicians, nurses, and other personnel of the
SBHC; and
``(B) may not be used to provide abortions.
``(2) Construction.--The Secretary may award grants which
may be used to pay the costs associated with expanding and
modernizing existing buildings for use as an SBHC, including
the purchase of trailers or manufactured buildings to install
on the school property.
``(3) Limitations.--
``(A) In general.--Any provider of services that is
determined by a State to be in violation of a State law
described in subsection (a)(3)(B) with respect to
activities carried out at a SBHC shall not be eligible
to receive additional funding under this section.
``(B) No overlapping grant period.--No entity that
has received funding under section 330 for a grant
period shall be eligible for a grant under this section
for with respect to the same grant period.
``(g) Matching Requirement.--
``(1) In general.--Each eligible entity that receives a
grant under this section shall provide, from non-Federal
sources, an amount equal to 20 percent of the amount of the
grant (which may be provided in cash or in-kind) to carry out
the activities supported by the grant.
``(2) Waiver.--The Secretary may waive all or part of the
matching requirement described in paragraph (1) for any fiscal
year for the SBHC if the Secretary determines that applying the
matching requirement to the SBHC would result in serious
hardship or an inability to carry out the purposes of this
section.
``(h) Supplement, Not Supplant.--Grant funds provided under this
section shall be used to supplement, not supplant, other Federal or
State funds.
``(i) Evaluation.--The Secretary shall develop and implement a plan
for evaluating SBHCs and monitoring quality performance under the
awards made under this section.
``(j) Age Appropriate Services.--An eligible entity receiving funds
under this section shall only provide age appropriate services through
a SBHC funded under this section to an individual.
``(k) Parental Consent.--An eligible entity receiving funds under
this section shall not provide services through a SBHC funded under
this section to an individual without the consent of the parent or
guardian of such individual if such individual is considered a minor
under applicable State law.
``(l) Authorization of Appropriations.--For purposes of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 2010 through 2014.''.
SEC. 4102. ORAL HEALTHCARE PREVENTION ACTIVITIES.
(a) In General.--Title III of the Public Health Service Act (42
U.S.C. 241 et seq.), as amended by section 3025, is amended by adding
at the end the following:
``PART T--ORAL HEALTHCARE PREVENTION ACTIVITIES
``SEC. 399LL. ORAL HEALTHCARE PREVENTION EDUCATION CAMPAIGN.
``(a) Establishment.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention and in consultation with
professional oral health organizations, shall, subject to the
availability of appropriations, establish a 5-year national, public
education campaign (referred to in this section as the `campaign') that
is focused on oral healthcare prevention and education, including
prevention of oral disease such as early childhood and other caries,
periodontal disease, and oral cancer.
``(b) Requirements.--In establishing the campaign, the Secretary
shall--
``(1) ensure that activities are targeted towards specific
populations such as children, pregnant women, parents, the
elderly, individuals with disabilities, and ethnic and racial
minority populations, including Indians, Alaska Natives and
Native Hawaiians (as defined in section 4(c) of the Indian
Health Care Improvement Act) in a culturally and linguistically
appropriate manner; and
``(2) utilize science-based strategies to convey oral
health prevention messages that include, but are not limited
to, community water fluoridation and dental sealants.
``(c) Planning and Implementation.--Not later than 2 years after
the date of enactment of this section, the Secretary shall begin
implementing the 5-year campaign. During the 2-year period referred to
in the previous sentence, the Secretary shall conduct planning
activities with respect to the campaign.
``SEC. 399LL-1. RESEARCH-BASED DENTAL CARIES DISEASE MANAGEMENT.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall award
demonstration grants to eligible entities to demonstrate the
effectiveness of research-based dental caries disease management
activities.
``(b) Eligibility.--To be eligible for a grant under this section,
an entity shall--
``(1) be a community-based provider of dental services (as
defined by the Secretary), including a Federally-qualified
health center, a clinic of a hospital owned or operated by a
State (or by an instrumentality or a unit of government within
a State), a State or local department of health, a dental
program of the Indian Health Service, an Indian tribe or tribal
organization, or an urban Indian organization (as such terms
are defined in section 4 of the Indian Health Care Improvement
Act), a health system provider, a private provider of dental
services, medical, dental, public health, nursing, nutrition
educational institutions, or national organizations involved in
improving children's oral health; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(c) Use of Funds.--A grantee shall use amounts received under a
grant under this section to demonstrate the effectiveness of research-
based dental caries disease management activities.
``(d) Use of Information.--The Secretary shall utilize information
generated from grantees under this section in planning and implementing
the public education campaign under section 399LL.
``SEC. 399LL-2. AUTHORIZATION OF APPROPRIATIONS.
``There is authorized to be appropriated to carry out this part,
such sums as may be necessary.''.
(b) School-based Sealant Programs.--Section 317M(c)(1) of the
Public Health Service Act (42 U.S.C. 247b-14(c)(1)) is amended by
striking ``may award grants to States and Indian tribes'' and inserting
``shall award a grant to each of the 50 States and territories and to
Indians, Indian tribes, tribal organizations and urban Indian
organizations (as such terms are defined in section 4 of the Indian
Health Care Improvement Act)''.
(c) Oral Health Infrastructure.--Section 317M of the Public Health
Service Act (42 U.S.C. 247b-14) is amended--
(1) by redesignating subsections (d) and (e) as subsections
(e) and (f), respectively; and
(2) by inserting after subsection (c), the following:
``(d) Oral Health Infrastructure.--
``(1) Cooperative agreements.--The Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall enter into cooperative agreements with State,
territorial, and Indian tribes or tribal organizations (as
those terms are defined in section 4 of the Indian Health Care
Improvement Act) to establish oral health leadership and
program guidance, oral health data collection and
interpretation, (including determinants of poor oral health
among vulnerable populations), a multi-dimensional delivery
system for oral health, and to implement science-based programs
(including dental sealants and community water fluoridation) to
improve oral health.
``(2) Authorization of appropriations.--There is authorized
to be appropriated such sums as necessary to carry out this
subsection for fiscal years 2010 through 2014.''.
(d) Updating National Oral Healthcare Surveillance Activities.--
(1) PRAMS.--
(A) In general.--The Secretary of Health and Human
Services (referred to in this subsection as the
``Secretary'') shall carry out activities to update and
improve the Pregnancy Risk Assessment Monitoring System
(referred to in this section as ``PRAMS'') as it
relates to oral healthcare.
(B) State reports and mandatory measurements.--
(i) In general.--Not later than 5 years
after the date of enactment of this Act, and
every 5 years thereafter, a State shall submit
to the Secretary a report concerning activities
conducted within the State under PRAMS.
(ii) Measurements.--The oral healthcare
measurements developed by the Secretary for use
under PRAMS shall be mandatory with respect to
States for purposes of the State reports under
clause (i).
(C) Funding.--There is authorized to be
appropriated to carry out this paragraph, such sums as
may be necessary.
(2) National health and nutrition examination survey.--The
Secretary shall develop oral healthcare components that shall
include tooth-level surveillance for inclusion in the National
Health and Nutrition Examination Survey. Such components shall
be updated by the Secretary at least every 6 years. For
purposes of this paragraph, the term ``tooth-level
surveillance'' means a clinical examination where an examiner
looks at each dental surface, on each tooth in the mouth and as
expanded by the Division of Oral Health of the Centers for
Disease Control and Prevention.
(3) Medical expenditures panel survey.--The Secretary shall
ensure that the Medical Expenditures Panel Survey by the Agency
for Healthcare Research and Quality includes the verification
of dental utilization, expenditure, and coverage findings
through conduct of a look-back analysis.
(4) National oral health surveillance system.--
(A) Appropriations.--There is authorized to be
appropriated, such sums as may be necessary for each of
fiscal years 2010 through 2014 to increase the
participation of States in the National Oral Health
Surveillance System from 16 States to all 50 States,
territories, and District of Columbia.
(B) Requirements.--The Secretary shall ensure that
the National Oral Health Surveillance System include
the measurement of early childhood caries.
SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT PROVIDING A
PERSONALIZED PREVENTION PLAN.
(a) Coverage of Personalized Prevention Plan Services.--
(1) In general.--Section 1861(s)(2) of the Social Security
Act (42 U.S.C. 1395x(s)(2)) is amended--
(A) in subparagraph (DD), by striking ``and'' at
the end;
(B) in subparagraph (EE), by adding ``and'' at the
end; and
(C) by adding at the end the following new
subparagraph:
``(FF) personalized prevention plan services (as defined in
subsection (hhh));''.
(2) Conforming amendments.--Clauses (i) and (ii) of section
1861(s)(2)(K) of the Social Security Act (42 U.S.C.
1395x(s)(2)(K)) are each amended by striking ``subsection
(ww)(1)'' and inserting ``subsections (ww)(1) and (hhh)''.
(b) Personalized Prevention Plan Services Defined.--Section 1861 of
the Social Security Act (42 U.S.C. 1395x) is amended by adding at the
end the following new subsection:
``Annual Wellness Visit
``(hhh)(1) The term `personalized prevention plan services' means
the creation of a plan for an individual--
``(A) that includes a health risk assessment (that meets
the guidelines established by the Secretary under paragraph
(4)(A)) of the individual that is completed prior to or as part
of the same visit with a health professional described in
paragraph (3); and
``(B) that--
``(i) takes into account the results of the health
risk assessment; and
``(ii) may contain the elements described in
paragraph (2).
``(2) Subject to paragraph (4)(H), the elements described in this
paragraph are the following:
``(A) The establishment of, or an update to, the
individual's medical and family history.
``(B) A list of current providers and suppliers that are
regularly involved in providing medical care to the individual
(including a list of all prescribed medications).
``(C) A measurement of height, weight, body mass index (or
waist circumference, if appropriate), blood pressure, and other
routine measurements.
``(D) Detection of any cognitive impairment.
``(E) The establishment of, or an update to, the following:
``(i) A screening schedule for the next 5 to 10
years, as appropriate, based on recommendations of the
United States Preventive Services Task Force and the
Advisory Committee on Immunization Practices, and the
individual's health status, screening history, and age-
appropriate preventive services covered under this
title.
``(ii) A list of risk factors and conditions for
which primary, secondary, or tertiary prevention
interventions are recommended or are underway,
including any mental health conditions or any such risk
factors or conditions that have been identified through
an initial preventive physical examination (as
described under subsection (ww)(1)), and a list of
treatment options and their associated risks and
benefits.
``(F) The furnishing of personalized health advice and a
referral, as appropriate, to health education or preventive
counseling services or programs aimed at reducing identified
risk factors and improving self-management, or community-based
lifestyle interventions to reduce health risks and promote
self-management and wellness, including weight loss, physical
activity, smoking cessation, fall prevention, and nutrition.
``(G) Any other element determined appropriate by the
Secretary.
``(3) A health professional described in this paragraph is--
``(A) a physician;
``(B) a practitioner described in clause (i) of section
1842(b)(18)(C); or
``(C) a medical professional (including a health educator,
registered dietitian, or nutrition professional) or a team of
medical professionals, as determined appropriate by the
Secretary, under the supervision of a physician.
``(4)(A) For purposes of paragraph (1)(A), the Secretary, not later
than 1 year after the date of enactment of this subsection, shall
establish publicly available guidelines for health risk assessments.
Such guidelines shall be developed in consultation with relevant groups
and entities and shall provide that a health risk assessment--
``(i) identify chronic diseases, injury risks, modifiable
risk factors, and urgent health needs of the individual; and
``(ii) may be furnished--
``(I) through an interactive telephonic or web-
based program that meets the standards established
under subparagraph (B);
``(II) during an encounter with a health care
professional;
``(III) through community-based prevention
programs; or
``(IV) through any other means the Secretary
determines appropriate to maximize accessibility and
ease of use by beneficiaries, while ensuring the
privacy of such beneficiaries.
``(B) Not later than 1 year after the date of enactment of this
subsection, the Secretary shall establish standards for interactive
telephonic or web-based programs used to furnish health risk
assessments under subparagraph (A)(ii)(I). The Secretary may utilize
any health risk assessment developed under section 4004(f) of the
Patient Protection and Affordable Care Act as part of the requirement
to develop a personalized prevention plan to comply with this
subparagraph.
``(C)(i) Not later than 18 months after the date of enactment of
this subsection, the Secretary shall develop and make available to the
public a health risk assessment model. Such model shall meet the
guidelines under subparagraph (A) and may be used to meet the
requirement under paragraph (1)(A).
``(ii) Any health risk assessment that meets the guidelines under
subparagraph (A) and is approved by the Secretary may be used to meet
the requirement under paragraph (1)(A).
``(D) The Secretary may coordinate with community-based entities
(including State Health Insurance Programs, Area Agencies on Aging,
Aging and Disability Resource Centers, and the Administration on Aging)
to--
``(i) ensure that health risk assessments are accessible to
beneficiaries; and
``(ii) provide appropriate support for the completion of
health risk assessments by beneficiaries.
``(E) The Secretary shall establish procedures to make
beneficiaries and providers aware of the requirement that a beneficiary
complete a health risk assessment prior to or at the same time as
receiving personalized prevention plan services.
``(F) To the extent practicable, the Secretary shall encourage the
use of, integration with, and coordination of health information
technology (including use of technology that is compatible with
electronic medical records and personal health records) and may
experiment with the use of personalized technology to aid in the
development of self-management skills and management of and adherence
to provider recommendations in order to improve the health status of
beneficiaries.
``(G)(i) A beneficiary shall only be eligible to receive an initial
preventive physical examination (as defined under subsection (ww)(1))
at any time during the 12-month period after the date that the
beneficiary's coverage begins under part B and shall be eligible to
receive personalized prevention plan services under this subsection
provided that the beneficiary has not received such services within the
preceding 12-month period.
``(ii) The Secretary shall establish procedures to make
beneficiaries aware of the option to select an initial preventive
physical examination or personalized prevention plan services during
the period of 12 months after the date that a beneficiary's coverage
begins under part B, which shall include information regarding any
relevant differences between such services.
``(H) The Secretary shall issue guidance that--
``(i) identifies elements under paragraph (2) that are
required to be provided to a beneficiary as part of their first
visit for personalized prevention plan services; and
``(ii) establishes a yearly schedule for appropriate
provision of such elements thereafter.''.
(c) Payment and Elimination of Cost-Sharing.--
(1) Payment and elimination of coinsurance.--Section
1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1))
is amended--
(A) in subparagraph (N), by inserting ``other than
personalized prevention plan services (as defined in
section 1861(hhh)(1))'' after ``(as defined in section
1848(j)(3))'';
(B) by striking ``and'' before ``(W)''; and
(C) by inserting before the semicolon at the end
the following: ``, and (X) with respect to personalized
prevention plan services (as defined in section
1861(hhh)(1)), the amount paid shall be 100 percent of
the lesser of the actual charge for the services or the
amount determined under the payment basis determined
under section 1848''.
(2) Payment under physician fee schedule.--Section
1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-4(j)(3))
is amended by inserting ``(2)(FF) (including administration of
the health risk assessment) ,'' after ``(2)(EE),''.
(3) Elimination of coinsurance in outpatient hospital
settings.--
(A) Exclusion from opd fee schedule.--Section
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(1)(B)(iv)) is amended by striking ``and
diagnostic mammography'' and inserting ``, diagnostic
mammography, or personalized prevention plan services
(as defined in section 1861(hhh)(1))''.
(B) Conforming amendments.--Section 1833(a)(2) of
the Social Security Act (42 U.S.C. 1395l(a)(2)) is
amended--
(i) in subparagraph (F), by striking
``and'' at the end;
(ii) in subparagraph (G)(ii), by striking
the comma at the end and inserting ``; and'';
and
(iii) by inserting after subparagraph
(G)(ii) the following new subparagraph:
``(H) with respect to personalized prevention plan
services (as defined in section 1861(hhh)(1)) furnished
by an outpatient department of a hospital, the amount
determined under paragraph (1)(X),''.
(4) Waiver of application of deductible.--The first
sentence of section 1833(b) of the Social Security Act (42
U.S.C. 1395l(b)) is amended--
(A) by striking ``and'' before ``(9)''; and
(B) by inserting before the period the following:
``, and (10) such deductible shall not apply with
respect to personalized prevention plan services (as
defined in section 1861(hhh)(1))''.
(d) Frequency Limitation.--Section 1862(a) of the Social Security
Act (42 U.S.C. 1395y(a)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (N), by striking ``and'' at the
end;
(B) in subparagraph (O), by striking the semicolon
at the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(P) in the case of personalized prevention plan services
(as defined in section 1861(hhh)(1)), which are performed more
frequently than is covered under such section;''; and
(2) in paragraph (7), by striking ``or (K)'' and inserting
``(K), or (P)''.
(e) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2011.
SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN MEDICARE.
(a) Definition of Preventive Services.--Section 1861(ddd) of the
Social Security Act (42 U.S.C. 1395x(ddd)) is amended--
(1) in the heading, by inserting ``; Preventive Services''
after ``Services'';
(2) in paragraph (1), by striking ``not otherwise described
in this title'' and inserting ``not described in subparagraph
(A) or (C) of paragraph (3)''; and
(3) by adding at the end the following new paragraph:
``(3) The term `preventive services' means the following:
``(A) The screening and preventive services described in
subsection (ww)(2) (other than the service described in
subparagraph (M) of such subsection).
``(B) An initial preventive physical examination (as
defined in subsection (ww)).
``(C) Personalized prevention plan services (as defined in
subsection (hhh)(1)).''.
(b) Coinsurance.--
(1) General application.--
(A) In general.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)), as amended by
section 4103(c)(1), is amended--
(i) in subparagraph (T), by inserting ``(or
100 percent if such services are recommended
with a grade of A or B by the United States
Preventive Services Task Force for any
indication or population and are appropriate
for the individual)'' after ``80 percent'';
(ii) in subparagraph (W)--
(I) in clause (i), by inserting
``(if such subparagraph were applied,
by substituting `100 percent' for `80
percent')'' after ``subparagraph (D)'';
and
(II) in clause (ii), by striking
``80 percent'' and inserting ``100
percent'';
(iii) by striking ``and'' before ``(X)'';
and
(iv) by inserting before the semicolon at
the end the following: ``, and (Y) with respect
to preventive services described in
subparagraphs (A) and (B) of section
1861(ddd)(3) that are appropriate for the
individual and, in the case of such services
described in subparagraph (A), are recommended
with a grade of A or B by the United States
Preventive Services Task Force for any
indication or population, the amount paid shall
be 100 percent of the lesser of the actual
charge for the services or the amount
determined under the fee schedule that applies
to such services under this part''.
(2) Elimination of coinsurance in outpatient hospital
settings.--
(A) Exclusion from opd fee schedule.--Section
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(1)(B)(iv)), as amended by section
4103(c)(3)(A), is amended--
(i) by striking ``or'' before
``personalized prevention plan services''; and
(ii) by inserting before the period the
following: ``, or preventive services described
in subparagraphs (A) and (B) of section
1861(ddd)(3) that are appropriate for the
individual and, in the case of such services
described in subparagraph (A), are recommended
with a grade of A or B by the United States
Preventive Services Task Force for any
indication or population''.
(B) Conforming amendments.--Section 1833(a)(2) of
the Social Security Act (42 U.S.C. 1395l(a)(2)), as
amended by section 4103(c)(3)(B), is amended--
(i) in subparagraph (G)(ii), by striking
``and'' after the semicolon at the end;
(ii) in subparagraph (H), by striking the
comma at the end and inserting ``; and''; and
(iii) by inserting after subparagraph (H)
the following new subparagraph:
``(I) with respect to preventive services described
in subparagraphs (A) and (B) of section 1861(ddd)(3)
that are appropriate for the individual and are
furnished by an outpatient department of a hospital
and, in the case of such services described in
subparagraph (A), are recommended with a grade of A or
B by the United States Preventive Services Task Force
for any indication or population, the amount determined
under paragraph (1)(W) or (1)(Y),''.
(c) Waiver of Application of Deductible for Preventive Services and
Colorectal Cancer Screening Tests.--Section 1833(b) of the Social
Security Act (42 U.S.C. 1395l(b)), as amended by section 4103(c)(4), is
amended--
(1) in paragraph (1), by striking ``items and services
described in section 1861(s)(10)(A)'' and inserting
``preventive services described in subparagraph (A) of section
1861(ddd)(3) that are recommended with a grade of A or B by the
United States Preventive Services Task Force for any indication
or population and are appropriate for the individual.''; and
(2) by adding at the end the following new sentence:
``Paragraph (1) of the first sentence of this subsection shall
apply with respect to a colorectal cancer screening test
regardless of the code that is billed for the establishment of
a diagnosis as a result of the test, or for the removal of
tissue or other matter or other procedure that is furnished in
connection with, as a result of, and in the same clinical
encounter as the screening test.''.
(d) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2011.
SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES IN MEDICARE.
(a) Authority To Modify or Eliminate Coverage of Certain Preventive
Services.--Section 1834 of the Social Security Act (42 U.S.C. 1395m) is
amended by adding at the end the following new subsection:
``(n) Authority To Modify or Eliminate Coverage of Certain
Preventive Services.--Notwithstanding any other provision of this
title, effective beginning on January 1, 2010, if the Secretary
determines appropriate, the Secretary may--
``(1) modify--
``(A) the coverage of any preventive service
described in subparagraph (A) of section 1861(ddd)(3)
to the extent that such modification is consistent with
the recommendations of the United States Preventive
Services Task Force; and
``(B) the services included in the initial
preventive physical examination described in
subparagraph (B) of such section; and
``(2) provide that no payment shall be made under this
title for a preventive service described in subparagraph (A) of
such section that has not received a grade of A, B, C, or I by
such Task Force.''.
(b) Construction.--Nothing in the amendment made by paragraph (1)
shall be construed to affect the coverage of diagnostic or treatment
services under title XVIII of the Social Security Act.
SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR ELIGIBLE ADULTS
IN MEDICAID.
(a) Clarification of Inclusion of Services.--Section 1905(a)(13) of
the Social Security Act (42 U.S.C. 1396d(a)(13)) is amended to read as
follows:
``(13) other diagnostic, screening, preventive, and
rehabilitative services, including--
``(A) any clinical preventive services that are
assigned a grade of A or B by the United States
Preventive Services Task Force;
``(B) with respect to an adult individual, approved
vaccines recommended by the Advisory Committee on
Immunization Practices (an advisory committee
established by the Secretary, acting through the
Director of the Centers for Disease Control and
Prevention) and their administration; and
``(C) any medical or remedial services (provided in
a facility, a home, or other setting) recommended by a
physician or other licensed practitioner of the healing
arts within the scope of their practice under State
law, for the maximum reduction of physical or mental
disability and restoration of an individual to the best
possible functional level;''.
(b) Increased Fmap.--Section 1905(b) of the Social Security Act (42
U.S.C. 1396d(b)), as amended by sections 2001(a)(3)(A) and 2004(c)(1),
is amended in the first sentence--
(1) by striking ``, and (4)'' and inserting ``, (4)''; and
(2) by inserting before the period the following: ``, and
(5) in the case of a State that provides medical assistance for
services and vaccines described in subparagraphs (A) and (B) of
subsection (a)(13), and prohibits cost-sharing for such
services and vaccines, the Federal medical assistance
percentage, as determined under this subsection and subsection
(y) (without regard to paragraph (1)(C) of such subsection),
shall be increased by 1 percentage point with respect to
medical assistance for such services and vaccines and for items
and services described in subsection (a)(4)(D)''.
(c) Effective Date.--The amendments made under this section shall
take effect on January 1, 2013.
SEC. 4107. COVERAGE OF COMPREHENSIVE TOBACCO CESSATION SERVICES FOR
PREGNANT WOMEN IN MEDICAID.
(a) Requiring Coverage of Counseling and Pharmacotherapy for
Cessation of Tobacco Use by Pregnant Women.--Section 1905 of the Social
Security Act (42 U.S.C. 1396d), as amended by sections 2001(a)(3)(B)
and 2303, is further amended--
(1) in subsection (a)(4)--
(A) by striking ``and'' before ``(C)''; and
(B) by inserting before the semicolon at the end
the following new subparagraph: ``; and (D) counseling
and pharmacotherapy for cessation of tobacco use by
pregnant women (as defined in subsection (bb))''; and
(2) by adding at the end the following:
``(bb)(1) For purposes of this title, the term `counseling and
pharmacotherapy for cessation of tobacco use by pregnant women' means
diagnostic, therapy, and counseling services and pharmacotherapy
(including the coverage of prescription and nonprescription tobacco
cessation agents approved by the Food and Drug Administration) for
cessation of tobacco use by pregnant women who use tobacco products or
who are being treated for tobacco use that is furnished--
``(A) by or under the supervision of a physician; or
``(B) by any other health care professional who--
``(i) is legally authorized to furnish such
services under State law (or the State regulatory
mechanism provided by State law) of the State in which
the services are furnished; and
``(ii) is authorized to receive payment for other
services under this title or is designated by the
Secretary for this purpose.
``(2) Subject to paragraph (3), such term is limited to--
``(A) services recommended with respect to pregnant women
in `Treating Tobacco Use and Dependence: 2008 Update: A
Clinical Practice Guideline', published by the Public Health
Service in May 2008, or any subsequent modification of such
Guideline; and
``(B) such other services that the Secretary recognizes to
be effective for cessation of tobacco use by pregnant women.
``(3) Such term shall not include coverage for drugs or biologicals
that are not otherwise covered under this title.''.
(b) Exception From Optional Restriction Under Medicaid Prescription
Drug Coverage.--Section 1927(d)(2)(F) of the Social Security Act (42
U.S.C. 1396r-8(d)(2)(F)), as redesignated by section 2502(a), is
amended by inserting before the period at the end the following: ``,
except, in the case of pregnant women when recommended in accordance
with the Guideline referred to in section 1905(bb)(2)(A), agents
approved by the Food and Drug Administration under the over-the-counter
monograph process for purposes of promoting, and when used to promote,
tobacco cessation''.
(c) Removal of Cost-Sharing for Counseling and Pharmacotherapy for
Cessation of Tobacco Use by Pregnant Women.--
(1) General cost-sharing limitations.--Section 1916 of the
Social Security Act (42 U.S.C. 1396o) is amended in each of
subsections (a)(2)(B) and (b)(2)(B) by inserting ``, and
counseling and pharmacotherapy for cessation of tobacco use by
pregnant women (as defined in section 1905(bb)) and covered
outpatient drugs (as defined in subsection (k)(2) of section
1927 and including nonprescription drugs described in
subsection (d)(2) of such section) that are prescribed for
purposes of promoting, and when used to promote, tobacco
cessation by pregnant women in accordance with the Guideline
referred to in section 1905(bb)(2)(A)'' after ``complicate the
pregnancy''.
(2) Application to alternative cost-sharing.--Section
1916A(b)(3)(B)(iii) of such Act (42 U.S.C. 1396o-
1(b)(3)(B)(iii)) is amended by inserting ``, and counseling and
pharmacotherapy for cessation of tobacco use by pregnant women
(as defined in section 1905(bb))'' after ``complicate the
pregnancy''.
(d) Effective Date.--The amendments made by this section shall take
effect on October 1, 2010.
SEC. 4108. INCENTIVES FOR PREVENTION OF CHRONIC DISEASES IN MEDICAID.
(a) Initiatives.--
(1) Establishment.--
(A) In general.--The Secretary shall award grants
to States to carry out initiatives to provide
incentives to Medicaid beneficiaries who--
(i) successfully participate in a program
described in paragraph (3); and
(ii) upon completion of such participation,
demonstrate changes in health risk and
outcomes, including the adoption and
maintenance of healthy behaviors by meeting
specific targets (as described in subsection
(c)(2)).
(B) Purpose.--The purpose of the initiatives under
this section is to test approaches that may encourage
behavior modification and determine scalable solutions.
(2) Duration.--
(A) Initiation of program; resources.--The
Secretary shall awards grants to States beginning on
January 1, 2011, or beginning on the date on which the
Secretary develops program criteria, whichever is
earlier. The Secretary shall develop program criteria
for initiatives under this section using relevant
evidence-based research and resources, including the
Guide to Community Preventive Services, the Guide to
Clinical Preventive Services, and the National Registry
of Evidence-Based Programs and Practices.
(B) Duration of program.--A State awarded a grant
to carry out initiatives under this section shall carry
out such initiatives within the 5-year period beginning
on January 1, 2011, or beginning on the date on which
the Secretary develops program criteria, whichever is
earlier. Initiatives under this section shall be
carried out by a State for a period of not less than 3
years.
(3) Program described.--
(A) In general.--A program described in this
paragraph is a comprehensive, evidence-based, widely
available, and easily accessible program, proposed by
the State and approved by the Secretary, that is
designed and uniquely suited to address the needs of
Medicaid beneficiaries and has demonstrated success in
helping individuals achieve one or more of the
following:
(i) Ceasing use of tobacco products.
(ii) Controlling or reducing their weight.
(iii) Lowering their cholesterol.
(iv) Lowering their blood pressure.
(v) Avoiding the onset of diabetes or, in
the case of a diabetic, improving the
management of that condition.
(B) Co-morbidities.--A program under this section
may also address co-morbidities (including depression)
that are related to any of the conditions described in
subparagraph (A).
(C) Waiver authority.--The Secretary may waive the
requirements of section 1902(a)(1) (relating to
statewideness) of the Social Security Act for a State
awarded a grant to conduct an initiative under this
section and shall ensure that a State makes any program
described in subparagraph (A) available and accessible
to Medicaid beneficiaries.
(D) Flexibility in implementation.--A State may
enter into arrangements with providers participating in
Medicaid, community-based organizations, faith-based
organizations, public-private partnerships, Indian
tribes, or similar entities or organizations to carry
out programs described in subparagraph (A).
(4) Application.--Following the development of program
criteria by the Secretary, a State may submit an application,
in such manner and containing such information as the Secretary
may require, that shall include a proposal for programs
described in paragraph (3)(A) and a plan to make Medicaid
beneficiaries and providers participating in Medicaid who
reside in the State aware and informed about such programs.
(b) Education and Outreach Campaign.--
(1) State awareness.--The Secretary shall conduct an
outreach and education campaign to make States aware of the
grants under this section.
(2) Provider and beneficiary education.--A State awarded a
grant to conduct an initiative under this section shall conduct
an outreach and education campaign to make Medicaid
beneficiaries and providers participating in Medicaid who
reside in the State aware of the programs described in
subsection (a)(3) that are to be carried out by the State under
the grant.
(c) Impact.--A State awarded a grant to conduct an initiative under
this section shall develop and implement a system to--
(1) track Medicaid beneficiary participation in the program
and validate changes in health risk and outcomes with clinical
data, including the adoption and maintenance of health
behaviors by such beneficiaries;
(2) to the extent practicable, establish standards and
health status targets for Medicaid beneficiaries participating
in the program and measure the degree to which such standards
and targets are met;
(3) evaluate the effectiveness of the program and provide
the Secretary with such evaluations;
(4) report to the Secretary on processes that have been
developed and lessons learned from the program; and
(5) report on preventive services as part of reporting on
quality measures for Medicaid managed care programs.
(d) Evaluations and Reports.--
(1) Independent assessment.--The Secretary shall enter into
a contract with an independent entity or organization to
conduct an evaluation and assessment of the initiatives carried
out by States under this section, for the purpose of
determining--
(A) the effect of such initiatives on the use of
health care services by Medicaid beneficiaries
participating in the program;
(B) the extent to which special populations
(including adults with disabilities, adults with
chronic illnesses, and children with special health
care needs) are able to participate in the program;
(C) the level of satisfaction of Medicaid
beneficiaries with respect to the accessibility and
quality of health care services provided through the
program; and
(D) the administrative costs incurred by State
agencies that are responsible for administration of the
program.
(2) State reporting.--A State awarded a grant to carry out
initiatives under this section shall submit reports to the
Secretary, on a semi-annual basis, regarding the programs that
are supported by the grant funds. Such report shall include
information, as specified by the Secretary, regarding--
(A) the specific uses of the grant funds;
(B) an assessment of program implementation and
lessons learned from the programs;
(C) an assessment of quality improvements and
clinical outcomes under such programs; and
(D) estimates of cost savings resulting from such
programs.
(3) Initial report.--Not later than January 1, 2014, the
Secretary shall submit to Congress an initial report on such
initiatives based on information provided by States through
reports required under paragraph (2). The initial report shall
include an interim evaluation of the effectiveness of the
initiatives carried out with grants awarded under this section
and a recommendation regarding whether funding for expanding or
extending the initiatives should be extended beyond January 1,
2016.
(4) Final report.--Not later than July 1, 2016, the
Secretary shall submit to Congress a final report on the
program that includes the results of the independent assessment
required under paragraph (1), together with recommendations for
such legislation and administrative action as the Secretary
determines appropriate.
(e) No Effect on Eligibility for, or Amount of, Medicaid or Other
Benefits.--Any incentives provided to a Medicaid beneficiary
participating in a program described in subsection (a)(3) shall not be
taken into account for purposes of determining the beneficiary's
eligibility for, or amount of, benefits under the Medicaid program or
any program funded in whole or in part with Federal funds.
(f) Funding.--Out of any funds in the Treasury not otherwise
appropriated, there are appropriated for the 5-year period beginning on
January 1, 2011, $100,000,000 to the Secretary to carry out this
section. Amounts appropriated under this subsection shall remain
available until expended.
(g) Definitions.--In this section:
(1) Medicaid beneficiary.--The term ``Medicaid
beneficiary'' means an individual who is eligible for medical
assistance under a State plan or waiver under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.) and is enrolled in
such plan or waiver.
(2) State.--The term ``State'' has the meaning given that
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
Subtitle C--Creating Healthier Communities
SEC. 4201. COMMUNITY TRANSFORMATION GRANTS.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting through the
Director of the Centers for Disease Control and Prevention (referred to
in this section as the ``Director''), shall award competitive grants to
State and local governmental agencies and community-based organizations
for the implementation, evaluation, and dissemination of evidence-based
community preventive health activities in order to reduce chronic
disease rates, prevent the development of secondary conditions, address
health disparities, and develop a stronger evidence-base of effective
prevention programming.
(b) Eligibility.--To be eligible to receive a grant under
subsection (a), an entity shall--
(1) be--
(A) a State governmental agency;
(B) a local governmental agency;
(C) a national network of community-based
organizations;
(D) a State or local non-profit organization; or
(E) an Indian tribe; and
(2) submit to the Director an application at such time, in
such a manner, and containing such information as the Director
may require, including a description of the program to be
carried out under the grant; and
(3) demonstrate a history or capacity, if funded, to
develop relationships necessary to engage key stakeholders from
multiple sectors within and beyond health care and across a
community, such as healthy futures corps and health care
providers.
(c) Use of Funds.--
(1) In general.--An eligible entity shall use amounts
received under a grant under this section to carry out programs
described in this subsection.
(2) Community transformation plan.--
(A) In general.--An eligible entity that receives a
grant under this section shall submit to the Director
(for approval) a detailed plan that includes the
policy, environmental, programmatic, and as appropriate
infrastructure changes needed to promote healthy living
and reduce disparities.
(B) Activities.--Activities within the plan may
focus on (but not be limited to)--
(i) creating healthier school environments,
including increasing healthy food options,
physical activity opportunities, promotion of
healthy lifestyle, emotional wellness, and
prevention curricula, and activities to prevent
chronic diseases;
(ii) creating the infrastructure to support
active living and access to nutritious foods in
a safe environment;
(iii) developing and promoting programs
targeting a variety of age levels to increase
access to nutrition, physical activity and
smoking cessation, improve social and emotional
wellness, enhance safety in a community, or
address any other chronic disease priority area
identified by the grantee;
(iv) assessing and implementing worksite
wellness programming and incentives;
(v) working to highlight healthy options at
restaurants and other food venues;
(vi) prioritizing strategies to reduce
racial and ethnic disparities, including
social, economic, and geographic determinants
of health; and
(vii) addressing special populations needs,
including all age groups and individuals with
disabilities, and individuals in both urban and
rural areas.
(3) Community-based prevention health activities.--
(A) In general.--An eligible entity shall use
amounts received under a grant under this section to
implement a variety of programs, policies, and
infrastructure improvements to promote healthier
lifestyles.
(B) Activities.--An eligible entity shall implement
activities detailed in the community transformation
plan under paragraph (2).
(C) In-kind support.--An eligible entity may
provide in-kind resources such as staff, equipment, or
office space in carrying out activities under this
section.
(4) Evaluation.--
(A) In general.--An eligible entity shall use
amounts provided under a grant under this section to
conduct activities to measure changes in the prevalence
of chronic disease risk factors among community members
participating in preventive health activities
(B) Types of measures.--In carrying out
subparagraph (A), the eligible entity shall, with
respect to residents in the community, measure--
(i) changes in weight;
(ii) changes in proper nutrition;
(iii) changes in physical activity;
(iv) changes in tobacco use prevalence;
(v) changes in emotional well-being and
overall mental health;
(vi) other factors using community-specific
data from the Behavioral Risk Factor
Surveillance Survey; and
(vii) other factors as determined by the
Secretary.
(C) Reporting.--An eligible entity shall annually
submit to the Director a report containing an
evaluation of activities carried out under the grant.
(5) Dissemination.--A grantee under this section shall--
(A) meet at least annually in regional or national
meetings to discuss challenges, best practices, and
lessons learned with respect to activities carried out
under the grant; and
(B) develop models for the replication of
successful programs and activities and the mentoring of
other eligible entities.
(d) Training.--
(1) In general.--The Director shall develop a program to
provide training for eligible entities on effective strategies
for the prevention and control of chronic disease and the link
between physical, emotional, and social well-being.
(2) Community transformation plan.--The Director shall
provide appropriate feedback and technical assistance to
grantees to establish community transformation plans
(3) Evaluation.--The Director shall provide a literature
review and framework for the evaluation of programs conducted
as part of the grant program under this section, in addition to
working with academic institutions or other entities with
expertise in outcome evaluation.
(e) Prohibition.--A grantee shall not use funds provided under a
grant under this section to create video games or to carry out any
other activities that may lead to higher rates of obesity or
inactivity.
(f) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section, such sums as may be necessary
for each fiscal years 2010 through 2014.
SEC. 4202. HEALTHY AGING, LIVING WELL; EVALUATION OF COMMUNITY-BASED
PREVENTION AND WELLNESS PROGRAMS FOR MEDICARE
BENEFICIARIES.
(a) Healthy Aging, Living Well.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting
through the Director of the Centers for Disease Control and
Prevention, shall award grants to State or local health
departments and Indian tribes to carry out 5-year pilot
programs to provide public health community interventions,
screenings, and where necessary, clinical referrals for
individuals who are between 55 and 64 years of age.
(2) Eligibility.--To be eligible to receive a grant under
paragraph (1), an entity shall--
(A) be--
(i) a State health department;
(ii) a local health department; or
(iii) an Indian tribe;
(B) submit to the Secretary an application at such
time, in such manner, and containing such information
as the Secretary may require including a description of
the program to be carried out under the grant;
(C) design a strategy for improving the health of
the 55-to-64 year-old population through community-
based public health interventions; and
(D) demonstrate the capacity, if funded, to develop
the relationships necessary with relevant health
agencies, health care providers, community-based
organizations, and insurers to carry out the activities
described in paragraph (3), such relationships to
include the identification of a community-based
clinical partner, such as a community health center or
rural health clinic.
(3) Use of funds.--
(A) In general.--A State or local health department
shall use amounts received under a grant under this
subsection to carry out a program to provide the
services described in this paragraph to individuals who
are between 55 and 64 years of age.
(B) Public health interventions.--
(i) In general.--In developing and
implementing such activities, a grantee shall
collaborate with the Centers for Disease
Control and Prevention and the Administration
on Aging, and relevant local agencies and
organizations.
(ii) Types of intervention activities.--
Intervention activities conducted under this
subparagraph may include efforts to improve
nutrition, increase physical activity, reduce
tobacco use and substance abuse, improve mental
health, and promote healthy lifestyles among
the target population.
(C) Community preventive screenings.--
(i) In general.--In addition to community-
wide public health interventions, a State or
local health department shall use amounts
received under a grant under this subsection to
conduct ongoing health screening to identify
risk factors for cardiovascular disease,
cancer, stroke, and diabetes among individuals
in both urban and rural areas who are between
55 and 64 years of age.
(ii) Types of screening activities.--
Screening activities conducted under this
subparagraph may include--
(I) mental health/behavioral health
and substance use disorders;
(II) physical activity, smoking,
and nutrition; and
(III) any other measures deemed
appropriate by the Secretary.
(iii) Monitoring.--Grantees under this
section shall maintain records of screening
results under this subparagraph to establish
the baseline data for monitoring the targeted
population
(D) Clinical referral/treatment for chronic
diseases.--
(i) In general.--A State or local health
department shall use amounts received under a
grant under this subsection to ensure that
individuals between 55 and 64 years of age who
are found to have chronic disease risk factors
through the screening activities described in
subparagraph (C)(ii), receive clinical
referral/treatment for follow-up services to
reduce such risk.
(ii) Mechanism.--
(I) Identification and
determination of status.--With respect
to each individual with risk factors
for or having heart disease, stroke,
diabetes, or any other condition for
which such individual was screened
under subparagraph (C), a grantee under
this section shall determine whether or
not such individual is covered under
any public or private health insurance
program.
(II) Insured individuals.--An
individual determined to be covered
under a health insurance program under
subclause (I) shall be referred by the
grantee to the existing providers under
such program or, if such individual
does not have a current provider, to a
provider who is in-network with respect
to the program involved.
(III) Uninsured individuals.--With
respect to an individual determined to
be uninsured under subclause (I), the
grantee's community-based clinical
partner described in paragraph (4)(D)
shall assist the individual in
determining eligibility for available
public coverage options and identify
other appropriate community health care
resources and assistance programs.
(iii) Public health intervention program.--
A State or local health department shall use
amounts received under a grant under this
subsection to enter into contracts with
community health centers or rural health
clinics and mental health and substance use
disorder service providers to assist in the
referral/treatment of at risk patients to
community resources for clinical follow-up and
help determine eligibility for other public
programs.
(E) Grantee evaluation.--An eligible entity shall
use amounts provided under a grant under this
subsection to conduct activities to measure changes in
the prevalence of chronic disease risk factors among
participants.
(4) Pilot program evaluation.--The Secretary shall conduct
an annual evaluation of the effectiveness of the pilot program
under this subsection. In determining such effectiveness, the
Secretary shall consider changes in the prevalence of
uncontrolled chronic disease risk factors among new Medicare
enrollees (or individuals nearing enrollment, including those
who are 63 and 64 years of age) who reside in States or
localities receiving grants under this section as compared with
national and historical data for those States and localities
for the same population.
(5) Authorization of appropriations.--There are authorized
to be appropriated to carry out this subsection, such sums as
may be necessary for each of fiscal years 2010 through 2014.
(b) Evaluation and Plan for Community-based Prevention and Wellness
Programs for Medicare Beneficiaries.--
(1) In general.--The Secretary shall conduct an evaluation
of community-based prevention and wellness programs and develop
a plan for promoting healthy lifestyles and chronic disease
self-management for Medicare beneficiaries.
(2) Medicare evaluation of prevention and wellness
programs.--
(A) In general.--The Secretary shall evaluate
community prevention and wellness programs including
those that are sponsored by the Administration on
Aging, are evidence-based, and have demonstrated
potential to help Medicare beneficiaries (particularly
beneficiaries that have attained 65 years of age)
reduce their risk of disease, disability, and injury by
making healthy lifestyle choices, including exercise,
diet, and self-management of chronic diseases.
(B) Evaluation.--The evaluation under subparagraph
(A) shall consist of the following:
(i) Evidence review.--The Secretary shall
review available evidence, literature, best
practices, and resources that are relevant to
programs that promote healthy lifestyles and
reduce risk factors for the Medicare
population. The Secretary may determine the
scope of the evidence review and such issues to
be considered, which shall include, at a
minimum--
(I) physical activity, nutrition,
and obesity;
(II) falls;
(III) chronic disease self-
management; and
(IV) mental health.
(ii) Independent evaluation of evidence-
based community prevention and wellness
programs.--The Administrator of the Centers for
Medicare & Medicaid Services, in consultation
with the Assistant Secretary for Aging, shall,
to the extent feasible and practicable, conduct
an evaluation of existing community prevention
and wellness programs that are sponsored by the
Administration on Aging to assess the extent to
which Medicare beneficiaries who participate in
such programs--
(I) reduce their health risks,
improve their health outcomes, and
adopt and maintain healthy behaviors;
(II) improve their ability to
manage their chronic conditions; and
(III) reduce their utilization of
health services and associated costs
under the Medicare program for
conditions that are amenable to
improvement under such programs.
(3) Report.--Not later than September 30, 2013, the
Secretary shall submit to Congress a report that includes--
(A) recommendations for such legislation and
administrative action as the Secretary determines
appropriate to promote healthy lifestyles and chronic
disease self-management for Medicare beneficiaries;
(B) any relevant findings relating to the evidence
review under paragraph (2)(B)(i); and
(C) the results of the evaluation under paragraph
(2)(B)(ii).
(4) Funding.--For purposes of carrying out this subsection,
the Secretary shall provide for the transfer, from the Federal
Hospital Insurance Trust Fund under section 1817 of the Social
Security Act (42 U.S.C. 1395i) and the Federal Supplemental
Medical Insurance Trust Fund under section 1841 of such Act (42
U.S.C. 1395t), in such proportion as the Secretary determines
appropriate, of $50,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account. Amounts
transferred under the preceding sentence shall remain available
until expended.
(5) Administration.--Chapter 35 of title 44, United States
Code shall not apply to the this subsection.
(6) Medicare beneficiary.--In this subsection, the term
``Medicare beneficiary'' means an individual who is entitled to
benefits under part A of title XVIII of the Social Security Act
and enrolled under part B of such title.
SEC. 4203. REMOVING BARRIERS AND IMPROVING ACCESS TO WELLNESS FOR
INDIVIDUALS WITH DISABILITIES.
Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et seq.)
is amended by adding at the end of the following:
``SEC. 510. ESTABLISHMENT OF STANDARDS FOR ACCESSIBLE MEDICAL
DIAGNOSTIC EQUIPMENT.
``(a) Standards.--Not later than 24 months after the date of
enactment of the Affordable Health Choices Act, the Architectural and
Transportation Barriers Compliance Board shall, in consultation with
the Commissioner of the Food and Drug Administration, promulgate
regulatory standards in accordance with the Administrative Procedure
Act (2 U.S.C. 551 et seq.) setting forth the minimum technical criteria
for medical diagnostic equipment used in (or in conjunction with)
physician's offices, clinics, emergency rooms, hospitals, and other
medical settings. The standards shall ensure that such equipment is
accessible to, and usable by, individuals with accessibility needs, and
shall allow independent entry to, use of, and exit from the equipment
by such individuals to the maximum extent possible.
``(b) Medical Diagnostic Equipment Covered.--The standards issued
under subsection (a) for medical diagnostic equipment shall apply to
equipment that includes examination tables, examination chairs
(including chairs used for eye examinations or procedures, and dental
examinations or procedures), weight scales, mammography equipment, x-
ray machines, and other radiological equipment commonly used for
diagnostic purposes by health professionals.
``(c) Review and Amendment.--The Architectural and Transportation
Barriers Compliance Board, in consultation with the Commissioner of the
Food and Drug Administration, shall periodically review and, as
appropriate, amend the standards in accordance with the Administrative
Procedure Act (2 U.S.C. 551 et seq.).''.
SEC. 4204. IMMUNIZATIONS.
(a) State Authority To Purchase Recommended Vaccines for Adults.--
Section 317 of the Public Health Service Act (42 U.S.C. 247b) is
amended by adding at the end the following:
``(l) Authority to Purchase Recommended Vaccines for Adults.--
``(1) In general.--The Secretary may negotiate and enter
into contracts with manufacturers of vaccines for the purchase
and delivery of vaccines for adults as provided for under
subsection (e).
``(2) State purchase.--A State may obtain additional
quantities of such adult vaccines (subject to amounts specified
to the Secretary by the State in advance of negotiations)
through the purchase of vaccines from manufacturers at the
applicable price negotiated by the Secretary under this
subsection.''.
(b) Demonstration Program to Improve Immunization Coverage.--
Section 317 of the Public Health Service Act (42 U.S.C. 247b), as
amended by subsection (a), is further amended by adding at the end the
following:
``(m) Demonstration Program To Improve Immunization Coverage.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish a demonstration program to award grants to
States to improve the provision of recommended immunizations
for children, adolescents, and adults through the use of
evidence-based, population-based interventions for high-risk
populations.
``(2) State plan.--To be eligible for a grant under
paragraph (1), a State shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require, including a State
plan that describes the interventions to be implemented under
the grant and how such interventions match with local needs and
capabilities, as determined through consultation with local
authorities.
``(3) Use of funds.--Funds received under a grant under
this subsection shall be used to implement interventions that
are recommended by the Task Force on Community Preventive
Services (as established by the Secretary, acting through the
Director of the Centers for Disease Control and Prevention) or
other evidence-based interventions, including--
``(A) providing immunization reminders or recalls
for target populations of clients, patients, and
consumers;
``(B) educating targeted populations and health
care providers concerning immunizations in combination
with one or more other interventions;
``(C) reducing out-of-pocket costs for families for
vaccines and their administration;
``(D) carrying out immunization-promoting
strategies for participants or clients of public
programs, including assessments of immunization status,
referrals to health care providers, education,
provision of on-site immunizations, or incentives for
immunization;
``(E) providing for home visits that promote
immunization through education, assessments of need,
referrals, provision of immunizations, or other
services;
``(F) providing reminders or recalls for
immunization providers;
``(G) conducting assessments of, and providing
feedback to, immunization providers;
``(H) any combination of one or more interventions
described in this paragraph; or
``(I) immunization information systems to allow all
States to have electronic databases for immunization
records.
``(4) Consideration.--In awarding grants under this
subsection, the Secretary shall consider any reviews or
recommendations of the Task Force on Community Preventive
Services.
``(5) Evaluation.--Not later than 3 years after the date on
which a State receives a grant under this subsection, the State
shall submit to the Secretary an evaluation of progress made
toward improving immunization coverage rates among high-risk
populations within the State.
``(6) Report to congress.--Not later than 4 years after the
date of enactment of the Affordable Health Choices Act, the
Secretary shall submit to Congress a report concerning the
effectiveness of the demonstration program established under
this subsection together with recommendations on whether to
continue and expand such program.
``(7) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection, such sums as
may be necessary for each of fiscal years 2010 through 2014.''.
(c) Reauthorization of Immunization Program.--Section 317(j) of the
Public Health Service Act (42 U.S.C. 247b(j)) is amended--
(1) in paragraph (1), by striking ``for each of the fiscal
years 1998 through 2005''; and
(2) in paragraph (2), by striking ``after October 1,
1997,''.
(d) Rule of Construction Regarding Access to Immunizations.--
Nothing in this section (including the amendments made by this
section), or any other provision of this Act (including any amendments
made by this Act) shall be construed to decrease children's access to
immunizations.
(e) GAO Study and Report on Medicare Beneficiary Access to
Vaccines.--
(1) Study.--The Comptroller General of the United States
(in this section referred to as the ``Comptroller General'')
shall conduct a study on the ability of Medicare beneficiaries
who were 65 years of age or older to access routinely
recommended vaccines covered under the prescription drug
program under part D of title XVIII of the Social Security Act
over the period since the establishment of such program. Such
study shall include the following:
(A) An analysis and determination of--
(i) the number of Medicare beneficiaries
who were 65 years of age or older and were
eligible for a routinely recommended
vaccination that was covered under part D;
(ii) the number of such beneficiaries who
actually received a routinely recommended
vaccination that was covered under part D; and
(iii) any barriers to access by such
beneficiaries to routinely recommended
vaccinations that were covered under part D.
(B) A summary of the findings and recommendations
by government agencies, departments, and advisory
bodies (as well as relevant professional organizations)
on the impact of coverage under part D of routinely
recommended adult immunizations for access to such
immunizations by Medicare beneficiaries.
(2) Report.--Not later than June 1, 2011, the Comptroller
General shall submit to the appropriate committees of
jurisdiction of the House of Representatives and the Senate a
report containing the results of the study conducted under
paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(3) Funding.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated $1,000,000 for
fiscal year 2010 to carry out this subsection.
SEC. 4205. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN
RESTAURANTS.
(a) Technical Amendments.--Section 403(q)(5)(A) of the Federal
Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) is amended--
(1) in subitem (i), by inserting at the beginning ``except
as provided in clause (H)(ii)(III),''; and
(2) in subitem (ii), by inserting at the beginning ``except
as provided in clause (H)(ii)(III),''.
(b) Labeling Requirements.--Section 403(q)(5) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is amended by adding at
the end the following:
``(H) Restaurants, Retail Food Establishments, and Vending
Machines.--
``(i) General requirements for restaurants and similar
retail food establishments.--Except for food described in
subclause (vii), in the case of food that is a standard menu
item that is offered for sale in a restaurant or similar retail
food establishment that is part of a chain with 20 or more
locations doing business under the same name (regardless of the
type of ownership of the locations) and offering for sale
substantially the same menu items, the restaurant or similar
retail food establishment shall disclose the information
described in subclauses (ii) and (iii).
``(ii) Information required to be disclosed by restaurants
and retail food establishments.--Except as provided in
subclause (vii), the restaurant or similar retail food
establishment shall disclose in a clear and conspicuous
manner--
``(I)(aa) in a nutrient content disclosure
statement adjacent to the name of the standard menu
item, so as to be clearly associated with the standard
menu item, on the menu listing the item for sale, the
number of calories contained in the standard menu item,
as usually prepared and offered for sale; and
``(bb) a succinct statement concerning suggested
daily caloric intake, as specified by the Secretary by
regulation and posted prominently on the menu and
designed to enable the public to understand, in the
context of a total daily diet, the significance of the
caloric information that is provided on the menu;
``(II)(aa) in a nutrient content disclosure
statement adjacent to the name of the standard menu
item, so as to be clearly associated with the standard
menu item, on the menu board, including a drive-through
menu board, the number of calories contained in the
standard menu item, as usually prepared and offered for
sale; and
``(bb) a succinct statement concerning suggested
daily caloric intake, as specified by the Secretary by
regulation and posted prominently on the menu board,
designed to enable the public to understand, in the
context of a total daily diet, the significance of the
nutrition information that is provided on the menu
board;
``(III) in a written form, available on the premises of the
restaurant or similar retail establishment and to the consumer
upon request, the nutrition information required under clauses
(C) and (D) of subparagraph (1); and
``(IV) on the menu or menu board, a prominent, clear, and
conspicuous statement regarding the availability of the
information described in item (III).
``(iii) Self-service food and food on display.--Except as
provided in subclause (vii), in the case of food sold at a
salad bar, buffet line, cafeteria line, or similar self-service
facility, and for self-service beverages or food that is on
display and that is visible to customers, a restaurant or
similar retail food establishment shall place adjacent to each
food offered a sign that lists calories per displayed food item
or per serving.
``(iv) Reasonable basis.--For the purposes of this clause,
a restaurant or similar retail food establishment shall have a
reasonable basis for its nutrient content disclosures,
including nutrient databases, cookbooks, laboratory analyses,
and other reasonable means, as described in section 101.10 of
title 21, Code of Federal Regulations (or any successor
regulation) or in a related guidance of the Food and Drug
Administration.
``(v) Menu variability and combination meals.--The
Secretary shall establish by regulation standards for
determining and disclosing the nutrient content for standard
menu items that come in different flavors, varieties, or
combinations, but which are listed as a single menu item, such
as soft drinks, ice cream, pizza, doughnuts, or children's
combination meals, through means determined by the Secretary,
including ranges, averages, or other methods.
``(vi) Additional information.--If the Secretary determines
that a nutrient, other than a nutrient required under subclause
(ii)(III), should be disclosed for the purpose of providing
information to assist consumers in maintaining healthy dietary
practices, the Secretary may require, by regulation, disclosure
of such nutrient in the written form required under subclause
(ii)(III).
``(vii) Nonapplicability to certain food.--
``(I) In general.--Subclauses (i) through (vi) do
not apply to--
``(aa) items that are not listed on a menu
or menu board (such as condiments and other
items placed on the table or counter for
general use);
``(bb) daily specials, temporary menu items
appearing on the menu for less than 60 days per
calendar year, or custom orders; or
``(cc) such other food that is part of a
customary market test appearing on the menu for
less than 90 days, under terms and conditions
established by the Secretary.
``(II) Written forms.--Subparagraph (5)(C) shall
apply to any regulations promulgated under subclauses
(ii)(III) and (vi).
``(viii) Vending machines.--
``(I) In general.--In the case of an article of
food sold from a vending machine that--
``(aa) does not permit a prospective
purchaser to examine the Nutrition Facts Panel
before purchasing the article or does not
otherwise provide visible nutrition information
at the point of purchase; and
``(bb) is operated by a person who is
engaged in the business of owning or operating
20 or more vending machines,
the vending machine operator shall provide a sign in
close proximity to each article of food or the
selection button that includes a clear and conspicuous
statement disclosing the number of calories contained
in the article.
``(ix) Voluntary provision of nutrition information.--
``(I) In general.--An authorized official of any
restaurant or similar retail food establishment or
vending machine operator not subject to the
requirements of this clause may elect to be subject to
the requirements of such clause, by registering
biannually the name and address of such restaurant or
similar retail food establishment or vending machine
operator with the Secretary, as specified by the
Secretary by regulation.
``(II) Registration.--Within 120 days of enactment
of this clause, the Secretary shall publish a notice in
the Federal Register specifying the terms and
conditions for implementation of item (I), pending
promulgation of regulations.
``(III) Rule of construction.--Nothing in this
subclause shall be construed to authorize the Secretary
to require an application, review, or licensing process
for any entity to register with the Secretary, as
described in such item.
``(x) Regulations.--
``(I) Proposed regulation.--Not later than 1 year
after the date of enactment of this clause, the
Secretary shall promulgate proposed regulations to
carry out this clause.
``(II) Contents.--In promulgating regulations, the
Secretary shall--
``(aa) consider standardization of recipes
and methods of preparation, reasonable
variation in serving size and formulation of
menu items, space on menus and menu boards,
inadvertent human error, training of food
service workers, variations in ingredients, and
other factors, as the Secretary determines; and
``(bb) specify the format and manner of the
nutrient content disclosure requirements under
this subclause.
``(III) Reporting.--The Secretary shall submit to
the Committee on Health, Education, Labor, and Pensions
of the Senate and the Committee on Energy and Commerce
of the House of Representatives a quarterly report that
describes the Secretary's progress toward promulgating
final regulations under this subparagraph.
``(xi) Definition.--In this clause, the term `menu' or
`menu board' means the primary writing of the restaurant or
other similar retail food establishment from which a consumer
makes an order selection.''
(c) National Uniformity.--Section 403A(a)(4) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is amended by striking
``except a requirement for nutrition labeling of food which is exempt
under subclause (i) or (ii) of section 403(q)(5)(A)'' and inserting
``except that this paragraph does not apply to food that is offered for
sale in a restaurant or similar retail food establishment that is not
part of a chain with 20 or more locations doing business under the same
name (regardless of the type of ownership of the locations) and
offering for sale substantially the same menu items unless such
restaurant or similar retail food establishment complies with the
voluntary provision of nutrition information requirements under section
403(q)(5)(H)(ix)''.
(d) Rule of Construction.--Nothing in the amendments made by this
section shall be construed--
(1) to preempt any provision of State or local law, unless
such provision establishes or continues into effect nutrient
content disclosures of the type required under section
403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as
added by subsection (b)) and is expressly preempted under
subsection (a)(4) of such section;
(2) to apply to any State or local requirement respecting a
statement in the labeling of food that provides for a warning
concerning the safety of the food or component of the food; or
(3) except as provided in section 403(q)(5)(H)(ix) of the
Federal Food, Drug, and Cosmetic Act (as added by subsection
(b)), to apply to any restaurant or similar retail food
establishment other than a restaurant or similar retail food
establishment described in section 403(q)(5)(H)(i) of such Act.
SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED WELLNESS
PLAN.
Section 330 of the Public Health Service Act (42 U.S.C. 245b) is
amended by adding at the end the following:
``(s) Demonstration Program for Individualized Wellness Plans.--
``(1) In general.--The Secretary shall establish a pilot
program to test the impact of providing at-risk populations who
utilize community health centers funded under this section an
individualized wellness plan that is designed to reduce risk
factors for preventable conditions as identified by a
comprehensive risk-factor assessment.
``(2) Agreements.--The Secretary shall enter into
agreements with not more than 10 community health centers
funded under this section to conduct activities under the pilot
program under paragraph (1).
``(3) Wellness plans.--
``(A) In general.--An individualized wellness plan
prepared under the pilot program under this subsection
may include one or more of the following as appropriate
to the individual's identified risk factors:
``(i) Nutritional counseling.
``(ii) A physical activity plan.
``(iii) Alcohol and smoking cessation
counseling and services.
``(iv) Stress management.
``(v) Dietary supplements that have health
claims approved by the Secretary.
``(vi) Compliance assistance provided by a
community health center employee.
``(B) Risk factors.--Wellness plan risk factors
shall include--
``(i) weight;
``(ii) tobacco and alcohol use;
``(iii) exercise rates;
``(iv) nutritional status; and
``(v) blood pressure.
``(C) Comparisons.--Individualized wellness plans
shall make comparisons between the individual involved
and a control group of individuals with respect to the
risk factors described in subparagraph (B).
``(4) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection, such sums as
may be necessary.''.
SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS.
Section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 207)
is amended by adding at the end the following:
``(r)(1) An employer shall provide--
``(A) a reasonable break time for an employee to express
breast milk for her nursing child for 1 year after the child's
birth each time such employee has need to express the milk; and
``(B) a place, other than a bathroom, that is shielded from
view and free from intrusion from coworkers and the public,
which may be used by an employee to express breast milk.
``(2) An employer shall not be required to compensate an employee
receiving reasonable break time under paragraph (1) for any work time
spent for such purpose.
``(3) An employer that employs less than 50 employees shall not be
subject to the requirements of this subsection, if such requirements
would impose an undue hardship by causing the employer significant
difficulty or expense when considered in relation to the size,
financial resources, nature, or structure of the employer's business.
``(4) Nothing in this subsection shall preempt a State law that
provides greater protections to employees than the protections provided
for under this subsection.''.
Subtitle D--Support for Prevention and Public Health Innovation
SEC. 4301. RESEARCH ON OPTIMIZING THE DELIVERY OF PUBLIC HEALTH
SERVICES.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting through the
Director of the Centers for Disease Control and Prevention, shall
provide funding for research in the area of public health services and
systems.
(b) Requirements of Research.--Research supported under this
section shall include--
(1) examining evidence-based practices relating to
prevention, with a particular focus on high priority areas as
identified by the Secretary in the National Prevention Strategy
or Healthy People 2020, and including comparing community-based
public health interventions in terms of effectiveness and cost;
(2) analyzing the translation of interventions from
academic settings to real world settings; and
(3) identifying effective strategies for organizing,
financing, or delivering public health services in real world
community settings, including comparing State and local health
department structures and systems in terms of effectiveness and
cost.
(c) Existing Partnerships.--Research supported under this section
shall be coordinated with the Community Preventive Services Task Force
and carried out by building on existing partnerships within the Federal
Government while also considering initiatives at the State and local
levels and in the private sector.
(d) Annual Report.--The Secretary shall, on an annual basis, submit
to Congress a report concerning the activities and findings with
respect to research supported under this section.
SEC. 4302. UNDERSTANDING HEALTH DISPARITIES: DATA COLLECTION AND
ANALYSIS.
(a) Uniform Categories and Collection Requirements.--The Public
Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the
end the following:
``TITLE XXXI--DATA COLLECTION, ANALYSIS, AND QUALITY
``SEC. 3101. DATA COLLECTION, ANALYSIS, AND QUALITY.
``(a) Data Collection.--
``(1) In general.--The Secretary shall ensure that, by not
later than 2 years after the date of enactment of this title,
any federally conducted or supported health care or public
health program, activity or survey (including Current
Population Surveys and American Community Surveys conducted by
the Bureau of Labor Statistics and the Bureau of the Census)
collects and reports, to the extent practicable--
``(A) data on race, ethnicity, sex, primary
language, and disability status for applicants,
recipients, or participants;
``(B) data at the smallest geographic level such as
State, local, or institutional levels if such data can
be aggregated;
``(C) sufficient data to generate statistically
reliable estimates by racial, ethnic, sex, primary
language, and disability status subgroups for
applicants, recipients or participants using, if
needed, statistical oversamples of these
subpopulations; and
``(D) any other demographic data as deemed
appropriate by the Secretary regarding health
disparities.
``(2) Collection standards.--In collecting data described
in paragraph (1), the Secretary or designee shall--
``(A) use Office of Management and Budget
standards, at a minimum, for race and ethnicity
measures;
``(B) develop standards for the measurement of sex,
primary language, and disability status;
``(C) develop standards for the collection of data
described in paragraph (1) that, at a minimum--
``(i) collects self-reported data by the
applicant, recipient, or participant; and
``(ii) collects data from a parent or legal
guardian if the applicant, recipient, or
participant is a minor or legally
incapacitated;
``(D) survey health care providers and establish
other procedures in order to assess access to care and
treatment for individuals with disabilities and to
identify--
``(i) locations where individuals with
disabilities access primary, acute (including
intensive), and long-term care;
``(ii) the number of providers with
accessible facilities and equipment to meet the
needs of the individuals with disabilities,
including medical diagnostic equipment that
meets the minimum technical criteria set forth
in section 510 of the Rehabilitation Act of
1973; and
``(iii) the number of employees of health
care providers trained in disability awareness
and patient care of individuals with
disabilities; and
``(E) require that any reporting requirement
imposed for purposes of measuring quality under any
ongoing or federally conducted or supported health care
or public health program, activity, or survey includes
requirements for the collection of data on individuals
receiving health care items or services under such
programs activities by race, ethnicity, sex, primary
language, and disability status.
``(3) Data management.--In collecting data described in
paragraph (1), the Secretary, acting through the National
Coordinator for Health Information Technology shall--
``(A) develop national standards for the management
of data collected; and
``(B) develop interoperability and security systems
for data management.
``(b) Data Analysis.--
``(1) In general.--For each federally conducted or
supported health care or public health program or activity, the
Secretary shall analyze data collected under paragraph (a) to
detect and monitor trends in health disparities (as defined for
purposes of section 485E) at the Federal and State levels.
``(c) Data Reporting and Dissemination.--
``(1) In general.--The Secretary shall make the analyses
described in (b) available to--
``(A) the Office of Minority Health;
``(B) the National Center on Minority Health and
Health Disparities;
``(C) the Agency for Healthcare Research and
Quality;
``(D) the Centers for Disease Control and
Prevention;
``(E) the Centers for Medicare & Medicaid Services;
``(F) the Indian Health Service and epidemiology
centers funded under the Indian Health Care Improvement
Act;
``(G) the Office of Rural health;
``(H) other agencies within the Department of
Health and Human Services; and
``(I) other entities as determined appropriate by
the Secretary.
``(2) Reporting of data.--The Secretary shall report data
and analyses described in (a) and (b) through--
``(A) public postings on the Internet websites of
the Department of Health and Human Services; and
``(B) any other reporting or dissemination
mechanisms determined appropriate by the Secretary.
``(3) Availability of data.--The Secretary may make data
described in (a) and (b) available for additional research,
analyses, and dissemination to other Federal agencies, non-
governmental entities, and the public, in accordance with any
Federal agency's data user agreements.
``(d) Limitations on Use of Data.--Nothing in this section shall be
construed to permit the use of information collected under this section
in a manner that would adversely affect any individual.
``(e) Protection and Sharing of Data.--
``(1) Privacy and other safeguards.--The Secretary shall
ensure (through the promulgation of regulations or otherwise)
that--
``(A) all data collected pursuant to subsection (a)
is protected--
``(i) under privacy protections that are at
least as broad as those that the Secretary
applies to other health data under the
regulations promulgated under section 264(c) of
the Health Insurance Portability and
Accountability Act of 1996 (Public Law 104-191;
110 Stat. 2033); and
``(ii) from all inappropriate internal use
by any entity that collects, stores, or
receives the data, including use of such data
in determinations of eligibility (or continued
eligibility) in health plans, and from other
inappropriate uses, as defined by the
Secretary; and
``(B) all appropriate information security
safeguards are used in the collection, analysis, and
sharing of data collected pursuant to subsection (a).
``(2) Data sharing.--The Secretary shall establish
procedures for sharing data collected pursuant to subsection
(a), measures relating to such data, and analyses of such data,
with other relevant Federal and State agencies including the
agencies, centers, and entities within the Department of Health
and Human Services specified in subsection (c)(1)..
``(f) Data on Rural Underserved Populations.--The Secretary shall
ensure that any data collected in accordance with this section
regarding racial and ethnic minority groups are also collected
regarding underserved rural and frontier populations.
``(g) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2010 through 2014.
``(h) Requirement for Implementation.--Notwithstanding any other
provision of this section, data may not be collected under this section
unless funds are directly appropriated for such purpose in an
appropriations Act.
``(i) Consultation.--The Secretary shall consult with the Director
of the Office of Personnel Management, the Secretary of Defense, the
Secretary of Veterans Affairs, the Director of the Bureau of the
Census, the Commissioner of Social Security, and the head of other
appropriate Federal agencies in carrying out this section.''.
(b) Addressing Health Care Disparities in Medicaid and CHIP.--
(1) Standardized collection requirements included in state
plans.--
(A) Medicaid.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)), as amended by
section 2001(d), is amended--
(i) in paragraph 4), by striking ``and'' at
the end;
(ii) in paragraph (75), by striking the
period at the end and inserting ``; and''; and
(iii) by inserting after paragraph (75) the
following new paragraph:
``(76) provide that any data collected under the State plan
meets the requirements of section 3101 of the Public Health
Service Act.''.
(B) CHIP.--Section 2108(e) of the Social Security
Act (42 U.S.C. 1397hh(e)) is amended by adding at the
end the following new paragraph:
``(7) Data collected and reported in accordance with
section 3101 of the Public Health Service Act, with respect to
individuals enrolled in the State child health plan (and, in
the case of enrollees under 19 years of age, their parents or
legal guardians), including data regarding the primary language
of such individuals, parents, and legal guardians.''.
(2) Extending medicare requirement to address health
disparities data collection to medicaid and chip.--Title XIX of
the Social Security Act (42 U.S.C. 1396 et seq.), as amended by
section 2703 is amended by adding at the end the following new
section:
``SEC. 1946. ADDRESSING HEALTH CARE DISPARITIES.
``(a) Evaluating Data Collection Approaches.--The Secretary shall
evaluate approaches for the collection of data under this title and
title XXI, to be performed in conjunction with existing quality
reporting requirements and programs under this title and title XXI,
that allow for the ongoing, accurate, and timely collection and
evaluation of data on disparities in health care services and
performance on the basis of race, ethnicity, sex, primary language, and
disability status. In conducting such evaluation, the Secretary shall
consider the following objectives:
``(1) Protecting patient privacy.
``(2) Minimizing the administrative burdens of data
collection and reporting on States, providers, and health plans
participating under this title or title XXI.
``(3) Improving program data under this title and title XXI
on race, ethnicity, sex, primary language, and disability
status.
``(b) Reports to Congress.--
``(1) Report on evaluation.--Not later than 18 months after
the date of the enactment of this section, the Secretary shall
submit to Congress a report on the evaluation conducted under
subsection (a). Such report shall, taking into consideration
the results of such evaluation--
``(A) identify approaches (including defining
methodologies) for identifying and collecting and
evaluating data on health care disparities on the basis
of race, ethnicity, sex, primary language, and
disability status for the programs under this title and
title XXI; and
``(B) include recommendations on the most effective
strategies and approaches to reporting HEDIS quality
measures as required under section 1852(e)(3) and other
nationally recognized quality performance measures, as
appropriate, on such bases.
``(2) Reports on data analyses.--Not later than 4 years
after the date of the enactment of this section, and 4 years
thereafter, the Secretary shall submit to Congress a report
that includes recommendations for improving the identification
of health care disparities for beneficiaries under this title
and under title XXI based on analyses of the data collected
under subsection (c).
``(c) Implementing Effective Approaches.--Not later than 24 months
after the date of the enactment of this section, the Secretary shall
implement the approaches identified in the report submitted under
subsection (b)(1) for the ongoing, accurate, and timely collection and
evaluation of data on health care disparities on the basis of race,
ethnicity, sex, primary language, and disability status.''.
SEC. 4303. CDC AND EMPLOYER-BASED WELLNESS PROGRAMS.
Title III of the Public Health Service Act (42 U.S.C. 241 et seq.),
by section 4102, is further amended by adding at the end the following:
``PART U--EMPLOYER-BASED WELLNESS PROGRAM
``SEC. 399MM. TECHNICAL ASSISTANCE FOR EMPLOYER-BASED WELLNESS
PROGRAMS.
``In order to expand the utilization of evidence-based prevention
and health promotion approaches in the workplace, the Director shall--
``(1) provide employers (including small, medium, and large
employers, as determined by the Director) with technical
assistance, consultation, tools, and other resources in
evaluating such employers' employer-based wellness programs,
including--
``(A) measuring the participation and methods to
increase participation of employees in such programs;
``(B) developing standardized measures that assess
policy, environmental and systems changes necessary to
have a positive health impact on employees' health
behaviors, health outcomes, and health care
expenditures; and
``(C) evaluating such programs as they relate to
changes in the health status of employees, the
absenteeism of employees, the productivity of
employees, the rate of workplace injury, and the
medical costs incurred by employees; and
``(2) build evaluation capacity among workplace staff by
training employers on how to evaluate employer-based wellness
programs by ensuring evaluation resources, technical
assistance, and consultation are available to workplace staff
as needed through such mechanisms as web portals, call centers,
or other means.
``SEC. 399MM-1. NATIONAL WORKSITE HEALTH POLICIES AND PROGRAMS STUDY.
``(a) In General.--In order to assess, analyze, and monitor over
time data about workplace policies and programs, and to develop
instruments to assess and evaluate comprehensive workplace chronic
disease prevention and health promotion programs, policies and
practices, not later than 2 years after the date of enactment of this
part, and at regular intervals (to be determined by the Director)
thereafter, the Director shall conduct a national worksite health
policies and programs survey to assess employer-based health policies
and programs.
``(b) Report.--Upon the completion of each study under subsection
(a), the Director shall submit to Congress a report that includes the
recommendations of the Director for the implementation of effective
employer-based health policies and programs.
``SEC. 399MM-2. PRIORITIZATION OF EVALUATION BY SECRETARY.
``The Secretary shall evaluate, in accordance with this part, all
programs funded through the Centers for Disease Control and Prevention
before conducting such an evaluation of privately funded programs
unless an entity with a privately funded wellness program requests such
an evaluation.
``SEC. 399MM-3. PROHIBITION OF FEDERAL WORKPLACE WELLNESS REQUIREMENTS.
``Notwithstanding any other provision of this part, any
recommendations, data, or assessments carried out under this part shall
not be used to mandate requirements for workplace wellness programs.''.
SEC. 4304. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS.
Title XXVIII of the Public Health Service Act (42 U.S.C. 300hh et
seq.) is amended by adding at the end the following:
``Subtitle C--Strengthening Public Health Surveillance Systems
``SEC. 2821. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS.
``(a) In General.--Subject to the availability of appropriations,
the Secretary, acting through the Director of the Centers for Disease
Control and Prevention, shall establish an Epidemiology and Laboratory
Capacity Grant Program to award grants to State health departments as
well as local health departments and tribal jurisdictions that meet
such criteria as the Director determines appropriate. Academic centers
that assist State and eligible local and tribal health departments may
also be eligible for funding under this section as the Director
determines appropriate. Grants shall be awarded under this section to
assist public health agencies in improving surveillance for, and
response to, infectious diseases and other conditions of public health
importance by--
``(1) strengthening epidemiologic capacity to identify and
monitor the occurrence of infectious diseases and other
conditions of public health importance;
``(2) enhancing laboratory practice as well as systems to
report test orders and results electronically;
``(3) improving information systems including developing
and maintaining an information exchange using national
guidelines and complying with capacities and functions
determined by an advisory council established and appointed by
the Director; and
``(4) developing and implementing prevention and control
strategies.
``(b) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section $190,000,000 for each of fiscal
years 2010 through 2013, of which--
``(1) not less than $95,000,000 shall be made available
each such fiscal year for activities under paragraphs (1) and
(4) of subsection (a);
``(2) not less than $60,000,000 shall be made available
each such fiscal year for activities under subsection (a)(3);
and
``(3) not less than $32,000,000 shall be made available
each such fiscal year for activities under subsection
(a)(2).''.
SEC. 4305. ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE MANAGEMENT.
(a) Institute of Medicine Conference on Pain.--
(1) Convening.--Not later than 1 year after funds are
appropriated to carry out this subsection, the Secretary of
Health and Human Services shall seek to enter into an agreement
with the Institute of Medicine of the National Academies to
convene a Conference on Pain (in this subsection referred to as
``the Conference'').
(2) Purposes.--The purposes of the Conference shall be to--
(A) increase the recognition of pain as a
significant public health problem in the United States;
(B) evaluate the adequacy of assessment, diagnosis,
treatment, and management of acute and chronic pain in
the general population, and in identified racial,
ethnic, gender, age, and other demographic groups that
may be disproportionately affected by inadequacies in
the assessment, diagnosis, treatment, and management of
pain;
(C) identify barriers to appropriate pain care;
(D) establish an agenda for action in both the
public and private sectors that will reduce such
barriers and significantly improve the state of pain
care research, education, and clinical care in the
United States.
(3) Other appropriate entity.--If the Institute of Medicine
declines to enter into an agreement under paragraph (1), the
Secretary of Health and Human Services may enter into such
agreement with another appropriate entity.
(4) Report.--A report summarizing the Conference's findings
and recommendations shall be submitted to the Congress not
later than June 30, 2011.
(5) Authorization of appropriations.--For the purpose of
carrying out this subsection, there is authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2010 and 2011.
(b) Pain Research at National Institutes of Health.--Part B of
title IV of the Public Health Service Act (42 U.S.C. 284 et seq.) is
amended by adding at the end the following:
``SEC. 409J. PAIN RESEARCH.
``(a) Research Initiatives.--
``(1) In general.--The Director of NIH is encouraged to
continue and expand, through the Pain Consortium, an aggressive
program of basic and clinical research on the causes of and
potential treatments for pain.
``(2) Annual recommendations.--Not less than annually, the
Pain Consortium, in consultation with the Division of Program
Coordination, Planning, and Strategic Initiatives, shall
develop and submit to the Director of NIH recommendations on
appropriate pain research initiatives that could be undertaken
with funds reserved under section 402A(c)(1) for the Common
Fund or otherwise available for such initiatives.
``(3) Definition.--In this subsection, the term `Pain
Consortium' means the Pain Consortium of the National
Institutes of Health or a similar trans-National Institutes of
Health coordinating entity designated by the Secretary for
purposes of this subsection.
``(b) Interagency Pain Research Coordinating Committee.--
``(1) Establishment.--The Secretary shall establish not
later than 1 year after the date of the enactment of this
section and as necessary maintain a committee, to be known as
the Interagency Pain Research Coordinating Committee (in this
section referred to as the `Committee'), to coordinate all
efforts within the Department of Health and Human Services and
other Federal agencies that relate to pain research.
``(2) Membership.--
``(A) In general.--The Committee shall be composed
of the following voting members:
``(i) Not more than 7 voting Federal
representatives appoint by the Secretary from
agencies that conduct pain care research and
treatment.
``(ii) 12 additional voting members
appointed under subparagraph (B).
``(B) Additional members.--The Committee shall
include additional voting members appointed by the
Secretary as follows:
``(i) 6 non-Federal members shall be
appointed from among scientists, physicians,
and other health professionals.
``(ii) 6 members shall be appointed from
members of the general public, who are
representatives of leading research, advocacy,
and service organizations for individuals with
pain-related conditions.
``(C) Nonvoting members.--The Committee shall
include such nonvoting members as the Secretary
determines to be appropriate.
``(3) Chairperson.--The voting members of the Committee
shall select a chairperson from among such members. The
selection of a chairperson shall be subject to the approval of
the Director of NIH.
``(4) Meetings.--The Committee shall meet at the call of
the chairperson of the Committee or upon the request of the
Director of NIH, but in no case less often than once each year.
``(5) Duties.--The Committee shall--
``(A) develop a summary of advances in pain care
research supported or conducted by the Federal agencies
relevant to the diagnosis, prevention, and treatment of
pain and diseases and disorders associated with pain;
``(B) identify critical gaps in basic and clinical
research on the symptoms and causes of pain;
``(C) make recommendations to ensure that the
activities of the National Institutes of Health and
other Federal agencies are free of unnecessary
duplication of effort;
``(D) make recommendations on how best to
disseminate information on pain care; and
``(E) make recommendations on how to expand
partnerships between public entities and private
entities to expand collaborative, cross-cutting
research.
``(6) Review.--The Secretary shall review the necessity of
the Committee at least once every 2 years.''.
(c) Pain Care Education and Training.--Part D of title VII of the
Public Health Service Act (42 U.S.C. 294 et seq.) is amended by adding
at the end the following new section:
``SEC. 759. PROGRAM FOR EDUCATION AND TRAINING IN PAIN CARE.
``(a) In General.--The Secretary may make awards of grants,
cooperative agreements, and contracts to health professions schools,
hospices, and other public and private entities for the development and
implementation of programs to provide education and training to health
care professionals in pain care.
``(b) Certain Topics.--An award may be made under subsection (a)
only if the applicant for the award agrees that the program carried out
with the award will include information and education on--
``(1) recognized means for assessing, diagnosing, treating,
and managing pain and related signs and symptoms, including the
medically appropriate use of controlled substances;
``(2) applicable laws, regulations, rules, and policies on
controlled substances, including the degree to which
misconceptions and concerns regarding such laws, regulations,
rules, and policies, or the enforcement thereof, may create
barriers to patient access to appropriate and effective pain
care;
``(3) interdisciplinary approaches to the delivery of pain
care, including delivery through specialized centers providing
comprehensive pain care treatment expertise;
``(4) cultural, linguistic, literacy, geographic, and other
barriers to care in underserved populations; and
``(5) recent findings, developments, and improvements in
the provision of pain care.
``(c) Evaluation of Programs.--The Secretary shall (directly or
through grants or contracts) provide for the evaluation of programs
implemented under subsection (a) in order to determine the effect of
such programs on knowledge and practice of pain care.
``(d) Pain Care Defined.--For purposes of this section the term
`pain care' means the assessment, diagnosis, treatment, or management
of acute or chronic pain regardless of causation or body location.
``(e) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section, such sums as may be necessary
for each of the fiscal years 2010 through 2012. Amounts appropriated
under this subsection shall remain available until expended.''.
SEC. 4306. FUNDING FOR CHILDHOOD OBESITY DEMONSTRATION PROJECT.
Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 1320b-
9a(e)(8)) is amended to read as follows:
``(8) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to carry out this
subsection, $25,000,000 for the period of fiscal years 2010
through 2014.''.
Subtitle E--Miscellaneous Provisions
SEC. 4401. SENSE OF THE SENATE CONCERNING CBO SCORING.
(a) Finding.--The Senate finds that the costs of prevention
programs are difficult to estimate due in part because prevention
initiatives are hard to measure and results may occur outside the 5 and
10 year budget windows.
(b) Sense of Congress.--It is the sense of the Senate that Congress
should work with the Congressional Budget Office to develop better
methodologies for scoring progress to be made in prevention and
wellness programs.
SEC. 4402. EFFECTIVENESS OF FEDERAL HEALTH AND WELLNESS INITIATIVES.
To determine whether existing Federal health and wellness
initiatives are effective in achieving their stated goals, the
Secretary of Health and Human Services shall--
(1) conduct an evaluation of such programs as they relate
to changes in health status of the American public and
specifically on the health status of the Federal workforce,
including absenteeism of employees, the productivity of
employees, the rate of workplace injury, and the medical costs
incurred by employees, and health conditions, including
workplace fitness, healthy food and beverages, and incentives
in the Federal Employee Health Benefits Program; and
(2) submit to Congress a report concerning such evaluation,
which shall include conclusions concerning the reasons that
such existing programs have proven successful or not successful
and what factors contributed to such conclusions.
TITLE V--HEALTH CARE WORKFORCE
Subtitle A--Purpose and Definitions
SEC. 5001. PURPOSE.
The purpose of this title is to improve access to and the delivery
of health care services for all individuals, particularly low income,
underserved, uninsured, minority, health disparity, and rural
populations by--
(1) gathering and assessing comprehensive data in order for
the health care workforce to meet the health care needs of
individuals, including research on the supply, demand,
distribution, diversity, and skills needs of the health care
workforce;
(2) increasing the supply of a qualified health care
workforce to improve access to and the delivery of health care
services for all individuals;
(3) enhancing health care workforce education and training
to improve access to and the delivery of health care services
for all individuals; and
(4) providing support to the existing health care workforce
to improve access to and the delivery of health care services
for all individuals.
SEC. 5002. DEFINITIONS.
(a) This Title.--In this title:
(1) Allied health professional.--The term ``allied health
professional'' means an allied health professional as defined
in section 799B(5) of the Public Heath Service Act (42 U.S.C.
295p(5)) who--
(A) has graduated and received an allied health
professions degree or certificate from an institution
of higher education; and
(B) is employed with a Federal, State, local or
tribal public health agency, or in a setting where
patients might require health care services, including
acute care facilities, ambulatory care facilities,
personal residences, and other settings located in
health professional shortage areas, medically
underserved areas, or medically underserved
populations, as recognized by the Secretary of Health
and Human Services.
(2) Health care career pathway.--The term ``healthcare
career pathway'' means a rigorous, engaging, and high quality
set of courses and services that--
(A) includes an articulated sequence of academic
and career courses, including 21st century skills;
(B) is aligned with the needs of healthcare
industries in a region or State;
(C) prepares students for entry into the full range
of postsecondary education options, including
registered apprenticeships, and careers;
(D) provides academic and career counseling in
student-to-counselor ratios that allow students to make
informed decisions about academic and career options;
(E) meets State academic standards, State
requirements for secondary school graduation and is
aligned with requirements for entry into postsecondary
education, and applicable industry standards; and
(F) leads to 2 or more credentials, including--
(i) a secondary school diploma; and
(ii) a postsecondary degree, an
apprenticeship or other occupational
certification, a certificate, or a license.
(3) Institution of higher education.--The term
``institution of higher education'' has the meaning given the
term in sections 101 and 102 of the Higher Education Act of
1965 (20 U.S.C. 1001 and 1002).
(4) Low income individual, state workforce investment
board, and local workforce investment board.--
(A) Low-income individual.--The term ``low-income
individual'' has the meaning given that term in section
101 of the Workforce investment Act of 1998 (29 U.S.C.
2801).
(B) State workforce investment board; local
workforce investment board.--The terms ``State
workforce investment board'' and ``local workforce
investment board'', refer to a State workforce
investment board established under section 111 of the
Workforce Investment Act of 1998 (29 U.S.C. 2821) and a
local workforce investment board established under
section 117 of such Act (29 U.S.C. 2832), respectively.
(5) Postsecondary education.--The term ``postsecondary
education'' means--
(A) a 4-year program of instruction, or not less
than a 1-year program of instruction that is acceptable
for credit toward an associate or a baccalaureate
degree, offered by an institution of higher education;
or
(B) a certificate or registered apprenticeship
program at the postsecondary level offered by an
institution of higher education or a non-profit
educational institution.
(6) Registered apprenticeship program.--The term
``registered apprenticeship program'' means an industry skills
training program at the postsecondary level that combines
technical and theoretical training through structure on the job
learning with related instruction (in a classroom or through
distance learning) while an individual is employed, working
under the direction of qualified personnel or a mentor, and
earning incremental wage increases aligned to enhance job
proficiency, resulting in the acquisition of a nationally
recognized and portable certificate, under a plan approved by
the Office of Apprenticeship or a State agency recognized by
the Department of Labor.
(b) Title VII of the Public Health Service Act.--Section 799B of
the Public Health Service Act (42 U.S.C. 295p) is amended--
(1) by striking paragraph (3) and inserting the following:
``(3) Physician assistant education program.--The term
`physician assistant education program' means an educational
program in a public or private institution in a State that--
``(A) has as its objective the education of
individuals who, upon completion of their studies in
the program, be qualified to provide primary care
medical services with the supervision of a physician;
and
``(B) is accredited by the Accreditation Review
Commission on Education for the Physician Assistant.'';
and
(2) by adding at the end the following:
``(12) Area health education center.--The term `area health
education center' means a public or nonprofit private
organization that has a cooperative agreement or contract in
effect with an entity that has received an award under
subsection (a)(1) or (a)(2) of section 751, satisfies the
requirements in section 751(d)(1), and has as one of its
principal functions the operation of an area health education
center. Appropriate organizations may include hospitals, health
organizations with accredited primary care training programs,
accredited physician assistant educational programs associated
with a college or university, and universities or colleges not
operating a school of medicine or osteopathic medicine.
``(13) Area health education center program.--The term
`area health education center program' means cooperative
program consisting of an entity that has received an award
under subsection (a)(1) or (a)(2) of section 751 for the
purpose of planning, developing, operating, and evaluating an
area health education center program and one or more area
health education centers, which carries out the required
activities described in section 751(c), satisfies the program
requirements in such section, has as one of its principal
functions identifying and implementing strategies and
activities that address health care workforce needs in its
service area, in coordination with the local workforce
investment boards.
``(14) Clinical social worker.--The term `clinical social
worker' has the meaning given the term in section 1861(hh)(1)
of the Social Security Act (42 U.S.C. 1395x(hh)(1)).
``(15) Cultural competency.--The term `cultural competency'
shall be defined by the Secretary in a manner consistent with
section 1707(d)(3).
``(16) Direct care worker.--The term `direct care worker'
has the meaning given that term in the 2010 Standard
Occupational Classifications of the Department of Labor for
Home Health Aides [31-1011], Psychiatric Aides [31-1013],
Nursing Assistants [31-1014], and Personal Care Aides [39-
9021].
``(17) Federally qualified health center.--The term
`Federally qualified health center' has the meaning given that
term in section 1861(aa) of the Social Security Act (42 U.S.C.
1395x(aa)).
``(18) Frontier health professional shortage area.--The
term `frontier health professional shortage area' means an
area--
``(A) with a population density less than 6 persons
per square mile within the service area; and
``(B) with respect to which the distance or time
for the population to access care is excessive.
``(19) Graduate psychology.--The term `graduate psychology'
means an accredited program in professional psychology.
``(20) Health disparity population.--The term `health
disparity population' has the meaning given such term in
section 903(d)(1).
``(21) Health literacy.--The term `health literacy' means
the degree to which an individual has the capacity to obtain,
communicate, process, and understand health information and
services in order to make appropriate health decisions.
``(22) Mental health service professional.--The term
`mental health service professional' means an individual with a
graduate or postgraduate degree from an accredited institution
of higher education in psychiatry, psychology, school
psychology, behavioral pediatrics, psychiatric nursing, social
work, school social work, substance abuse disorder prevention
and treatment, marriage and family counseling, school
counseling, or professional counseling.
``(23) One-stop delivery system center.--The term `one-stop
delivery system' means a one-stop delivery system described in
section 134(c) of the Workforce Investment Act of 1998 (29
U.S.C. 2864(c)).
``(24) Paraprofessional child and adolescent mental health
worker.--The term `paraprofessional child and adolescent mental
health worker' means an individual who is not a mental or
behavioral health service professional, but who works at the
first stage of contact with children and families who are
seeking mental or behavioral health services, including
substance abuse prevention and treatment services.
``(25) Racial and ethnic minority group; racial and ethnic
minority population.--The terms `racial and ethnic minority
group' and `racial and ethnic minority population' have the
meaning given the term `racial and ethnic minority group' in
section 1707.
``(26) Rural health clinic.--The term `rural health clinic'
has the meaning given that term in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)).''.
(c) Title VIII of the Public Health Service Act.--Section 801 of
the Public Health Service Act (42 U.S.C. 296) is amended--
(1) in paragraph (2)--
(A) by striking ``means a'' and inserting ``means
an accredited (as defined in paragraph 6)''; and
(B) by striking the period as inserting the
following: ``where graduates are--
``(A) authorized to sit for the National Council
Licensure EXamination-Registered Nurse (NCLEX-RN); or
``(B) licensed registered nurses who will receive a
graduate or equivalent degree or training to become an
advanced education nurse as defined by section
811(b).''; and
(2) by adding at the end the following:
``(16) Accelerated nursing degree program.--The term
`accelerated nursing degree program' means a program of
education in professional nursing offered by an accredited
school of nursing in which an individual holding a bachelors
degree in another discipline receives a BSN or MSN degree in an
accelerated time frame as determined by the accredited school
of nursing.
``(17) Bridge or degree completion program.--The term
`bridge or degree completion program' means a program of
education in professional nursing offered by an accredited
school of nursing, as defined in paragraph (2), that leads to a
baccalaureate degree in nursing. Such programs may include,
Registered Nurse (RN) to Bachelor's of Science of Nursing (BSN)
programs, RN to MSN (Master of Science of Nursing) programs, or
BSN to Doctoral programs.''.
Subtitle B--Innovations in the Health Care Workforce
SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION.
(a) Purpose.--It is the purpose of this section to establish a
National Health Care Workforce Commission that--
(1) serves as a national resource for Congress, the
President, States, and localities;
(2) communicates and coordinates with the Departments of
Health and Human Services, Labor, Veterans Affairs, Homeland
Security, and Education on related activities administered by
one or more of such Departments;
(3) develops and commissions evaluations of education and
training activities to determine whether the demand for health
care workers is being met;
(4) identifies barriers to improved coordination at the
Federal, State, and local levels and recommend ways to address
such barriers; and
(5) encourages innovations to address population needs,
constant changes in technology, and other environmental
factors.
(b) Establishment.--There is hereby established the National Health
Care Workforce Commission (in this section referred to as the
``Commission'').
(c) Membership.--
(1) Number and appointment.--The Commission shall be
composed of 15 members to be appointed by the Comptroller
General, without regard to section 5 of the Federal Advisory
Committee Act (5 U.S.C. App.).
(2) Qualifications.--
(A) In general.--The membership of the Commission
shall include individuals--
(i) with national recognition for their
expertise in health care labor market analysis,
including health care workforce analysis;
health care finance and economics; health care
facility management; health care plans and
integrated delivery systems; health care
workforce education and training; health care
philanthropy; providers of health care
services; and other related fields; and
(ii) who will provide a combination of
professional perspectives, broad geographic
representation, and a balance between urban,
suburban, rural, and frontier representatives.
(B) Inclusion.--
(i) In general.--The membership of the
Commission shall include no less than one
representative of--
(I) the health care workforce and
health professionals;
(II) employers;
(III) third-party payers;
(IV) individuals skilled in the
conduct and interpretation of health
care services and health economics
research;
(V) representatives of consumers;
(VI) labor unions;
(VII) State or local workforce
investment boards; and
(VIII) educational institutions
(which may include elementary and
secondary institutions, institutions of
higher education, including 2 and 4
year institutions, or registered
apprenticeship programs).
(ii) Additional members.--The remaining
membership may include additional
representatives from clause (i) and other
individuals as determined appropriate by the
Comptroller General of the United States.
(C) Majority non-providers.--Individuals who are
directly involved in health professions education or
practice shall not constitute a majority of the
membership of the Commission.
(D) Ethical disclosure.--The Comptroller General
shall establish a system for public disclosure by
members of the Commission of financial and other
potential conflicts of interest relating to such
members. Members of the Commission shall be treated as
employees of Congress for purposes of applying title I
of the Ethics in Government Act of 1978. Members of the
Commission shall not be treated as special government
employees under title 18, United States Code.
(3) Terms.--
(A) In general.--The terms of members of the
Commission shall be for 3 years except that the
Comptroller General shall designate staggered terms for
the members first appointed.
(B) Vacancies.--Any member appointed to fill a
vacancy occurring before the expiration of the term for
which the member's predecessor was appointed shall be
appointed only for the remainder of that term. A member
may serve after the expiration of that member's term
until a successor has taken office. A vacancy in the
Commission shall be filled in the manner in which the
original appointment was made.
(C) Initial appointments.--The Comptroller General
shall make initial appointments of members to the
Commission not later than September 30, 2010.
(4) Compensation.--While serving on the business of the
Commission (including travel time), a member of the Commission
shall be entitled to compensation at the per diem equivalent of
the rate provided for level IV of the Executive Schedule under
section 5315 of tile 5, United States Code, and while so
serving away from home and the member's regular place of
business, a member may be allowed travel expenses, as
authorized by the Chairman of the Commission. Physicians
serving as personnel of the Commission may be provided a
physician comparability allowance by the Commission in the same
manner as Government physicians may be provided such an
allowance by an agency under section 5948 of title 5, United
States Code, and for such purpose subsection (i) of such
section shall apply to the Commission in the same manner as it
applies to the Tennessee Valley Authority. For purposes of pay
(other than pay of members of the Commission) and employment
benefits, rights, and privileges, all personnel of the
Commission shall be treated as if they were employees of the
United States Senate. Personnel of the Commission shall not be
treated as employees of the Government Accountability Office
for any purpose.
(5) Chairman, vice chairman.--The Comptroller General shall
designate a member of the Commission, at the time of
appointment of the member, as Chairman and a member as Vice
Chairman for that term of appointment, except that in the case
of vacancy of the chairmanship or vice chairmanship, the
Comptroller General may designate another member for the
remainder of that member's term.
(6) Meetings.--The Commission shall meet at the call of the
chairman, but no less frequently than on a quarterly basis.
(d) Duties.--
(1) Recognition, dissemination, and communication.--The
Commission shall--
(A) recognize efforts of Federal, State, and local
partnerships to develop and offer health care career
pathways of proven effectiveness;
(B) disseminate information on promising retention
practices for health care professionals; and
(C) communicate information on important policies
and practices that affect the recruitment, education
and training, and retention of the health care
workforce.
(2) Review of health care workforce and annual reports.--In
order to develop a fiscally sustainable integrated workforce
that supports a high-quality, readily accessible health care
delivery system that meets the needs of patients and
populations, the Commission, in consultation with relevant
Federal, State, and local agencies, shall--
(A) review current and projected health care
workforce supply and demand, including the topics
described in paragraph (3);
(B) make recommendations to Congress and the
Administration concerning national health care
workforce priorities, goals, and policies;
(C) by not later than October 1 of each year
(beginning with 2011), submit a report to Congress and
the Administration containing the results of such
reviews and recommendations concerning related
policies; and
(D) by not later than April 1 of each year
(beginning with 2011), submit a report to Congress and
the Administration containing a review of, and
recommendations on, at a minimum one high priority area
as described in paragraph (4).
(3) Specific topics to be reviewed.--The topics described
in this paragraph include--
(A) current health care workforce supply and
distribution, including demographics, skill sets, and
demands, with projected demands during the subsequent
10 and 25 year periods;
(B) health care workforce education and training
capacity, including the number of students who have
completed education and training, including registered
apprenticeships; the number of qualified faculty; the
education and training infrastructure; and the
education and training demands, with projected demands
during the subsequent 10 and 25 year periods;
(C) the education loan and grant programs in titles
VII and VIII of the Public Health Service Act (42
U.S.C. 292 et seq. and 296 et seq.), with
recommendations on whether such programs should become
part of the Higher Education Act of 1965 (20 U.S.C.
1001 et seq);
(D) the implications of new and existing Federal
policies which affect the health care workforce,
including Medicare and Medicaid graduate medical
education policies, titles VII and VIII of the Public
Health Service Act (42 U.S.C. 292 et seq. and 296 et
seq.), the National Health Service Corps (with
recommendations for aligning such programs with
national health workforce priorities and goals), and
other health care workforce programs, including those
supported through the Workforce Investment Act of 1998
(29 U.S.C. 2801 et seq.), the Carl D. Perkins Career
and Technical Education Act of 2006 (20 U.S.C. 2301 et
seq.), the Higher Education Act of 1965 (20 U.S.C. 1001
et seq.), and any other Federal health care workforce
programs;
(E) the health care workforce needs of special
populations, such as minorities, rural populations,
medically underserved populations, gender specific
needs, individuals with disabilities, and geriatric and
pediatric populations with recommendations for new and
existing Federal policies to meet the needs of these
special populations; and
(F) recommendations creating or revising national
loan repayment programs and scholarship programs to
require low-income, minority medical students to serve
in their home communities, if designated as medical
underserved community.
(4) High priority areas.--
(A) In general.--The initial high priority topics
described in this paragraph include each of the
following:
(i) Integrated health care workforce
planning that identifies health care
professional skills needed and maximizes the
skill sets of health care professionals across
disciplines.
(ii) An analysis of the nature, scopes of
practice, and demands for health care workers
in the enhanced information technology and
management workplace.
(iii) An analysis of how to align Medicare
and Medicaid graduate medical education
policies with national workforce goals.
(iv) The education and training capacity,
projected demands, and integration with the
health care delivery system of each of the
following:
(I) Nursing workforce capacity at
all levels.
(II) Oral health care workforce
capacity at all levels.
(III) Mental and behavioral health
care workforce capacity at all levels.
(IV) Allied health and public
health care workforce capacity at all
levels.
(V) Emergency medical service
workforce capacity, including the
retention and recruitment of the
volunteer workforce, at all levels.
(VI) The geographic distribution of
health care providers as compared to
the identified health care workforce
needs of States and regions.
(B) Future determinations.--The Commission may
require that additional topics be included under
subparagraph (A). The appropriate committees of
Congress may recommend to the Commission the inclusion
of other topics for health care workforce development
areas that require special attention.
(5) Grant program.--The Commission shall--
(A) review implementation progress reports on, and
report to Congress about, the State Health Care
Workforce Development Grant program established in
section 5102;
(B) in collaboration with the Department of Labor
and in coordination with the Department of Education
and other relevant Federal agencies, make
recommendations to the fiscal and administrative agent
under section 5102(b) for grant recipients under
section 5102;
(C) assess the implementation of the grants under
such section; and
(D) collect performance and report information,
including identified models and best practices, on
grants from the fiscal and administrative agent under
such section and distribute this information to
Congress, relevant Federal agencies, and to the public.
(6) Study.--The Commission shall study effective mechanisms
for financing education and training for careers in health
care, including public health and allied health.
(7) Recommendations.--The Commission shall submit
recommendations to Congress, the Department of Labor, and the
Department of Health and Human Services about improving safety,
health, and worker protections in the workplace for the health
care workforce.
(8) Assessment.--The Commission shall assess and receive
reports from the National Center for Health Care Workforce
Analysis established under section 761(b) of the Public Service
Health Act (as amended by section 5103).
(e) Consultation With Federal, State, and Local Agencies, Congress,
and Other Organizations.--
(1) In general.--The Commission shall consult with Federal
agencies (including the Departments of Health and Human
Services, Labor, Education, Commerce, Agriculture, Defense, and
Veterans Affairs and the Environmental Protection Agency),
Congress, the Medicare Payment Advisory Commission, the
Medicaid and CHIP Payment and Access Commission, and, to the
extent practicable, with State and local agencies, Indian
tribes, voluntary health care organizations, professional
societies, and other relevant public-private health care
partnerships.
(2) Obtaining official data.--The Commission, consistent
with established privacy rules, may secure directly from any
department or agency of the Executive Branch information
necessary to enable the Commission to carry out this section.
(3) Detail of federal government employees.--An employee of
the Federal Government may be detailed to the Commission
without reimbursement. The detail of such an employee shall be
without interruption or loss of civil service status.
(f) Director and Staff; Experts and Consultants.--Subject to such
review as the Comptroller General of the United States determines to be
necessary to ensure the efficient administration of the Commission, the
Commission may--
(1) employ and fix the compensation of an executive
director that shall not exceed the rate of basic pay payable
for level V of the Executive Schedule and such other personnel
as may be necessary to carry out its duties (without regard to
the provisions of title 5, United States Code, governing
appointments in the competitive service);
(2) seek such assistance and support as may be required in
the performance of its duties from appropriate Federal
departments and agencies;
(3) enter into contracts or make other arrangements, as may
be necessary for the conduct of the work of the Commission
(without regard to section 3709 of the Revised Statutes (41
U.S.C. 5));
(4) make advance, progress, and other payments which relate
to the work of the Commission;
(5) provide transportation and subsistence for persons
serving without compensation; and
(6) prescribe such rules and regulations as the Commission
determines to be necessary with respect to the internal
organization and operation of the Commission.
(g) Powers.--
(1) Data collection.--In order to carry out its functions
under this section, the Commission shall--
(A) utilize existing information, both published
and unpublished, where possible, collected and assessed
either by its own staff or under other arrangements
made in accordance with this section, including
coordination with the Bureau of Labor Statistics;
(B) carry out, or award grants or contracts for the
carrying out of, original research and development,
where existing information is inadequate, and
(C) adopt procedures allowing interested parties to
submit information for the Commission's use in making
reports and recommendations.
(2) Access of the government accountability office to
information.--The Comptroller General of the United States
shall have unrestricted access to all deliberations, records,
and data of the Commission, immediately upon request.
(3) Periodic audit.--The Commission shall be subject to
periodic audit by an independent public accountant under
contract to the Commission.
(h) Authorization of Appropriations.--
(1) Request for appropriations.--The Commission shall
submit requests for appropriations in the same manner as the
Comptroller General of the United States submits requests for
appropriations. Amounts so appropriated for the Commission
shall be separate from amounts appropriated for the Comptroller
General.
(2) Authorization.--There are authorized to be appropriated
such sums as may be necessary to carry out this section.
(3) Gifts and services.--The Commission may not accept
gifts, bequeaths, or donations of property, but may accept and
use donations of services for purposes of carrying out this
section.
(i) Definitions.--In this section:
(1) Health care workforce.--The term ``health care
workforce'' includes all health care providers with direct
patient care and support responsibilities, such as physicians,
nurses, nurse practitioners, primary care providers, preventive
medicine physicians, optometrists, ophthalmologists, physician
assistants, pharmacists, dentists, dental hygienists, and other
oral healthcare professionals, allied health professionals,
doctors of chiropractic, community health workers, health care
paraprofessionals, direct care workers, psychologists and other
behavioral and mental health professionals (including substance
abuse prevention and treatment providers), social workers,
physical and occupational therapists, certified nurse midwives,
podiatrists, the EMS workforce (including professional and
volunteer ambulance personnel and firefighters who perform
emergency medical services), licensed complementary and
alternative medicine providers, integrative health
practitioners, public health professionals, and any other
health professional that the Comptroller General of the United
States determines appropriate.
(2) Health professionals.--The term ``health
professionals'' includes--
(A) dentists, dental hygienists, primary care
providers, specialty physicians, nurses, nurse
practitioners, physician assistants, psychologists and
other behavioral and mental health professionals
(including substance abuse prevention and treatment
providers), social workers, physical and occupational
therapists, public health professionals, clinical
pharmacists, allied health professionals, doctors of
chiropractic, community health workers, school nurses,
certified nurse midwives, podiatrists, licensed
complementary and alternative medicine providers, the
EMS workforce (including professional and volunteer
ambulance personnel and firefighters who perform
emergency medical services), and integrative health
practitioners;
(B) national representatives of health
professionals;
(C) representatives of schools of medicine,
osteopathy, nursing, dentistry, optometry, pharmacy,
chiropractic, allied health, educational programs for
public health professionals, behavioral and mental
health professionals (as so defined), social workers,
pharmacists, physical and occupational therapists, oral
health care industry dentistry and dental hygiene, and
physician assistants;
(D) representatives of public and private teaching
hospitals, and ambulatory health facilities, including
Federal medical facilities; and
(E) any other health professional the Comptroller
General of the United States determines appropriate.
SEC. 5102. STATE HEALTH CARE WORKFORCE DEVELOPMENT GRANTS.
(a) Establishment.--There is established a competitive health care
workforce development grant program (referred to in this section as the
``program'') for the purpose of enabling State partnerships to complete
comprehensive planning and to carry out activities leading to coherent
and comprehensive health care workforce development strategies at the
State and local levels.
(b) Fiscal and Administrative Agent.--The Health Resources and
Services Administration of the Department of Health and Human Services
(referred to in this section as the ``Administration'') shall be the
fiscal and administrative agent for the grants awarded under this
section. The Administration is authorized to carry out the program, in
consultation with the National Health Care Workforce Commission
(referred to in this section as the ``Commission''), which shall review
reports on the development, implementation, and evaluation activities
of the grant program, including--
(1) administering the grants;
(2) providing technical assistance to grantees; and
(3) reporting performance information to the Commission.
(c) Planning Grants.--
(1) Amount and duration.--A planning grant shall be awarded
under this subsection for a period of not more than one year
and the maximum award may not be more than $150,000.
(2) Eligibility.--To be eligible to receive a planning
grant, an entity shall be an eligible partnership. An eligible
partnership shall be a State workforce investment board, if it
includes or modifies the members to include at least one
representative from each of the following: health care
employer, labor organization, a public 2-year institution of
higher education, a public 4-year institution of higher
education, the recognized State federation of labor, the State
public secondary education agency, the State P-16 or P-20
Council if such a council exists, and a philanthropic
organization that is actively engaged in providing learning,
mentoring, and work opportunities to recruit, educate, and
train individuals for, and retain individuals in, careers in
health care and related industries.
(3) Fiscal and administrative agent.--The Governor of the
State receiving a planning grant has the authority to appoint a
fiscal and an administrative agency for the partnership.
(4) Application.--Each State partnership desiring a
planning grant shall submit an application to the Administrator
of the Administration at such time and in such manner, and
accompanied by such information as the Administrator may
reasonable require. Each application submitted for a planning
grant shall describe the members of the State partnership, the
activities for which assistance is sought, the proposed
performance benchmarks to be used to measure progress under the
planning grant, a budget for use of the funds to complete the
required activities described in paragraph (5), and such
additional assurance and information as the Administrator
determines to be essential to ensure compliance with the grant
program requirements.
(5) Required activities.--A State partnership receiving a
planning grant shall carry out the following:
(A) Analyze State labor market information in order
to create health care career pathways for students and
adults, including dislocated workers.
(B) Identify current and projected high demand
State or regional health care sectors for purposes of
planning career pathways.
(C) Identify existing Federal, State, and private
resources to recruit, educate or train, and retain a
skilled health care workforce and strengthen
partnerships.
(D) Describe the academic and health care industry
skill standards for high school graduation, for entry
into postsecondary education, and for various
credentials and licensure.
(E) Describe State secondary and postsecondary
education and training policies, models, or practices
for the health care sector, including career
information and guidance counseling.
(F) Identify Federal or State policies or rules to
developing a coherent and comprehensive health care
workforce development strategy and barriers and a plan
to resolve these barriers.
(G) Participate in the Administration's evaluation
and reporting activities.
(6) Performance and evaluation.--Before the State
partnership receives a planning grant, such partnership and the
Administrator of the Administration shall jointly determine the
performance benchmarks that will be established for the
purposes of the planning grant.
(7) Match.--Each State partnership receiving a planning
grant shall provide an amount, in cash or in kind, that is not
less that 15 percent of the amount of the grant, to carry out
the activities supported by the grant. The matching requirement
may be provided from funds available under other Federal,
State, local or private sources to carry out the activities.
(8) Report.--
(A) Report to administration.--Not later than 1
year after a State partnership receives a planning
grant, the partnership shall submit a report to the
Administration on the State's performance of the
activities under the grant, including the use of funds,
including matching funds, to carry out required
activities, and a description of the progress of the
State workforce investment board in meeting the
performance benchmarks.
(B) Report to congress.--The Administration shall
submit a report to Congress analyzing the planning
activities, performance, and fund utilization of each
State grant recipient, including an identification of
promising practices and a profile of the activities of
each State grant recipient.
(d) Implementation Grants.--
(1) In general.--The Administration shall--
(A) competitively award implementation grants to
State partnerships to enable such partnerships to
implement activities that will result in a coherent and
comprehensive plan for health workforce development
that will address current and projected workforce
demands within the State; and
(B) inform the Commission and Congress about the
awards made.
(2) Duration.--An implementation grant shall be awarded for
a period of no more than 2 years, except in those cases where
the Administration determines that the grantee is high
performing and the activities supported by the grant warrant up
to 1 additional year of funding.
(3) Eligibility.--To be eligible for an implementation
grant, a State partnership shall have--
(A) received a planning grant under subsection (c)
and completed all requirements of such grant; or
(B) completed a satisfactory application, including
a plan to coordinate with required partners and
complete the required activities during the 2 year
period of the implementation grant.
(4) Fiscal and administrative agent.--A State partnership
receiving an implementation grant shall appoint a fiscal and an
administration agent for the implementation of such grant.
(5) Application.--Each eligible State partnership desiring
an implementation grant shall submit an application to the
Administration at such time, in such manner, and accompanied by
such information as the Administration may reasonably require.
Each application submitted shall include--
(A) a description of the members of the State
partnership;
(B) a description of how the State partnership
completed the required activities under the planning
grant, if applicable;
(C) a description of the activities for which
implementation grant funds are sought, including grants
to regions by the State partnership to advance coherent
and comprehensive regional health care workforce
planning activities;
(D) a description of how the State partnership will
coordinate with required partners and complete the
required partnership activities during the duration of
an implementation grant;
(E) a budget proposal of the cost of the activities
supported by the implementation grant and a timeline
for the provision of matching funds required;
(F) proposed performance benchmarks to be used to
assess and evaluate the progress of the partnership
activities;
(G) a description of how the State partnership will
collect data to report progress in grant activities;
and
(H) such additional assurances as the
Administration determines to be essential to ensure
compliance with grant requirements.
(6) Required activities.--
(A) In general.--A State partnership that receives
an implementation grant may reserve not less than 60
percent of the grant funds to make grants to be
competitively awarded by the State partnership,
consistent with State procurement rules, to encourage
regional partnerships to address health care workforce
development needs and to promote innovative health care
workforce career pathway activities, including career
counseling, learning, and employment.
(B) Eligible partnership duties.--An eligible State
partnership receiving an implementation grant shall--
(i) identify and convene regional
leadership to discuss opportunities to engage
in statewide health care workforce development
planning, including the potential use of
competitive grants to improve the development,
distribution, and diversity of the regional
health care workforce; the alignment of
curricula for health care careers; and the
access to quality career information and
guidance and education and training
opportunities;
(ii) in consultation with key stakeholders
and regional leaders, take appropriate steps to
reduce Federal, State, or local barriers to a
comprehensive and coherent strategy, including
changes in State or local policies to foster
coherent and comprehensive health care
workforce development activities, including
health care career pathways at the regional and
State levels, career planning information,
retraining for dislocated workers, and as
appropriate, requests for Federal program or
administrative waivers;
(iii) develop, disseminate, and review with
key stakeholders a preliminary statewide
strategy that addresses short- and long-term
health care workforce development supply versus
demand;
(iv) convene State partnership members on a
regular basis, and at least on a semiannual
basis;
(v) assist leaders at the regional level to
form partnerships, including technical
assistance and capacity building activities;
(vi) collect and assess data on and report
on the performance benchmarks selected by the
State partnership and the Administration for
implementation activities carried out by
regional and State partnerships; and
(vii) participate in the Administration's
evaluation and reporting activities.
(7) Performance and evaluation.--Before the State
partnership receives an implementation grant, it and the
Administrator shall jointly determine the performance
benchmarks that shall be established for the purposes of the
implementation grant.
(8) Match.--Each State partnership receiving an
implementation grant shall provide an amount, in cash or in
kind that is not less than 25 percent of the amount of the
grant, to carry out the activities supported by the grant. The
matching funds may be provided from funds available from other
Federal, State, local, or private sources to carry out such
activities.
(9) Reports.--
(A) Report to administration.--For each year of the
implementation grant, the State partnership receiving
the implementation grant shall submit a report to the
Administration on the performance of the State of the
grant activities, including a description of the use of
the funds, including matched funds, to complete
activities, and a description of the performance of the
State partnership in meeting the performance
benchmarks.
(B) Report to congress.--The Administration shall
submit a report to Congress analyzing implementation
activities, performance, and fund utilization of the
State grantees, including an identification of
promising practices and a profile of the activities of
each State grantee.
(e) Authorization for Appropriations.--
(1) Planning grants.--There are authorized to be
appropriated to award planning grants under subsection (c)
$8,000,000 for fiscal year 2010, and such sums as may be
necessary for each subsequent fiscal year.
(2) Implementation grants.--There are authorized to be
appropriated to award implementation grants under subsection
(d), $150,000,000 for fiscal year 2010, and such sums as may be
necessary for each subsequent fiscal year.
SEC. 5103. HEALTH CARE WORKFORCE ASSESSMENT.
(a) In General.--Section 761 of the Public Health Service Act (42
U.S.C. 294m) is amended--
(1) by redesignating subsection (c) as subsection (e);
(2) by striking subsection (b) and inserting the following:
``(b) National Center for Health Care Workforce Analysis.--
``(1) Establishment.--The Secretary shall establish the
National Center for Health Workforce Analysis (referred to in
this section as the `National Center').
``(2) Purposes.--The National Center, in coordination to
the extent practicable with the National Health Care Workforce
Commission (established in section 5101 of the Patient
Protection and Affordable Care Act), and relevant regional and
State centers and agencies, shall--
``(A) provide for the development of information
describing and analyzing the health care workforce and
workforce related issues;
``(B) carry out the activities under section
792(a);
``(C) annually evaluate programs under this title;
``(D) develop and publish performance measures and
benchmarks for programs under this title; and
``(E) establish, maintain, and publicize a national
Internet registry of each grant awarded under this
title and a database to collect data from longitudinal
evaluations (as described in subsection (d)(2)) on
performance measures (as developed under sections
749(d)(3), 757(d)(3), and 762(a)(3)).
``(3) Collaboration and data sharing.--
``(A) In general.--The National Center shall
collaborate with Federal agencies and relevant
professional and educational organizations or societies
for the purpose of linking data regarding grants
awarded under this title.
``(B) Contracts for health workforce analysis.--For
the purpose of carrying out the activities described in
subparagraph (A), the National Center may enter into
contracts with relevant professional and educational
organizations or societies.
``(c) State and Regional Centers for Health Workforce Analysis.--
``(1) In general.--The Secretary shall award grants to, or
enter into contracts with, eligible entities for purposes of--
``(A) collecting, analyzing, and reporting data
regarding programs under this title to the National
Center and to the public; and
``(B) providing technical assistance to local and
regional entities on the collection, analysis, and
reporting of data.
``(2) Eligible entities.--To be eligible for a grant or
contract under this subsection, an entity shall--
``(A) be a State, a State workforce investment
board, a public health or health professions school, an
academic health center, or an appropriate public or
private nonprofit entity; and
``(B) submit to the Secretary an application at
such time, in such manner, and containing such
information as the Secretary may require.
``(d) Increase in Grants for Longitudinal Evaluations.--
``(1) In general.--The Secretary shall increase the amount
awarded to an eligible entity under this title for a
longitudinal evaluation of individuals who have received
education, training, or financial assistance from programs
under this title.
``(2) Capability.--A longitudinal evaluation shall be
capable of--
``(A) studying practice patterns; and
``(B) collecting and reporting data on performance
measures developed under sections 749(d)(3), 757(d)(3),
and 762(a)(3).
``(3) Guidelines.--A longitudinal evaluation shall comply
with guidelines issued under sections 749(d)(4), 757(d)(4), and
762(a)(4).
``(4) Eligible entities.--To be eligible to obtain an
increase under this section, an entity shall be a recipient of
a grant or contract under this title.''; and
(3) in subsection (e), as so redesignated--
(A) by striking paragraph (1) and inserting the
following:
``(1) In general.--
``(A) National center.--To carry out subsection
(b), there are authorized to be appropriated $7,500,000
for each of fiscal years 2010 through 2014.
``(B) State and regional centers.--To carry out
subsection (c), there are authorized to be appropriated
$4,500,000 for each of fiscal years 2010 through 2014.
``(C) Grants for longitudinal evaluations.--To
carry out subsection (d), there are authorized to be
appropriated such sums as may be necessary for fiscal
years 2010 through 2014.''; and
(4) in paragraph (2), by striking ``subsection (a)'' and
inserting ``paragraph (1)''.
(b) Transfers.--Not later than 180 days after the date of enactment
of this Act, the responsibilities and resources of the National Center
for Health Workforce Analysis, as in effect on the date before the date
of enactment of this Act, shall be transferred to the National Center
for Health Care Workforce Analysis established under section 761 of the
Public Health Service Act, as amended by subsection (a).
(c) Use of Longitudinal Evaluations.--Section 791(a)(1) of the
Public Health Service Act (42 U.S.C. 295j(a)(1)) is amended--
(1) in subparagraph (A), by striking ``or'' at the end;
(2) in subparagraph (B), by striking the period and
inserting ``; or''; and
(3) by adding at the end the following:
``(C) utilizes a longitudinal evaluation (as
described in section 761(d)(2)) and reports data from
such system to the national workforce database (as
established under section 761(b)(2)(E)).''.
(d) Performance Measures; Guidelines for Longitudinal
Evaluations.--
(1) Advisory committee on training in primary care medicine
and dentistry.--Section 748(d) of the Public Health Service Act
is amended--
(A) in paragraph (1), by striking ``and'' at the
end;
(B) in paragraph (2), by striking the period and
inserting a semicolon; and
(C) by adding at the end the following:
``(3) develop, publish, and implement performance measures
for programs under this part;
``(4) develop and publish guidelines for longitudinal
evaluations (as described in section 761(d)(2)) for programs
under this part; and
``(5) recommend appropriation levels for programs under
this part.''.
(2) Advisory committee on interdisciplinary, community-
based linkages.--Section 756(d) of the Public Health Service
Act is amended--
(A) in paragraph (1), by striking ``and'' at the
end;
(B) in paragraph (2), by striking the period and
inserting a semicolon; and
(C) by adding at the end the following:
``(3) develop, publish, and implement performance measures
for programs under this part;
``(4) develop and publish guidelines for longitudinal
evaluations (as described in section 761(d)(2)) for programs
under this part; and
``(5) recommend appropriation levels for programs under
this part.''.
(3) Advisory council on graduate medical education.--
Section 762(a) of the Public Health Service Act (42 U.S.C.
294o(a)) is amended--
(A) in paragraph (1), by striking ``and'' at the
end;
(B) in paragraph (2), by striking the period and
inserting a semicolon; and
(C) by adding at the end the following:
``(3) develop, publish, and implement performance measures
for programs under this title, except for programs under part C
or D;
``(4) develop and publish guidelines for longitudinal
evaluations (as described in section 761(d)(2)) for programs
under this title, except for programs under part C or D; and
``(5) recommend appropriation levels for programs under
this title, except for programs under part C or D.''.
Subtitle C--Increasing the Supply of the Health Care Workforce
SEC. 5201. FEDERALLY SUPPORTED STUDENT LOAN FUNDS.
(a) Medical Schools and Primary Health Care.--Section 723 of the
Public Health Service Act (42 U.S.C. 292s) is amended--
(1) in subsection (a)--
(A) in paragraph (1), by striking subparagraph (B)
and inserting the following:
``(B) to practice in such care for 10 years
(including residency training in primary health care)
or through the date on which the loan is repaid in
full, whichever occurs first.''; and
(B) by striking paragraph (3) and inserting the
following:
``(3) Noncompliance by student.--Each agreement entered
into with a student pursuant to paragraph (1) shall provide
that, if the student fails to comply with such agreement, the
loan involved will begin to accrue interest at a rate of 2
percent per year greater than the rate at which the student
would pay if compliant in such year.''; and
(2) by adding at the end the following:
``(d) Sense of Congress.--It is the sense of Congress that funds
repaid under the loan program under this section should not be
transferred to the Treasury of the United States or otherwise used for
any other purpose other than to carry out this section.''.
(b) Student Loan Guidelines.--The Secretary of Health and Human
Services shall not require parental financial information for an
independent student to determine financial need under section 723 of
the Public Health Service Act (42 U.S.C. 292s) and the determination of
need for such information shall be at the discretion of applicable
school loan officer. The Secretary shall amend guidelines issued by the
Health Resources and Services Administration in accordance with the
preceding sentence.
SEC. 5202. NURSING STUDENT LOAN PROGRAM.
(a) Loan Agreements.--Section 836(a) of the Public Health Service
Act (42 U.S.C. 297b(a)) is amended--
(1) by striking ``$2,500'' and inserting ``$3,300'';
(2) by striking ``$4,000'' and inserting ``$5,200''; and
(3) by striking ``$13,000'' and all that follows through
the period and inserting ``$17,000 in the case of any student
during fiscal years 2010 and 2011. After fiscal year 2011, such
amounts shall be adjusted to provide for a cost-of-attendance
increase for the yearly loan rate and the aggregate of the
loans.''.
(b) Loan Provisions.--Section 836(b) of the Public Health Service
Act (42 U.S.C. 297b(b)) is amended--
(1) in paragraph (1)(C), by striking ``1986'' and inserting
``2000''; and
(2) in paragraph (3), by striking ``the date of enactment
of the Nurse Training Amendments of 1979'' and inserting
``September 29, 1995''.
SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS.
Part E of title VII of the Public Health Service Act (42 U.S.C.
294n et seq.) is amended by adding at the end the following:
``Subpart 3--Recruitment and Retention Programs
``SEC. 775. INVESTMENT IN TOMORROW'S PEDIATRIC HEALTH CARE WORKFORCE.
``(a) Establishment.--The Secretary shall establish and carry out a
pediatric specialty loan repayment program under which the eligible
individual agrees to be employed full-time for a specified period
(which shall not be less than 2 years) in providing pediatric medical
subspecialty, pediatric surgical specialty, or child and adolescent
mental and behavioral health care, including substance abuse prevention
and treatment services.
``(b) Program Administration.--Through the program established
under this section, the Secretary shall enter into contracts with
qualified health professionals under which--
``(1) such qualified health professionals will agree to
provide pediatric medical subspecialty, pediatric surgical
specialty, or child and adolescent mental and behavioral health
care in an area with a shortage of the specified pediatric
subspecialty that has a sufficient pediatric population to
support such pediatric subspecialty, as determined by the
Secretary; and
``(2) the Secretary agrees to make payments on the
principal and interest of undergraduate, graduate, or graduate
medical education loans of professionals described in paragraph
(1) of not more than $35,000 a year for each year of agreed
upon service under such paragraph for a period of not more than
3 years during the qualified health professional's--
``(A) participation in an accredited pediatric
medical subspecialty, pediatric surgical specialty, or
child and adolescent mental health subspecialty
residency or fellowship; or
``(B) employment as a pediatric medical
subspecialist, pediatric surgical specialist, or child
and adolescent mental health professional serving an
area or population described in such paragraph.
``(c) In General.--
``(1) Eligible individuals.--
``(A) Pediatric medical specialists and pediatric
surgical specialists.--For purposes of contracts with
respect to pediatric medical specialists and pediatric
surgical specialists, the term `qualified health
professional' means a licensed physician who--
``(i) is entering or receiving training in
an accredited pediatric medical subspecialty or
pediatric surgical specialty residency or
fellowship; or
``(ii) has completed (but not prior to the
end of the calendar year in which this section
is enacted) the training described in
subparagraph (B).
``(B) Child and adolescent mental and behavioral
health.--For purposes of contracts with respect to
child and adolescent mental and behavioral health care,
the term `qualified health professional' means a health
care professional who--
``(i) has received specialized training or
clinical experience in child and adolescent
mental health in psychiatry, psychology, school
psychology, behavioral pediatrics, psychiatric
nursing, social work, school social work,
substance abuse disorder prevention and
treatment, marriage and family therapy, school
counseling, or professional counseling;
``(ii) has a license or certification in a
State to practice allopathic medicine,
osteopathic medicine, psychology, school
psychology, psychiatric nursing, social work,
school social work, marriage and family
therapy, school counseling, or professional
counseling; or
``(iii) is a mental health service
professional who completed (but not before the
end of the calendar year in which this section
is enacted) specialized training or clinical
experience in child and adolescent mental
health described in clause (i).
``(2) Additional eligibility requirements.--The Secretary
may not enter into a contract under this subsection with an
eligible individual unless--
``(A) the individual agrees to work in, or for a
provider serving, a health professional shortage area
or medically underserved area, or to serve a medically
underserved population;
``(B) the individual is a United States citizen or
a permanent legal United States resident; and
``(C) if the individual is enrolled in a graduate
program, the program is accredited, and the individual
has an acceptable level of academic standing (as
determined by the Secretary).
``(d) Priority.--In entering into contracts under this subsection,
the Secretary shall give priority to applicants who--
``(1) are or will be working in a school or other pre-
kindergarten, elementary, or secondary education setting;
``(2) have familiarity with evidence-based methods and
cultural and linguistic competence health care services; and
``(3) demonstrate financial need.
``(e) Authorization of Appropriations.--There is authorized to be
appropriated $30,000,000 for each of fiscal years 2010 through 2014 to
carry out subsection (c)(1)(A) and $20,000,000 for each of fiscal years
2010 through 2013 to carry out subsection (c)(1)(B).''.
SEC. 5204. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETENTION PROGRAMS.
Part E of title VII of the Public Health Service Act (42 U.S.C.
294n et seq.), as amended by section 5203, is further amended by adding
at the end the following:
``SEC. 776. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.
``(a) Establishment.--The Secretary shall establish the Public
Health Workforce Loan Repayment Program (referred to in this section as
the `Program') to assure an adequate supply of public health
professionals to eliminate critical public health workforce shortages
in Federal, State, local, and tribal public health agencies.
``(b) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1)(A) be accepted for enrollment, or be enrolled, as a
student in an accredited academic educational institution in a
State or territory in the final year of a course of study or
program leading to a public health or health professions degree
or certificate; and have accepted employment with a Federal,
State, local, or tribal public health agency, or a related
training fellowship, as recognized by the Secretary, to
commence upon graduation;
``(B)(i) have graduated, during the preceding 10-year
period, from an accredited educational institution in a State
or territory and received a public health or health professions
degree or certificate; and
``(ii) be employed by, or have accepted employment with, a
Federal, State, local, or tribal public health agency or a
related training fellowship, as recognized by the Secretary;
``(2) be a United States citizen; and
``(3)(A) submit an application to the Secretary to
participate in the Program;
``(B) execute a written contract as required in subsection
(c); and
``(4) not have received, for the same service, a reduction
of loan obligations under section 455(m), 428J, 428K, 428L, or
460 of the Higher Education Act of 1965.
``(c) Contract.--The written contract (referred to in this section
as the `written contract') between the Secretary and an individual
shall contain--
``(1) an agreement on the part of the Secretary that the
Secretary will repay on behalf of the individual loans incurred
by the individual in the pursuit of the relevant degree or
certificate in accordance with the terms of the contract;
``(2) an agreement on the part of the individual that the
individual will serve in the full-time employment of a Federal,
State, local, or tribal public health agency or a related
fellowship program in a position related to the course of study
or program for which the contract was awarded for a period of
time (referred to in this section as the `period of obligated
service') equal to the greater of--
``(A) 3 years; or
``(B) such longer period of time as determined
appropriate by the Secretary and the individual;
``(3) an agreement, as appropriate, on the part of the
individual to relocate to a priority service area (as
determined by the Secretary) in exchange for an additional loan
repayment incentive amount to be determined by the Secretary;
``(4) a provision that any financial obligation of the
United States arising out of a contract entered into under this
section and any obligation of the individual that is
conditioned thereon, is contingent on funds being appropriated
for loan repayments under this section;
``(5) a statement of the damages to which the United States
is entitled, under this section for the individual's breach of
the contract; and
``(6) such other statements of the rights and liabilities
of the Secretary and of the individual, not inconsistent with
this section.
``(d) Payments.--
``(1) In general.--A loan repayment provided for an
individual under a written contract under the Program shall
consist of payment, in accordance with paragraph (2), on behalf
of the individual of the principal, interest, and related
expenses on government and commercial loans received by the
individual regarding the undergraduate or graduate education of
the individual (or both), which loans were made for tuition
expenses incurred by the individual.
``(2) Payments for years served.--For each year of
obligated service that an individual contracts to serve under
subsection (c) the Secretary may pay up to $35,000 on behalf of
the individual for loans described in paragraph (1). With
respect to participants under the Program whose total eligible
loans are less than $105,000, the Secretary shall pay an amount
that does not exceed \1/3\ of the eligible loan balance for
each year of obligated service of the individual.
``(3) Tax liability.--For the purpose of providing
reimbursements for tax liability resulting from payments under
paragraph (2) on behalf of an individual, the Secretary shall,
in addition to such payments, make payments to the individual
in an amount not to exceed 39 percent of the total amount of
loan repayments made for the taxable year involved.
``(e) Postponing Obligated Service.--With respect to an individual
receiving a degree or certificate from a health professions or other
related school, the date of the initiation of the period of obligated
service may be postponed as approved by the Secretary.
``(f) Breach of Contract.--An individual who fails to comply with
the contract entered into under subsection (c) shall be subject to the
same financial penalties as provided for under section 338E for
breaches of loan repayment contracts under section 338B.
``(g) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section $195,000,000 for fiscal year
2010, and such sums as may be necessary for each of fiscal years 2011
through 2015.''.
SEC. 5205. ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION PROGRAMS.
(a) Purpose.--The purpose of this section is to assure an adequate
supply of allied health professionals to eliminate critical allied
health workforce shortages in Federal, State, local, and tribal public
health agencies or in settings where patients might require health care
services, including acute care facilities, ambulatory care facilities,
personal residences and other settings, as recognized by the Secretary
of Health and Human Services by authorizing an Allied Health Loan
Forgiveness Program.
(b) Allied Health Workforce Recruitment and Retention Program.--
Section 428K of the Higher Education Act of 1965 (20 U.S.C. 1078-11) is
amended--
(1) in subsection (b), by adding at the end the following:
``(18) Allied health professionals.--The individual is
employed full-time as an allied health professional--
``(A) in a Federal, State, local, or tribal public
health agency; or
``(B) in a setting where patients might require
health care services, including acute care facilities,
ambulatory care facilities, personal residences and
other settings located in health professional shortage
areas, medically underserved areas, or medically
underserved populations, as recognized by the Secretary
of Health and Human Services.''; and
(2) in subsection (g)--
(A) by redesignating paragraphs (1) through (9) as
paragraphs (2) through (10), respectively; and
(B) by inserting before paragraph (2) (as
redesignated by subparagraph (A)) the following:
``(1) Allied health professional.--The term `allied health
professional' means an allied health professional as defined in
section 799B(5) of the Public Heath Service Act (42 U.S.C.
295p(5)) who--
``(A) has graduated and received an allied health
professions degree or certificate from an institution
of higher education; and
``(B) is employed with a Federal, State, local or
tribal public health agency, or in a setting where
patients might require health care services, including
acute care facilities, ambulatory care facilities,
personal residences and other settings located in
health professional shortage areas, medically
underserved areas, or medically underserved
populations, as recognized by the Secretary of Health
and Human Services.''.
SEC. 5206. GRANTS FOR STATE AND LOCAL PROGRAMS.
(a) In General.--Section 765(d) of the Public Health Service Act
(42 U.S.C. 295(d)) is amended--
(1) in paragraph (7), by striking ``; or'' and inserting a
semicolon;
(2) by redesignating paragraph (8) as paragraph (9); and
(3) by inserting after paragraph (7) the following:
``(8) public health workforce loan repayment programs;
or''.
(b) Training for Mid-career Public Health Professionals.--Part E of
title VII of the Public Health Service Act (42 U.S.C. 294n et seq.), as
amended by section 5204, is further amended by adding at the end the
following:
``SEC. 777. TRAINING FOR MID-CAREER PUBLIC AND ALLIED HEALTH
PROFESSIONALS.
``(a) In General.--The Secretary may make grants to, or enter into
contracts with, any eligible entity to award scholarships to eligible
individuals to enroll in degree or professional training programs for
the purpose of enabling mid-career professionals in the public health
and allied health workforce to receive additional training in the field
of public health and allied health.
``(b) Eligibility.--
``(1) Eligible entity.--The term `eligible entity'
indicates an accredited educational institution that offers a
course of study, certificate program, or professional training
program in public or allied health or a related discipline, as
determined by the Secretary
``(2) Eligible individuals.--The term `eligible
individuals' includes those individuals employed in public and
allied health positions at the Federal, State, tribal, or local
level who are interested in retaining or upgrading their
education.
``(c) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section, $60,000,000 for fiscal year
2010 and such sums as may be necessary for each of fiscal years 2011
through 2015. Fifty percent of appropriated funds shall be allotted to
public health mid-career professionals and 50 percent shall be allotted
to allied health mid-career professionals.''.
SEC. 5207. FUNDING FOR NATIONAL HEALTH SERVICE CORPS.
Section 338H(a) of the Public Health Service Act (42 U.S.C.
254q(a)) is amended to read as follows:
``(a) Authorization of Appropriations.--For the purpose of carrying
out this section, there is authorized to be appropriated, out of any
funds in the Treasury not otherwise appropriated, the following:
``(1) For fiscal year 2010, $320,461,632.
``(2) For fiscal year 2011, $414,095,394.
``(3) For fiscal year 2012, $535,087,442.
``(4) For fiscal year 2013, $691,431,432.
``(5) For fiscal year 2014, $893,456,433.
``(6) For fiscal year 2015, $1,154,510,336.
``(7) For fiscal year 2016, and each subsequent fiscal
year, the amount appropriated for the preceding fiscal year
adjusted by the product of--
``(A) one plus the average percentage increase in
the costs of health professions education during the
prior fiscal year; and
``(B) one plus the average percentage change in the
number of individuals residing in health professions
shortage areas designated under section 333 during the
prior fiscal year, relative to the number of
individuals residing in such areas during the previous
fiscal year.''.
SEC. 5208. NURSE-MANAGED HEALTH CLINICS.
(a) Purpose.--The purpose of this section is to fund the
development and operation of nurse-managed health clinics.
(b) Grants.--Subpart 1 of part D of title III of the Public Health
Service Act (42 U.S.C. 254b et seq.) is amended by inserting after
section 330A the following:
``SEC. 330A-1. GRANTS TO NURSE-MANAGED HEALTH CLINICS.
``(a) Definitions.--
``(1) Comprehensive primary health care services.--In this
section, the term `comprehensive primary health care services'
means the primary health services described in section
330(b)(1).
``(2) Nurse-managed health clinic.--The term `nurse-managed
health clinic' means a nurse-practice arrangement, managed by
advanced practice nurses, that provides primary care or
wellness services to underserved or vulnerable populations and
that is associated with a school, college, university or
department of nursing, federally qualified health center, or
independent nonprofit health or social services agency.
``(b) Authority to Award Grants.--The Secretary shall award grants
for the cost of the operation of nurse-managed health clinics that meet
the requirements of this section.
``(c) Applications.--To be eligible to receive a grant under this
section, an entity shall--
``(1) be an NMHC; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing--
``(A) assurances that nurses are the major
providers of services at the NMHC and that at least 1
advanced practice nurse holds an executive management
position within the organizational structure of the
NMHC;
``(B) an assurance that the NMHC will continue
providing comprehensive primary health care services or
wellness services without regard to income or insurance
status of the patient for the duration of the grant
period; and
``(C) an assurance that, not later than 90 days of
receiving a grant under this section, the NMHC will
establish a community advisory committee, for which a
majority of the members shall be individuals who are
served by the NMHC.
``(d) Grant Amount.--The amount of any grant made under this
section for any fiscal year shall be determined by the Secretary,
taking into account--
``(1) the financial need of the NMHC, considering State,
local, and other operational funding provided to the NMHC; and
``(2) other factors, as the Secretary determines
appropriate.
``(e) Authorization of Appropriations.--For the purposes of
carrying out this section, there are authorized to be appropriated
$50,000,000 for the fiscal year 2010 and such sums as may be necessary
for each of the fiscal years 2011 through 2014.''.
SEC. 5209. ELIMINATION OF CAP ON COMMISSIONED CORPS.
Section 202 of the Department of Health and Human Services
Appropriations Act, 1993 (Public Law 102-394) is amended by striking
``not to exceed 2,800''.
SEC. 5210. ESTABLISHING A READY RESERVE CORPS.
Section 203 of the Public Health Service Act (42 U.S.C. 204) is
amended to read as follows:
``SEC. 203. COMMISSIONED CORPS AND READY RESERVE CORPS.
``(a) Establishment.--
``(1) In general.--There shall be in the Service a
commissioned Regular Corps and a Ready Reserve Corps for
service in time of national emergency.
``(2) Requirement.--All commissioned officers shall be
citizens of the United States and shall be appointed without
regard to the civil-service laws and compensated without regard
to the Classification Act of 1923, as amended.
``(3) Appointment.--Commissioned officers of the Ready
Reserve Corps shall be appointed by the President and
commissioned officers of the Regular Corps shall be appointed
by the President with the advice and consent of the Senate.
``(4) Active duty.--Commissioned officers of the Ready
Reserve Corps shall at all times be subject to call to active
duty by the Surgeon General, including active duty for the
purpose of training.
``(5) Warrant officers.--Warrant officers may be appointed
to the Service for the purpose of providing support to the
health and delivery systems maintained by the Service and any
warrant officer appointed to the Service shall be considered
for purposes of this Act and title 37, United States Code, to
be a commissioned officer within the Commissioned Corps of the
Service.
``(b) Assimilating Reserve Corp Officers Into the Regular Corps.--
Effective on the date of enactment of the Patient Protection and
Affordable Care Act, all individuals classified as officers in the
Reserve Corps under this section (as such section existed on the day
before the date of enactment of such Act) and serving on active duty
shall be deemed to be commissioned officers of the Regular Corps.
``(c) Purpose and Use of Ready Research.--
``(1) Purpose.--The purpose of the Ready Reserve Corps is
to fulfill the need to have additional Commissioned Corps
personnel available on short notice (similar to the uniformed
service's reserve program) to assist regular Commissioned Corps
personnel to meet both routine public health and emergency
response missions.
``(2) Uses.--The Ready Reserve Corps shall--
``(A) participate in routine training to meet the
general and specific needs of the Commissioned Corps;
``(B) be available and ready for involuntary calls
to active duty during national emergencies and public
health crises, similar to the uniformed service reserve
personnel;
``(C) be available for backfilling critical
positions left vacant during deployment of active duty
Commissioned Corps members, as well as for deployment
to respond to public health emergencies, both foreign
and domestic; and
``(D) be available for service assignment in
isolated, hardship, and medically underserved
communities (as defined in section 799B) to improve
access to health services.
``(d) Funding.--For the purpose of carrying out the duties and
responsibilities of the Commissioned Corps under this section, there
are authorized to be appropriated $5,000,000 for each of fiscal years
2010 through 2014 for recruitment and training and $12,500,000 for each
of fiscal years 2010 through 2014 for the Ready Reserve Corps.''.
Subtitle D--Enhancing Health Care Workforce Education and Training
SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE,
GENERAL PEDIATRICS, AND PHYSICIAN ASSISTANTSHIP.
Part C of title VII (42 U.S.C. 293k et seq.) is amended by striking
section 747 and inserting the following:
``SEC. 747. PRIMARY CARE TRAINING AND ENHANCEMENT.
``(a) Support and Development of Primary Care Training Programs.--
``(1) In general.--The Secretary may make grants to, or
enter into contracts with, an accredited public or nonprofit
private hospital, school of medicine or osteopathic medicine,
academically affiliated physician assistant training program,
or a public or private nonprofit entity which the Secretary has
determined is capable of carrying out such grant or contract--
``(A) to plan, develop, operate, or participate in
an accredited professional training program, including
an accredited residency or internship program in the
field of family medicine, general internal medicine, or
general pediatrics for medical students, interns,
residents, or practicing physicians as defined by the
Secretary;
``(B) to provide need-based financial assistance in
the form of traineeships and fellowships to medical
students, interns, residents, practicing physicians, or
other medical personnel, who are participants in any
such program, and who plan to specialize or work in the
practice of the fields defined in subparagraph (A);
``(C) to plan, develop, and operate a program for
the training of physicians who plan to teach in family
medicine, general internal medicine, or general
pediatrics training programs;
``(D) to plan, develop, and operate a program for
the training of physicians teaching in community-based
settings;
``(E) to provide financial assistance in the form
of traineeships and fellowships to physicians who are
participants in any such programs and who plan to teach
or conduct research in a family medicine, general
internal medicine, or general pediatrics training
program;
``(F) to plan, develop, and operate a physician
assistant education program, and for the training of
individuals who will teach in programs to provide such
training;
``(G) to plan, develop, and operate a demonstration
program that provides training in new competencies, as
recommended by the Advisory Committee on Training in
Primary Care Medicine and Dentistry and the National
Health Care Workforce Commission established in section
5101 of the Patient Protection and Affordable Care Act,
which may include--
``(i) providing training to primary care
physicians relevant to providing care through
patient-centered medical homes (as defined by
the Secretary for purposes of this section);
``(ii) developing tools and curricula
relevant to patient-centered medical homes; and
``(iii) providing continuing education to
primary care physicians relevant to patient-
centered medical homes; and
``(H) to plan, develop, and operate joint degree
programs to provide interdisciplinary and
interprofessional graduate training in public health
and other health professions to provide training in
environmental health, infectious disease control,
disease prevention and health promotion,
epidemiological studies and injury control.
``(2) Duration of awards.--The period during which payments
are made to an entity from an award of a grant or contract
under this subsection shall be 5 years.
``(b) Capacity Building in Primary Care.--
``(1) In general.--The Secretary may make grants to or
enter into contracts with accredited schools of medicine or
osteopathic medicine to establish, maintain, or improve--
``(A) academic units or programs that improve
clinical teaching and research in fields defined in
subsection (a)(1)(A); or
``(B) programs that integrate academic
administrative units in fields defined in subsection
(a)(1)(A) to enhance interdisciplinary recruitment,
training, and faculty development.
``(2) Preference in making awards under this subsection.--
In making awards of grants and contracts under paragraph (1),
the Secretary shall give preference to any qualified applicant
for such an award that agrees to expend the award for the
purpose of--
``(A) establishing academic units or programs in
fields defined in subsection (a)(1)(A); or
``(B) substantially expanding such units or
programs.
``(3) Priorities in making awards.--In awarding grants or
contracts under paragraph (1), the Secretary shall give
priority to qualified applicants that--
``(A) proposes a collaborative project between
academic administrative units of primary care;
``(B) proposes innovative approaches to clinical
teaching using models of primary care, such as the
patient centered medical home, team management of
chronic disease, and interprofessional integrated
models of health care that incorporate transitions in
health care settings and integration physical and
mental health provision;
``(C) have a record of training the greatest
percentage of providers, or that have demonstrated
significant improvements in the percentage of providers
trained, who enter and remain in primary care practice;
``(D) have a record of training individuals who are
from underrepresented minority groups or from a rural
or disadvantaged background;
``(E) provide training in the care of vulnerable
populations such as children, older adults, homeless
individuals, victims of abuse or trauma, individuals
with mental health or substance-related disorders,
individuals with HIV/AIDS, and individuals with
disabilities;
``(F) establish formal relationships and submit
joint applications with federally qualified health
centers, rural health clinics, area health education
centers, or clinics located in underserved areas or
that serve underserved populations;
``(G) teach trainees the skills to provide
interprofessional, integrated care through
collaboration among health professionals;
``(H) provide training in enhanced communication
with patients, evidence-based practice, chronic disease
management, preventive care, health information
technology, or other competencies as recommended by the
Advisory Committee on Training in Primary Care Medicine
and Dentistry and the National Health Care Workforce
Commission established in section 5101 of the Patient
Protection and Affordable Care Act; or
``(I) provide training in cultural competency and
health literacy.
``(4) Duration of awards.--The period during which payments
are made to an entity from an award of a grant or contract
under this subsection shall be 5 years.
``(c) Authorization of Appropriations.--
``(1) In general.--For purposes of carrying out this
section (other than subsection (b)(1)(B)), there are authorized
to be appropriated $125,000,000 for fiscal year 2010, and such
sums as may be necessary for each of fiscal years 2011 through
2014.
``(2) Training programs.--Fifteen percent of the amount
appropriated pursuant to paragraph (1) in each such fiscal year
shall be allocated to the physician assistant training programs
described in subsection (a)(1)(F), which prepare students for
practice in primary care.
``(3) Integrating academic administrative units.--For
purposes of carrying out subsection (b)(1)(B), there are
authorized to be appropriated $750,000 for each of fiscal years
2010 through 2014.''.
SEC. 5302. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS.
Part C of title VII of the Public Health Service Act (42 U.S.C.
293k et seq.) is amended by inserting after section 747, as amended by
section 5301, the following:
``SEC. 747A. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS.
``(a) In General.--The Secretary shall award grants to eligible
entities to enable such entities to provide new training opportunities
for direct care workers who are employed in long-term care settings
such as nursing homes (as defined in section 1908(e)(1) of the Social
Security Act (42 U.S.C. 1396g(e)(1)), assisted living facilities and
skilled nursing facilities, intermediate care facilities for
individuals with mental retardation, home and community based settings,
and any other setting the Secretary determines to be appropriate.
``(b) Eligibility.--To be eligible to receive a grant under this
section, an entity shall--
``(1) be an institution of higher education (as defined in
section 102 of the Higher Education Act of 1965 (20 U.S.C.
1002)) that--
``(A) is accredited by a nationally recognized
accrediting agency or association listed under section
101(c) of the Higher Education Act of 1965 (20 U.S.C.
1001(c)); and
``(B) has established a public-private educational
partnership with a nursing home or skilled nursing
facility, agency or entity providing home and community
based services to individuals with disabilities, or
other long-term care provider; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(c) Use of Funds.--An eligible entity shall use amounts awarded
under a grant under this section to provide assistance to eligible
individuals to offset the cost of tuition and required fees for
enrollment in academic programs provided by such entity.
``(d) Eligible Individual.--
``(1) Eligibility.--To be eligible for assistance under
this section, an individual shall be enrolled in courses
provided by a grantee under this subsection and maintain
satisfactory academic progress in such courses.
``(2) Condition of assistance.--As a condition of receiving
assistance under this section, an individual shall agree that,
following completion of the assistance period, the individual
will work in the field of geriatrics, disability services, long
term services and supports, or chronic care management for a
minimum of 2 years under guidelines set by the Secretary.
``(e) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section, $10,000,000 for the period of
fiscal years 2011 through 2013.''.
SEC. 5303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTRY.
Part C of Title VII of the Public Health Service Act (42 U.S.C.
293k et seq.) is amended by--
(1) redesignating section 748, as amended by section 5103
of this Act, as section 749; and
(2) inserting after section 747A, as added by section 5302,
the following:
``SEC. 748. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH
DENTISTRY.
``(a) Support and Development of Dental Training Programs.--
``(1) In general.--The Secretary may make grants to, or
enter into contracts with, a school of dentistry, public or
nonprofit private hospital, or a public or private nonprofit
entity which the Secretary has determined is capable of
carrying out such grant or contract--
``(A) to plan, develop, and operate, or participate
in, an approved professional training program in the
field of general dentistry, pediatric dentistry, or
public health dentistry for dental students, residents,
practicing dentists, dental hygienists, or other
approved primary care dental trainees, that emphasizes
training for general, pediatric, or public health
dentistry;
``(B) to provide financial assistance to dental
students, residents, practicing dentists, and dental
hygiene students who are in need thereof, who are
participants in any such program, and who plan to work
in the practice of general, pediatric, public heath
dentistry, or dental hygiene;
``(C) to plan, develop, and operate a program for
the training of oral health care providers who plan to
teach in general, pediatric, public health dentistry,
or dental hygiene;
``(D) to provide financial assistance in the form
of traineeships and fellowships to dentists who plan to
teach or are teaching in general, pediatric, or public
health dentistry;
``(E) to meet the costs of projects to establish,
maintain, or improve dental faculty development
programs in primary care (which may be departments,
divisions or other units);
``(F) to meet the costs of projects to establish,
maintain, or improve predoctoral and postdoctoral
training in primary care programs;
``(G) to create a loan repayment program for
faculty in dental programs; and
``(H) to provide technical assistance to pediatric
training programs in developing and implementing
instruction regarding the oral health status, dental
care needs, and risk-based clinical disease management
of all pediatric populations with an emphasis on
underserved children.
``(2) Faculty loan repayment.--
``(A) In general.--A grant or contract under
subsection (a)(1)(G) may be awarded to a program of
general, pediatric, or public health dentistry
described in such subsection to plan, develop, and
operate a loan repayment program under which--
``(i) individuals agree to serve full-time
as faculty members; and
``(ii) the program of general, pediatric or
public health dentistry agrees to pay the
principal and interest on the outstanding
student loans of the individuals.
``(B) Manner of payments.--With respect to the
payments described in subparagraph (A)(ii), upon
completion by an individual of each of the first,
second, third, fourth, and fifth years of service, the
program shall pay an amount equal to 10, 15, 20, 25,
and 30 percent, respectively, of the individual's
student loan balance as calculated based on principal
and interest owed at the initiation of the agreement.
``(b) Eligible Entity.--For purposes of this subsection, entities
eligible for such grants or contracts in general, pediatric, or public
health dentistry shall include entities that have programs in dental or
dental hygiene schools, or approved residency or advanced education
programs in the practice of general, pediatric, or public health
dentistry. Eligible entities may partner with schools of public health
to permit the education of dental students, residents, and dental
hygiene students for a master's year in public health at a school of
public health.
``(c) Priorities in Making Awards.--With respect to training
provided for under this section, the Secretary shall give priority in
awarding grants or contracts to the following:
``(1) Qualified applicants that propose collaborative
projects between departments of primary care medicine and
departments of general, pediatric, or public health dentistry.
``(2) Qualified applicants that have a record of training
the greatest percentage of providers, or that have demonstrated
significant improvements in the percentage of providers, who
enter and remain in general, pediatric, or public health
dentistry.
``(3) Qualified applicants that have a record of training
individuals who are from a rural or disadvantaged background,
or from underrepresented minorities.
``(4) Qualified applicants that establish formal
relationships with Federally qualified health centers, rural
health centers, or accredited teaching facilities and that
conduct training of students, residents, fellows, or faculty at
the center or facility.
``(5) Qualified applicants that conduct teaching programs
targeting vulnerable populations such as older adults, homeless
individuals, victims of abuse or trauma, individuals with
mental health or substance-related disorders, individuals with
disabilities, and individuals with HIV/AIDS, and in the risk-
based clinical disease management of all populations.
``(6) Qualified applicants that include educational
activities in cultural competency and health literacy.
``(7) Qualified applicants that have a high rate for
placing graduates in practice settings that serve underserved
areas or health disparity populations, or who achieve a
significant increase in the rate of placing graduates in such
settings.
``(8) Qualified applicants that intend to establish a
special populations oral health care education center or
training program for the didactic and clinical education of
dentists, dental health professionals, and dental hygienists
who plan to teach oral health care for people with
developmental disabilities, cognitive impairment, complex
medical problems, significant physical limitations, and
vulnerable elderly.
``(d) Application.--An eligible entity desiring a grant under this
section shall submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary may
require.
``(e) Duration of Award.--The period during which payments are made
to an entity from an award of a grant or contract under subsection (a)
shall be 5 years. The provision of such payments shall be subject to
annual approval by the Secretary and subject to the availability of
appropriations for the fiscal year involved to make the payments.
``(f) Authorizations of Appropriations.--For the purpose of
carrying out subsections (a) and (b), there is authorized to be
appropriated $30,000,000 for fiscal year 2010 and such sums as may be
necessary for each of fiscal years 2011 through 2015.
``(g) Carryover Funds.--An entity that receives an award under this
section may carry over funds from 1 fiscal year to another without
obtaining approval from the Secretary. In no case may any funds be
carried over pursuant to the preceding sentence for more than 3
years.''.
SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEMONSTRATION
PROJECT.
Subpart X of part D of title III of the Public Health Service Act
(42 U.S.C. 256f et seq.) is amended by adding at the end the following:
``SEC. 340G-1. DEMONSTRATION PROGRAM.
``(a) In General.--
``(1) Authorization.--The Secretary is authorized to award
grants to 15 eligible entities to enable such entities to
establish a demonstration program to establish training
programs to train, or to employ, alternative dental health care
providers in order to increase access to dental health care
services in rural and other underserved communities.
``(2) Definition.--The term `alternative dental health care
providers' includes community dental health coordinators,
advance practice dental hygienists, independent dental
hygienists, supervised dental hygienists, primary care
physicians, dental therapists, dental health aides, and any
other health professional that the Secretary determines
appropriate.
``(b) Timeframe.--The demonstration projects funded under this
section shall begin not later than 2 years after the date of enactment
of this section, and shall conclude not later than 7 years after such
date of enactment.
``(c) Eligible Entities.--To be eligible to receive a grant under
subsection (a), an entity shall--
``(1) be--
``(A) an institution of higher education, including
a community college;
``(B) a public-private partnership;
``(C) a federally qualified health center;
``(D) an Indian Health Service facility or a tribe
or tribal organization (as such terms are defined in
section 4 of the Indian Self-Determination and
Education Assistance Act);
``(E) a State or county public health clinic, a
health facility operated by an Indian tribe or tribal
organization, or urban Indian organization providing
dental services; or
``(F) a public hospital or health system;
``(2) be within a program accredited by the Commission on
Dental Accreditation or within a dental education program in an
accredited institution; and
``(3) shall submit an application to the Secretary at such
time, in such manner, and containing such information as the
Secretary may require.
``(d) Administrative Provisions.--
``(1) Amount of grant.--Each grant under this section shall
be in an amount that is not less than $4,000,000 for the 5-year
period during which the demonstration project being conducted.
``(2) Disbursement of funds.--
``(A) Preliminary disbursements.--Beginning 1 year
after the enactment of this section, the Secretary may
disperse to any entity receiving a grant under this
section not more than 20 percent of the total funding
awarded to such entity under such grant, for the
purpose of enabling the entity to plan the
demonstration project to be conducted under such grant.
``(B) Subsequent disbursements.--The remaining
amount of grant funds not dispersed under subparagraph
(A) shall be dispersed such that not less than 15
percent of such remaining amount is dispersed each
subsequent year.
``(e) Compliance With State Requirements.--Each entity receiving a
grant under this section shall certify that it is in compliance with
all applicable State licensing requirements.
``(f) Evaluation.--The Secretary shall contract with the Director
of the Institute of Medicine to conduct a study of the demonstration
programs conducted under this section that shall provide analysis,
based upon quantitative and qualitative data, regarding access to
dental health care in the United States.
``(g) Clarification Regarding Dental Health Aide Program.--Nothing
in this section shall prohibit a dental health aide training program
approved by the Indian Health Service from being eligible for a grant
under this section.
``(h) Authorization of Appropriations.--There is authorized to be
appropriated such sums as may be necessary to carry out this
section.''.
SEC. 5305. GERIATRIC EDUCATION AND TRAINING; CAREER AWARDS;
COMPREHENSIVE GERIATRIC EDUCATION.
(a) Workforce Development; Career Awards.--Section 753 of the
Public Health Service Act (42 U.S.C. 294c) is amended by adding at the
end the following:
``(d) Geriatric Workforce Development.--
``(1) In general.--The Secretary shall award grants or
contracts under this subsection to entities that operate a
geriatric education center pursuant to subsection (a)(1).
``(2) Application.--To be eligible for an award under
paragraph (1), an entity described in such paragraph shall
submit to the Secretary an application at such time, in such
manner, and containing such information as the Secretary may
require.
``(3) Use of funds.--Amounts awarded under a grant or
contract under paragraph (1) shall be used to--
``(A) carry out the fellowship program described in
paragraph (4); and
``(B) carry out 1 of the 2 activities described in
paragraph (5).
``(4) Fellowship program.--
``(A) In general.--Pursuant to paragraph (3), a
geriatric education center that receives an award under
this subsection shall use such funds to offer short-
term intensive courses (referred to in this subsection
as a `fellowship') that focus on geriatrics, chronic
care management, and long-term care that provide
supplemental training for faculty members in medical
schools and other health professions schools with
programs in psychology, pharmacy, nursing, social work,
dentistry, public health, allied health, or other
health disciplines, as approved by the Secretary. Such
a fellowship shall be open to current faculty, and
appropriately credentialed volunteer faculty and
practitioners, who do not have formal training in
geriatrics, to upgrade their knowledge and clinical
skills for the care of older adults and adults with
functional limitations and to enhance their
interdisciplinary teaching skills.
``(B) Location.--A fellowship shall be offered
either at the geriatric education center that is
sponsoring the course, in collaboration with other
geriatric education centers, or at medical schools,
schools of dentistry, schools of nursing, schools of
pharmacy, schools of social work, graduate programs in
psychology, or allied health and other health
professions schools approved by the Secretary with
which the geriatric education centers are affiliated.
``(C) CME credit.--Participation in a fellowship
under this paragraph shall be accepted with respect to
complying with continuing health profession education
requirements. As a condition of such acceptance, the
recipient shall agree to subsequently provide a minimum
of 18 hours of voluntary instructional support through
a geriatric education center that is providing clinical
training to students or trainees in long-term care
settings.
``(5) Additional required activities described.--Pursuant
to paragraph (3), a geriatric education center that receives an
award under this subsection shall use such funds to carry out 1
of the following 2 activities.
``(A) Family caregiver and direct care provider
training.--A geriatric education center that receives
an award under this subsection shall offer at least 2
courses each year, at no charge or nominal cost, to
family caregivers and direct care providers that are
designed to provide practical training for supporting
frail elders and individuals with disabilities. The
Secretary shall require such Centers to work with
appropriate community partners to develop training
program content and to publicize the availability of
training courses in their service areas. All family
caregiver and direct care provider training programs
shall include instruction on the management of
psychological and behavioral aspects of dementia,
communication techniques for working with individuals
who have dementia, and the appropriate, safe, and
effective use of medications for older adults.
``(B) Incorporation of best practices.--A geriatric
education center that receives an award under this
subsection shall develop and include material on
depression and other mental disorders common among
older adults, medication safety issues for older
adults, and management of the psychological and
behavioral aspects of dementia and communication
techniques with individuals who have dementia in all
training courses, where appropriate.
``(6) Targets.--A geriatric education center that receives
an award under this subsection shall meet targets approved by
the Secretary for providing geriatric training to a certain
number of faculty or practitioners during the term of the
award, as well as other parameters established by the
Secretary.
``(7) Amount of award.--An award under this subsection
shall be in an amount of $150,000. Not more than 24 geriatric
education centers may receive an award under this subsection.
``(8) Maintenance of effort.--A geriatric education center
that receives an award under this subsection shall provide
assurances to the Secretary that funds provided to the
geriatric education center under this subsection will be used
only to supplement, not to supplant, the amount of Federal,
State, and local funds otherwise expended by the geriatric
education center.
``(9) Authorization of appropriations.--In addition to any
other funding available to carry out this section, there is
authorized to be appropriated to carry out this subsection,
$10,800,000 for the period of fiscal year 2011 through 2014.
``(e) Geriatric Career Incentive Awards.--
``(1) In general.--The Secretary shall award grants or
contracts under this section to individuals described in
paragraph (2) to foster greater interest among a variety of
health professionals in entering the field of geriatrics, long-
term care, and chronic care management.
``(2) Eligible individuals.--To be eligible to received an
award under paragraph (1), an individual shall--
``(A) be an advanced practice nurse, a clinical
social worker, a pharmacist, or student of psychology
who is pursuing a doctorate or other advanced degree in
geriatrics or related fields in an accredited health
professions school; and
``(B) submit to the Secretary an application at
such time, in such manner, and containing such
information as the Secretary may require.
``(3) Condition of award.--As a condition of receiving an
award under this subsection, an individual shall agree that,
following completion of the award period, the individual will
teach or practice in the field of geriatrics, long-term care,
or chronic care management for a minimum of 5 years under
guidelines set by the Secretary.
``(4) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection, $10,000,000
for the period of fiscal years 2011 through 2013.''.
(b) Expansion of Eligibility for Geriatric Academic Career Awards;
Payment to Institution.--Section 753(c) of the Public Health Service
Act 294(c)) is amended--
(1) by redesignating paragraphs (4) and (5) as paragraphs
(5) and (6), respectively;
(2) by striking paragraph (2) through paragraph (3) and
inserting the following:
``(2) Eligible individuals.--To be eligible to receive an
Award under paragraph (1), an individual shall--
``(A) be board certified or board eligible in
internal medicine, family practice, psychiatry, or
licensed dentistry, or have completed any required
training in a discipline and employed in an accredited
health professions school that is approved by the
Secretary;
``(B) have completed an approved fellowship program
in geriatrics or have completed specialty training in
geriatrics as required by the discipline and any
addition geriatrics training as required by the
Secretary; and
``(C) have a junior (non-tenured) faculty
appointment at an accredited (as determined by the
Secretary) school of medicine, osteopathic medicine,
nursing, social work, psychology, dentistry, pharmacy,
or other allied health disciplines in an accredited
health professions school that is approved by the
Secretary.
``(3) Limitations.--No Award under paragraph (1) may be
made to an eligible individual unless the individual--
``(A) has submitted to the Secretary an
application, at such time, in such manner, and
containing such information as the Secretary may
require, and the Secretary has approved such
application;
``(B) provides, in such form and manner as the
Secretary may require, assurances that the individual
will meet the service requirement described in
paragraph (6); and
``(C) provides, in such form and manner as the
Secretary may require, assurances that the individual
has a full-time faculty appointment in a health
professions institution and documented commitment from
such institution to spend 75 percent of the total time
of such individual on teaching and developing skills in
interdisciplinary education in geriatrics.
``(4) Maintenance of effort.--An eligible individual that
receives an Award under paragraph (1) shall provide assurances
to the Secretary that funds provided to the eligible individual
under this subsection will be used only to supplement, not to
supplant, the amount of Federal, State, and local funds
otherwise expended by the eligible individual.''; and
(3) in paragraph (5), as so designated--
(A) in subparagraph (A)--
(i) by inserting ``for individuals who are
physicians'' after ``this section''; and
(ii) by inserting after the period at the
end the following: ``The Secretary shall
determine the amount of an Award under this
section for individuals who are not
physicians.''; and
(B) by adding at the end the following:
``(C) Payment to institution.--The Secretary shall
make payments to institutions which include schools of
medicine, osteopathic medicine, nursing, social work,
psychology, dentistry, and pharmacy, or other allied
health discipline in an accredited health professions
school that is approved by the Secretary.''.
(c) Comprehensive Geriatric Education.--Section 855 of the Public
Health Service Act (42 U.S.C. 298) is amended--
(1) in subsection (b)--
(A) in paragraph (3), by striking ``or'' at the
end;
(B) in paragraph (4), by striking the period and
inserting ``; or''; and
(C) by adding at the end the following:
``(5) establish traineeships for individuals who are
preparing for advanced education nursing degrees in geriatric
nursing, long-term care, gero-psychiatric nursing or other
nursing areas that specialize in the care of the elderly
population.''; and
(2) in subsection (e), by striking ``2003 through 2007''
and inserting ``2010 through 2014''.
SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND TRAINING GRANTS.
(a) In General.--Part D of title VII (42 U.S.C. 294 et seq.) is
amended by--
(1) striking section 757;
(2) redesignating section 756 (as amended by section 5103)
as section 757; and
(3) inserting after section 755 the following:
``SEC. 756. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND TRAINING GRANTS.
``(a) Grants Authorized.--The Secretary may award grants to
eligible institutions of higher education to support the recruitment of
students for, and education and clinical experience of the students
in--
``(1) baccalaureate, master's, and doctoral degree programs
of social work, as well as the development of faculty in social
work;
``(2) accredited master's, doctoral, internship, and post-
doctoral residency programs of psychology for the development
and implementation of interdisciplinary training of psychology
graduate students for providing behavioral and mental health
services, including substance abuse prevention and treatment
services;
``(3) accredited institutions of higher education or
accredited professional training programs that are establishing
or expanding internships or other field placement programs in
child and adolescent mental health in psychiatry, psychology,
school psychology, behavioral pediatrics, psychiatric nursing,
social work, school social work, substance abuse prevention and
treatment, marriage and family therapy, school counseling, or
professional counseling; and
``(4) State-licensed mental health nonprofit and for-profit
organizations to enable such organizations to pay for programs
for preservice or in-service training of paraprofessional child
and adolescent mental health workers.
``(b) Eligibility Requirements.--To be eligible for a grant under
this section, an institution shall demonstrate--
``(1) participation in the institutions' programs of
individuals and groups from different racial, ethnic, cultural,
geographic, religious, linguistic, and class backgrounds, and
different genders and sexual orientations;
``(2) knowledge and understanding of the concerns of the
individuals and groups described in subsection (a);
``(3) any internship or other field placement program
assisted under the grant will prioritize cultural and
linguistic competency;
``(4) the institution will provide to the Secretary such
data, assurances, and information as the Secretary may require;
and
``(5) with respect to any violation of the agreement
between the Secretary and the institution, the institution will
pay such liquidated damages as prescribed by the Secretary by
regulation.
``(c) Institutional Requirement.--For grants authorized under
subsection (a)(1), at least 4 of the grant recipients shall be
historically black colleges or universities or other minority-serving
institutions.
``(d) Priority.--
``(1) In selecting the grant recipients in social work
under subsection (a)(1), the Secretary shall give priority to
applicants that--
``(A) are accredited by the Council on Social Work
Education;
``(B) have a graduation rate of not less than 80
percent for social work students; and
``(C) exhibit an ability to recruit social workers
from and place social workers in areas with a high need
and high demand population.
``(2) In selecting the grant recipients in graduate
psychology under subsection (a)(2), the Secretary shall give
priority to institutions in which training focuses on the needs
of vulnerable groups such as older adults and children,
individuals with mental health or substance-related disorders,
victims of abuse or trauma and of combat stress disorders such
as posttraumatic stress disorder and traumatic brain injuries,
homeless individuals, chronically ill persons, and their
families.
``(3) In selecting the grant recipients in training
programs in child and adolescent mental health under
subsections (a)(3) and (a)(4), the Secretary shall give
priority to applicants that--
``(A) have demonstrated the ability to collect data
on the number of students trained in child and
adolescent mental health and the populations served by
such students after graduation or completion of
preservice or in-service training;
``(B) have demonstrated familiarity with evidence-
based methods in child and adolescent mental health
services, including substance abuse prevention and
treatment services;
``(C) have programs designed to increase the number
of professionals and paraprofessionals serving high-
priority populations and to applicants who come from
high-priority communities and plan to serve medically
underserved populations, in health professional
shortage areas, or in medically underserved areas;
``(D) offer curriculum taught collaboratively with
a family on the consumer and family lived experience or
the importance of family-professional or family-
paraprofessional partnerships; and
``(E) provide services through a community mental
health program described in section 1913(b)(1).
``(e) Authorization of Appropriation.--For the fiscal years 2010
through 2013, there is authorized to be appropriated to carry out this
section--
``(1) $8,000,000 for training in social work in subsection
(a)(1);
``(2) $12,000,000 for training in graduate psychology in
subsection (a)(2), of which not less than $10,000,000 shall be
allocated for doctoral, postdoctoral, and internship level
training;
``(3) $10,000,000 for training in professional child and
adolescent mental health in subsection (a)(3); and
``(4) $5,000,000 for training in paraprofessional child and
adolescent work in subsection (a)(4).''.
(b) Conforming Amendments.--Section 757(b)(2) of the Public Health
Service Act, as redesignated by subsection (a), is amended by striking
``sections 751(a)(1)(A), 751(a)(1)(B), 753(b), 754(3)(A), and 755(b)''
and inserting ``sections 751(b)(1)(A), 753(b), and 755(b)''.
SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND PUBLIC HEALTH AND
INDIVIDUALS WITH DISABILITIES TRAINING.
(a) Title VII.--Section 741 of the Public Health Service Act (42
U.S.C. 293e) is amended--
(1) in subsection (a)--
(A) by striking the subsection heading and
inserting ``Cultural Competency, Prevention, and Public
Health and Individuals With Disability Grants''; and
(B) in paragraph (1), by striking ``for the purpose
of'' and all that follows through the period at the end
and inserting ``for the development, evaluation, and
dissemination of research, demonstration projects, and
model curricula for cultural competency, prevention,
public health proficiency, reducing health disparities,
and aptitude for working with individuals with
disabilities training for use in health professions
schools and continuing education programs, and for
other purposes determined as appropriate by the
Secretary.''; and
(2) by striking subsection (b) and inserting the following:
``(b) Collaboration.--In carrying out subsection (a), the Secretary
shall collaborate with health professional societies, licensing and
accreditation entities, health professions schools, and experts in
minority health and cultural competency, prevention, and public health
and disability groups, community-based organizations, and other
organizations as determined appropriate by the Secretary. The Secretary
shall coordinate with curricula and research and demonstration projects
developed under section 807.
``(c) Dissemination.--
``(1) In general.--Model curricula developed under this
section shall be disseminated through the Internet
Clearinghouse under section 270 and such other means as
determined appropriate by the Secretary.
``(2) Evaluation.--The Secretary shall evaluate the
adoption and the implementation of cultural competency,
prevention, and public health, and working with individuals
with a disability training curricula, and the facilitate
inclusion of these competency measures in quality measurement
systems as appropriate.
``(d) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section such sums as may be necessary
for each of fiscal years 2010 through 2015.''.
(b) Title VIII.--Section 807 of the Public Health Service Act (42
U.S.C. 296e-1) is amended--
(1) in subsection (a)--
(A) by striking the subsection heading and
inserting ``Cultural Competency, Prevention, and Public
Health and Individuals With Disability Grants''; and
(B) by striking ``for the purpose of'' and all that
follows through ``health care.'' and inserting ``for
the development, evaluation, and dissemination of
research, demonstration projects, and model curricula
for cultural competency, prevention, public health
proficiency, reducing health disparities, and aptitude
for working with individuals with disabilities training
for use in health professions schools and continuing
education programs, and for other purposes determined
as appropriate by the Secretary.''; and
(2) by redesignating subsection (b) as subsection (d);
(3) by inserting after subsection (a) the following:
``(b) Collaboration.--In carrying out subsection (a), the Secretary
shall collaborate with the entities described in section 741(b). The
Secretary shall coordinate with curricula and research and
demonstration projects developed under such section 741.
``(c) Dissemination.--Model curricula developed under this section
shall be disseminated and evaluated in the same manner as model
curricula developed under section 741, as described in subsection (c)
of such section.''; and
(4) in subsection (d), as so redesignated--
(A) by striking ``subsection (a)'' and inserting
``this section''; and
(B) by striking ``2001 through 2004'' and inserting
``2010 through 2015''.
SEC. 5308. ADVANCED NURSING EDUCATION GRANTS.
Section 811 of the Public Health Service Act (42 U.S.C. 296j) is
amended--
(1) in subsection (c)--
(A) in the subsection heading, by striking ``and
Nurse Midwifery Programs''; and
(B) by striking ``and nurse midwifery'';
(2) in subsection (f)--
(A) by striking paragraph (2); and
(B) by redesignating paragraph (3) as paragraph
(2); and
(3) by redesignating subsections (d), (e), and (f) as
subsections (e), (f), and (g), respectively; and
(4) by inserting after subsection (c), the following:
``(d) Authorized Nurse-midwifery Programs.--Midwifery programs that
are eligible for support under this section are educational programs
that--
``(1) have as their objective the education of midwives;
and
``(2) are accredited by the American College of Nurse-
Midwives Accreditation Commission for Midwifery Education.''.
SEC. 5309. NURSE EDUCATION, PRACTICE, AND RETENTION GRANTS.
(a) In General.--Section 831 of the Public Health Service Act (42
U.S.C. 296p) is amended--
(1) in the section heading, by striking ``retention'' and
inserting ``quality'';
(2) in subsection (a)--
(A) in paragraph (1), by adding ``or'' after the
semicolon;
(B) by striking paragraph (2); and
(C) by redesignating paragraph (3) as paragraph
(2);
(3) in subsection (b)(3), by striking ``managed care,
quality improvement'' and inserting ``coordinated care'';
(4) in subsection (g), by inserting ``, as defined in
section 801(2),'' after ``school of nursing''; and
(5) in subsection (h), by striking ``2003 through 2007''
and inserting ``2010 through 2014''.
(b) Nurse Retention Grants.--Title VIII of the Public Health
Service Act is amended by inserting after section 831 (42 U.S.C. 296b)
the following:
``SEC. 831A. NURSE RETENTION GRANTS.
``(a) Retention Priority Areas.--The Secretary may award grants to,
and enter into contracts with, eligible entities to enhance the nursing
workforce by initiating and maintaining nurse retention programs
pursuant to subsection (b) or (c).
``(b) Grants for Career Ladder Program.--The Secretary may award
grants to, and enter into contracts with, eligible entities for
programs--
``(1) to promote career advancement for individuals
including licensed practical nurses, licensed vocational
nurses, certified nurse assistants, home health aides, diploma
degree or associate degree nurses, to become baccalaureate
prepared registered nurses or advanced education nurses in
order to meet the needs of the registered nurse workforce;
``(2) developing and implementing internships and residency
programs in collaboration with an accredited school of nursing,
as defined by section 801(2), to encourage mentoring and the
development of specialties; or
``(3) to assist individuals in obtaining education and
training required to enter the nursing profession and advance
within such profession.
``(c) Enhancing Patient Care Delivery Systems.--
``(1) Grants.--The Secretary may award grants to eligible
entities to improve the retention of nurses and enhance patient
care that is directly related to nursing activities by
enhancing collaboration and communication among nurses and
other health care professionals, and by promoting nurse
involvement in the organizational and clinical decision-making
processes of a health care facility.
``(2) Priority.--In making awards of grants under this
subsection, the Secretary shall give preference to applicants
that have not previously received an award under this
subsection (or section 831(c) as such section existed on the
day before the date of enactment of this section).
``(3) Continuation of an award.--The Secretary shall make
continuation of any award under this subsection beyond the
second year of such award contingent on the recipient of such
award having demonstrated to the Secretary measurable and
substantive improvement in nurse retention or patient care.
``(d) Other Priority Areas.--The Secretary may award grants to, or
enter into contracts with, eligible entities to address other areas
that are of high priority to nurse retention, as determined by the
Secretary.
``(e) Report.--The Secretary shall submit to the Congress before
the end of each fiscal year a report on the grants awarded and the
contracts entered into under this section. Each such report shall
identify the overall number of such grants and contracts and provide an
explanation of why each such grant or contract will meet the priority
need of the nursing workforce.
``(f) Eligible Entity.--For purposes of this section, the term
`eligible entity' includes an accredited school of nursing, as defined
by section 801(2), a health care facility, or a partnership of such a
school and facility.
``(g) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary
for each of fiscal years 2010 through 2012.''.
SEC. 5310. LOAN REPAYMENT AND SCHOLARSHIP PROGRAM.
(a) Loan Repayments and Scholarships.--Section 846(a)(3) of the
Public Health Service Act (42 U.S.C. 297n(a)(3)) is amended by
inserting before the semicolon the following: ``, or in a accredited
school of nursing, as defined by section 801(2), as nurse faculty''.
(b) Technical and Conforming Amendments.--Title VIII (42 U.S.C. 296
et seq.) is amended--
(1) by redesignating section 810 (relating to prohibition
against discrimination by schools on the basis of sex) as
section 809 and moving such section so that it follows section
808;
(2) in sections 835, 836, 838, 840, and 842, by striking
the term ``this subpart'' each place it appears and inserting
``this part'';
(3) in section 836(h), by striking the last sentence;
(4) in section 836, by redesignating subsection (l) as
subsection (k);
(5) in section 839, by striking ``839'' and all that
follows through ``(a)'' and inserting ``839. (a)'';
(6) in section 835(b), by striking ``841'' each place it
appears and inserting ``871'';
(7) by redesignating section 841 as section 871, moving
part F to the end of the title, and redesignating such part as
part I;
(8) in part G--
(A) by redesignating section 845 as section 851;
and
(B) by redesignating part G as part F;
(9) in part H--
(A) by redesignating sections 851 and 852 as
sections 861 and 862, respectively; and
(B) by redesignating part H as part G; and
(10) in part I--
(A) by redesignating section 855, as amended by
section 5305, as section 865; and
(B) by redesignating part I as part H.
SEC. 5311. NURSE FACULTY LOAN PROGRAM.
(a) In General.--Section 846A of the Public Health Service Act (42
U.S.C. 297n-1) is amended--
(1) in subsection (a)--
(A) in the subsection heading, by striking
``Establishment'' and inserting ``School of Nursing
Student Loan Fund''; and
(B) by inserting ``accredited'' after ``agreement
with any'';
(2) in subsection (c)--
(A) in paragraph (2), by striking ``$30,000'' and
all that follows through the semicolon and inserting
``$35,500, during fiscal years 2010 and 2011 fiscal
years (after fiscal year 2011, such amounts shall be
adjusted to provide for a cost-of-attendance increase
for the yearly loan rate and the aggregate loan;''; and
(B) in paragraph (3)(A), by inserting ``an
accredited'' after ``faculty member in'';
(3) in subsection (e), by striking ``a school'' and
inserting ``an accredited school''; and
(4) in subsection (f), by striking ``2003 through 2007''
and inserting ``2010 through 2014''.
(b) Eligible Individual Student Loan Repayment.--Title VIII of the
Public Health Service Act is amended by inserting after section 846A
(42 U.S.C. 297n-1) the following:
``SEC. 847. ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT.
``(a) In General.--The Secretary, acting through the Administrator
of the Health Resources and Services Administration, may enter into an
agreement with eligible individuals for the repayment of education
loans, in accordance with this section, to increase the number of
qualified nursing faculty.
``(b) Agreements.--Each agreement entered into under this
subsection shall require that the eligible individual shall serve as a
full-time member of the faculty of an accredited school of nursing, for
a total period, in the aggregate, of at least 4 years during the 6-year
period beginning on the later of--
``(1) the date on which the individual receives a master's
or doctorate nursing degree from an accredited school of
nursing; or
``(2) the date on which the individual enters into an
agreement under this subsection.
``(c) Agreement Provisions.--Agreements entered into pursuant to
subsection (b) shall be entered into on such terms and conditions as
the Secretary may determine, except that--
``(1) not more than 10 months after the date on which the
6-year period described under subsection (b) begins, but in no
case before the individual starts as a full-time member of the
faculty of an accredited school of nursing the Secretary shall
begin making payments, for and on behalf of that individual, on
the outstanding principal of, and interest on, any loan of that
individual obtained to pay for such degree;
``(2) for an individual who has completed a master's in
nursing or equivalent degree in nursing--
``(A) payments may not exceed $10,000 per calendar
year; and
``(B) total payments may not exceed $40,000 during
the 2010 and 2011 fiscal years (after fiscal year 2011,
such amounts shall be adjusted to provide for a cost-
of-attendance increase for the yearly loan rate and the
aggregate loan); and
``(3) for an individual who has completed a doctorate or
equivalent degree in nursing--
``(A) payments may not exceed $20,000 per calendar
year; and
``(B) total payments may not exceed $80,000 during
the 2010 and 2011 fiscal years (adjusted for subsequent
fiscal years as provided for in the same manner as in
paragraph (2)(B)).
``(d) Breach of Agreement.--
``(1) In general.--In the case of any agreement made under
subsection (b), the individual is liable to the Federal
Government for the total amount paid by the Secretary under
such agreement, and for interest on such amount at the maximum
legal prevailing rate, if the individual fails to meet the
agreement terms required under such subsection.
``(2) Waiver or suspension of liability.--In the case of an
individual making an agreement for purposes of paragraph (1),
the Secretary shall provide for the waiver or suspension of
liability under such paragraph if compliance by the individual
with the agreement involved is impossible or would involve
extreme hardship to the individual or if enforcement of the
agreement with respect to the individual would be
unconscionable.
``(3) Date certain for recovery.--Subject to paragraph (2),
any amount that the Federal Government is entitled to recover
under paragraph (1) shall be paid to the United States not
later than the expiration of the 3-year period beginning on the
date the United States becomes so entitled.
``(4) Availability.--Amounts recovered under paragraph (1)
shall be available to the Secretary for making loan repayments
under this section and shall remain available for such purpose
until expended.
``(e) Eligible Individual Defined.--For purposes of this section,
the term `eligible individual' means an individual who--
``(1) is a United States citizen, national, or lawful
permanent resident;
``(2) holds an unencumbered license as a registered nurse;
and
``(3) has either already completed a master's or doctorate
nursing program at an accredited school of nursing or is
currently enrolled on a full-time or part-time basis in such a
program.
``(f) Priority.--For the purposes of this section and section 846A,
funding priority will be awarded to School of Nursing Student Loans
that support doctoral nursing students or Individual Student Loan
Repayment that support doctoral nursing students.
``(g) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary
for each of fiscal years 2010 through 2014.''.
SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR PARTS B THROUGH D OF
TITLE VIII.
Section 871 of the Public Health Service Act, as redesignated and
moved by section 5310, is amended to read as follows:
``SEC. 871. AUTHORIZATION OF APPROPRIATIONS.
``For the purpose of carrying out parts B, C, and D (subject to
section 851(g)), there are authorized to be appropriated $338,000,000
for fiscal year 2010, and such sums as may be necessary for each of the
fiscal years 2011 through 2016.''.
SEC. 5313. GRANTS TO PROMOTE THE COMMUNITY HEALTH WORKFORCE.
(a) In General.--Part P of title III of the Public Health Service
Act (42 U.S.C. 280g et seq.) is amended by adding at the end the
following:
``SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND OUTCOMES.
``(a) Grants Authorized.--The Director of the Centers for Disease
Control and Prevention, in collaboration with the Secretary, shall
award grants to eligible entities to promote positive health behaviors
and outcomes for populations in medically underserved communities
through the use of community health workers.
``(b) Use of Funds.--Grants awarded under subsection (a) shall be
used to support community health workers--
``(1) to educate, guide, and provide outreach in a
community setting regarding health problems prevalent in
medically underserved communities, particularly racial and
ethnic minority populations;
``(2) to educate and provide guidance regarding effective
strategies to promote positive health behaviors and discourage
risky health behaviors;
``(3) to educate and provide outreach regarding enrollment
in health insurance including the Children's Health Insurance
Program under title XXI of the Social Security Act, Medicare
under title XVIII of such Act and Medicaid under title XIX of
such Act;
``(4) to identify, educate, refer, and enroll underserved
populations to appropriate healthcare agencies and community-
based programs and organizations in order to increase access to
quality healthcare services and to eliminate duplicative care;
or
``(5) to educate, guide, and provide home visitation
services regarding maternal health and prenatal care.
``(c) Application.--Each eligible entity that desires to receive a
grant under subsection (a) shall submit an application to the
Secretary, at such time, in such manner, and accompanied by such
information as the Secretary may require.
``(d) Priority.--In awarding grants under subsection (a), the
Secretary shall give priority to applicants that--
``(1) propose to target geographic areas--
``(A) with a high percentage of residents who are
eligible for health insurance but are uninsured or
underinsured;
``(B) with a high percentage of residents who
suffer from chronic diseases; or
``(C) with a high infant mortality rate;
``(2) have experience in providing health or health-related
social services to individuals who are underserved with respect
to such services; and
``(3) have documented community activity and experience
with community health workers.
``(e) Collaboration With Academic Institutions and the One-stop
Delivery System.--The Secretary shall encourage community health worker
programs receiving funds under this section to collaborate with
academic institutions and one-stop delivery systems under section
134(c) of the Workforce Investment Act of 1998. Nothing in this section
shall be construed to require such collaboration.
``(f) Evidence-based Interventions.--The Secretary shall encourage
community health worker programs receiving funding under this section
to implement a process or an outcome-based payment system that rewards
community health workers for connecting underserved populations with
the most appropriate services at the most appropriate time. Nothing in
this section shall be construed to require such a payment.
``(g) Quality Assurance and Cost Effectiveness.--The Secretary
shall establish guidelines for assuring the quality of the training and
supervision of community health workers under the programs funded under
this section and for assuring the cost-effectiveness of such programs.
``(h) Monitoring.--The Secretary shall monitor community health
worker programs identified in approved applications under this section
and shall determine whether such programs are in compliance with the
guidelines established under subsection (g).
``(i) Technical Assistance.--The Secretary may provide technical
assistance to community health worker programs identified in approved
applications under this section with respect to planning, developing,
and operating programs under the grant.
``(j) Authorization of Appropriations.--There are authorized to be
appropriated, such sums as may be necessary to carry out this section
for each of fiscal years 2010 through 2014.
``(k) Definitions.--In this section:
``(1) Community health worker.--The term `community health
worker', as defined by the Department of Labor as Standard
Occupational Classification [21-1094] means an individual who
promotes health or nutrition within the community in which the
individual resides--
``(A) by serving as a liaison between communities
and healthcare agencies;
``(B) by providing guidance and social assistance
to community residents;
``(C) by enhancing community residents' ability to
effectively communicate with healthcare providers;
``(D) by providing culturally and linguistically
appropriate health or nutrition education;
``(E) by advocating for individual and community
health;
``(F) by providing referral and follow-up services
or otherwise coordinating care; and
``(G) by proactively identifying and enrolling
eligible individuals in Federal, State, local, private
or nonprofit health and human services programs.
``(2) Community setting.--The term `community setting'
means a home or a community organization located in the
neighborhood in which a participant in the program under this
section resides.
``(3) Eligible entity.--The term `eligible entity' means a
public or nonprofit private entity (including a State or public
subdivision of a State, a public health department, a free
health clinic, a hospital, or a Federally-qualified health
center (as defined in section 1861(aa) of the Social Security
Act)), or a consortium of any such entities.
``(4) Medically underserved community.--The term `medically
underserved community' means a community identified by a
State--
``(A) that has a substantial number of individuals
who are members of a medically underserved population,
as defined by section 330(b)(3); and
``(B) a significant portion of which is a health
professional shortage area as designated under section
332.''.
SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH.
Part E of title VII of the Public Health Service Act (42 U.S.C.
294n et seq.), as amended by section 5206, is further amended by adding
at the end the following:
``SEC. 778. FELLOWSHIP TRAINING IN APPLIED PUBLIC HEALTH EPIDEMIOLOGY,
PUBLIC HEALTH LABORATORY SCIENCE, PUBLIC HEALTH
INFORMATICS, AND EXPANSION OF THE EPIDEMIC INTELLIGENCE
SERVICE.
``(a) In General.--The Secretary may carry out activities to
address documented workforce shortages in State and local health
departments in the critical areas of applied public health epidemiology
and public health laboratory science and informatics and may expand the
Epidemic Intelligence Service.
``(b) Specific Uses.--In carrying out subsection (a), the Secretary
shall provide for the expansion of existing fellowship programs
operated through the Centers for Disease Control and Prevention in a
manner that is designed to alleviate shortages of the type described in
subsection (a).
``(c) Other Programs.--The Secretary may provide for the expansion
of other applied epidemiology training programs that meet objectives
similar to the objectives of the programs described in subsection (b).
``(d) Work Obligation.--Participation in fellowship training
programs under this section shall be deemed to be service for purposes
of satisfying work obligations stipulated in contracts under section
338I(j).
``(e) General Support.--Amounts may be used from grants awarded
under this section to expand the Public Health Informatics Fellowship
Program at the Centers for Disease Control and Prevention to better
support all public health systems at all levels of government.
``(f) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section $39,500,000 for each of fiscal
years 2010 through 2013, of which--
``(1) $5,000,000 shall be made available in each such
fiscal year for epidemiology fellowship training program
activities under subsections (b) and (c);
``(2) $5,000,000 shall be made available in each such
fiscal year for laboratory fellowship training programs under
subsection (b);
``(3) $5,000,000 shall be made available in each such
fiscal year for the Public Health Informatics Fellowship
Program under subsection (e); and
``(4) $24,500,000 shall be made available for expanding the
Epidemic Intelligence Service under subsection (a).''.
SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK.
Title II of the Public Health Service Act (42 U.S.C. 202 et seq.)
is amended by adding at the end the following:
``PART D--UNITED STATES PUBLIC HEALTH SCIENCES TRACK
``SEC. 271. ESTABLISHMENT.
``(a) United States Public Health Services Track.--
``(1) In general.--There is hereby authorized to be
established a United States Public Health Sciences Track
(referred to in this part as the `Track'), at sites to be
selected by the Secretary, with authority to grant appropriate
advanced degrees in a manner that uniquely emphasizes team-
based service, public health, epidemiology, and emergency
preparedness and response. It shall be so organized as to
graduate not less than--
``(A) 150 medical students annually, 10 of whom
shall be awarded studentships to the Uniformed Services
University of Health Sciences;
``(B) 100 dental students annually;
``(C) 250 nursing students annually;
``(D) 100 public health students annually;
``(E) 100 behavioral and mental health professional
students annually;
``(F) 100 physician assistant or nurse practitioner
students annually; and
``(G) 50 pharmacy students annually.
``(2) Locations.--The Track shall be located at existing
and accredited, affiliated health professions education
training programs at academic health centers located in regions
of the United States determined appropriate by the Surgeon
General, in consultation with the National Health Care
Workforce Commission established in section 5101 of the Patient
Protection and Affordable Care Act.
``(b) Number of Graduates.--Except as provided in subsection (a),
the number of persons to be graduated from the Track shall be
prescribed by the Secretary. In so prescribing the number of persons to
be graduated from the Track, the Secretary shall institute actions
necessary to ensure the maximum number of first-year enrollments in the
Track consistent with the academic capacity of the affiliated sites and
the needs of the United States for medical, dental, and nursing
personnel.
``(c) Development.--The development of the Track may be by such
phases as the Secretary may prescribe subject to the requirements of
subsection (a).
``(d) Integrated Longitudinal Plan.--The Surgeon General shall
develop an integrated longitudinal plan for health professions
continuing education throughout the continuum of health-related
education, training, and practice. Training under such plan shall
emphasize patient-centered, interdisciplinary, and care coordination
skills. Experience with deployment of emergency response teams shall be
included during the clinical experiences.
``(e) Faculty Development.--The Surgeon General shall develop
faculty development programs and curricula in decentralized venues of
health care, to balance urban, tertiary, and inpatient venues.
``SEC. 272. ADMINISTRATION.
``(a) In General.--The business of the Track shall be conducted by
the Surgeon General with funds appropriated for and provided by the
Department of Health and Human Services. The National Health Care
Workforce Commission shall assist the Surgeon General in an advisory
capacity.
``(b) Faculty.--
``(1) In general.--The Surgeon General, after considering
the recommendations of the National Health Care Workforce
Commission, shall obtain the services of such professors,
instructors, and administrative and other employees as may be
necessary to operate the Track, but utilize when possible,
existing affiliated health professions training institutions.
Members of the faculty and staff shall be employed under salary
schedules and granted retirement and other related benefits
prescribed by the Secretary so as to place the employees of the
Track faculty on a comparable basis with the employees of fully
accredited schools of the health professions within the United
States.
``(2) Titles.--The Surgeon General may confer academic
titles, as appropriate, upon the members of the faculty.
``(3) Nonapplication of provisions.--The limitations in
section 5373 of title 5, United States Code, shall not apply to
the authority of the Surgeon General under paragraph (1) to
prescribe salary schedules and other related benefits.
``(c) Agreements.--The Surgeon General may negotiate agreements
with agencies of the Federal Government to utilize on a reimbursable
basis appropriate existing Federal medical resources located in the
United States (or locations selected in accordance with section
271(a)(2)). Under such agreements the facilities concerned will retain
their identities and basic missions. The Surgeon General may negotiate
affiliation agreements with accredited universities and health
professions training institutions in the United States. Such agreements
may include provisions for payments for educational services provided
students participating in Department of Health and Human Services
educational programs.
``(d) Programs.--The Surgeon General may establish the following
educational programs for Track students:
``(1) Postdoctoral, postgraduate, and technological
programs.
``(2) A cooperative program for medical, dental, physician
assistant, pharmacy, behavioral and mental health, public
health, and nursing students.
``(3) Other programs that the Surgeon General determines
necessary in order to operate the Track in a cost-effective
manner.
``(e) Continuing Medical Education.--The Surgeon General shall
establish programs in continuing medical education for members of the
health professions to the end that high standards of health care may be
maintained within the United States.
``(f) Authority of the Surgeon General.--
``(1) In general.--The Surgeon General is authorized--
``(A) to enter into contracts with, accept grants
from, and make grants to any nonprofit entity for the
purpose of carrying out cooperative enterprises in
medical, dental, physician assistant, pharmacy,
behavioral and mental health, public health, and
nursing research, consultation, and education;
``(B) to enter into contracts with entities under
which the Surgeon General may furnish the services of
such professional, technical, or clerical personnel as
may be necessary to fulfill cooperative enterprises
undertaken by the Track;
``(C) to accept, hold, administer, invest, and
spend any gift, devise, or bequest of personal property
made to the Track, including any gift, devise, or
bequest for the support of an academic chair, teaching,
research, or demonstration project;
``(D) to enter into agreements with entities that
may be utilized by the Track for the purpose of
enhancing the activities of the Track in education,
research, and technological applications of knowledge;
and
``(E) to accept the voluntary services of guest
scholars and other persons.
``(2) Limitation.--The Surgeon General may not enter into
any contract with an entity if the contract would obligate the
Track to make outlays in advance of the enactment of budget
authority for such outlays.
``(3) Scientists.--Scientists or other medical, dental, or
nursing personnel utilized by the Track under an agreement
described in paragraph (1) may be appointed to any position
within the Track and may be permitted to perform such duties
within the Track as the Surgeon General may approve.
``(4) Volunteer services.--A person who provides voluntary
services under the authority of subparagraph (E) of paragraph
(1) shall be considered to be an employee of the Federal
Government for the purposes of chapter 81 of title 5, relating
to compensation for work-related injuries, and to be an
employee of the Federal Government for the purposes of chapter
171 of title 28, relating to tort claims. Such a person who is
not otherwise employed by the Federal Government shall not be
considered to be a Federal employee for any other purpose by
reason of the provision of such services.
``SEC. 273. STUDENTS; SELECTION; OBLIGATION.
``(a) Student Selection.--
``(1) In general.--Medical, dental, physician assistant,
pharmacy, behavioral and mental health, public health, and
nursing students at the Track shall be selected under
procedures prescribed by the Surgeon General. In so
prescribing, the Surgeon General shall consider the
recommendations of the National Health Care Workforce
Commission.
``(2) Priority.--In developing admissions procedures under
paragraph (1), the Surgeon General shall ensure that such
procedures give priority to applicant medical, dental,
physician assistant, pharmacy, behavioral and mental health,
public health, and nursing students from rural communities and
underrepresented minorities.
``(b) Contract and Service Obligation.--
``(1) Contract.--Upon being admitted to the Track, a
medical, dental, physician assistant, pharmacy, behavioral and
mental health, public health, or nursing student shall enter
into a written contract with the Surgeon General that shall
contain--
``(A) an agreement under which--
``(i) subject to subparagraph (B), the
Surgeon General agrees to provide the student
with tuition (or tuition remission) and a
student stipend (described in paragraph (2)) in
each school year for a period of years (not to
exceed 4 school years) determined by the
student, during which period the student is
enrolled in the Track at an affiliated or other
participating health professions institution
pursuant to an agreement between the Track and
such institution; and
``(ii) subject to subparagraph (B), the
student agrees--
``(I) to accept the provision of
such tuition and student stipend to the
student;
``(II) to maintain enrollment at
the Track until the student completes
the course of study involved;
``(III) while enrolled in such
course of study, to maintain an
acceptable level of academic standing
(as determined by the Surgeon General);
``(IV) if pursuing a degree from a
school of medicine or osteopathic
medicine, dental, public health, or
nursing school or a physician
assistant, pharmacy, or behavioral and
mental health professional program, to
complete a residency or internship in a
specialty that the Surgeon General
determines is appropriate; and
``(V) to serve for a period of time
(referred to in this part as the
`period of obligated service') within
the Commissioned Corps of the Public
Health Service equal to 2 years for
each school year during which such
individual was enrolled at the College,
reduced as provided for in paragraph
(3);
``(B) a provision that any financial obligation of
the United States arising out of a contract entered
into under this part and any obligation of the student
which is conditioned thereon, is contingent upon funds
being appropriated to carry out this part;
``(C) a statement of the damages to which the
United States is entitled for the student's breach of
the contract; and
``(D) such other statements of the rights and
liabilities of the Secretary and of the individual, not
inconsistent with the provisions of this part.
``(2) Tuition and student stipend.--
``(A) Tuition remission rates.--The Surgeon
General, based on the recommendations of the National
Health Care Workforce Commission, shall establish
Federal tuition remission rates to be used by the Track
to provide reimbursement to affiliated and other
participating health professions institutions for the
cost of educational services provided by such
institutions to Track students. The agreement entered
into by such participating institutions under paragraph
(1)(A)(i) shall contain an agreement to accept as
payment in full the established remission rate under
this subparagraph.
``(B) Stipend.--The Surgeon General, based on the
recommendations of the National Health Care Workforce
Commission, shall establish and update Federal stipend
rates for payment to students under this part.
``(3) Reductions in the period of obligated service.--The
period of obligated service under paragraph (1)(A)(ii)(V) shall
be reduced--
``(A) in the case of a student who elects to
participate in a high-needs speciality residency (as
determined by the National Health Care Workforce
Commission), by 3 months for each year of such
participation (not to exceed a total of 12 months); and
``(B) in the case of a student who, upon completion
of their residency, elects to practice in a Federal
medical facility (as defined in section 781(e)) that is
located in a health professional shortage area (as
defined in section 332), by 3 months for year of full-
time practice in such a facility (not to exceed a total
of 12 months).
``(c) Second 2 Years of Service.--During the third and fourth years
in which a medical, dental, physician assistant, pharmacy, behavioral
and mental health, public health, or nursing student is enrolled in the
Track, training should be designed to prioritize clinical rotations in
Federal medical facilities in health professional shortage areas, and
emphasize a balance of hospital and community-based experiences, and
training within interdisciplinary teams.
``(d) Dentist, Physician Assistant, Pharmacist, Behavioral and
Mental Health Professional, Public Health Professional, and Nurse
Training.--The Surgeon General shall establish provisions applicable
with respect to dental, physician assistant, pharmacy, behavioral and
mental health, public health, and nursing students that are comparable
to those for medical students under this section, including service
obligations, tuition support, and stipend support. The Surgeon General
shall give priority to health professions training institutions that
train medical, dental, physician assistant, pharmacy, behavioral and
mental health, public health, and nursing students for some significant
period of time together, but at a minimum have a discrete and shared
core curriculum.
``(e) Elite Federal Disaster Teams.--The Surgeon General, in
consultation with the Secretary, the Director of the Centers for
Disease Control and Prevention, and other appropriate military and
Federal government agencies, shall develop criteria for the appointment
of highly qualified Track faculty, medical, dental, physician
assistant, pharmacy, behavioral and mental health, public health, and
nursing students, and graduates to elite Federal disaster preparedness
teams to train and to respond to public health emergencies, natural
disasters, bioterrorism events, and other emergencies.
``(f) Student Dropped From Track in Affiliate School.--A medical,
dental, physician assistant, pharmacy, behavioral and mental health,
public health, or nursing student who, under regulations prescribed by
the Surgeon General, is dropped from the Track in an affiliated school
for deficiency in conduct or studies, or for other reasons, shall be
liable to the United States for all tuition and stipend support
provided to the student.
``SEC. 274. FUNDING.
``Beginning with fiscal year 2010, the Secretary shall transfer
from the Public Health and Social Services Emergency Fund such sums as
may be necessary to carry out this part.''.
Subtitle E--Supporting the Existing Health Care Workforce
SEC. 5401. CENTERS OF EXCELLENCE.
Section 736 of the Public Health Service Act (42 U.S.C. 293) is
amended by striking subsection (h) and inserting the following:
``(h) Formula for Allocations.--
``(1) Allocations.--Based on the amount appropriated under
subsection (i) for a fiscal year, the following subparagraphs
shall apply as appropriate:
``(A) In general.--If the amounts appropriated
under subsection (i) for a fiscal year are $24,000,000
or less--
``(i) the Secretary shall make available
$12,000,000 for grants under subsection (a) to
health professions schools that meet the
conditions described in subsection (c)(2)(A);
and
``(ii) and available after grants are made
with funds under clause (i), the Secretary
shall make available--
``(I) 60 percent of such amount for
grants under subsection (a) to health
professions schools that meet the
conditions described in paragraph (3)
or (4) of subsection (c) (including
meeting the conditions under subsection
(e)); and
``(II) 40 percent of such amount
for grants under subsection (a) to
health professions schools that meet
the conditions described in subsection
(c)(5).
``(B) Funding in excess of $24,000,000.--If amounts
appropriated under subsection (i) for a fiscal year
exceed $24,000,000 but are less than $30,000,000--
``(i) 80 percent of such excess amounts
shall be made available for grants under
subsection (a) to health professions schools
that meet the requirements described in
paragraph (3) or (4) of subsection (c)
(including meeting conditions pursuant to
subsection (e)); and
``(ii) 20 percent of such excess amount
shall be made available for grants under
subsection (a) to health professions schools
that meet the conditions described in
subsection (c)(5).
``(C) Funding in excess of $30,000,000.--If amounts
appropriated under subsection (i) for a fiscal year
exceed $30,000,000 but are less than $40,000,000, the
Secretary shall make available--
``(i) not less than $12,000,000 for grants
under subsection (a) to health professions
schools that meet the conditions described in
subsection (c)(2)(A);
``(ii) not less than $12,000,000 for grants
under subsection (a) to health professions
schools that meet the conditions described in
paragraph (3) or (4) of subsection (c)
(including meeting conditions pursuant to
subsection (e));
``(iii) not less than $6,000,000 for grants
under subsection (a) to health professions
schools that meet the conditions described in
subsection (c)(5); and
``(iv) after grants are made with funds
under clauses (i) through (iii), any remaining
excess amount for grants under subsection (a)
to health professions schools that meet the
conditions described in paragraph (2)(A), (3),
(4), or (5) of subsection (c).
``(D) Funding in excess of $40,000,000.--If amounts
appropriated under subsection (i) for a fiscal year are
$40,000,000 or more, the Secretary shall make
available--
``(i) not less than $16,000,000 for grants
under subsection (a) to health professions
schools that meet the conditions described in
subsection (c)(2)(A);
``(ii) not less than $16,000,000 for grants
under subsection (a) to health professions
schools that meet the conditions described in
paragraph (3) or (4) of subsection (c)
(including meeting conditions pursuant to
subsection (e));
``(iii) not less than $8,000,000 for grants
under subsection (a) to health professions
schools that meet the conditions described in
subsection (c)(5); and
``(iv) after grants are made with funds
under clauses (i) through (iii), any remaining
funds for grants under subsection (a) to health
professions schools that meet the conditions
described in paragraph (2)(A), (3), (4), or (5)
of subsection (c).
``(2) No limitation.--Nothing in this subsection shall be
construed as limiting the centers of excellence referred to in
this section to the designated amount, or to preclude such
entities from competing for grants under this section.
``(3) Maintenance of effort.--
``(A) In general.--With respect to activities for
which a grant made under this part are authorized to be
expended, the Secretary may not make such a grant to a
center of excellence for any fiscal year unless the
center agrees to maintain expenditures of non-Federal
amounts for such activities at a level that is not less
than the level of such expenditures maintained by the
center for the fiscal year preceding the fiscal year
for which the school receives such a grant.
``(B) Use of federal funds.--With respect to any
Federal amounts received by a center of excellence and
available for carrying out activities for which a grant
under this part is authorized to be expended, the
center shall, before expending the grant, expend the
Federal amounts obtained from sources other than the
grant, unless given prior approval from the Secretary.
``(i) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section--
``(1) $50,000,000 for each of the fiscal years 2010 through
2015; and
``(2) and such sums as are necessary for each subsequent
fiscal year.''.
SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR DIVERSITY.
(a) Loan Repayments and Fellowships Regarding Faculty Positions.--
Section 738(a)(1) of the Public Health Service Act (42 U.S.C.
293b(a)(1)) is amended by striking ``$20,000 of the principal and
interest of the educational loans of such individuals.'' and inserting
``$30,000 of the principal and interest of the educational loans of
such individuals.''.
(b) Scholarships for Disadvantaged Students.--Section 740(a) of
such Act (42 U.S.C. 293d(a)) is amended by striking ``$37,000,000'' and
all that follows through ``2002'' and inserting ``$51,000,000 for
fiscal year 2010, and such sums as may be necessary for each of the
fiscal years 2011 through 2014''.
(c) Reauthorization for Loan Repayments and Fellowships Regarding
Faculty Positions.--Section 740(b) of such Act (42 U.S.C. 293d(b)) is
amended by striking ``appropriated'' and all that follows through the
period at the end and inserting ``appropriated, $5,000,000 for each of
the fiscal years 2010 through 2014.''.
(d) Reauthorization for Educational Assistance in the Health
Professions Regarding Individuals From a Disadvantaged Background.--
Section 740(c) of such Act (42 U.S.C. 293d(c)) is amended by striking
the first sentence and inserting the following: ``For the purpose of
grants and contracts under section 739(a)(1), there is authorized to be
appropriated $60,000,000 for fiscal year 2010 and such sums as may be
necessary for each of the fiscal years 2011 through 2014.''
SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES.
(a) Area Health Education Centers.--Section 751 of the Public
Health Service Act (42 U.S.C. 294a) is amended to read as follows:
``SEC. 751. AREA HEALTH EDUCATION CENTERS.
``(a) Establishment of Awards.--The Secretary shall make the
following 2 types of awards in accordance with this section:
``(1) Infrastructure development award.--The Secretary
shall make awards to eligible entities to enable such entities
to initiate health care workforce educational programs or to
continue to carry out comparable programs that are operating at
the time the award is made by planning, developing, operating,
and evaluating an area health education center program.
``(2) Point of service maintenance and enhancement award.--
The Secretary shall make awards to eligible entities to
maintain and improve the effectiveness and capabilities of an
existing area health education center program, and make other
modifications to the program that are appropriate due to
changes in demographics, needs of the populations served, or
other similar issues affecting the area health education center
program. For the purposes of this section, the term `Program'
refers to the area health education center program.
``(b) Eligible Entities; Application.--
``(1) Eligible entities.--
``(A) Infrastructure development.--For purposes of
subsection (a)(1), the term `eligible entity' means a
school of medicine or osteopathic medicine, an
incorporated consortium of such schools, or the parent
institutions of such a school. With respect to a State
in which no area health education center program is in
operation, the Secretary may award a grant or contract
under subsection (a)(1) to a school of nursing.
``(B) Point of service maintenance and
enhancement.--For purposes of subsection (a)(2), the
term `eligible entity' means an entity that has
received funds under this section, is operating an area
health education center program, including an area
health education center or centers, and has a center or
centers that are no longer eligible to receive
financial assistance under subsection (a)(1).
``(2) Application.--An eligible entity desiring to receive
an award under this section shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require.
``(c) Use of Funds.--
``(1) Required activities.--An eligible entity shall use
amounts awarded under a grant under subsection (a)(1) or (a)(2)
to carry out the following activities:
``(A) Develop and implement strategies, in
coordination with the applicable one-stop delivery
system under section 134(c) of the Workforce Investment
Act of 1998, to recruit individuals from
underrepresented minority populations or from
disadvantaged or rural backgrounds into health
professions, and support such individuals in attaining
such careers.
``(B) Develop and implement strategies to foster
and provide community-based training and education to
individuals seeking careers in health professions
within underserved areas for the purpose of developing
and maintaining a diverse health care workforce that is
prepared to deliver high-quality care, with an emphasis
on primary care, in underserved areas or for health
disparity populations, in collaboration with other
Federal and State health care workforce development
programs, the State workforce agency, and local
workforce investment boards, and in health care safety
net sites.
``(C) Prepare individuals to more effectively
provide health services to underserved areas and health
disparity populations through field placements or
preceptorships in conjunction with community-based
organizations, accredited primary care residency
training programs, Federally qualified health centers,
rural health clinics, public health departments, or
other appropriate facilities.
``(D) Conduct and participate in interdisciplinary
training that involves physicians, physician
assistants, nurse practitioners, nurse midwives,
dentists, psychologists, pharmacists, optometrists,
community health workers, public and allied health
professionals, or other health professionals, as
practicable.
``(E) Deliver or facilitate continuing education
and information dissemination programs for health care
professionals, with an emphasis on individuals
providing care in underserved areas and for health
disparity populations.
``(F) Propose and implement effective program and
outcomes measurement and evaluation strategies.
``(G) Establish a youth public health program to
expose and recruit high school students into health
careers, with a focus on careers in public health.
``(2) Innovative opportunities.--An eligible entity may use
amounts awarded under a grant under subsection (a)(1) or
subsection (a)(2) to carry out any of the following activities:
``(A) Develop and implement innovative curricula in
collaboration with community-based accredited primary
care residency training programs, Federally qualified
health centers, rural health clinics, behavioral and
mental health facilities, public health departments, or
other appropriate facilities, with the goal of
increasing the number of primary care physicians and
other primary care providers prepared to serve in
underserved areas and health disparity populations.
``(B) Coordinate community-based participatory
research with academic health centers, and facilitate
rapid flow and dissemination of evidence-based health
care information, research results, and best practices
to improve quality, efficiency, and effectiveness of
health care and health care systems within community
settings.
``(C) Develop and implement other strategies to
address identified workforce needs and increase and
enhance the health care workforce in the area served by
the area health education center program.
``(d) Requirements.--
``(1) Area health education center program.--In carrying
out this section, the Secretary shall ensure the following:
``(A) An entity that receives an award under this
section shall conduct at least 10 percent of clinical
education required for medical students in community
settings that are removed from the primary teaching
facility of the contracting institution for grantees
that operate a school of medicine or osteopathic
medicine. In States in which an entity that receives an
award under this section is a nursing school or its
parent institution, the Secretary shall alternatively
ensure that--
``(i) the nursing school conducts at least
10 percent of clinical education required for
nursing students in community settings that are
remote from the primary teaching facility of
the school; and
``(ii) the entity receiving the award
maintains a written agreement with a school of
medicine or osteopathic medicine to place
students from that school in training sites in
the area health education center program area.
``(B) An entity receiving funds under subsection
(a)(2) does not distribute such funding to a center
that is eligible to receive funding under subsection
(a)(1).
``(2) Area health education center.--The Secretary shall
ensure that each area health education center program includes
at least 1 area health education center, and that each such
center--
``(A) is a public or private organization whose
structure, governance, and operation is independent
from the awardee and the parent institution of the
awardee;
``(B) is not a school of medicine or osteopathic
medicine, the parent institution of such a school, or a
branch campus or other subunit of a school of medicine
or osteopathic medicine or its parent institution, or a
consortium of such entities;
``(C) designates an underserved area or population
to be served by the center which is in a location
removed from the main location of the teaching
facilities of the schools participating in the program
with such center and does not duplicate, in whole or in
part, the geographic area or population served by any
other center;
``(D) fosters networking and collaboration among
communities and between academic health centers and
community-based centers;
``(E) serves communities with a demonstrated need
of health professionals in partnership with academic
medical centers;
``(F) addresses the health care workforce needs of
the communities served in coordination with the public
workforce investment system; and
``(G) has a community-based governing or advisory
board that reflects the diversity of the communities
involved.
``(e) Matching Funds.--With respect to the costs of operating a
program through a grant under this section, to be eligible for
financial assistance under this section, an entity shall make available
(directly or through contributions from State, county or municipal
governments, or the private sector) recurring non-Federal contributions
in cash or in kind, toward such costs in an amount that is equal to not
less than 50 percent of such costs. At least 25 percent of the total
required non-Federal contributions shall be in cash. An entity may
apply to the Secretary for a waiver of not more than 75 percent of the
matching fund amount required by the entity for each of the first 3
years the entity is funded through a grant under subsection (a)(1).
``(f) Limitation.--Not less than 75 percent of the total amount
provided to an area health education center program under subsection
(a)(1) or (a)(2) shall be allocated to the area health education
centers participating in the program under this section. To provide
needed flexibility to newly funded area health education center
programs, the Secretary may waive the requirement in the sentence for
the first 2 years of a new area health education center program funded
under subsection (a)(1).
``(g) Award.--An award to an entity under this section shall be not
less than $250,000 annually per area health education center included
in the program involved. If amounts appropriated to carry out this
section are not sufficient to comply with the preceding sentence, the
Secretary may reduce the per center amount provided for in such
sentence as necessary, provided the distribution established in
subsection (j)(2) is maintained.
``(h) Project Terms.--
``(1) In general.--Except as provided in paragraph (2), the
period during which payments may be made under an award under
subsection (a)(1) may not exceed--
``(A) in the case of a program, 12 years; or
``(B) in the case of a center within a program, 6
years.
``(2) Exception.--The periods described in paragraph (1)
shall not apply to programs receiving point of service
maintenance and enhancement awards under subsection (a)(2) to
maintain existing centers and activities.
``(i) Inapplicability of Provision.--Notwithstanding any other
provision of this title, section 791(a) shall not apply to an area
health education center funded under this section.
``(j) Authorization of Appropriations.--
``(1) In general.--There is authorized to be appropriated
to carry out this section $125,000,000 for each of the fiscal
years 2010 through 2014.
``(2) Requirements.--Of the amounts appropriated for a
fiscal year under paragraph (1)--
``(A) not more than 35 percent shall be used for
awards under subsection (a)(1);
``(B) not less than 60 percent shall be used for
awards under subsection (a)(2);
``(C) not more than 1 percent shall be used for
grants and contracts to implement outcomes evaluation
for the area health education centers; and
``(D) not more than 4 percent shall be used for
grants and contracts to provide technical assistance to
entities receiving awards under this section.
``(3) Carryover funds.--An entity that receives an award
under this section may carry over funds from 1 fiscal year to
another without obtaining approval from the Secretary. In no
case may any funds be carried over pursuant to the preceding
sentence for more than 3 years.
``(k) Sense of Congress.--It is the sense of the Congress that
every State have an area health education center program in effect
under this section.''.
(b) Continuing Educational Support for Health Professionals Serving
in Underserved Communities.--Part D of title VII of the Public Health
Service Act (42 U.S.C. 294 et seq.) is amended by striking section 752
and inserting the following:
``SEC. 752. CONTINUING EDUCATIONAL SUPPORT FOR HEALTH PROFESSIONALS
SERVING IN UNDERSERVED COMMUNITIES.
``(a) In General.--The Secretary shall make grants to, and enter
into contracts with, eligible entities to improve health care, increase
retention, increase representation of minority faculty members, enhance
the practice environment, and provide information dissemination and
educational support to reduce professional isolation through the timely
dissemination of research findings using relevant resources.
``(b) Eligible Entities.--For purposes of this section, the term
`eligible entity' means an entity described in section 799(b).
``(c) Application.--An eligible entity desiring to receive an award
under this section shall submit to the Secretary an application at such
time, in such manner, and containing such information as the Secretary
may require.
``(d) Use of Funds.--An eligible entity shall use amounts awarded
under a grant or contract under this section to provide innovative
supportive activities to enhance education through distance learning,
continuing educational activities, collaborative conferences, and
electronic and telelearning activities, with priority for primary care.
``(e) Authorization.--There is authorized to be appropriated to
carry out this section $5,000,000 for each of the fiscal years 2010
through 2014, and such sums as may be necessary for each subsequent
fiscal year.''.
SEC. 5404. WORKFORCE DIVERSITY GRANTS.
Section 821 of the Public Health Service Act (42 U.S.C. 296m) is
amended--
(1) in subsection (a)--
(A) by striking ``The Secretary may'' and inserting
the following:
``(1) Authority.--The Secretary may'';
(B) by striking ``pre-entry preparation, and
retention activities'' and inserting the following:
``stipends for diploma or associate degree nurses to
enter a bridge or degree completion program, student
scholarships or stipends for accelerated nursing degree
programs, pre-entry preparation, advanced education
preparation, and retention activities''; and
(2) in subsection (b)--
(A) by striking ``First'' and all that follows
through ``including the'' and inserting ``National
Advisory Council on Nurse Education and Practice and
consult with nursing associations including the
National Coalition of Ethnic Minority Nurse
Associations,''; and
(B) by inserting before the period the following:
``, and other organizations determined appropriate by
the Secretary''.
SEC. 5405. PRIMARY CARE EXTENSION PROGRAM.
Part P of title III of the Public Health Service Act (42 U.S.C.
280g et seq.), as amended by section 5313, is further amended by adding
at the end the following:
``SEC. 399W. PRIMARY CARE EXTENSION PROGRAM.
``(a) Establishment, Purpose and Definition.--
``(1) In general.--The Secretary, acting through the
Director of the Agency for Healthcare Research and Quality,
shall establish a Primary Care Extension Program.
``(2) Purpose.--The Primary Care Extension Program shall
provide support and assistance to primary care providers to
educate providers about preventive medicine, health promotion,
chronic disease management, mental and behavioral health
services (including substance abuse prevention and treatment
services), and evidence-based and evidence-informed therapies
and techniques, in order to enable providers to incorporate
such matters into their practice and to improve community
health by working with community-based health connectors
(referred to in this section as `Health Extension Agents').
``(3) Definitions.--In this section:
``(A) Health extension agent.--The term `Health
Extension Agent' means any local, community-based
health worker who facilitates and provides assistance
to primary care practices by implementing quality
improvement or system redesign, incorporating the
principles of the patient-centered medical home to
provide high-quality, effective, efficient, and safe
primary care and to provide guidance to patients in
culturally and linguistically appropriate ways, and
linking practices to diverse health system resources.
``(B) Primary care provider.--The term `primary
care provider' means a clinician who provides
integrated, accessible health care services and who is
accountable for addressing a large majority of personal
health care needs, including providing preventive and
health promotion services for men, women, and children
of all ages, developing a sustained partnership with
patients, and practicing in the context of family and
community, as recognized by a State licensing or
regulatory authority, unless otherwise specified in
this section.
``(b) Grants To Establish State Hubs and Local Primary Care
Extension Agencies.--
``(1) Grants.--The Secretary shall award competitive grants
to States for the establishment of State- or multistate-level
primary care Primary Care Extension Program State Hubs
(referred to in this section as `Hubs').
``(2) Composition of hubs.--A Hub established by a State
pursuant to paragraph (1)--
``(A) shall consist of, at a minimum, the State
health department, the entity responsible for
administering the State Medicaid program (if other than
the State health department), the State-level entity
administering the Medicare program, and the departments
of 1 or more health professions schools in the State
that train providers in primary care; and
``(B) may include entities such as hospital
associations, primary care practice-based research
networks, health professional societies, State primary
care associations, State licensing boards,
organizations with a contract with the Secretary under
section 1153 of the Social Security Act, consumer
groups, and other appropriate entities.
``(c) State and Local Activities.--
``(1) Hub activities.--Hubs established under a grant under
subsection (b) shall--
``(A) submit to the Secretary a plan to coordinate
functions with quality improvement organizations and
area health education centers if such entities are
members of the Hub not described in subsection
(b)(2)(A);
``(B) contract with a county- or local-level entity
that shall serve as the Primary Care Extension Agency
to administer the services described in paragraph (2);
``(C) organize and administer grant funds to
county- or local-level Primary Care Extension Agencies
that serve a catchment area, as determined by the
State; and
``(D) organize State-wide or multistate networks of
local-level Primary Care Extension Agencies to share
and disseminate information and practices.
``(2) Local primary care extension agency activities.--
``(A) Required activities.--Primary Care Extension
Agencies established by a Hub under paragraph (1)
shall--
``(i) assist primary care providers to
implement a patient-centered medical home to
improve the accessibility, quality, and
efficiency of primary care services, including
health homes;
``(ii) develop and support primary care
learning communities to enhance the
dissemination of research findings for
evidence-based practice, assess implementation
of practice improvement, share best practices,
and involve community clinicians in the
generation of new knowledge and identification
of important questions for research;
``(iii) participate in a national network
of Primary Care Extension Hubs and propose how
the Primary Care Extension Agency will share
and disseminate lessons learned and best
practices; and
``(iv) develop a plan for financial
sustainability involving State, local, and
private contributions, to provide for the
reduction in Federal funds that is expected
after an initial 6-year period of program
establishment, infrastructure development, and
planning.
``(B) Discretionary activities.--Primary Care
Extension Agencies established by a Hub under paragraph
(1) may--
``(i) provide technical assistance,
training, and organizational support for
community health teams established under
section 3602 of the Patient Protection and
Affordable Care Act;
``(ii) collect data and provision of
primary care provider feedback from
standardized measurements of processes and
outcomes to aid in continuous performance
improvement;
``(iii) collaborate with local health
departments, community health centers, tribes
and tribal entities, and other community
agencies to identify community health
priorities and local health workforce needs,
and participate in community-based efforts to
address the social and primary determinants of
health, strengthen the local primary care
workforce, and eliminate health disparities;
``(iv) develop measures to monitor the
impact of the proposed program on the health of
practice enrollees and of the wider community
served; and
``(v) participate in other activities, as
determined appropriate by the Secretary.
``(d) Federal Program Administration.--
``(1) Grants; types.--Grants awarded under subsection (b)
shall be--
``(A) program grants, that are awarded to State or
multistate entities that submit fully-developed plans
for the implementation of a Hub, for a period of 6
years; or
``(B) planning grants, that are awarded to State or
multistate entities with the goal of developing a plan
for a Hub, for a period of 2 years.
``(2) Applications.--To be eligible for a grant under
subsection (b), a State or multistate entity shall submit to
the Secretary an application, at such time, in such manner, and
containing such information as the Secretary may require.
``(3) Evaluation.--A State that receives a grant under
subsection (b) shall be evaluated at the end of the grant
period by an evaluation panel appointed by the Secretary.
``(4) Continuing support.--After the sixth year in which
assistance is provided to a State under a grant awarded under
subsection (b), the State may receive additional support under
this section if the State program has received satisfactory
evaluations with respect to program performance and the merits
of the State sustainability plan, as determined by the
Secretary.
``(5) Limitation.--A State shall not use in excess of 10
percent of the amount received under a grant to carry out
administrative activities under this section. Funds awarded
pursuant to this section shall not be used for funding direct
patient care.
``(e) Requirements on the Secretary.--In carrying out this section,
the Secretary shall consult with the heads of other Federal agencies
with demonstrated experience and expertise in health care and
preventive medicine, such as the Centers for Disease Control and
Prevention, the Substance Abuse and Mental Health Administration, the
Health Resources and Services Administration, the National Institutes
of Health, the Office of the National Coordinator for Health
Information Technology, the Indian Health Service, the Agricultural
Cooperative Extension Service of the Department of Agriculture, and
other entities, as the Secretary determines appropriate.
``(f) Authorization of Appropriations.--To awards grants as
provided in subsection (d), there are authorized to be appropriated
$120,000,000 for each of fiscal years 2011 and 2012, and such sums as
may be necessary to carry out this section for each of fiscal years
2013 through 2014.''.
Subtitle F--Strengthening Primary Care and Other Workforce Improvements
SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERVICES AND GENERAL
SURGERY SERVICES.
(a) Incentive Payment Program for Primary Care Services.--
(1) In general.--Section 1833 of the Social Security Act
(42 U.S.C. 1395l) is amended by adding at the end the following
new subsection:
``(x) Incentive Payments for Primary Care Services.--
``(1) In general.--In the case of primary care services
furnished on or after January 1, 2011, and before January 1,
2016, by a primary care practitioner, in addition to the amount
of payment that would otherwise be made for such services under
this part, there also shall be paid (on a monthly or quarterly
basis) an amount equal to 10 percent of the payment amount for
the service under this part.
``(2) Definitions.--In this subsection:
``(A) Primary care practitioner.--The term `primary
care practitioner' means an individual--
``(i) who--
``(I) is a physician (as described
in section 1861(r)(1)) who has a
primary specialty designation of family
medicine, internal medicine, geriatric
medicine, or pediatric medicine; or
``(II) is a nurse practitioner,
clinical nurse specialist, or physician
assistant (as those terms are defined
in section 1861(aa)(5)); and
``(ii) for whom primary care services
accounted for at least 60 percent of the
allowed charges under this part for such
physician or practitioner in a prior period as
determined appropriate by the Secretary.
``(B) Primary care services.--The term `primary
care services' means services identified, as of January
1, 2009, by the following HCPCS codes (and as
subsequently modified by the Secretary):
``(i) 99201 through 99215.
``(ii) 99304 through 99340.
``(iii) 99341 through 99350.
``(3) Coordination with other payments.--The amount of the
additional payment for a service under this subsection and
subsection (m) shall be determined without regard to any
additional payment for the service under subsection (m) and
this subsection, respectively.
``(4) Limitation on review.--There shall be no
administrative or judicial review under section 1869, 1878, or
otherwise, respecting the identification of primary care
practitioners under this subsection.''.
(2) Conforming amendment.--Section 1834(g)(2)(B) of the
Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by
adding at the end the following sentence: ``Section 1833(x)
shall not be taken into account in determining the amounts that
would otherwise be paid pursuant to the preceding sentence.''.
(b) Incentive Payment Program for Major Surgical Procedures
Furnished in Health Professional Shortage Areas.--
(1) In general.--Section 1833 of the Social Security Act
(42 U.S.C. 1395l), as amended by subsection (a)(1), is amended
by adding at the end the following new subsection:
``(y) Incentive Payments for Major Surgical Procedures Furnished in
Health Professional Shortage Areas.--
``(1) In general.--In the case of major surgical procedures
furnished on or after January 1, 2011, and before January 1,
2016, by a general surgeon in an area that is designated (under
section 332(a)(1)(A) of the Public Health Service Act) as a
health professional shortage area as identified by the
Secretary prior to the beginning of the year involved, in
addition to the amount of payment that would otherwise be made
for such services under this part, there also shall be paid (on
a monthly or quarterly basis) an amount equal to 10 percent of
the payment amount for the service under this part.
``(2) Definitions.--In this subsection:
``(A) General surgeon.--In this subsection, the
term `general surgeon' means a physician (as described
in section 1861(r)(1)) who has designated CMS specialty
code 02-General Surgery as their primary specialty code
in the physician's enrollment under section 1866(j).
``(B) Major surgical procedures.--The term `major
surgical procedures' means physicians' services which
are surgical procedures for which a 10-day or 90-day
global period is used for payment under the fee
schedule under section 1848(b).
``(3) Coordination with other payments.--The amount of the
additional payment for a service under this subsection and
subsection (m) shall be determined without regard to any
additional payment for the service under subsection (m) and
this subsection, respectively.
``(4) Application.--The provisions of paragraph (2) and (4)
of subsection (m) shall apply to the determination of
additional payments under this subsection in the same manner as
such provisions apply to the determination of additional
payments under subsection (m).''.
(2) Conforming amendment.--Section 1834(g)(2)(B) of the
Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended by
subsection (a)(2), is amended by striking ``Section 1833(x)''
and inserting ``Subsections (x) and (y) of section 1833'' in
the last sentence.
(c) Budget-neutrality Adjustment.--Section 1848(c)(2)(B) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is amended by adding
at the end the following new clause:
``(vii) Adjustment for certain physician
incentive payments.--Fifty percent of the
additional expenditures under this part
attributable to subsections (x) and (y) of
section 1833 for a year (as estimated by the
Secretary) shall be taken into account in
applying clause (ii)(II) for 2011 and
subsequent years. In lieu of applying the
budget-neutrality adjustments required under
clause (ii)(II) to relative value units to
account for such costs for the year, the
Secretary shall apply such budget-neutrality
adjustments to the conversion factor otherwise
determined for the year. For 2011 and
subsequent years, the Secretary shall increase
the incentive payment otherwise applicable
under section 1833(m) by a percent estimated to
be equal to the additional expenditures
estimated under the first sentence of this
clause for such year that is applicable to
physicians who primarily furnish services in
areas designated (under section 332(a)(1)(A) of
the Public Health Service Act) as health
professional shortage areas.''.
SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CENTER IMPROVEMENTS.
(a) Expansion of Medicare-Covered Preventive Services at Federally
Qualified Health Centers.--
(1) In general.--Section 1861(aa)(3)(A) of the Social
Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read as
follows:
``(A) services of the type described subparagraphs
(A) through (C) of paragraph (1) and preventive
services (as defined in section 1861(ddd)(3)); and''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to services furnished on or after January 1, 2011.
(b) Prospective Payment System for Federally Qualified Health
Centers.--Section 1834 of the Social Security Act (42 U.S.C. 1395m) is
amended by adding at the end the following new subsection:
``(n) Development and Implementation of Prospective Payment
System.--
``(1) Development.--
``(A) In general.--The Secretary shall develop a
prospective payment system for payment for Federally
qualified health services furnished by Federally
qualified health centers under this title. Such system
shall include a process for appropriately describing
the services furnished by Federally qualified health
centers.
``(B) Collection of data and evaluation.--The
Secretary shall require Federally qualified health
centers to submit to the Secretary such information as
the Secretary may require in order to develop and
implement the prospective payment system under this
paragraph and paragraph (2), respectively, including
the reporting of services using HCPCS codes.
``(2) Implementation.--
``(A) In general.--Notwithstanding section
1833(a)(3)(B), the Secretary shall provide, for cost
reporting periods beginning on or after October 1,
2014, for payments for Federally qualified health
services furnished by Federally qualified health
centers under this title in accordance with the
prospective payment system developed by the Secretary
under paragraph (1).
``(B) Payments.--
``(i) Initial payments.--The Secretary
shall implement such prospective payment system
so that the estimated amount of expenditures
under this title for Federally qualified health
services in the first year that the prospective
payment system is implemented is equal to 103
percent of the estimated amount of expenditures
under this title that would have occurred for
such services in such year if the system had
not been implemented.
``(ii) Payments in subsequent years.--In
the year after the first year of implementation
of such system, and in each subsequent year,
the payment rate for Federally qualified health
services furnished in the year shall be equal
to the payment rate established for such
services furnished in the preceding year under
this subparagraph increased by the percentage
increase in the MEI (as defined in 1842(i)(3))
for the year involved.''.
SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.
(a) In General.--Section 1886(h) of the Social Security Act (42
U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(F)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(2) in paragraph (4)(H)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(3) in paragraph (7)(E), by inserting ``or paragraph (8)''
before the period at the end; and
(4) by adding at the end the following new paragraph:
``(8) Distribution of additional residency positions.--
``(A) Reductions in limit based on unused
positions.--
``(i) In general.--Except as provided in
clause (ii), if a hospital's reference resident
level (as defined in subparagraph (H)(i)) is
less than the otherwise applicable resident
limit (as defined in subparagraph (H)(iii)),
effective for portions of cost reporting
periods occurring on or after July 1, 2011, the
otherwise applicable resident limit shall be
reduced by 65 percent of the difference between
such otherwise applicable resident limit and
such reference resident level.
``(ii) Exceptions.--This subparagraph shall
not apply to--
``(I) a hospital located in a rural
area (as defined in subsection
(d)(2)(D)(ii)) with fewer than 250
acute care inpatient beds;
``(II) a hospital that was part of
a qualifying entity which had a
voluntary residency reduction plan
approved under paragraph (6)(B) or
under the authority of section 402 of
Public Law 90-248, if the hospital
demonstrates to the Secretary that it
has a specified plan in place for
filling the unused positions by not
later than 2 years after the date of
enactment of this paragraph; or
``(III) a hospital described in
paragraph (4)(H)(v).
``(B) Distribution.--
``(i) In general.--The Secretary shall
increase the otherwise applicable resident
limit for each qualifying hospital that submits
an application under this subparagraph by such
number as the Secretary may approve for
portions of cost reporting periods occurring on
or after July 1, 2011. The aggregate number of
increases in the otherwise applicable resident
limit under this subparagraph shall be equal to
the aggregate reduction in such limits
attributable to subparagraph (A) (as estimated
by the Secretary).
``(ii) Requirements.--Subject to clause
(iii), a hospital that receives an increase in
the otherwise applicable resident limit under
this subparagraph shall ensure, during the 5-
year period beginning on the date of such
increase, that--
``(I) the number of full-time
equivalent primary care residents, as
defined in paragraph (5)(H) (as
determined by the Secretary), excluding
any additional positions under
subclause (II), is not less than the
average number of full-time equivalent
primary care residents (as so
determined) during the 3 most recent
cost reporting periods ending prior to
the date of enactment of this
paragraph; and
``(II) not less than 75 percent of
the positions attributable to such
increase are in a primary care or
general surgery residency (as
determined by the Secretary).
The Secretary may determine whether a hospital
has met the requirements under this clause
during such 5-year period in such manner and at
such time as the Secretary determines
appropriate, including at the end of such 5-
year period.
``(iii) Redistribution of positions if
hospital no longer meets certain
requirements.--In the case where the Secretary
determines that a hospital described in clause
(ii) does not meet either of the requirements
under subclause (I) or (II) of such clause, the
Secretary shall--
``(I) reduce the otherwise
applicable resident limit of the
hospital by the amount by which such
limit was increased under this
paragraph; and
``(II) provide for the distribution
of positions attributable to such
reduction in accordance with the
requirements of this paragraph.
``(C) Considerations in redistribution.--In
determining for which hospitals the increase in the
otherwise applicable resident limit is provided under
subparagraph (B), the Secretary shall take into
account--
``(i) the demonstration likelihood of the
hospital filling the positions made available
under this paragraph within the first 3 cost
reporting periods beginning on or after July 1,
2011, as determined by the Secretary; and
``(ii) whether the hospital has an
accredited rural training track (as described
in paragraph (4)(H)(iv)).
``(D) Priority for certain areas.--In determining
for which hospitals the increase in the otherwise
applicable resident limit is provided under
subparagraph (B), subject to subparagraph (E), the
Secretary shall distribute the increase to hospitals
based on the following factors:
``(i) Whether the hospital is located in a
State with a resident-to-population ratio in
the lowest quartile (as determined by the
Secretary).
``(ii) Whether the hospital is located in a
State, a territory of the United States, or the
District of Columbia that is among the top 10
States, territories, or Districts in terms of
the ratio of--
``(I) the total population of the
State, territory, or District living in
an area designated (under such section
332(a)(1)(A)) as a health professional
shortage area (as of the date of
enactment of this paragraph); to
``(II) the total population of the
State, territory, or District (as
determined by the Secretary based on
the most recent available population
data published by the Bureau of the
Census).
``(iii) Whether the hospital is located in
a rural area (as defined in subsection
(d)(2)(D)(ii)).
``(E) Reservation of positions for certain
hospitals.--
``(i) In general.--Subject to clause (ii),
the Secretary shall reserve the positions
available for distribution under this paragraph
as follows:
``(I) 70 percent of such positions
for distribution to hospitals described
in clause (i) of subparagraph (D).
``(II) 30 percent of such positions
for distribution to hospitals described
in clause (ii) and (iii) of such
subparagraph.
``(ii) Exception if positions not
redistributed by july 1, 2011.--In the case
where the Secretary does not distribute
positions to hospitals in accordance with
clause (i) by July 1, 2011, the Secretary shall
distribute such positions to other hospitals in
accordance with the considerations described in
subparagraph (C) and the priority described in
subparagraph (D).
``(F) Limitation.--A hospital may not receive more
than 75 full-time equivalent additional residency
positions under this paragraph.
``(G) Application of per resident amounts for
primary care and nonprimary care.--With respect to
additional residency positions in a hospital
attributable to the increase provided under this
paragraph, the approved FTE per resident amounts are
deemed to be equal to the hospital per resident amounts
for primary care and nonprimary care computed under
paragraph (2)(D) for that hospital.
``(H) Definitions.--In this paragraph:
``(i) Reference resident level.--The term
`reference resident level' means, with respect
to a hospital, the highest resident level for
any of the 3 most recent cost reporting periods
(ending before the date of the enactment of
this paragraph) of the hospital for which a
cost report has been settled (or, if not,
submitted (subject to audit)), as determined by
the Secretary.
``(ii) Resident level.--The term `resident
level' has the meaning given such term in
paragraph (7)(C)(i).
``(iii) Otherwise applicable resident
limit.--The term `otherwise applicable resident
limit' means, with respect to a hospital, the
limit otherwise applicable under subparagraphs
(F)(i) and (H) of paragraph (4) on the resident
level for the hospital determined without
regard to this paragraph but taking into
account paragraph (7)(A).''.
(b) IME.--
(1) In general.--Section 1886(d)(5)(B)(v) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second
sentence, is amended--
(A) by striking ``subsection (h)(7)'' and inserting
``subsections (h)(7) and (h)(8)''; and
(B) by striking ``it applies'' and inserting ``they
apply''.
(2) Conforming amendment.--Section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by
adding at the end the following clause:
``(x) For discharges occurring on or after July 1, 2011,
insofar as an additional payment amount under this subparagraph
is attributable to resident positions distributed to a hospital
under subsection (h)(8)(B), the indirect teaching adjustment
factor shall be computed in the same manner as provided under
clause (ii) with respect to such resident positions.''.
(c) Conforming Amendment.--Section 422(b)(2) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173) is amended by striking ``section 1886(h)(7)'' and all that
follows and inserting ``paragraphs (7) and (8) of subsection (h) of
section 1886 of the Social Security Act''.
SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER SETTINGS.
(a) GME.--Section 1886(h)(4)(E) of the Social Security Act (42
U.S.C. 1395ww(h)(4)(E)) is amended--
(1) by striking ``shall be counted and that all the time''
and inserting ``shall be counted and that--
``(i) effective for cost reporting periods
beginning before July 1, 2010, all the time;'';
(2) in clause (i), as inserted by paragraph (1), by
striking the period at the end and inserting ``; and'';
(3) by inserting after clause (i), as so inserted, the
following new clause:
``(ii) effective for cost reporting periods
beginning on or after July 1, 2010, all the
time so spent by a resident shall be counted
towards the determination of full-time
equivalency, without regard to the setting in
which the activities are performed, if a
hospital incurs the costs of the stipends and
fringe benefits of the resident during the time
the resident spends in that setting. If more
than one hospital incurs these costs, either
directly or through a third party, such
hospitals shall count a proportional share of
the time, as determined by written agreement
between the hospitals, that a resident spends
training in that setting.''; and
(4) by adding at the end the following flush sentence:
``Any hospital claiming under this subparagraph for
time spent in a nonprovider setting shall maintain and
make available to the Secretary records regarding the
amount of such time and such amount in comparison with
amounts of such time in such base year as the Secretary
shall specify.''.
(b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security Act (42
U.S.C. 1395ww(d)(5)) is amended--
(1) by striking ``(iv) Effective for discharges occurring
on or after October 1, 1997'' and inserting ``(iv)(I) Effective
for discharges occurring on or after October 1, 1997, and
before July 1, 2010''; and
(2) by inserting after clause (I), as inserted by paragraph
(1), the following new subparagraph:
``(II) Effective for discharges occurring on or after July
1, 2010, all the time spent by an intern or resident in patient
care activities in a nonprovider setting shall be counted
towards the determination of full-time equivalency if a
hospital incurs the costs of the stipends and fringe benefits
of the intern or resident during the time the intern or
resident spends in that setting. If more than one hospital
incurs these costs, either directly or through a third party,
such hospitals shall count a proportional share of the time, as
determined by written agreement between the hospitals, that a
resident spends training in that setting.''.
(c) Application.--The amendments made by this section shall not be
applied in a manner that requires reopening of any settled hospital
cost reports as to which there is not a jurisdictionally proper appeal
pending as of the date of the enactment of this Act on the issue of
payment for indirect costs of medical education under section
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or
for direct graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. 1395ww(h)).
SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY
ACTIVITIES AND OTHER ACTIVITIES.
(a) GME.--Section 1886(h) of the Social Security Act (42 U.S.C.
1395ww(h)), as amended by section 5504, is amended--
(1) in paragraph (4)--
(A) in subparagraph (E), by striking ``Such rules''
and inserting ``Subject to subparagraphs (J) and (K),
such rules''; and
(B) by adding at the end the following new
subparagraphs:
``(J) Treatment of certain nonprovider and didactic
activities.--Such rules shall provide that all time
spent by an intern or resident in an approved medical
residency training program in a nonprovider setting
that is primarily engaged in furnishing patient care
(as defined in paragraph (5)(K)) in non-patient care
activities, such as didactic conferences and seminars,
but not including research not associated with the
treatment or diagnosis of a particular patient, as such
time and activities are defined by the Secretary, shall
be counted toward the determination of full-time
equivalency.
``(K) Treatment of certain other activities.--In
determining the hospital's number of full-time
equivalent residents for purposes of this subsection,
all the time that is spent by an intern or resident in
an approved medical residency training program on
vacation, sick leave, or other approved leave, as such
time is defined by the Secretary, and that does not
prolong the total time the resident is participating in
the approved program beyond the normal duration of the
program shall be counted toward the determination of
full-time equivalency.''; and
(2) in paragraph (5), by adding at the end the following
new subparagraph:
``(K) Nonprovider setting that is primarily engaged
in furnishing patient care.--The term `nonprovider
setting that is primarily engaged in furnishing patient
care' means a nonprovider setting in which the primary
activity is the care and treatment of patients, as
defined by the Secretary.''.
(b) IME Determinations.--Section 1886(d)(5)(B) of such Act (42
U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following
new clause:
``(x)(I) The provisions of subparagraph (K)
of subsection (h)(4) shall apply under this
subparagraph in the same manner as they apply
under such subsection.
``(II) In determining the hospital's number
of full-time equivalent residents for purposes
of this subparagraph, all the time spent by an
intern or resident in an approved medical
residency training program in non-patient care
activities, such as didactic conferences and
seminars, as such time and activities are
defined by the Secretary, that occurs in the
hospital shall be counted toward the
determination of full-time equivalency if the
hospital--
``(aa) is recognized as a
subsection (d) hospital;
``(bb) is recognized as a
subsection (d) Puerto Rico hospital;
``(cc) is reimbursed under a
reimbursement system authorized under
section 1814(b)(3); or
``(dd) is a provider-based hospital
outpatient department.
``(III) In determining the hospital's
number of full-time equivalent residents for
purposes of this subparagraph, all the time
spent by an intern or resident in an approved
medical residency training program in research
activities that are not associated with the
treatment or diagnosis of a particular patient,
as such time and activities are defined by the
Secretary, shall not be counted toward the
determination of full-time equivalency.''.
(c) Effective Dates.--
(1) In general.--Except as otherwise provided, the
Secretary of Health and Human Services shall implement the
amendments made by this section in a manner so as to apply to
cost reporting periods beginning on or after January 1, 1983.
(2) GME.--Section 1886(h)(4)(J) of the Social Security Act,
as added by subsection (a)(1)(B), shall apply to cost reporting
periods beginning on or after July 1, 2009.
(3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social
Security Act, as added by subsection (b), shall apply to cost
reporting periods beginning on or after October 1, 2001. Such
section, as so added, shall not give rise to any inference as
to how the law in effect prior to such date should be
interpreted.
SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED
HOSPITALS.
(a) GME.--Section 1886(h)(4)(H) of the Social Security Act (42
U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end the
following new clause:
``(vi) Redistribution of residency slots
after a hospital closes.--
``(I) In general.--Subject to the
succeeding provisions of this clause,
the Secretary shall, by regulation,
establish a process under which, in the
case where a hospital (other than a
hospital described in clause (v)) with
an approved medical residency program
closes on or after a date that is 2
years before the date of enactment of
this clause, the Secretary shall
increase the otherwise applicable
resident limit under this paragraph for
other hospitals in accordance with this
clause.
``(II) Priority for hospitals in
certain areas.--Subject to the
succeeding provisions of this clause,
in determining for which hospitals the
increase in the otherwise applicable
resident limit is provided under such
process, the Secretary shall distribute
the increase to hospitals in the
following priority order (with
preference given within each category
to hospitals that are members of the
same affiliated group (as defined by
the Secretary under clause (ii)) as the
closed hospital):
``(aa) First, to hospitals
located in the same core-based
statistical area as, or a core-
based statistical area
contiguous to, the hospital
that closed.
``(bb) Second, to hospitals
located in the same State as
the hospital that closed.
``(cc) Third, to hospitals
located in the same region of
the country as the hospital
that closed.
``(dd) Fourth, only if the
Secretary is not able to
distribute the increase to
hospitals described in item
(cc), to qualifying hospitals
in accordance with the
provisions of paragraph (8).
``(III) Requirement hospital likely
to fill position within certain time
period.--The Secretary may only
increase the otherwise applicable
resident limit of a hospital under such
process if the Secretary determines the
hospital has demonstrated a likelihood
of filling the positions made available
under this clause within 3 years.
``(IV) Limitation.--The aggregate
number of increases in the otherwise
applicable resident limits for
hospitals under this clause shall be
equal to the number of resident
positions in the approved medical
residency programs that closed on or
after the date described in subclause
(I).
``(V) Administration.--Chapter 35
of title 44, United States Code, shall
not apply to the implementation of this
clause.''.
(b) IME.--Section 1886(d)(5)(B)(v) of the Social Security Act (42
U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended by
section 5503, is amended by striking ``subsections (h)(7) and (h)(8)''
and inserting ``subsections (h)(4)(H)(vi), (h)(7), and (h)(8)''.
(c) Application.--The amendments made by this section shall not be
applied in a manner that requires reopening of any settled hospital
cost reports as to which there is not a jurisdictionally proper appeal
pending as of the date of the enactment of this Act on the issue of
payment for indirect costs of medical education under section
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or
for direct graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. Section 1395ww(h)).
(d) Effect on Temporary FTE Cap Adjustments.--The Secretary of
Health and Human Services shall give consideration to the effect of the
amendments made by this section on any temporary adjustment to a
hospital's FTE cap under section 413.79(h) of title 42, Code of Federal
Regulations (as in effect on the date of enactment of this Act) in
order to ensure that there is no duplication of FTE slots. Such
amendments shall not affect the application of section 1886(h)(4)(H)(v)
of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)(v)).
(e) Conforming Amendment.--Section 1886(h)(7)(E) of the Social
Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended by section
5503(a), is amended by striking ``paragraph or paragraph (8)'' and
inserting ``this paragraph, paragraph (8), or paragraph (4)(H)(vi)''.
SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFESSIONS
WORKFORCE NEEDS; EXTENSION OF FAMILY-TO-FAMILY HEALTH
INFORMATION CENTERS.
(a) Authority To Conduct Demonstration Projects.--Title XX of the
Social Security Act (42 U.S.C. 1397 et seq.) is amended by adding at
the end the following:
``SEC. 2008. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFESSIONS
WORKFORCE NEEDS.
``(a) Demonstration Projects To Provide Low-Income Individuals With
Opportunities for Education, Training, and Career Advancement To
Address Health Professions Workforce Needs.--
``(1) Authority to award grants.--The Secretary, in
consultation with the Secretary of Labor, shall award grants to
eligible entities to conduct demonstration projects that are
designed to provide eligible individuals with the opportunity
to obtain education and training for occupations in the health
care field that pay well and are expected to either experience
labor shortages or be in high demand.
``(2) Requirements.--
``(A) Aid and supportive services.--
``(i) In general.--A demonstration project
conducted by an eligible entity awarded a grant
under this section shall, if appropriate,
provide eligible individuals participating in
the project with financial aid, child care,
case management, and other supportive services.
``(ii) Treatment.--Any aid, services, or
incentives provided to an eligible beneficiary
participating in a demonstration project under
this section shall not be considered income,
and shall not be taken into account for
purposes of determining the individual's
eligibility for, or amount of, benefits under
any means-tested program.
``(B) Consultation and coordination.--An eligible
entity applying for a grant to carry out a
demonstration project under this section shall
demonstrate in the application that the entity has
consulted with the State agency responsible for
administering the State TANF program, the local
workforce investment board in the area in which the
project is to be conducted (unless the applicant is
such board), the State workforce investment board
established under section 111 of the Workforce
Investment Act of 1998, and the State Apprenticeship
Agency recognized under the Act of August 16, 1937
(commonly known as the `National Apprenticeship Act')
(or if no agency has been recognized in the State, the
Office of Apprenticeship of the Department of Labor)
and that the project will be carried out in
coordination with such entities.
``(C) Assurance of opportunities for indian
populations.--The Secretary shall award at least 3
grants under this subsection to an eligible entity that
is an Indian tribe, tribal organization, or Tribal
College or University.
``(3) Reports and evaluation.--
``(A) Eligible entities.--An eligible entity
awarded a grant to conduct a demonstration project
under this subsection shall submit interim reports to
the Secretary on the activities carried out under the
project and a final report on such activities upon the
conclusion of the entities' participation in the
project. Such reports shall include assessments of the
effectiveness of such activities with respect to
improving outcomes for the eligible individuals
participating in the project and with respect to
addressing health professions workforce needs in the
areas in which the project is conducted.
``(B) Evaluation.--The Secretary shall, by grant,
contract, or interagency agreement, evaluate the
demonstration projects conducted under this subsection.
Such evaluation shall include identification of
successful activities for creating opportunities for
developing and sustaining, particularly with respect to
low-income individuals and other entry-level workers, a
health professions workforce that has accessible entry
points, that meets high standards for education,
training, certification, and professional development,
and that provides increased wages and affordable
benefits, including health care coverage, that are
responsive to the workforce's needs.
``(C) Report to congress.--The Secretary shall
submit interim reports and, based on the evaluation
conducted under subparagraph (B), a final report to
Congress on the demonstration projects conducted under
this subsection.
``(4) Definitions.--In this subsection:
``(A) Eligible entity.--The term `eligible entity'
means a State, an Indian tribe or tribal organization,
an institution of higher education, a local workforce
investment board established under section 117 of the
Workforce Investment Act of 1998, a sponsor of an
apprenticeship program registered under the National
Apprenticeship Act or a community-based organization.
``(B) Eligible individual.--
``(i) In general.--The term `eligible
individual' means a individual receiving
assistance under the State TANF program.
``(ii) Other low-income individuals.--Such
term may include other low-income individuals
described by the eligible entity in its
application for a grant under this section.
``(C) Indian tribe; tribal organization.--The terms
`Indian tribe' and `tribal organization' have the
meaning given such terms in section 4 of the Indian
Self-Determination and Education Assistance Act (25
U.S.C. 450b).
``(D) Institution of higher education.--The term
`institution of higher education' has the meaning given
that term in section 101 of the Higher Education Act of
1965 (20 U.S.C. 1001).
``(E) State.--The term `State' means each of the 50
States, the District of Columbia, the Commonwealth of
Puerto Rico, the United States Virgin Islands, Guam,
and American Samoa.
``(F) State tanf program.--The term `State TANF
program' means the temporary assistance for needy
families program funded under part A of title IV.
``(G) Tribal college or university.--The term
`Tribal College or University' has the meaning given
that term in section 316(b) of the Higher Education Act
of 1965 (20 U.S.C. 1059c(b)).
``(b) Demonstration Project To Develop Training and Certification
Programs for Personal or Home Care Aides.--
``(1) Authority to award grants.--Not later than 18 months
after the date of enactment of this section, the Secretary
shall award grants to eligible entities that are States to
conduct demonstration projects for purposes of developing core
training competencies and certification programs for personal
or home care aides. The Secretary shall--
``(A) evaluate the efficacy of the core training
competencies described in paragraph (3)(A) for newly
hired personal or home care aides and the methods used
by States to implement such core training competencies
in accordance with the issues specified in paragraph
(3)(B); and
``(B) ensure that the number of hours of training
provided by States under the demonstration project with
respect to such core training competencies are not less
than the number of hours of training required under any
applicable State or Federal law or regulation.
``(2) Duration.--A demonstration project shall be conducted
under this subsection for not less than 3 years.
``(3) Core training competencies for personal or home care
aides.--
``(A) In general.--The core training competencies
for personal or home care aides described in this
subparagraph include competencies with respect to the
following areas:
``(i) The role of the personal or home care
aide (including differences between a personal
or home care aide employed by an agency and a
personal or home care aide employed directly by
the health care consumer or an independent
provider).
``(ii) Consumer rights, ethics, and
confidentiality (including the role of proxy
decision-makers in the case where a health care
consumer has impaired decision-making
capacity).
``(iii) Communication, cultural and
linguistic competence and sensitivity, problem
solving, behavior management, and relationship
skills.
``(iv) Personal care skills.
``(v) Health care support.
``(vi) Nutritional support.
``(vii) Infection control.
``(viii) Safety and emergency training.
``(ix) Training specific to an individual
consumer's needs (including older individuals,
younger individuals with disabilities,
individuals with developmental disabilities,
individuals with dementia, and individuals with
mental and behavioral health needs).
``(x) Self-Care.
``(B) Implementation.--The implementation issues
specified in this subparagraph include the following:
``(i) The length of the training.
``(ii) The appropriate trainer to student
ratio.
``(iii) The amount of instruction time
spent in the classroom as compared to on-site
in the home or a facility.
``(iv) Trainer qualifications.
``(v) Content for a `hands-on' and written
certification exam.
``(vi) Continuing education requirements.
``(4) Application and selection criteria.--
``(A) In general.--
``(i) Number of states.--The Secretary
shall enter into agreements with not more than
6 States to conduct demonstration projects
under this subsection.
``(ii) Requirements for states.--An
agreement entered into under clause (i) shall
require that a participating State--
``(I) implement the core training
competencies described in paragraph
(3)(A); and
``(II) develop written materials
and protocols for such core training
competencies, including the development
of a certification test for personal or
home care aides who have completed such
training competencies.
``(iii) Consultation and collaboration with
community and vocational colleges.--The
Secretary shall encourage participating States
to consult with community and vocational
colleges regarding the development of curricula
to implement the project with respect to
activities, as applicable, which may include
consideration of such colleges as partners in
such implementation.
``(B) Application and eligibility.--A State seeking
to participate in the project shall--
``(i) submit an application to the
Secretary containing such information and at
such time as the Secretary may specify;
``(ii) meet the selection criteria
established under subparagraph (C); and
``(iii) meet such additional criteria as
the Secretary may specify.
``(C) Selection criteria.--In selecting States to
participate in the program, the Secretary shall
establish criteria to ensure (if applicable with
respect to the activities involved)--
``(i) geographic and demographic diversity;
``(ii) that participating States offer
medical assistance for personal care services
under the State Medicaid plan;
``(iii) that the existing training
standards for personal or home care aides in
each participating State--
``(I) are different from such
standards in the other participating
States; and
``(II) are different from the core
training competencies described in
paragraph (3)(A);
``(iv) that participating States do not
reduce the number of hours of training required
under applicable State law or regulation after
being selected to participate in the project;
and
``(v) that participating States recruit a
minimum number of eligible health and long-term
care providers to participate in the project.
``(D) Technical assistance.--The Secretary shall
provide technical assistance to States in developing
written materials and protocols for such core training
competencies.
``(5) Evaluation and report.--
``(A) Evaluation.--The Secretary shall develop an
experimental or control group testing protocol in
consultation with an independent evaluation contractor
selected by the Secretary. Such contractor shall
evaluate--
``(i) the impact of core training
competencies described in paragraph (3)(A),
including curricula developed to implement such
core training competencies, for personal or
home care aides within each participating State
on job satisfaction, mastery of job skills,
beneficiary and family caregiver satisfaction
with services, and additional measures
determined by the Secretary in consultation
with the expert panel;
``(ii) the impact of providing such core
training competencies on the existing training
infrastructure and resources of States; and
``(iii) whether a minimum number of hours
of initial training should be required for
personal or home care aides and, if so, what
minimum number of hours should be required.
``(B) Reports.--
``(i) Report on initial implementation.--
Not later than 2 years after the date of
enactment of this section, the Secretary shall
submit to Congress a report on the initial
implementation of activities conducted under
the demonstration project, including any
available results of the evaluation conducted
under subparagraph (A) with respect to such
activities, together with such recommendations
for legislation or administrative action as the
Secretary determines appropriate.
``(ii) Final report.--Not later than 1 year
after the completion of the demonstration
project, the Secretary shall submit to Congress
a report containing the results of the
evaluation conducted under subparagraph (A),
together with such recommendations for
legislation or administrative action as the
Secretary determines appropriate.
``(6) Definitions.--In this subsection:
``(A) Eligible health and long-term care
provider.--The term `eligible health and long-term care
provider' means a personal or home care agency
(including personal or home care public authorities), a
nursing home, a home health agency (as defined in
section 1861(o)), or any other health care provider the
Secretary determines appropriate which--
``(i) is licensed or authorized to provide
services in a participating State; and
``(ii) receives payment for services under
title XIX.
``(B) Personal care services.--The term `personal
care services' has the meaning given such term for
purposes of title XIX.
``(C) Personal or home care aide.--The term
`personal or home care aide' means an individual who
helps individuals who are elderly, disabled, ill, or
mentally disabled (including an individual with
Alzheimer's disease or other dementia) to live in their
own home or a residential care facility (such as a
nursing home, assisted living facility, or any other
facility the Secretary determines appropriate) by
providing routine personal care services and other
appropriate services to the individual.
``(D) State.--The term `State' has the meaning
given that term for purposes of title XIX.
``(c) Funding.--
``(1) In general.--Subject to paragraph (2), out of any
funds in the Treasury not otherwise appropriated, there are
appropriated to the Secretary to carry out subsections (a) and
(b), $85,000,000 for each of fiscal years 2010 through 2014.
``(2) Training and certification programs for personal and
home care aides.--With respect to the demonstration projects
under subsection (b), the Secretary shall use $5,000,000 of the
amount appropriated under paragraph (1) for each of fiscal
years 2010 through 2012 to carry out such projects. No funds
appropriated under paragraph (1) shall be used to carry out
demonstration projects under subsection (b) after fiscal year
2012.
``(d) Nonapplication.--
``(1) In general.--Except as provided in paragraph (2), the
preceding sections of this title shall not apply to grant
awarded under this section.
``(2) Limitations on use of grants.--Section 2005(a) (other
than paragraph (6)) shall apply to a grant awarded under this
section to the same extent and in the same manner as such
section applies to payments to States under this title.''.
(b) Extension of Family-To-Family Health Information Centers.--
Section 501(c)(1)(A)(iii) of the Social Security Act (42 U.S.C.
701(c)(1)(A)(iii)) is amended by striking ``fiscal year 2009'' and
inserting ``each of fiscal years 2009 through 2012''.
SEC. 5508. INCREASING TEACHING CAPACITY.
(a) Teaching Health Centers Training and Enhancement.--Part C of
title VII of the Public Health Service Act (42 U.S.C. 293k et. seq.),
as amended by section 5303, is further amended by inserting after
section 749 the following:
``SEC. 749A. TEACHING HEALTH CENTERS DEVELOPMENT GRANTS.
``(a) Program Authorized.--The Secretary may award grants under
this section to teaching health centers for the purpose of establishing
new accredited or expanded primary care residency programs.
``(b) Amount and Duration.--Grants awarded under this section shall
be for a term of not more than 3 years and the maximum award may not be
more than $500,000.
``(c) Use of Funds.--Amounts provided under a grant under this
section shall be used to cover the costs of--
``(1) establishing or expanding a primary care residency
training program described in subsection (a), including costs
associated with--
``(A) curriculum development;
``(B) recruitment, training and retention of
residents and faculty:
``(C) accreditation by the Accreditation Council
for Graduate Medical Education (ACGME), the American
Dental Association (ADA), or the American Osteopathic
Association (AOA); and
``(D) faculty salaries during the development
phase; and
``(2) technical assistance provided by an eligible entity.
``(d) Application.--A teaching health center seeking a grant under
this section shall submit an application to the Secretary at such time,
in such manner, and containing such information as the Secretary may
require.
``(e) Preference for Certain Applications.--In selecting recipients
for grants under this section, the Secretary shall give preference to
any such application that documents an existing affiliation agreement
with an area health education center program as defined in sections 751
and 799B.
``(f) Definitions.--In this section:
``(1) Eligible entity.--The term `eligible entity' means an
organization capable of providing technical assistance
including an area health education center program as defined in
sections 751 and 799B.
``(2) Primary care residency program.--The term `primary
care residency program' means an approved graduate medical
residency training program (as defined in section 340H) in
family medicine, internal medicine, pediatrics, internal
medicine-pediatrics, obstetrics and gynecology, psychiatry,
general dentistry, pediatric dentistry, and geriatrics.
``(3) Teaching health center.--
``(A) In general.--The term `teaching health
center' means an entity that--
``(i) is a community based, ambulatory
patient care center; and
``(ii) operates a primary care residency
program.
``(B) Inclusion of certain entities.--Such term
includes the following:
``(i) A Federally qualified health center
(as defined in section 1905(l)(2)(B), of the
Social Security Act).
``(ii) A community mental health center (as
defined in section 1861(ff)(3)(B) of the Social
Security Act).
``(iii) A rural health clinic, as defined
in section 1861(aa) of the Social Security Act.
``(iv) A health center operated by the
Indian Health Service, an Indian tribe or
tribal organization, or an urban Indian
organization (as defined in section 4 of the
Indian Health Care Improvement Act).
``(v) An entity receiving funds under title
X of the Public Health Service Act.
``(g) Authorization of Appropriations.--There is authorized to be
appropriated, $25,000,000 for fiscal year 2010, $50,000,000 for fiscal
year 2011, $50,000,000 for fiscal year 2012, and such sums as may be
necessary for each fiscal year thereafter to carry out this section.
Not to exceed $5,000,000 annually may be used for technical assistance
program grants.''.
(b) National Health Service Corps Teaching Capacity.--Section
338C(a) of the Public Health Service Act (42 U.S.C. 254m(a)) is amended
to read as follows:
``(a) Service in Full-time Clinical Practice.--Except as provided
in section 338D, each individual who has entered into a written
contract with the Secretary under section 338A or 338B shall provide
service in the full-time clinical practice of such individual's
profession as a member of the Corps for the period of obligated service
provided in such contract. For the purpose of calculating time spent in
full-time clinical practice under this subsection, up to 50 percent of
time spent teaching by a member of the Corps may be counted toward his
or her service obligation.''.
(c) Payments to Qualified Teaching Health Centers.--Part D of title
III of the Public Health Service Act (42 U.S.C. 254b et seq.) is
amended by adding at the end the following:
``Subpart XI--Support of Graduate Medical Education in Qualified
Teaching Health Centers
``SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS THAT
OPERATE GRADUATE MEDICAL EDUCATION PROGRAMS.
``(a) Payments.--Subject to subsection (h)(2), the Secretary shall
make payments under this section for direct expenses and for indirect
expenses to qualified teaching health centers that are listed as
sponsoring institutions by the relevant accrediting body for expansion
of existing or establishment of new approved graduate medical residency
training programs.
``(b) Amount of Payments.--
``(1) In general.--Subject to paragraph (2), the amounts
payable under this section to qualified teaching health centers
for an approved graduate medical residency training program for
a fiscal year are each of the following amounts:
``(A) Direct expense amount.--The amount determined
under subsection (c) for direct expenses associated
with sponsoring approved graduate medical residency
training programs.
``(B) Indirect expense amount.--The amount
determined under subsection (d) for indirect expenses
associated with the additional costs relating to
teaching residents in such programs.
``(2) Capped amount.--
``(A) In general.--The total of the payments made
to qualified teaching health centers under paragraph
(1)(A) or paragraph (1)(B) in a fiscal year shall not
exceed the amount of funds appropriated under
subsection (g) for such payments for that fiscal year.
``(B) Limitation.--The Secretary shall limit the
funding of full-time equivalent residents in order to
ensure the direct and indirect payments as determined
under subsection (c) and (d) do not exceed the total
amount of funds appropriated in a fiscal year under
subsection (g).
``(c) Amount of Payment for Direct Graduate Medical Education.--
``(1) In general.--The amount determined under this
subsection for payments to qualified teaching health centers
for direct graduate expenses relating to approved graduate
medical residency training programs for a fiscal year is equal
to the product of--
``(A) the updated national per resident amount for
direct graduate medical education, as determined under
paragraph (2); and
``(B) the average number of full-time equivalent
residents in the teaching health center's graduate
approved medical residency training programs as
determined under section 1886(h)(4) of the Social
Security Act (without regard to the limitation under
subparagraph (F) of such section) during the fiscal
year.
``(2) Updated national per resident amount for direct
graduate medical education.--The updated per resident amount
for direct graduate medical education for a qualified teaching
health center for a fiscal year is an amount determined as
follows:
``(A) Determination of qualified teaching health
center per resident amount.--The Secretary shall
compute for each individual qualified teaching health
center a per resident amount--
``(i) by dividing the national average per
resident amount computed under section
340E(c)(2)(D) into a wage-related portion and a
non-wage related portion by applying the
proportion determined under subparagraph (B);
``(ii) by multiplying the wage-related
portion by the factor applied under section
1886(d)(3)(E) of the Social Security Act (but
without application of section 4410 of the
Balanced Budget Act of 1997 (42 U.S.C. 1395ww
note)) during the preceding fiscal year for the
teaching health center's area; and
``(iii) by adding the non-wage-related
portion to the amount computed under clause
(ii).
``(B) Updating rate.--The Secretary shall update
such per resident amount for each such qualified
teaching health center as determined appropriate by the
Secretary.
``(d) Amount of Payment for Indirect Medical Education.--
``(1) In general.--The amount determined under this
subsection for payments to qualified teaching health centers
for indirect expenses associated with the additional costs of
teaching residents for a fiscal year is equal to an amount
determined appropriate by the Secretary.
``(2) Factors.--In determining the amount under paragraph
(1), the Secretary shall--
``(A) evaluate indirect training costs relative to
supporting a primary care residency program in
qualified teaching health centers; and
``(B) based on this evaluation, assure that the
aggregate of the payments for indirect expenses under
this section and the payments for direct graduate
medical education as determined under subsection (c) in
a fiscal year do not exceed the amount appropriated for
such expenses as determined in subsection (g).
``(3) Interim payment.--Before the Secretary makes a
payment under this subsection pursuant to a determination of
indirect expenses under paragraph (1), the Secretary may
provide to qualified teaching health centers a payment, in
addition to any payment made under subsection (c), for expected
indirect expenses associated with the additional costs of
teaching residents for a fiscal year, based on an estimate by
the Secretary.
``(e) Clarification Regarding Relationship to Other Payments for
Graduate Medical Education.--Payments under this section--
``(1) shall be in addition to any payments--
``(A) for the indirect costs of medical education
under section 1886(d)(5)(B) of the Social Security Act;
``(B) for direct graduate medical education costs
under section 1886(h) of such Act; and
``(C) for direct costs of medical education under
section 1886(k) of such Act;
``(2) shall not be taken into account in applying the
limitation on the number of total full-time equivalent
residents under subparagraphs (F) and (G) of section 1886(h)(4)
of such Act and clauses (v), (vi)(I), and (vi)(II) of section
1886(d)(5)(B) of such Act for the portion of time that a
resident rotates to a hospital; and
``(3) shall not include the time in which a resident is
counted toward full-time equivalency by a hospital under
paragraph (2) or under section 1886(d)(5)(B)(iv) of the Social
Security Act, section 1886(h)(4)(E) of such Act, or section
340E of this Act.
``(f) Reconciliation.--The Secretary shall determine any changes to
the number of residents reported by a hospital in the application of
the hospital for the current fiscal year to determine the final amount
payable to the hospital for the current fiscal year for both direct
expense and indirect expense amounts. Based on such determination, the
Secretary shall recoup any overpayments made to pay any balance due to
the extent possible. The final amount so determined shall be considered
a final intermediary determination for the purposes of section 1878 of
the Social Security Act and shall be subject to administrative and
judicial review under that section in the same manner as the amount of
payment under section 1186(d) of such Act is subject to review under
such section.
``(g) Funding.--To carry out this section, there are appropriated
such sums as may be necessary, not to exceed $230,000,000, for the
period of fiscal years 2011 through 2015.
``(h) Annual Reporting Required.--
``(1) Annual report.--The report required under this
paragraph for a qualified teaching health center for a fiscal
year is a report that includes (in a form and manner specified
by the Secretary) the following information for the residency
academic year completed immediately prior to such fiscal year:
``(A) The types of primary care resident approved
training programs that the qualified teaching health
center provided for residents.
``(B) The number of approved training positions for
residents described in paragraph (4).
``(C) The number of residents described in
paragraph (4) who completed their residency training at
the end of such residency academic year and care for
vulnerable populations living in underserved areas.
``(D) Other information as deemed appropriate by
the Secretary.
``(2) Audit authority; limitation on payment.--
``(A) Audit authority.--The Secretary may audit a
qualified teaching health center to ensure the accuracy
and completeness of the information submitted in a
report under paragraph (1).
``(B) Limitation on payment.--A teaching health
center may only receive payment in a cost reporting
period for a number of such resident positions that is
greater than the base level of primary care resident
positions, as determined by the Secretary. For purposes
of this subparagraph, the `base level of primary care
residents' for a teaching health center is the level of
such residents as of a base period.
``(3) Reduction in payment for failure to report.--
``(A) In general.--The amount payable under this
section to a qualified teaching health center for a
fiscal year shall be reduced by at least 25 percent if
the Secretary determines that--
``(i) the qualified teaching health center
has failed to provide the Secretary, as an
addendum to the qualified teaching health
center's application under this section for
such fiscal year, the report required under
paragraph (1) for the previous fiscal year; or
``(ii) such report fails to provide
complete and accurate information required
under any subparagraph of such paragraph.
``(B) Notice and opportunity to provide accurate
and missing information.--Before imposing a reduction
under subparagraph (A) on the basis of a qualified
teaching health center's failure to provide complete
and accurate information described in subparagraph
(A)(ii), the Secretary shall provide notice to the
teaching health center of such failure and the
Secretary's intention to impose such reduction and
shall provide the teaching health center with the
opportunity to provide the required information within
the period of 30 days beginning on the date of such
notice. If the teaching health center provides such
information within such period, no reduction shall be
made under subparagraph (A) on the basis of the
previous failure to provide such information.
``(4) Residents.--The residents described in this paragraph
are those who are in part-time or full-time equivalent resident
training positions at a qualified teaching health center in any
approved graduate medical residency training program.
``(i) Regulations.--The Secretary shall promulgate regulations to
carry out this section.
``(j) Definitions.--In this section:
``(1) Approved graduate medical residency training
program.--The term `approved graduate medical residency
training program' means a residency or other postgraduate
medical training program--
``(A) participation in which may be counted toward
certification in a specialty or subspecialty and
includes formal postgraduate training programs in
geriatric medicine approved by the Secretary; and
``(B) that meets criteria for accreditation (as
established by the Accreditation Council for Graduate
Medical Education, the American Osteopathic
Association, or the American Dental Association).
``(2) Primary care residency program.--The term `primary
care residency program' has the meaning given that term in
section 749A.
``(3) Qualified teaching health center.--The term
`qualified teaching health center' has the meaning given the
term `teaching health center' in section 749A.''.
SEC. 5509. GRADUATE NURSE EDUCATION DEMONSTRATION.
(a) In General.--
(1) Establishment.--
(A) In general.--The Secretary shall establish a
graduate nurse education demonstration under title
XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) under which an eligible hospital may receive
payment for the hospital's reasonable costs (described
in paragraph (2)) for the provision of qualified
clinical training to advance practice nurses.
(B) Number.--The demonstration shall include up to
5 eligible hospitals.
(C) Written agreements.--Eligible hospitals
selected to participate in the demonstration shall
enter into written agreements pursuant to subsection
(b) in order to reimburse the eligible partners of the
hospital the share of the costs attributable to each
partner.
(2) Costs described.--
(A) In general.--Subject to subparagraph (B) and
subsection (d), the costs described in this paragraph
are the reasonable costs (as described in section
1861(v) of the Social Security Act (42 U.S.C.
1395x(v))) of each eligible hospital for the clinical
training costs (as determined by the Secretary) that
are attributable to providing advanced practice
registered nurses with qualified training.
(B) Limitation.--With respect to a year, the amount
reimbursed under subparagraph (A) may not exceed the
amount of costs described in subparagraph (A) that are
attributable to an increase in the number of advanced
practice registered nurses enrolled in a program that
provides qualified training during the year and for
which the hospital is being reimbursed under the
demonstration, as compared to the average number of
advanced practice registered nurses who graduated in
each year during the period beginning on January 1,
2006, and ending on December 31, 2010 (as determined by
the Secretary) from the graduate nursing education
program operated by the applicable school of nursing
that is an eligible partner of the hospital for
purposes of the demonstration.
(3) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security Act
as may be necessary to carry out the demonstration.
(4) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to the implementation of this section.
(b) Written Agreements With Eligible Partners.--No payment shall be
made under this section to an eligible hospital unless such hospital
has in effect a written agreement with the eligible partners of the
hospital. Such written agreement shall describe, at a minimum--
(1) the obligations of the eligible partners with respect
to the provision of qualified training; and
(2) the obligation of the eligible hospital to reimburse
such eligible partners applicable (in a timely manner) for the
costs of such qualified training attributable to partner.
(c) Evaluation.--Not later than October 17, 2017, the Secretary
shall submit to Congress a report on the demonstration. Such report
shall include an analysis of the following:
(1) The growth in the number of advanced practice
registered nurses with respect to a specific base year as a
result of the demonstration.
(2) The growth for each of the specialties described in
subparagraphs (A) through (D) of subsection (e)(1).
(3) The costs to the Medicare program under title XVIII of
the Social Security Act as a result of the demonstration.
(4) Other items the Secretary determines appropriate and
relevant.
(d) Funding.--
(1) In general.--There is hereby appropriated to the
Secretary, out of any funds in the Treasury not otherwise
appropriated, $50,000,000 for each of fiscal years 2012 through
2015 to carry out this section, including the design,
implementation, monitoring, and evaluation of the
demonstration.
(2) Proration.--If the aggregate payments to eligible
hospitals under the demonstration exceed $50,000,000 for a
fiscal year described in paragraph (1), the Secretary shall
prorate the payment amounts to each eligible hospital in order
to ensure that the aggregate payments do not exceed such
amount.
(3) Without fiscal year limitation.--Amounts appropriated
under this subsection shall remain available without fiscal
year limitation.
(e) Definitions.--In this section:
(1) Advanced practice registered nurse.--The term
``advanced practice registered nurse'' includes the following:
(A) A clinical nurse specialist (as defined in
subsection (aa)(5) of section 1861 of the Social
Security Act (42 U.S.C. 1395x)).
(B) A nurse practitioner (as defined in such
subsection).
(C) A certified registered nurse anesthetist (as
defined in subsection (bb)(2) of such section).
(D) A certified nurse-midwife (as defined in
subsection (gg)(2) of such section).
(2) Applicable non-hospital community-based care setting.--
The term ``applicable non-hospital community-based care
setting'' means a non-hospital community-based care setting
which has entered into a written agreement (as described in
subsection (b)) with the eligible hospital participating in the
demonstration. Such settings include Federally qualified health
centers, rural health clinics, and other non-hospital settings
as determined appropriate by the Secretary.
(3) Applicable school of nursing.--The term ``applicable
school of nursing'' means an accredited school of nursing (as
defined in section 801 of the Public Health Service Act) which
has entered into a written agreement (as described in
subsection (b)) with the eligible hospital participating in the
demonstration.
(4) Demonstration.--The term ``demonstration'' means the
graduate nurse education demonstration established under
subsection (a).
(5) Eligible hospital.--The term ``eligible hospital''
means a hospital (as defined in subsection (e) of section 1861
of the Social Security Act (42 U.S.C. 1395x)) or a critical
access hospital (as defined in subsection (mm)(1) of such
section) that has a written agreement in place with--
(A) 1 or more applicable schools of nursing; and
(B) 2 or more applicable non-hospital community-
based care settings.
(6) Eligible partners.--The term ``eligible partners''
includes the following:
(A) An applicable non-hospital community-based care
setting.
(B) An applicable school of nursing.
(7) Qualified training.--
(A) In general.--The term ``qualified training''
means training--
(i) that provides an advanced practice
registered nurse with the clinical skills
necessary to provide primary care, preventive
care, transitional care, chronic care
management, and other services appropriate for
individuals entitled to, or enrolled for,
benefits under part A of title XVIII of the
Social Security Act, or enrolled under part B
of such title; and
(ii) subject to subparagraph (B), at least
half of which is provided in a non-hospital
community-based care setting.
(B) Waiver of requirement half of training be
provided in non-hospital community-based care setting
in certain areas.--The Secretary may waive the
requirement under subparagraph (A)(ii) with respect to
eligible hospitals located in rural or medically
underserved areas.
(8) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
Subtitle G--Improving Access to Health Care Services
SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS).
(a) In General.--Section 330(r) of the Public Health Service Act
(42 U.S.C. 254b(r)) is amended by striking paragraph (1) and inserting
the following:
``(1) General amounts for grants.--For the purpose of
carrying out this section, in addition to the amounts
authorized to be appropriated under subsection (d), there is
authorized to be appropriated the following:
``(A) For fiscal year 2010, $2,988,821,592.
``(B) For fiscal year 2011, $3,862,107,440.
``(C) For fiscal year 2012, $4,990,553,440.
``(D) For fiscal year 2013, $6,448,713,307.
``(E) For fiscal year 2014, $7,332,924,155.
``(F) For fiscal year 2015, $8,332,924,155.
``(G) For fiscal year 2016, and each subsequent
fiscal year, the amount appropriated for the preceding
fiscal year adjusted by the product of--
``(i) one plus the average percentage
increase in costs incurred per patient served;
and
``(ii) one plus the average percentage
increase in the total number of patients
served.''.
(b) Rule of Construction.--Section 330(r) of the Public Health
Service Act (42 U.S.C. 254b(r)) is amended by adding at the end the
following:
``(4) Rule of construction with respect to rural health
clinics.--
``(A) In general.--Nothing in this section shall be
construed to prevent a community health center from
contracting with a Federally certified rural health
clinic (as defined in section 1861(aa)(2) of the Social
Security Act), a low-volume hospital (as defined for
purposes of section 1886 of such Act), a critical
access hospital, a sole community hospital (as defined
for purposes of section 1886(d)(5)(D)(iii) of such
Act), or a medicare-dependent share hospital (as
defined for purposes of section 1886(d)(5)(G)(iv) of
such Act) for the delivery of primary health care
services that are available at the clinic or hospital
to individuals who would otherwise be eligible for free
or reduced cost care if that individual were able to
obtain that care at the community health center. Such
services may be limited in scope to those primary
health care services available in that clinic or
hospitals.
``(B) Assurances.--In order for a clinic or
hospital to receive funds under this section through a
contract with a community health center under
subparagraph (A), such clinic or hospital shall
establish policies to ensure--
``(i) nondiscrimination based on the
ability of a patient to pay; and
``(ii) the establishment of a sliding fee
scale for low-income patients.''.
SEC. 5602. NEGOTIATED RULEMAKING FOR DEVELOPMENT OF METHODOLOGY AND
CRITERIA FOR DESIGNATING MEDICALLY UNDERSERVED
POPULATIONS AND HEALTH PROFESSIONS SHORTAGE AREAS.
(a) Establishment.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish, through a negotiated rulemaking process under
subchapter 3 of chapter 5 of title 5, United States Code, a
comprehensive methodology and criteria for designation of--
(A) medically underserved populations in accordance
with section 330(b)(3) of the Public Health Service Act
(42 U.S.C. 254b(b)(3));
(B) health professions shortage areas under section
332 of the Public Health Service Act (42 U.S.C. 254e).
(2) Factors to consider.--In establishing the methodology
and criteria under paragraph (1), the Secretary--
(A) shall consult with relevant stakeholders who
will be significantly affected by a rule (such as
national, State and regional organizations representing
affected entities), State health offices, community
organizations, health centers and other affected
entities, and other interested parties; and
(B) shall take into account--
(i) the timely availability and
appropriateness of data used to determine a
designation to potential applicants for such
designations;
(ii) the impact of the methodology and
criteria on communities of various types and on
health centers and other safety net providers;
(iii) the degree of ease or difficulty that
will face potential applicants for such
designations in securing the necessary data;
and
(iv) the extent to which the methodology
accurately measures various barriers that
confront individuals and population groups in
seeking health care services.
(b) Publication of Notice.--In carrying out the rulemaking process
under this subsection, the Secretary shall publish the notice provided
for under section 564(a) of title 5, United States Code, by not later
than 45 days after the date of the enactment of this Act.
(c) Target Date for Publication of Rule.--As part of the notice
under subsection (b), and for purposes of this subsection, the ``target
date for publication'', as referred to in section 564(a)(5) of title 5,
United Sates Code, shall be July 1, 2010.
(d) Appointment of Negotiated Rulemaking Committee and
Facilitator.--The Secretary shall provide for--
(1) the appointment of a negotiated rulemaking committee
under section 565(a) of title 5, United States Code, by not
later than 30 days after the end of the comment period provided
for under section 564(c) of such title; and
(2) the nomination of a facilitator under section 566(c) of
such title 5 by not later than 10 days after the date of
appointment of the committee.
(e) Preliminary Committee Report.--The negotiated rulemaking
committee appointed under subsection (d) shall report to the Secretary,
by not later than April 1, 2010, regarding the committee's progress on
achieving a consensus with regard to the rulemaking proceeding and
whether such consensus is likely to occur before one month before the
target date for publication of the rule. If the committee reports that
the committee has failed to make significant progress toward such
consensus or is unlikely to reach such consensus by the target date,
the Secretary may terminate such process and provide for the
publication of a rule under this section through such other methods as
the Secretary may provide.
(f) Final Committee Report.--If the committee is not terminated
under subsection (e), the rulemaking committee shall submit a report
containing a proposed rule by not later than one month before the
target publication date.
(g) Interim Final Effect.--The Secretary shall publish a rule under
this section in the Federal Register by not later than the target
publication date. Such rule shall be effective and final immediately on
an interim basis, but is subject to change and revision after public
notice and opportunity for a period (of not less than 90 days) for
public comment. In connection with such rule, the Secretary shall
specify the process for the timely review and approval of applications
for such designations pursuant to such rules and consistent with this
section.
(h) Publication of Rule After Public Comment.--The Secretary shall
provide for consideration of such comments and republication of such
rule by not later than 1 year after the target publication date.
SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMERGENCY MEDICAL SERVICES
FOR CHILDREN PROGRAM.
Section 1910 of the Public Health Service Act (42 U.S.C. 300w-9) is
amended--
(1) in subsection (a), by striking ``3-year period (with an
optional 4th year'' and inserting ``4-year period (with an
optional 5th year''; and
(2) in subsection (d)--
(A) by striking ``and such sums'' and inserting
``such sums''; and
(B) by inserting before the period the following:
``, $25,000,000 for fiscal year 2010, $26,250,000 for
fiscal year 2011, $27,562,500 for fiscal year 2012,
$28,940,625 for fiscal year 2013, and $30,387,656 for
fiscal year 2014''.
SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN COMMUNITY-BASED
MENTAL HEALTH SETTINGS.
Subpart 3 of part B of title V of the Public Health Service Act (42
U.S.C. 290bb-31 et seq.) is amended by adding at the end the following:
``SEC. 520K. AWARDS FOR CO-LOCATING PRIMARY AND SPECIALTY CARE IN
COMMUNITY-BASED MENTAL HEALTH SETTINGS.
``(a) Definitions.--In this section:
``(1) Eligible entity.--The term `eligible entity' means a
qualified community mental health program defined under section
1913(b)(1).
``(2) Special populations.--The term `special populations'
means adults with mental illnesses who have co-occurring
primary care conditions and chronic diseases.
``(b) Program Authorized.--The Secretary, acting through the
Administrator shall award grants and cooperative agreements to eligible
entities to establish demonstration projects for the provision of
coordinated and integrated services to special populations through the
co-location of primary and specialty care services in community-based
mental and behavioral health settings.
``(c) Application.--To be eligible to receive a grant or
cooperative agreement under this section, an eligible entity shall
submit an application to the Administrator at such time, in such
manner, and accompanied by such information as the Administrator may
require, including a description of partnerships, or other arrangements
with local primary care providers, including community health centers,
to provide services to special populations.
``(d) Use of Funds.--
``(1) In general.--For the benefit of special populations,
an eligible entity shall use funds awarded under this section
for--
``(A) the provision, by qualified primary care
professionals, of on site primary care services;
``(B) reasonable costs associated with medically
necessary referrals to qualified specialty care
professionals, other coordinators of care or, if
permitted by the terms of the grant or cooperative
agreement, by qualified specialty care professionals on
a reasonable cost basis on site at the eligible entity;
``(C) information technology required to
accommodate the clinical needs of primary and specialty
care professionals; or
``(D) facility modifications needed to bring
primary and specialty care professionals on site at the
eligible entity.
``(2) Limitation.--Not to exceed 15 percent of grant or
cooperative agreement funds may be used for activities
described in subparagraphs (C) and (D) of paragraph (1).
``(e) Evaluation.--Not later than 90 days after a grant or
cooperative agreement awarded under this section expires, an eligible
entity shall submit to the Secretary the results of an evaluation to be
conducted by the entity concerning the effectiveness of the activities
carried out under the grant or agreement.
``(f) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section, $50,000,000 for fiscal year
2010 and such sums as may be necessary for each of fiscal years 2011
through 2014.''.
SEC. 5605. KEY NATIONAL INDICATORS.
(a) Definitions.--In this section:
(1) Academy.--The term ``Academy'' means the National
Academy of Sciences.
(2) Commission.--The term ``Commission'' means the
Commission on Key National Indicators established under
subsection (b).
(3) Institute.--The term ``Institute'' means a Key National
Indicators Institute as designated under subsection (c)(3).
(b) Commission on Key National Indicators.--
(1) Establishment.--There is established a ``Commission on
Key National Indicators''.
(2) Membership.--
(A) Number and appointment.--The Commission shall
be composed of 8 members, to be appointed equally by
the majority and minority leaders of the Senate and the
Speaker and minority leader of the House of
Representatives.
(B) Prohibited appointments.--Members of the
Commission shall not include Members of Congress or
other elected Federal, State, or local government
officials.
(C) Qualifications.--In making appointments under
subparagraph (A), the majority and minority leaders of
the Senate and the Speaker and minority leader of the
House of Representatives shall appoint individuals who
have shown a dedication to improving civic dialogue and
decision-making through the wide use of scientific
evidence and factual information.
(D) Period of appointment.--Each member of the
Commission shall be appointed for a 2-year term, except
that 1 initial appointment shall be for 3 years. Any
vacancies shall not affect the power and duties of the
Commission but shall be filled in the same manner as
the original appointment and shall last only for the
remainder of that term.
(E) Date.--Members of the Commission shall be
appointed by not later than 30 days after the date of
enactment of this Act.
(F) Initial organizing period.---Not later than 60
days after the date of enactment of this Act, the
Commission shall develop and implement a schedule for
completion of the review and reports required under
subsection (d).
(G) Co-chairpersons.--The Commission shall select 2
Co-Chairpersons from among its members.
(c) Duties of the Commission.--
(1) In general.--The Commission shall--
(A) conduct comprehensive oversight of a newly
established key national indicators system consistent
with the purpose described in this subsection;
(B) make recommendations on how to improve the key
national indicators system;
(C) coordinate with Federal Government users and
information providers to assure access to relevant and
quality data; and
(D) enter into contracts with the Academy.
(2) Reports.--
(A) Annual report to congress.--Not later than 1
year after the selection of the 2 Co-Chairpersons of
the Commission, and each subsequent year thereafter,
the Commission shall prepare and submit to the
appropriate Committees of Congress and the President a
report that contains a detailed statement of the
recommendations, findings, and conclusions of the
Commission on the activities of the Academy and a
designated Institute related to the establishment of a
Key National Indicator System.
(B) Annual report to the academy.--
(i) In general.--Not later than 6 months
after the selection of the 2 Co-Chairpersons of
the Commission, and each subsequent year
thereafter, the Commission shall prepare and
submit to the Academy and a designated
Institute a report making recommendations
concerning potential issue areas and key
indicators to be included in the Key National
Indicators.
(ii) Limitation.--The Commission shall not
have the authority to direct the Academy or, if
established, the Institute, to adopt, modify,
or delete any key indicators.
(3) Contract with the national academy of sciences.--
(A) In general.---As soon as practicable after the
selection of the 2 Co-Chairpersons of the Commission,
the Co-Chairpersons shall enter into an arrangement
with the National Academy of Sciences under which the
Academy shall--
(i) review available public and private
sector research on the selection of a set of
key national indicators;
(ii) determine how best to establish a key
national indicator system for the United
States, by either creating its own
institutional capability or designating an
independent private nonprofit organization as
an Institute to implement a key national
indicator system;
(iii) if the Academy designates an
independent Institute under clause (ii),
provide scientific and technical advice to the
Institute and create an appropriate governance
mechanism that balances Academy involvement and
the independence of the Institute; and
(iv) provide an annual report to the
Commission addressing scientific and technical
issues related to the key national indicator
system and, if established, the Institute, and
governance of the Institute's budget and
operations.
(B) Participation.--In executing the arrangement
under subparagraph (A), the National Academy of
Sciences shall convene a multi-sector, multi-
disciplinary process to define major scientific and
technical issues associated with developing,
maintaining, and evolving a Key National Indicator
System and, if an Institute is established, to provide
it with scientific and technical advice.
(C) Establishment of a key national indicator
system.--
(i) In general.--In executing the
arrangement under subparagraph (A), the
National Academy of Sciences shall enable the
establishment of a key national indicator
system by--
(I) creating its own institutional
capability; or
(II) partnering with an independent
private nonprofit organization as an
Institute to implement a key national
indicator system.
(ii) Institute.--If the Academy designates
an Institute under clause (i)(II), such
Institute shall be a non-profit entity (as
defined for purposes of section 501(c)(3) of
the Internal Revenue Code of 1986) with an
educational mission, a governance structure
that emphasizes independence, and
characteristics that make such entity
appropriate for establishing a key national
indicator system.
(iii) Responsibilities.--Either the Academy
or the Institute designated under clause
(i)(II) shall be responsible for the following:
(I) Identifying and selecting issue
areas to be represented by the key
national indicators.
(II) Identifying and selecting the
measures used for key national
indicators within the issue areas under
subclause (I).
(III) Identifying and selecting
data to populate the key national
indicators described under subclause
(II).
(IV) Designing, publishing, and
maintaining a public website that
contains a freely accessible database
allowing public access to the key
national indicators.
(V) Developing a quality assurance
framework to ensure rigorous and
independent processes and the selection
of quality data.
(VI) Developing a budget for the
construction and management of a
sustainable, adaptable, and evolving
key national indicator system that
reflects all Commission funding of
Academy and, if an Institute is
established, Institute activities.
(VII) Reporting annually to the
Commission regarding its selection of
issue areas, key indicators, data, and
progress toward establishing a web-
accessible database.
(VIII) Responding directly to the
Commission in response to any
Commission recommendations and to the
Academy regarding any inquiries by the
Academy.
(iv) Governance.--Upon the establishment of
a key national indicator system, the Academy
shall create an appropriate governance
mechanism that incorporates advisory and
control functions. If an Institute is
designated under clause (i)(II), the governance
mechanism shall balance appropriate Academy
involvement and the independence of the
Institute.
(v) Modification and changes.--The Academy
shall retain the sole discretion, at any time,
to alter its approach to the establishment of a
key national indicator system or, if an
Institute is designated under clause (i)(II),
to alter any aspect of its relationship with
the Institute or to designate a different non-
profit entity to serve as the Institute.
(vi) Construction.--Nothing in this section
shall be construed to limit the ability of the
Academy or the Institute designated under
clause (i)(II) to receive private funding for
activities related to the establishment of a
key national indicator system.
(D) Annual report.--As part of the arrangement
under subparagraph (A), the National Academy of
Sciences shall, not later than 270 days after the date
of enactment of this Act, and annually thereafter,
submit to the Co-Chairpersons of the Commission a
report that contains the findings and recommendations
of the Academy.
(d) Government Accountability Office Study and Report.--
(1) GAO study.--The Comptroller General of the United
States shall conduct a study of previous work conducted by all
public agencies, private organizations, or foreign countries
with respect to best practices for a key national indicator
system. The study shall be submitted to the appropriate
authorizing committees of Congress.
(2) GAO financial audit.--If an Institute is established
under this section, the Comptroller General shall conduct an
annual audit of the financial statements of the Institute, in
accordance with generally accepted government auditing
standards and submit a report on such audit to the Commission
and the appropriate authorizing committees of Congress.
(3) GAO programmatic review.--The Comptroller General of
the United States shall conduct programmatic assessments of the
Institute established under this section as determined
necessary by the Comptroller General and report the findings to
the Commission and to the appropriate authorizing committees of
Congress.
(e) Authorization of Appropriations.--
(1) In general.---There are authorized to be appropriated
to carry out the purposes of this section, $10,000,000 for
fiscal year 2010, and $7,500,000 for each of fiscal year 2011
through 2018.
(2) Availability.---Amounts appropriated under paragraph
(1) shall remain available until expended.
Subtitle H--General Provisions
SEC. 5701. REPORTS.
(a) Reports by Secretary of Health and Human Services.--On an
annual basis, the Secretary of Health and Human Services shall submit
to the appropriate Committees of Congress a report on the activities
carried out under the amendments made by this title, and the
effectiveness of such activities.
(b) Reports by Recipients of Funds.--The Secretary of Health and
Human Services may require, as a condition of receiving funds under the
amendments made by this title, that the entity receiving such award
submit to such Secretary such reports as the such Secretary may require
on activities carried out with such award, and the effectiveness of
such activities.
TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A--Physician Ownership and Other Transparency
SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE PROHIBITION ON
CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS.
(a) In General.--Section 1877 of the Social Security Act (42 U.S.C.
1395nn) is amended--
(1) in subsection (d)(2)--
(A) in subparagraph (A), by striking ``and'' at the
end;
(B) in subparagraph (B), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(C) in the case where the entity is a hospital,
the hospital meets the requirements of paragraph
(3)(D).'';
(2) in subsection (d)(3)--
(A) in subparagraph (B), by striking ``and'' at the
end;
(B) in subparagraph (C), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(D) the hospital meets the requirements described
in subsection (i)(1) not later than 18 months after the
date of the enactment of this subparagraph.''; and
(3) by adding at the end the following new subsection:
``(i) Requirements for Hospitals To Qualify for Rural Provider and
Hospital Exception to Ownership or Investment Prohibition.--
``(1) Requirements described.--For purposes of subsection
(d)(3)(D), the requirements described in this paragraph for a
hospital are as follows:
``(A) Provider agreement.--The hospital had--
``(i) physician ownership or investment on
February 1, 2010; and
``(ii) a provider agreement under section
1866 in effect on such date.
``(B) Limitation on expansion of facility
capacity.--Except as provided in paragraph (3), the
number of operating rooms, procedure rooms, and beds
for which the hospital is licensed at any time on or
after the date of the enactment of this subsection is
no greater than the number of operating rooms,
procedure rooms, and beds for which the hospital is
licensed as of such date.
``(C) Preventing conflicts of interest.--
``(i) The hospital submits to the Secretary
an annual report containing a detailed
description of--
``(I) the identity of each
physician owner or investor and any
other owners or investors of the
hospital; and
``(II) the nature and extent of all
ownership and investment interests in
the hospital.
``(ii) The hospital has procedures in place
to require that any referring physician owner
or investor discloses to the patient being
referred, by a time that permits the patient to
make a meaningful decision regarding the
receipt of care, as determined by the
Secretary--
``(I) the ownership or investment
interest, as applicable, of such
referring physician in the hospital;
and
``(II) if applicable, any such
ownership or investment interest of the
treating physician.
``(iii) The hospital does not condition any
physician ownership or investment interests
either directly or indirectly on the physician
owner or investor making or influencing
referrals to the hospital or otherwise
generating business for the hospital.
``(iv) The hospital discloses the fact that
the hospital is partially owned or invested in
by physicians--
``(I) on any public website for the
hospital; and
``(II) in any public advertising
for the hospital.
``(D) Ensuring bona fide investment.--
``(i) The percentage of the total value of
the ownership or investment interests held in
the hospital, or in an entity whose assets
include the hospital, by physician owners or
investors in the aggregate does not exceed such
percentage as of the date of enactment of this
subsection.
``(ii) Any ownership or investment
interests that the hospital offers to a
physician owner or investor are not offered on
more favorable terms than the terms offered to
a person who is not a physician owner or
investor.
``(iii) The hospital (or any owner or
investor in the hospital) does not directly or
indirectly provide loans or financing for any
investment in the hospital by a physician owner
or investor.
``(iv) The hospital (or any owner or
investor in the hospital) does not directly or
indirectly guarantee a loan, make a payment
toward a loan, or otherwise subsidize a loan,
for any individual physician owner or investor
or group of physician owners or investors that
is related to acquiring any ownership or
investment interest in the hospital.
``(v) Ownership or investment returns are
distributed to each owner or investor in the
hospital in an amount that is directly
proportional to the ownership or investment
interest of such owner or investor in the
hospital.
``(vi) Physician owners and investors do
not receive, directly or indirectly, any
guaranteed receipt of or right to purchase
other business interests related to the
hospital, including the purchase or lease of
any property under the control of other owners
or investors in the hospital or located near
the premises of the hospital.
``(vii) The hospital does not offer a
physician owner or investor the opportunity to
purchase or lease any property under the
control of the hospital or any other owner or
investor in the hospital on more favorable
terms than the terms offered to an individual
who is not a physician owner or investor.
``(E) Patient safety.--
``(i) Insofar as the hospital admits a
patient and does not have any physician
available on the premises to provide services
during all hours in which the hospital is
providing services to such patient, before
admitting the patient--
``(I) the hospital discloses such
fact to a patient; and
``(II) following such disclosure,
the hospital receives from the patient
a signed acknowledgment that the
patient understands such fact.
``(ii) The hospital has the capacity to--
``(I) provide assessment and
initial treatment for patients; and
``(II) refer and transfer patients
to hospitals with the capability to
treat the needs of the patient
involved.
``(F) Limitation on application to certain
converted facilities.--The hospital was not converted
from an ambulatory surgical center to a hospital on or
after the date of enactment of this subsection.
``(2) Publication of information reported.--The Secretary
shall publish, and update on an annual basis, the information
submitted by hospitals under paragraph (1)(C)(i) on the public
Internet website of the Centers for Medicare & Medicaid
Services.
``(3) Exception to prohibition on expansion of facility
capacity.--
``(A) Process.--
``(i) Establishment.--The Secretary shall
establish and implement a process under which
an applicable hospital (as defined in
subparagraph (E)) may apply for an exception
from the requirement under paragraph (1)(B).
``(ii) Opportunity for community input.--
The process under clause (i) shall provide
individuals and entities in the community in
which the applicable hospital applying for an
exception is located with the opportunity to
provide input with respect to the application.
``(iii) Timing for implementation.--The
Secretary shall implement the process under
clause (i) on August 1, 2011.
``(iv) Regulations.--Not later than July 1,
2011, the Secretary shall promulgate
regulations to carry out the process under
clause (i).
``(B) Frequency.--The process described in
subparagraph (A) shall permit an applicable hospital to
apply for an exception up to once every 2 years.
``(C) Permitted increase.--
``(i) In general.--Subject to clause (ii)
and subparagraph (D), an applicable hospital
granted an exception under the process
described in subparagraph (A) may increase the
number of operating rooms, procedure rooms, and
beds for which the applicable hospital is
licensed above the baseline number of operating
rooms, procedure rooms, and beds of the
applicable hospital (or, if the applicable
hospital has been granted a previous exception
under this paragraph, above the number of
operating rooms, procedure rooms, and beds for
which the hospital is licensed after the
application of the most recent increase under
such an exception).
``(ii) 100 percent increase limitation.--
The Secretary shall not permit an increase in
the number of operating rooms, procedure rooms,
and beds for which an applicable hospital is
licensed under clause (i) to the extent such
increase would result in the number of
operating rooms, procedure rooms, and beds for
which the applicable hospital is licensed
exceeding 200 percent of the baseline number of
operating rooms, procedure rooms, and beds of
the applicable hospital.
``(iii) Baseline number of operating rooms,
procedure rooms, and beds.--In this paragraph,
the term `baseline number of operating rooms,
procedure rooms, and beds' means the number of
operating rooms, procedure rooms, and beds for
which the applicable hospital is licensed as of
the date of enactment of this subsection.
``(D) Increase limited to facilities on the main
campus of the hospital.--Any increase in the number of
operating rooms, procedure rooms, and beds for which an
applicable hospital is licensed pursuant to this
paragraph may only occur in facilities on the main
campus of the applicable hospital.
``(E) Applicable hospital.--In this paragraph, the
term `applicable hospital' means a hospital--
``(i) that is located in a county in which
the percentage increase in the population
during the most recent 5-year period (as of the
date of the application under subparagraph (A))
is at least 150 percent of the percentage
increase in the population growth of the State
in which the hospital is located during that
period, as estimated by Bureau of the Census;
``(ii) whose annual percent of total
inpatient admissions that represent inpatient
admissions under the program under title XIX is
equal to or greater than the average percent
with respect to such admissions for all
hospitals located in the county in which the
hospital is located;
``(iii) that does not discriminate against
beneficiaries of Federal health care programs
and does not permit physicians practicing at
the hospital to discriminate against such
beneficiaries;
``(iv) that is located in a State in which
the average bed capacity in the State is less
than the national average bed capacity; and
``(v) that has an average bed occupancy
rate that is greater than the average bed
occupancy rate in the State in which the
hospital is located.
``(F) Procedure rooms.--In this subsection, the
term `procedure rooms' includes rooms in which
catheterizations, angiographies, angiograms, and
endoscopies are performed, except such term shall not
include emergency rooms or departments (exclusive of
rooms in which catheterizations, angiographies,
angiograms, and endoscopies are performed).
``(G) Publication of final decisions.--Not later
than 60 days after receiving a complete application
under this paragraph, the Secretary shall publish in
the Federal Register the final decision with respect to
such application.
``(H) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the process under this
paragraph (including the establishment of such
process).
``(4) Collection of ownership and investment information.--
For purposes of subparagraphs (A)(i) and (D)(i) of paragraph
(1), the Secretary shall collect physician ownership and
investment information for each hospital.
``(5) Physician owner or investor defined.--For purposes of
this subsection, the term `physician owner or investor' means a
physician (or an immediate family member of such physician)
with a direct or an indirect ownership or investment interest
in the hospital.
``(6) Clarification.--Nothing in this subsection shall be
construed as preventing the Secretary from revoking a
hospital's provider agreement if not in compliance with
regulations implementing section 1866.''.
(b) Enforcement.--
(1) Ensuring compliance.--The Secretary of Health and Human
Services shall establish policies and procedures to ensure
compliance with the requirements described in subsection (i)(1)
of section 1877 of the Social Security Act, as added by
subsection (a)(3), beginning on the date such requirements
first apply. Such policies and procedures may include
unannounced site reviews of hospitals.
(2) Audits.--Beginning not later than November 1, 2011, the
Secretary of Health and Human Services shall conduct audits to
determine if hospitals violate the requirements referred to in
paragraph (1).
SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN OWNERSHIP OR
INVESTMENT INTERESTS.
Part A of title XI of the Social Security Act (42 U.S.C. 1301 et
seq.) is amended by inserting after section 1128F the following new
section:
``SEC. 1128G. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN OWNERSHIP
OR INVESTMENT INTERESTS.
``(a) Transparency Reports.--
``(1) Payments or other transfers of value.--
``(A) In general.--On March 31, 2013, and on the
90th day of each calendar year beginning thereafter,
any applicable manufacturer that provides a payment or
other transfer of value to a covered recipient (or to
an entity or individual at the request of or designated
on behalf of a covered recipient), shall submit to the
Secretary, in such electronic form as the Secretary
shall require, the following information with respect
to the preceding calendar year:
``(i) The name of the covered recipient.
``(ii) The business address of the covered
recipient and, in the case of a covered
recipient who is a physician, the specialty and
National Provider Identifier of the covered
recipient.
``(iii) The amount of the payment or other
transfer of value.
``(iv) The dates on which the payment or
other transfer of value was provided to the
covered recipient.
``(v) A description of the form of the
payment or other transfer of value, indicated
(as appropriate for all that apply) as--
``(I) cash or a cash equivalent;
``(II) in-kind items or services;
``(III) stock, a stock option, or
any other ownership interest, dividend,
profit, or other return on investment;
or
``(IV) any other form of payment or
other transfer of value (as defined by
the Secretary).
``(vi) A description of the nature of the
payment or other transfer of value, indicated
(as appropriate for all that apply) as--
``(I) consulting fees;
``(II) compensation for services
other than consulting;
``(III) honoraria;
``(IV) gift;
``(V) entertainment;
``(VI) food;
``(VII) travel (including the
specified destinations);
``(VIII) education;
``(IX) research;
``(X) charitable contribution;
``(XI) royalty or license;
``(XII) current or prospective
ownership or investment interest;
``(XIII) direct compensation for
serving as faculty or as a speaker for
a medical education program;
``(XIV) grant; or
``(XV) any other nature of the
payment or other transfer of value (as
defined by the Secretary).
``(vii) If the payment or other transfer of
value is related to marketing, education, or
research specific to a covered drug, device,
biological, or medical supply, the name of that
covered drug, device, biological, or medical
supply.
``(viii) Any other categories of
information regarding the payment or other
transfer of value the Secretary determines
appropriate.
``(B) Special rule for certain payments or other
transfers of value.--In the case where an applicable
manufacturer provides a payment or other transfer of
value to an entity or individual at the request of or
designated on behalf of a covered recipient, the
applicable manufacturer shall disclose that payment or
other transfer of value under the name of the covered
recipient.
``(2) Physician ownership.--In addition to the requirement
under paragraph (1)(A), on March 31, 2013, and on the 90th day
of each calendar year beginning thereafter, any applicable
manufacturer or applicable group purchasing organization shall
submit to the Secretary, in such electronic form as the
Secretary shall require, the following information regarding
any ownership or investment interest (other than an ownership
or investment interest in a publicly traded security and mutual
fund, as described in section 1877(c)) held by a physician (or
an immediate family member of such physician (as defined for
purposes of section 1877(a))) in the applicable manufacturer or
applicable group purchasing organization during the preceding
year:
``(A) The dollar amount invested by each physician
holding such an ownership or investment interest.
``(B) The value and terms of each such ownership or
investment interest.
``(C) Any payment or other transfer of value
provided to a physician holding such an ownership or
investment interest (or to an entity or individual at
the request of or designated on behalf of a physician
holding such an ownership or investment interest),
including the information described in clauses (i)
through (viii) of paragraph (1)(A), except that in
applying such clauses, `physician' shall be substituted
for `covered recipient' each place it appears.
``(D) Any other information regarding the ownership
or investment interest the Secretary determines
appropriate.
``(b) Penalties for Noncompliance.--
``(1) Failure to report.--
``(A) In general.--Subject to subparagraph (B)
except as provided in paragraph (2), any applicable
manufacturer or applicable group purchasing
organization that fails to submit information required
under subsection (a) in a timely manner in accordance
with rules or regulations promulgated to carry out such
subsection, shall be subject to a civil money penalty
of not less than $1,000, but not more than $10,000, for
each payment or other transfer of value or ownership or
investment interest not reported as required under such
subsection. Such penalty shall be imposed and collected
in the same manner as civil money penalties under
subsection (a) of section 1128A are imposed and
collected under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect
to each annual submission of information under
subsection (a) by an applicable manufacturer or
applicable group purchasing organization shall not
exceed $150,000.
``(2) Knowing failure to report.--
``(A) In general.--Subject to subparagraph (B), any
applicable manufacturer or applicable group purchasing
organization that knowingly fails to submit information
required under subsection (a) in a timely manner in
accordance with rules or regulations promulgated to
carry out such subsection, shall be subject to a civil
money penalty of not less than $10,000, but not more
than $100,000, for each payment or other transfer of
value or ownership or investment interest not reported
as required under such subsection. Such penalty shall
be imposed and collected in the same manner as civil
money penalties under subsection (a) of section 1128A
are imposed and collected under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect
to each annual submission of information under
subsection (a) by an applicable manufacturer or
applicable group purchasing organization shall not
exceed $1,000,000.
``(3) Use of funds.--Funds collected by the Secretary as a
result of the imposition of a civil money penalty under this
subsection shall be used to carry out this section.
``(c) Procedures for Submission of Information and Public
Availability.--
``(1) In general.--
``(A) Establishment.--Not later than October 1,
2011, the Secretary shall establish procedures--
``(i) for applicable manufacturers and
applicable group purchasing organizations to
submit information to the Secretary under
subsection (a); and
``(ii) for the Secretary to make such
information submitted available to the public.
``(B) Definition of terms.--The procedures
established under subparagraph (A) shall provide for
the definition of terms (other than those terms defined
in subsection (e)), as appropriate, for purposes of
this section.
``(C) Public availability.--Except as provided in
subparagraph (E), the procedures established under
subparagraph (A)(ii) shall ensure that, not later than
September 30, 2013, and on June 30 of each calendar
year beginning thereafter, the information submitted
under subsection (a) with respect to the preceding
calendar year is made available through an Internet
website that--
``(i) is searchable and is in a format that
is clear and understandable;
``(ii) contains information that is
presented by the name of the applicable
manufacturer or applicable group purchasing
organization, the name of the covered
recipient, the business address of the covered
recipient, the specialty of the covered
recipient, the value of the payment or other
transfer of value, the date on which the
payment or other transfer of value was provided
to the covered recipient, the form of the
payment or other transfer of value, indicated
(as appropriate) under subsection (a)(1)(A)(v),
the nature of the payment or other transfer of
value, indicated (as appropriate) under
subsection (a)(1)(A)(vi), and the name of the
covered drug, device, biological, or medical
supply, as applicable;
``(iii) contains information that is able
to be easily aggregated and downloaded;
``(iv) contains a description of any
enforcement actions taken to carry out this
section, including any penalties imposed under
subsection (b), during the preceding year;
``(v) contains background information on
industry-physician relationships;
``(vi) in the case of information submitted
with respect to a payment or other transfer of
value described in subparagraph (E)(i), lists
such information separately from the other
information submitted under subsection (a) and
designates such separately listed information
as funding for clinical research;
``(vii) contains any other information the
Secretary determines would be helpful to the
average consumer;
``(viii) does not contain the National
Provider Identifier of the covered recipient,
and
``(ix) subject to subparagraph (D),
provides the applicable manufacturer,
applicable group purchasing organization, or
covered recipient an opportunity to review and
submit corrections to the information submitted
with respect to the applicable manufacturer,
applicable group purchasing organization, or
covered recipient, respectively, for a period
of not less than 45 days prior to such
information being made available to the public.
``(D) Clarification of time period for review and
corrections.--In no case may the 45-day period for
review and submission of corrections to information
under subparagraph (C)(ix) prevent such information
from being made available to the public in accordance
with the dates described in the matter preceding clause
(i) in subparagraph (C).
``(E) Delayed publication for payments made
pursuant to product research or development agreements
and clinical investigations.--
``(i) In general.--In the case of
information submitted under subsection (a) with
respect to a payment or other transfer of value
made to a covered recipient by an applicable
manufacturer pursuant to a product research or
development agreement for services furnished in
connection with research on a potential new
medical technology or a new application of an
existing medical technology or the development
of a new drug, device, biological, or medical
supply, or by an applicable manufacturer in
connection with a clinical investigation
regarding a new drug, device, biological, or
medical supply, the procedures established
under subparagraph (A)(ii) shall provide that
such information is made available to the
public on the first date described in the
matter preceding clause (i) in subparagraph (C)
after the earlier of the following:
``(I) The date of the approval or
clearance of the covered drug, device,
biological, or medical supply by the
Food and Drug Administration.
``(II) Four calendar years after
the date such payment or other transfer
of value was made.
``(ii) Confidentiality of information prior
to publication.--Information described in
clause (i) shall be considered confidential and
shall not be subject to disclosure under
section 552 of title 5, United States Code, or
any other similar Federal, State, or local law,
until on or after the date on which the
information is made available to the public
under such clause.
``(2) Consultation.--In establishing the procedures under
paragraph (1), the Secretary shall consult with the Inspector
General of the Department of Health and Human Services,
affected industry, consumers, consumer advocates, and other
interested parties in order to ensure that the information made
available to the public under such paragraph is presented in
the appropriate overall context.
``(d) Annual Reports and Relation to State Laws.--
``(1) Annual report to congress.--Not later than April 1 of
each year beginning with 2013, the Secretary shall submit to
Congress a report that includes the following:
``(A) The information submitted under subsection
(a) during the preceding year, aggregated for each
applicable manufacturer and applicable group purchasing
organization that submitted such information during
such year (except, in the case of information submitted
with respect to a payment or other transfer of value
described in subsection (c)(1)(E)(i), such information
shall be included in the first report submitted to
Congress after the date on which such information is
made available to the public under such subsection).
``(B) A description of any enforcement actions
taken to carry out this section, including any
penalties imposed under subsection (b), during the
preceding year.
``(2) Annual reports to states.--Not later than September
30, 2013 and on June 30 of each calendar year thereafter, the
Secretary shall submit to States a report that includes a
summary of the information submitted under subsection (a)
during the preceding year with respect to covered recipients in
the State (except, in the case of information submitted with
respect to a payment or other transfer of value described in
subsection (c)(1)(E)(i), such information shall be included in
the first report submitted to States after the date on which
such information is made available to the public under such
subsection).
``(3) Relation to state laws.--
``(A) In general.--In the case of a payment or
other transfer of value provided by an applicable
manufacturer that is received by a covered recipient
(as defined in subsection (e)) on or after January 1,
2012, subject to subparagraph (B), the provisions of
this section shall preempt any statute or regulation of
a State or of a political subdivision of a State that
requires an applicable manufacturer (as so defined) to
disclose or report, in any format, the type of
information (as described in subsection (a)) regarding
such payment or other transfer of value.
``(B) No preemption of additional requirements.--
Subparagraph (A) shall not preempt any statute or
regulation of a State or of a political subdivision of
a State that requires the disclosure or reporting of
information--
``(i) not of the type required to be
disclosed or reported under this section;
``(ii) described in subsection (e)(10)(B),
except in the case of information described in
clause (i) of such subsection;
``(iii) by any person or entity other than
an applicable manufacturer (as so defined) or a
covered recipient (as defined in subsection
(e)); or
``(iv) to a Federal, State, or local
governmental agency for public health
surveillance, investigation, or other public
health purposes or health oversight purposes.
``(C) Nothing in subparagraph (A) shall be
construed to limit the discovery or admissibility of
information described in such subparagraph in a
criminal, civil, or administrative proceeding.
``(4) Consultation.--The Secretary shall consult with the
Inspector General of the Department of Health and Human
Services on the implementation of this section.
``(e) Definitions.--In this section:
``(1) Applicable group purchasing organization.--The term
`applicable group purchasing organization' means a group
purchasing organization (as defined by the Secretary) that
purchases, arranges for, or negotiates the purchase of a
covered drug, device, biological, or medical supply which is
operating in the United States, or in a territory, possession,
or commonwealth of the United States.
``(2) Applicable manufacturer.--The term `applicable
manufacturer' means a manufacturer of a covered drug, device,
biological, or medical supply which is operating in the United
States, or in a territory, possession, or commonwealth of the
United States.
``(3) Clinical investigation.--The term `clinical
investigation' means any experiment involving 1 or more human
subjects, or materials derived from human subjects, in which a
drug or device is administered, dispensed, or used.
``(4) Covered device.--The term `covered device' means any
device for which payment is available under title XVIII or a
State plan under title XIX or XXI (or a waiver of such a plan).
``(5) Covered drug, device, biological, or medical
supply.--The term `covered drug, device, biological, or medical
supply' means any drug, biological product, device, or medical
supply for which payment is available under title XVIII or a
State plan under title XIX or XXI (or a waiver of such a plan).
``(6) Covered recipient.--
``(A) In general.--Except as provided in
subparagraph (B), the term `covered recipient' means
the following:
``(i) A physician.
``(ii) A teaching hospital.
``(B) Exclusion.--Such term does not include a
physician who is an employee of the applicable
manufacturer that is required to submit information
under subsection (a).
``(7) Employee.--The term `employee' has the meaning given
such term in section 1877(h)(2).
``(8) Knowingly.--The term `knowingly' has the meaning
given such term in section 3729(b) of title 31, United States
Code.
``(9) Manufacturer of a covered drug, device, biological,
or medical supply.--The term `manufacturer of a covered drug,
device, biological, or medical supply' means any entity which
is engaged in the production, preparation, propagation,
compounding, or conversion of a covered drug, device,
biological, or medical supply (or any entity under common
ownership with such entity which provides assistance or support
to such entity with respect to the production, preparation,
propagation, compounding, conversion, marketing, promotion,
sale, or distribution of a covered drug, device, biological, or
medical supply).
``(10) Payment or other transfer of value.--
``(A) In general.--The term `payment or other
transfer of value' means a transfer of anything of
value. Such term does not include a transfer of
anything of value that is made indirectly to a covered
recipient through a third party in connection with an
activity or service in the case where the applicable
manufacturer is unaware of the identity of the covered
recipient.
``(B) Exclusions.--An applicable manufacturer shall
not be required to submit information under subsection
(a) with respect to the following:
``(i) A transfer of anything the value of
which is less than $10, unless the aggregate
amount transferred to, requested by, or
designated on behalf of the covered recipient
by the applicable manufacturer during the
calendar year exceeds $100. For calendar years
after 2012, the dollar amounts specified in the
preceding sentence shall be increased by the
same percentage as the percentage increase in
the consumer price index for all urban
consumers (all items; U.S. city average) for
the 12-month period ending with June of the
previous year.
``(ii) Product samples that are not
intended to be sold and are intended for
patient use.
``(iii) Educational materials that directly
benefit patients or are intended for patient
use.
``(iv) The loan of a covered device for a
short-term trial period, not to exceed 90 days,
to permit evaluation of the covered device by
the covered recipient.
``(v) Items or services provided under a
contractual warranty, including the replacement
of a covered device, where the terms of the
warranty are set forth in the purchase or lease
agreement for the covered device.
``(vi) A transfer of anything of value to a
covered recipient when the covered recipient is
a patient and not acting in the professional
capacity of a covered recipient.
``(vii) Discounts (including rebates).
``(viii) In-kind items used for the
provision of charity care.
``(ix) A dividend or other profit
distribution from, or ownership or investment
interest in, a publicly traded security and
mutual fund (as described in section 1877(c)).
``(x) In the case of an applicable
manufacturer who offers a self-insured plan,
payments for the provision of health care to
employees under the plan.
``(xi) In the case of a covered recipient
who is a licensed non-medical professional, a
transfer of anything of value to the covered
recipient if the transfer is payment solely for
the non-medical professional services of such
licensed non-medical professional.
``(xii) In the case of a covered recipient
who is a physician, a transfer of anything of
value to the covered recipient if the transfer
is payment solely for the services of the
covered recipient with respect to a civil or
criminal action or an administrative
proceeding.
``(11) Physician.--The term `physician' has the meaning
given that term in section 1861(r).''.
SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE ANCILLARY SERVICES
EXCEPTION TO THE PROHIBITION ON PHYSICIAN SELF-REFERRAL
FOR CERTAIN IMAGING SERVICES.
(a) In General.--Section 1877(b)(2) of the Social Security Act (42
U.S.C. 1395nn(b)(2)) is amended by adding at the end the following new
sentence: ``Such requirements shall, with respect to magnetic resonance
imaging, computed tomography, positron emission tomography, and any
other designated health services specified under subsection (h)(6)(D)
that the Secretary determines appropriate, include a requirement that
the referring physician inform the individual in writing at the time of
the referral that the individual may obtain the services for which the
individual is being referred from a person other than a person
described in subparagraph (A)(i) and provide such individual with a
written list of suppliers (as defined in section 1861(d)) who furnish
such services in the area in which such individual resides.''.
(b) Effective Date.--The amendment made by this section shall apply
to services furnished on or after January 1, 2010.
SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY.
Part A of title XI of the Social Security Act (42 U.S.C. 1301 et
seq.), as amended by section 6002, is amended by inserting after
section 1128G the following new section:
``SEC. 1128H. REPORTING OF INFORMATION RELATING TO DRUG SAMPLES.
``(a) In General.--Not later than April 1 of each year (beginning
with 2012), each manufacturer and authorized distributor of record of
an applicable drug shall submit to the Secretary (in a form and manner
specified by the Secretary) the following information with respect to
the preceding year:
``(1) In the case of a manufacturer or authorized
distributor of record which makes distributions by mail or
common carrier under subsection (d)(2) of section 503 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 353), the
identity and quantity of drug samples requested and the
identity and quantity of drug samples distributed under such
subsection during that year, aggregated by--
``(A) the name, address, professional designation,
and signature of the practitioner making the request
under subparagraph (A)(i) of such subsection, or of any
individual who makes or signs for the request on behalf
of the practitioner; and
``(B) any other category of information determined
appropriate by the Secretary.
``(2) In the case of a manufacturer or authorized
distributor of record which makes distributions by means other
than mail or common carrier under subsection (d)(3) of such
section 503, the identity and quantity of drug samples
requested and the identity and quantity of drug samples
distributed under such subsection during that year, aggregated
by--
``(A) the name, address, professional designation,
and signature of the practitioner making the request
under subparagraph (A)(i) of such subsection, or of any
individual who makes or signs for the request on behalf
of the practitioner; and
``(B) any other category of information determined
appropriate by the Secretary.
``(b) Definitions.--In this section:
``(1) Applicable drug.--The term `applicable drug' means a
drug--
``(A) which is subject to subsection (b) of such
section 503; and
``(B) for which payment is available under title
XVIII or a State plan under title XIX or XXI (or a
waiver of such a plan).
``(2) Authorized distributor of record.--The term
`authorized distributor of record' has the meaning given that
term in subsection (e)(3)(A) of such section.
``(3) Manufacturer.--The term `manufacturer' has the
meaning given that term for purposes of subsection (d) of such
section.''.
SEC. 6005. PHARMACY BENEFIT MANAGERS TRANSPARENCY REQUIREMENTS.
Part A of title XI of the Social Security Act (42 U.S.C. 1301 et
seq.) is amended by inserting after section 1150 the following new
section:
``SEC. 1150A. PHARMACY BENEFIT MANAGERS TRANSPARENCY REQUIREMENTS.
``(a) Provision of Information.--A health benefits plan or any
entity that provides pharmacy benefits management services on behalf of
a health benefits plan (in this section referred to as a `PBM') that
manages prescription drug coverage under a contract with--
``(1) a PDP sponsor of a prescription drug plan or an MA
organization offering an MA-PD plan under part D of title
XVIII; or
``(2) a qualified health benefits plan offered through an
exchange established by a State under section 1311 of the
Patient Protection and Affordable Care Act,
shall provide the information described in subsection (b) to the
Secretary and, in the case of a PBM, to the plan with which the PBM is
under contract with, at such times, and in such form and manner, as the
Secretary shall specify.
``(b) Information Described.--The information described in this
subsection is the following with respect to services provided by a
health benefits plan or PBM for a contract year:
``(1) The percentage of all prescriptions that were
provided through retail pharmacies compared to mail order
pharmacies, and the percentage of prescriptions for which a
generic drug was available and dispensed (generic dispensing
rate), by pharmacy type (which includes an independent
pharmacy, chain pharmacy, supermarket pharmacy, or mass
merchandiser pharmacy that is licensed as a pharmacy by the
State and that dispenses medication to the general public),
that is paid by the health benefits plan or PBM under the
contract.
``(2) The aggregate amount, and the type of rebates,
discounts, or price concessions (excluding bona fide service
fees, which include but are not limited to distribution service
fees, inventory management fees, product stocking allowances,
and fees associated with administrative services agreements and
patient care programs (such as medication compliance programs
and patient education programs)) that the PBM negotiates that
are attributable to patient utilization under the plan, and the
aggregate amount of the rebates, discounts, or price
concessions that are passed through to the plan sponsor, and
the total number of prescriptions that were dispensed.
``(3) The aggregate amount of the difference between the
amount the health benefits plan pays the PBM and the amount
that the PBM pays retail pharmacies, and mail order pharmacies,
and the total number of prescriptions that were dispensed.
``(c) Confidentiality.--Information disclosed by a health benefits
plan or PBM under this section is confidential and shall not be
disclosed by the Secretary or by a plan receiving the information,
except that the Secretary may disclose the information in a form which
does not disclose the identity of a specific PBM, plan, or prices
charged for drugs, for the following purposes:
``(1) As the Secretary determines to be necessary to carry
out this section or part D of title XVIII.
``(2) To permit the Comptroller General to review the
information provided.
``(3) To permit the Director of the Congressional Budget
Office to review the information provided.
``(4) To States to carry out section 1311 of the Patient
Protection and Affordable Care Act.
``(d) Penalties.--The provisions of subsection (b)(3)(C) of section
1927 shall apply to a health benefits plan or PBM that fails to provide
information required under subsection (a) on a timely basis or that
knowingly provides false information in the same manner as such
provisions apply to a manufacturer with an agreement under that
section.''.
Subtitle B--Nursing Home Transparency and Improvement
PART I--IMPROVING TRANSPARENCY OF INFORMATION
SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL DISCLOSABLE
PARTIES INFORMATION.
(a) In General.--Section 1124 of the Social Security Act (42 U.S.C.
1320a-3) is amended by adding at the end the following new subsection:
``(c) Required Disclosure of Ownership and Additional Disclosable
Parties Information.--
``(1) Disclosure.--A facility shall have the information
described in paragraph (2) available--
``(A) during the period beginning on the date of
the enactment of this subsection and ending on the date
such information is made available to the public under
section 6101(b) of the Patient Protection and
Affordable Care Act for submission to the Secretary,
the Inspector General of the Department of Health and
Human Services, the State in which the facility is
located, and the State long-term care ombudsman in the
case where the Secretary, the Inspector General, the
State, or the State long-term care ombudsman requests
such information; and
``(B) beginning on the effective date of the final
regulations promulgated under paragraph (3)(A), for
reporting such information in accordance with such
final regulations.
Nothing in subparagraph (A) shall be construed as authorizing a
facility to dispose of or delete information described in such
subparagraph after the effective date of the final regulations
promulgated under paragraph (3)(A).
``(2) Information described.--
``(A) In general.--The following information is
described in this paragraph:
``(i) The information described in
subsections (a) and (b), subject to
subparagraph (C).
``(ii) The identity of and information on--
``(I) each member of the governing
body of the facility, including the
name, title, and period of service of
each such member;
``(II) each person or entity who is
an officer, director, member, partner,
trustee, or managing employee of the
facility, including the name, title,
and period of service of each such
person or entity; and
``(III) each person or entity who
is an additional disclosable party of
the facility.
``(iii) The organizational structure of
each additional disclosable party of the
facility and a description of the relationship
of each such additional disclosable party to
the facility and to one another.
``(B) Special rule where information is already
reported or submitted.--To the extent that information
reported by a facility to the Internal Revenue Service
on Form 990, information submitted by a facility to the
Securities and Exchange Commission, or information
otherwise submitted to the Secretary or any other
Federal agency contains the information described in
clauses (i), (ii), or (iii) of subparagraph (A), the
facility may provide such Form or such information
submitted to meet the requirements of paragraph (1).
``(C) Special rule.--In applying subparagraph
(A)(i)--
``(i) with respect to subsections (a) and
(b), `ownership or control interest' shall
include direct or indirect interests, including
such interests in intermediate entities; and
``(ii) subsection (a)(3)(A)(ii) shall
include the owner of a whole or part interest
in any mortgage, deed of trust, note, or other
obligation secured, in whole or in part, by the
entity or any of the property or assets
thereof, if the interest is equal to or exceeds
5 percent of the total property or assets of
the entirety.
``(3) Reporting.--
``(A) In general.--Not later than the date that is
2 years after the date of the enactment of this
subsection, the Secretary shall promulgate final
regulations requiring, effective on the date that is 90
days after the date on which such final regulations are
published in the Federal Register, a facility to report
the information described in paragraph (2) to the
Secretary in a standardized format, and such other
regulations as are necessary to carry out this
subsection. Such final regulations shall ensure that
the facility certifies, as a condition of participation
and payment under the program under title XVIII or XIX,
that the information reported by the facility in
accordance with such final regulations is, to the best
of the facility's knowledge, accurate and current.
``(B) Guidance.--The Secretary shall provide
guidance and technical assistance to States on how to
adopt the standardized format under subparagraph (A).
``(4) No effect on existing reporting requirements.--
Nothing in this subsection shall reduce, diminish, or alter any
reporting requirement for a facility that is in effect as of
the date of the enactment of this subsection.
``(5) Definitions.--In this subsection:
``(A) Additional disclosable party.--The term
`additional disclosable party' means, with respect to a
facility, any person or entity who--
``(i) exercises operational, financial, or
managerial control over the facility or a part
thereof, or provides policies or procedures for
any of the operations of the facility, or
provides financial or cash management services
to the facility;
``(ii) leases or subleases real property to
the facility, or owns a whole or part interest
equal to or exceeding 5 percent of the total
value of such real property; or
``(iii) provides management or
administrative services, management or clinical
consulting services, or accounting or financial
services to the facility.
``(B) Facility.--The term `facility' means a
disclosing entity which is--
``(i) a skilled nursing facility (as
defined in section 1819(a)); or
``(ii) a nursing facility (as defined in
section 1919(a)).
``(C) Managing employee.--The term `managing
employee' means, with respect to a facility, an
individual (including a general manager, business
manager, administrator, director, or consultant) who
directly or indirectly manages, advises, or supervises
any element of the practices, finances, or operations
of the facility.
``(D) Organizational structure.--The term
`organizational structure' means, in the case of--
``(i) a corporation, the officers,
directors, and shareholders of the corporation
who have an ownership interest in the
corporation which is equal to or exceeds 5
percent;
``(ii) a limited liability company, the
members and managers of the limited liability
company (including, as applicable, what
percentage each member and manager has of the
ownership interest in the limited liability
company);
``(iii) a general partnership, the partners
of the general partnership;
``(iv) a limited partnership, the general
partners and any limited partners of the
limited partnership who have an ownership
interest in the limited partnership which is
equal to or exceeds 10 percent;
``(v) a trust, the trustees of the trust;
``(vi) an individual, contact information
for the individual; and
``(vii) any other person or entity, such
information as the Secretary determines
appropriate.''.
(b) Public Availability of Information.--Not later than the date
that is 1 year after the date on which the final regulations
promulgated under section 1124(c)(3)(A) of the Social Security Act, as
added by subsection (a), are published in the Federal Register, the
Secretary of Health and Human Services shall make the information
reported in accordance with such final regulations available to the
public in accordance with procedures established by the Secretary.
(c) Conforming Amendments.--
(1) In general.--
(A) Skilled nursing facilities.--Section 1819(d)(1)
of the Social Security Act (42 U.S.C. 1395i-3(d)(1)) is
amended by striking subparagraph (B) and redesignating
subparagraph (C) as subparagraph (B).
(B) Nursing facilities.--Section 1919(d)(1) of the
Social Security Act (42 U.S.C. 1396r(d)(1)) is amended
by striking subparagraph (B) and redesignating
subparagraph (C) as subparagraph (B).
(2) Effective date.--The amendments made by paragraph (1)
shall take effect on the date on which the Secretary makes the
information described in subsection (b)(1) available to the
public under such subsection.
SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING FACILITIES
AND NURSING FACILITIES.
Part A of title XI of the Social Security Act (42 U.S.C. 1301 et
seq.), as amended by sections 6002 and 6004, is amended by inserting
after section 1128H the following new section:
``SEC. 1128I. ACCOUNTABILITY REQUIREMENTS FOR FACILITIES.
``(a) Definition of Facility.--In this section, the term `facility'
means--
``(1) a skilled nursing facility (as defined in section
1819(a)); or
``(2) a nursing facility (as defined in section 1919(a)).
``(b) Effective Compliance and Ethics Programs.--
``(1) Requirement.--On or after the date that is 36 months
after the date of the enactment of this section, a facility
shall, with respect to the entity that operates the facility
(in this subparagraph referred to as the `operating
organization' or `organization'), have in operation a
compliance and ethics program that is effective in preventing
and detecting criminal, civil, and administrative violations
under this Act and in promoting quality of care consistent with
regulations developed under paragraph (2).
``(2) Development of regulations.--
``(A) In general.--Not later than the date that is
2 years after such date of the enactment, the
Secretary, working jointly with the Inspector General
of the Department of Health and Human Services, shall
promulgate regulations for an effective compliance and
ethics program for operating organizations, which may
include a model compliance program.
``(B) Design of regulations.--Such regulations
with respect to specific elements or formality of a
program shall, in the case of an organization that
operates 5 or more facilities, vary with the size of
the organization, such that larger organizations should
have a more formal program and include established
written policies defining the standards and procedures
to be followed by its employees. Such requirements may
specifically apply to the corporate level management of
multi unit nursing home chains.
``(C) Evaluation.--Not later than 3 years after the
date of the promulgation of regulations under this
paragraph, the Secretary shall complete an evaluation
of the compliance and ethics programs required to be
established under this subsection. Such evaluation
shall determine if such programs led to changes in
deficiency citations, changes in quality performance,
or changes in other metrics of patient quality of care.
The Secretary shall submit to Congress a report on such
evaluation and shall include in such report such
recommendations regarding changes in the requirements
for such programs as the Secretary determines
appropriate.
``(3) Requirements for compliance and ethics programs.--In
this subsection, the term `compliance and ethics program'
means, with respect to a facility, a program of the operating
organization that--
``(A) has been reasonably designed, implemented,
and enforced so that it generally will be effective in
preventing and detecting criminal, civil, and
administrative violations under this Act and in
promoting quality of care; and
``(B) includes at least the required components
specified in paragraph (4).
``(4) Required components of program.--The required
components of a compliance and ethics program of an operating
organization are the following:
``(A) The organization must have established
compliance standards and procedures to be followed by
its employees and other agents that are reasonably
capable of reducing the prospect of criminal, civil,
and administrative violations under this Act.
``(B) Specific individuals within high-level
personnel of the organization must have been assigned
overall responsibility to oversee compliance with such
standards and procedures and have sufficient resources
and authority to assure such compliance.
``(C) The organization must have used due care not
to delegate substantial discretionary authority to
individuals whom the organization knew, or should have
known through the exercise of due diligence, had a
propensity to engage in criminal, civil, and
administrative violations under this Act.
``(D) The organization must have taken steps to
communicate effectively its standards and procedures to
all employees and other agents, such as by requiring
participation in training programs or by disseminating
publications that explain in a practical manner what is
required.
``(E) The organization must have taken reasonable
steps to achieve compliance with its standards, such as
by utilizing monitoring and auditing systems reasonably
designed to detect criminal, civil, and administrative
violations under this Act by its employees and other
agents and by having in place and publicizing a
reporting system whereby employees and other agents
could report violations by others within the
organization without fear of retribution.
``(F) The standards must have been consistently
enforced through appropriate disciplinary mechanisms,
including, as appropriate, discipline of individuals
responsible for the failure to detect an offense.
``(G) After an offense has been detected, the
organization must have taken all reasonable steps to
respond appropriately to the offense and to prevent
further similar offenses, including any necessary
modification to its program to prevent and detect
criminal, civil, and administrative violations under
this Act.
``(H) The organization must periodically undertake
reassessment of its compliance program to identify
changes necessary to reflect changes within the
organization and its facilities.
``(c) Quality Assurance and Performance Improvement Program.--
``(1) In general.--Not later than December 31, 2011, the
Secretary shall establish and implement a quality assurance and
performance improvement program (in this subparagraph referred
to as the `QAPI program') for facilities, including multi unit
chains of facilities. Under the QAPI program, the Secretary
shall establish standards relating to quality assurance and
performance improvement with respect to facilities and provide
technical assistance to facilities on the development of best
practices in order to meet such standards. Not later than 1
year after the date on which the regulations are promulgated
under paragraph (2), a facility must submit to the Secretary a
plan for the facility to meet such standards and implement such
best practices, including how to coordinate the implementation
of such plan with quality assessment and assurance activities
conducted under sections 1819(b)(1)(B) and 1919(b)(1)(B), as
applicable.
``(2) Regulations.--The Secretary shall promulgate
regulations to carry out this subsection.''.
SEC. 6103. NURSING HOME COMPARE MEDICARE WEBSITE.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819 of the Social Security Act
(42 U.S.C. 1395i-3) is amended--
(A) by redesignating subsection (i) as subsection
(j); and
(B) by inserting after subsection (h) the following
new subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that
the Department of Health and Human Services includes,
as part of the information provided for comparison of
nursing homes on the official Internet website of the
Federal Government for Medicare beneficiaries (commonly
referred to as the `Nursing Home Compare' Medicare
website) (or a successor website), the following
information in a manner that is prominent, updated on a
timely basis, easily accessible, readily understandable
to consumers of long-term care services, and
searchable:
``(i) Staffing data for each facility
(including resident census data and data on the
hours of care provided per resident per day)
based on data submitted under section 1128I(g),
including information on staffing turnover and
tenure, in a format that is clearly
understandable to consumers of long-term care
services and allows such consumers to compare
differences in staffing between facilities and
State and national averages for the facilities.
Such format shall include--
``(I) concise explanations of how
to interpret the data (such as a plain
English explanation of data reflecting
`nursing home staff hours per resident
day');
``(II) differences in types of
staff (such as training associated with
different categories of staff);
``(III) the relationship between
nurse staffing levels and quality of
care; and
``(IV) an explanation that
appropriate staffing levels vary based
on patient case mix.
``(ii) Links to State Internet websites
with information regarding State survey and
certification programs, links to Form 2567
State inspection reports (or a successor form)
on such websites, information to guide
consumers in how to interpret and understand
such reports, and the facility plan of
correction or other response to such report.
Any such links shall be posted on a timely
basis.
``(iii) The standardized complaint form
developed under section 1128I(f), including
explanatory material on what complaint forms
are, how they are used, and how to file a
complaint with the State survey and
certification program and the State long-term
care ombudsman program.
``(iv) Summary information on the number,
type, severity, and outcome of substantiated
complaints.
``(v) The number of adjudicated instances
of criminal violations by a facility or the
employees of a facility--
``(I) that were committed inside
the facility;
``(II) with respect to such
instances of violations or crimes
committed inside of the facility that
were the violations or crimes of abuse,
neglect, and exploitation, criminal
sexual abuse, or other violations or
crimes that resulted in serious bodily
injury; and
``(III) the number of civil
monetary penalties levied against the
facility, employees, contractors, and
other agents.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in
clause (ii), the Secretary shall ensure that
the information described in subparagraph (A)
is included on such website (or a successor
website) not later than 1 year after the date
of the enactment of this subsection.
``(ii) Exception.--The Secretary shall
ensure that the information described in
subparagraph (A)(i) is included on such website
(or a successor website) not later than the
date on which the requirements under section
1128I(g) are implemented.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of
presentation, timeliness, and comprehensiveness
of information reported on such website as of
the day before the date of the enactment of
this subsection; and
``(ii) not later than 1 year after the date
of the enactment of this subsection, to modify
or revamp such website in accordance with the
review conducted under clause (i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman
programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups; and
``(iv) any other representatives of
programs or groups the Secretary determines
appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1819(g)(5) of the Social
Security Act (42 U.S.C. 1395i-3(g)(5)) is amended by
adding at the end the following new subparagraph:
``(E) Submission of survey and certification
information to the secretary.--In order to improve the
timeliness of information made available to the public
under subparagraph (A) and provided on the Nursing Home
Compare Medicare website under subsection (i), each
State shall submit information respecting any survey or
certification made respecting a skilled nursing
facility (including any enforcement actions taken by
the State) to the Secretary not later than the date on
which the State sends such information to the facility.
The Secretary shall use the information submitted under
the preceding sentence to update the information
provided on the Nursing Home Compare Medicare website
as expeditiously as practicable but not less frequently
than quarterly.''.
(B) Effective date.--The amendment made by this
paragraph shall take effect 1 year after the date of
the enactment of this Act.
(3) Special focus facility program.--Section 1819(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)) is amended by adding
at the end the following new paragraph:
``(8) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a
special focus facility program for enforcement of
requirements for skilled nursing facilities that the
Secretary has identified as having substantially failed
to meet applicable requirement of this Act.
``(B) Periodic surveys.--Under such program the
Secretary shall conduct surveys of each facility in the
program not less than once every 6 months.''.
(b) Nursing Facilities.--
(1) In general.--Section 1919 of the Social Security Act
(42 U.S.C. 1396r) is amended--
(A) by redesignating subsection (i) as subsection
(j); and
(B) by inserting after subsection (h) the following
new subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that
the Department of Health and Human Services includes,
as part of the information provided for comparison of
nursing homes on the official Internet website of the
Federal Government for Medicare beneficiaries (commonly
referred to as the `Nursing Home Compare' Medicare
website) (or a successor website), the following
information in a manner that is prominent, updated on a
timely basis, easily accessible, readily understandable
to consumers of long-term care services, and
searchable:
``(i) Staffing data for each facility
(including resident census data and data on the
hours of care provided per resident per day)
based on data submitted under section 1128I(g),
including information on staffing turnover and
tenure, in a format that is clearly
understandable to consumers of long-term care
services and allows such consumers to compare
differences in staffing between facilities and
State and national averages for the facilities.
Such format shall include--
``(I) concise explanations of how
to interpret the data (such as plain
English explanation of data reflecting
`nursing home staff hours per resident
day');
``(II) differences in types of
staff (such as training associated with
different categories of staff);
``(III) the relationship between
nurse staffing levels and quality of
care; and
``(IV) an explanation that
appropriate staffing levels vary based
on patient case mix.
``(ii) Links to State Internet websites
with information regarding State survey and
certification programs, links to Form 2567
State inspection reports (or a successor form)
on such websites, information to guide
consumers in how to interpret and understand
such reports, and the facility plan of
correction or other response to such report.
Any such links shall be posted on a timely
basis.
``(iii) The standardized complaint form
developed under section 1128I(f), including
explanatory material on what complaint forms
are, how they are used, and how to file a
complaint with the State survey and
certification program and the State long-term
care ombudsman program.
``(iv) Summary information on the number,
type, severity, and outcome of substantiated
complaints.
``(v) The number of adjudicated instances
of criminal violations by a facility or the
employees of a facility--
``(I) that were committed inside of
the facility; and
``(II) with respect to such
instances of violations or crimes
committed outside of the facility, that
were violations or crimes that resulted
in the serious bodily injury of an
elder.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in
clause (ii), the Secretary shall ensure that
the information described in subparagraph (A)
is included on such website (or a successor
website) not later than 1 year after the date
of the enactment of this subsection.
``(ii) Exception.--The Secretary shall
ensure that the information described in
subparagraph (A)(i) is included on such website
(or a successor website) not later than the
date on which the requirements under section
1128I(g) are implemented.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of
presentation, timeliness, and comprehensiveness
of information reported on such website as of
the day before the date of the enactment of
this subsection; and
``(ii) not later than 1 year after the date
of the enactment of this subsection, to modify
or revamp such website in accordance with the
review conducted under clause (i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman
programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups;
``(iv) skilled nursing facility employees
and their representatives; and
``(v) any other representatives of programs
or groups the Secretary determines
appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1919(g)(5) of the Social
Security Act (42 U.S.C. 1396r(g)(5)) is amended by
adding at the end the following new subparagraph:
``(E) Submission of survey and certification
information to the secretary.--In order to improve the
timeliness of information made available to the public
under subparagraph (A) and provided on the Nursing Home
Compare Medicare website under subsection (i), each
State shall submit information respecting any survey or
certification made respecting a nursing facility
(including any enforcement actions taken by the State)
to the Secretary not later than the date on which the
State sends such information to the facility. The
Secretary shall use the information submitted under the
preceding sentence to update the information provided
on the Nursing Home Compare Medicare website as
expeditiously as practicable but not less frequently
than quarterly.''.
(B) Effective date.--The amendment made by this
paragraph shall take effect 1 year after the date of
the enactment of this Act.
(3) Special focus facility program.--Section 1919(f) of the
Social Security Act (42 U.S.C. 1396r(f)) is amended by adding
at the end of the following new paragraph:
``(10) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a
special focus facility program for enforcement of
requirements for nursing facilities that the Secretary
has identified as having substantially failed to meet
applicable requirements of this Act.
``(B) Periodic surveys.--Under such program the
Secretary shall conduct surveys of each facility in the
program not less often than once every 6 months.''.
(c) Availability of Reports on Surveys, Certifications, and
Complaint Investigations.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by
section 6101, is amended by adding at the end the following new
subparagraph:
``(C) Availability of survey, certification, and
complaint investigation reports.--A skilled nursing
facility must--
``(i) have reports with respect to any
surveys, certifications, and complaint
investigations made respecting the facility
during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of
such reports in areas of the facility that are
prominent and accessible to the public.
The facility shall not make available under clause (i)
identifying information about complainants or
residents.''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by section
6101, is amended by adding at the end the following new
subparagraph:
``(V) Availability of survey, certification, and
complaint investigation reports.--A nursing facility
must--
``(i) have reports with respect to any
surveys, certifications, and complaint
investigations made respecting the facility
during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of
such reports in areas of the facility that are
prominent and accessible to the public.
The facility shall not make available under clause (i)
identifying information about complainants or
residents.''.
(3) Effective date.--The amendments made by this subsection
shall take effect 1 year after the date of the enactment of
this Act.
(d) Guidance to States on Form 2567 State Inspection Reports and
Complaint Investigation Reports.--
(1) Guidance.--The Secretary of Health and Human Services
(in this subtitle referred to as the ``Secretary'') shall
provide guidance to States on how States can establish
electronic links to Form 2567 State inspection reports (or a
successor form), complaint investigation reports, and a
facility's plan of correction or other response to such Form
2567 State inspection reports (or a successor form) on the
Internet website of the State that provides information on
skilled nursing facilities and nursing facilities and the
Secretary shall, if possible, include such information on
Nursing Home Compare.
(2) Requirement.--Section 1902(a)(9) of the Social Security
Act (42 U.S.C. 1396a(a)(9)) is amended--
(A) by striking ``and'' at the end of subparagraph
(B);
(B) by striking the semicolon at the end of
subparagraph (C) and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(D) that the State maintain a consumer-oriented
website providing useful information to consumers
regarding all skilled nursing facilities and all
nursing facilities in the State, including for each
facility, Form 2567 State inspection reports (or a
successor form), complaint investigation reports, the
facility's plan of correction, and such other
information that the State or the Secretary considers
useful in assisting the public to assess the quality of
long term care options and the quality of care provided
by individual facilities;''.
(3) Definitions.--In this subsection:
(A) Nursing facility.--The term ``nursing
facility'' has the meaning given such term in section
1919(a) of the Social Security Act (42 U.S.C.
1396r(a)).
(B) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(C) Skilled nursing facility.--The term ``skilled
nursing facility'' has the meaning given such term in
section 1819(a) of the Social Security Act (42 U.S.C.
1395i-3(a)).
(e) Development of Consumer Rights Information Page on Nursing Home
Compare Website.--Not later than 1 year after the date of enactment of
this Act, the Secretary shall ensure that the Department of Health and
Human Services, as part of the information provided for comparison of
nursing facilities on the Nursing Home Compare Medicare website
develops and includes a consumer rights information page that contains
links to descriptions of, and information with respect to, the
following:
(1) The documentation on nursing facilities that is
available to the public.
(2) General information and tips on choosing a nursing
facility that meets the needs of the individual.
(3) General information on consumer rights with respect to
nursing facilities.
(4) The nursing facility survey process (on a national and
State-specific basis).
(5) On a State-specific basis, the services available
through the State long-term care ombudsman for such State.
SEC. 6104. REPORTING OF EXPENDITURES.
Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is
amended by adding at the end the following new subsection:
``(f) Reporting of Direct Care Expenditures.--
``(1) In general.--For cost reports submitted under this
title for cost reporting periods beginning on or after the date
that is 2 years after the date of the enactment of this
subsection, skilled nursing facilities shall separately report
expenditures for wages and benefits for direct care staff
(breaking out (at a minimum) registered nurses, licensed
professional nurses, certified nurse assistants, and other
medical and therapy staff).
``(2) Modification of form.--The Secretary, in consultation
with private sector accountants experienced with Medicare and
Medicaid nursing facility home cost reports, shall redesign
such reports to meet the requirement of paragraph (1) not later
than 1 year after the date of the enactment of this subsection.
``(3) Categorization by functional accounts.--Not later
than 30 months after the date of the enactment of this
subsection, the Secretary, working in consultation with the
Medicare Payment Advisory Commission, the Medicaid and CHIP
Payment and Access Commission, the Inspector General of the
Department of Health and Human Services, and other expert
parties the Secretary determines appropriate, shall take the
expenditures listed on cost reports, as modified under
paragraph (1), submitted by skilled nursing facilities and
categorize such expenditures, regardless of any source of
payment for such expenditures, for each skilled nursing
facility into the following functional accounts on an annual
basis:
``(A) Spending on direct care services (including
nursing, therapy, and medical services).
``(B) Spending on indirect care (including
housekeeping and dietary services).
``(C) Capital assets (including building and land
costs).
``(D) Administrative services costs.
``(4) Availability of information submitted.--The Secretary
shall establish procedures to make information on expenditures
submitted under this subsection readily available to interested
parties upon request, subject to such requirements as the
Secretary may specify under the procedures established under
this paragraph.''.
SEC. 6105. STANDARDIZED COMPLAINT FORM.
(a) In General.--Section 1128I of the Social Security Act, as added
and amended by this Act, is amended by adding at the end the following
new subsection:
``(f) Standardized Complaint Form.--
``(1) Development by the secretary.--The Secretary shall
develop a standardized complaint form for use by a resident (or
a person acting on the resident's behalf) in filing a complaint
with a State survey and certification agency and a State long-
term care ombudsman program with respect to a facility.
``(2) Complaint forms and resolution processes.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under paragraph
(1) available upon request to--
``(i) a resident of a facility; and
``(ii) any person acting on the resident's
behalf.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to
ensure that the legal representative of a resident of a
facility or other responsible party is not denied
access to such resident or otherwise retaliated against
if they have complained about the quality of care
provided by the facility or other issues relating to
the facility. Such complaint resolution process shall
include--
``(i) procedures to assure accurate
tracking of complaints received, including
notification to the complainant that a
complaint has been received;
``(ii) procedures to determine the likely
severity of a complaint and for the
investigation of the complaint; and
``(iii) deadlines for responding to a
complaint and for notifying the complainant of
the outcome of the investigation.
``(3) Rule of construction.--Nothing in this subsection
shall be construed as preventing a resident of a facility (or a
person acting on the resident's behalf) from submitting a
complaint in a manner or format other than by using the
standardized complaint form developed under paragraph (1)
(including submitting a complaint orally).''.
(b) Effective Date.--The amendment made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 6106. ENSURING STAFFING ACCOUNTABILITY.
Section 1128I of the Social Security Act, as added and amended by
this Act, is amended by adding at the end the following new subsection:
``(g) Submission of Staffing Information Based on Payroll Data in a
Uniform Format.--Beginning not later than 2 years after the date of the
enactment of this subsection, and after consulting with State long-term
care ombudsman programs, consumer advocacy groups, provider stakeholder
groups, employees and their representatives, and other parties the
Secretary deems appropriate, the Secretary shall require a facility to
electronically submit to the Secretary direct care staffing information
(including information with respect to agency and contract staff) based
on payroll and other verifiable and auditable data in a uniform format
(according to specifications established by the Secretary in
consultation with such programs, groups, and parties). Such
specifications shall require that the information submitted under the
preceding sentence--
``(1) specify the category of work a certified employee
performs (such as whether the employee is a registered nurse,
licensed practical nurse, licensed vocational nurse, certified
nursing assistant, therapist, or other medical personnel);
``(2) include resident census data and information on
resident case mix;
``(3) include a regular reporting schedule; and
``(4) include information on employee turnover and tenure
and on the hours of care provided by each category of certified
employees referenced in paragraph (1) per resident per day.
Nothing in this subsection shall be construed as preventing the
Secretary from requiring submission of such information with respect to
specific categories, such as nursing staff, before other categories of
certified employees. Information under this subsection with respect to
agency and contract staff shall be kept separate from information on
employee staffing.''.
SEC. 6107. GAO STUDY AND REPORT ON FIVE-STAR QUALITY RATING SYSTEM.
(a) Study.--The Comptroller General of the United States (in this
section referred to as the ``Comptroller General'') shall conduct a
study on the Five-Star Quality Rating System for nursing homes of the
Centers for Medicare & Medicaid Services. Such study shall include an
analysis of--
(1) how such system is being implemented;
(2) any problems associated with such system or its
implementation; and
(3) how such system could be improved.
(b) Report.--Not later than 2 years after the date of enactment of
this Act, the Comptroller General shall submit to Congress a report
containing the results of the study conducted under subsection (a),
together with recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
PART II--TARGETING ENFORCEMENT
SEC. 6111. CIVIL MONEY PENALTIES.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(h)(2)(B)(ii) of the Social
Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended--
(A) by striking ``Penalties.--The Secretary'' and
inserting ``penalties.--
``(I) In general.--Subject to
subclause (II), the Secretary''; and
(B) by adding at the end the following new
subclauses:
``(II) Reduction of civil money
penalties in certain circumstances.--
Subject to subclause (III), in the case
where a facility self-reports and
promptly corrects a deficiency for
which a penalty was imposed under this
clause not later than 10 calendar days
after the date of such imposition, the
Secretary may reduce the amount of the
penalty imposed by not more than 50
percent.
``(III) Prohibitions on reduction
for certain deficiencies.--
``(aa) Repeat
deficiencies.--The Secretary
may not reduce the amount of a
penalty under subclause (II) if
the Secretary had reduced a
penalty imposed on the facility
in the preceding year under
such subclause with respect to
a repeat deficiency.
``(bb) Certain other
deficiencies.--The Secretary
may not reduce the amount of a
penalty under subclause (II) if
the penalty is imposed on the
facility for a deficiency that
is found to result in a pattern
of harm or widespread harm,
immediately jeopardizes the
health or safety of a resident
or residents of the facility,
or results in the death of a
resident of the facility.
``(IV) Collection of civil money
penalties.--In the case of a civil
money penalty imposed under this
clause, the Secretary shall issue
regulations that--
``(aa) subject to item
(cc), not later than 30 days
after the imposition of the
penalty, provide for the
facility to have the
opportunity to participate in
an independent informal dispute
resolution process which
generates a written record
prior to the collection of such
penalty;
``(bb) in the case where
the penalty is imposed for each
day of noncompliance, provide
that a penalty may not be
imposed for any day during the
period beginning on the initial
day of the imposition of the
penalty and ending on the day
on which the informal dispute
resolution process under item
(aa) is completed;
``(cc) may provide for the
collection of such civil money
penalty and the placement of
such amounts collected in an
escrow account under the
direction of the Secretary on
the earlier of the date on
which the informal dispute
resolution process under item
(aa) is completed or the date
that is 90 days after the date
of the imposition of the
penalty;
``(dd) may provide that
such amounts collected are kept
in such account pending the
resolution of any subsequent
appeals;
``(ee) in the case where
the facility successfully
appeals the penalty, may
provide for the return of such
amounts collected (plus
interest) to the facility; and
``(ff) in the case where
all such appeals are
unsuccessful, may provide that
some portion of such amounts
collected may be used to
support activities that benefit
residents, including assistance
to support and protect
residents of a facility that
closes (voluntarily or
involuntarily) or is
decertified (including
offsetting costs of relocating
residents to home and
community-based settings or
another facility), projects
that support resident and
family councils and other
consumer involvement in
assuring quality care in
facilities, and facility
improvement initiatives
approved by the Secretary
(including joint training of
facility staff and surveyors,
technical assistance for
facilities implementing quality
assurance programs, the
appointment of temporary
management firms, and other
activities approved by the
Secretary).''.
(2) Conforming amendment.--The second sentence of section
1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-3(h)(5))
is amended by inserting ``(ii)(IV),'' after ``(i),''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(h)(3)(C)(ii) of the Social
Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended--
(A) by striking ``Penalties.--The Secretary'' and
inserting ``penalties.--
``(I) In general.--Subject to
subclause (II), the Secretary''; and
(B) by adding at the end the following new
subclauses:
``(II) Reduction of civil money
penalties in certain circumstances.--
Subject to subclause (III), in the case
where a facility self-reports and
promptly corrects a deficiency for
which a penalty was imposed under this
clause not later than 10 calendar days
after the date of such imposition, the
Secretary may reduce the amount of the
penalty imposed by not more than 50
percent.
``(III) Prohibitions on reduction
for certain deficiencies.--
``(aa) Repeat
deficiencies.--The Secretary
may not reduce the amount of a
penalty under subclause (II) if
the Secretary had reduced a
penalty imposed on the facility
in the preceding year under
such subclause with respect to
a repeat deficiency.
``(bb) Certain other
deficiencies.--The Secretary
may not reduce the amount of a
penalty under subclause (II) if
the penalty is imposed on the
facility for a deficiency that
is found to result in a pattern
of harm or widespread harm,
immediately jeopardizes the
health or safety of a resident
or residents of the facility,
or results in the death of a
resident of the facility.
``(IV) Collection of civil money
penalties.--In the case of a civil
money penalty imposed under this
clause, the Secretary shall issue
regulations that--
``(aa) subject to item
(cc), not later than 30 days
after the imposition of the
penalty, provide for the
facility to have the
opportunity to participate in
an independent informal dispute
resolution process which
generates a written record
prior to the collection of such
penalty;
``(bb) in the case where
the penalty is imposed for each
day of noncompliance, provide
that a penalty may not be
imposed for any day during the
period beginning on the initial
day of the imposition of the
penalty and ending on the day
on which the informal dispute
resolution process under item
(aa) is completed;
``(cc) may provide for the
collection of such civil money
penalty and the placement of
such amounts collected in an
escrow account under the
direction of the Secretary on
the earlier of the date on
which the informal dispute
resolution process under item
(aa) is completed or the date
that is 90 days after the date
of the imposition of the
penalty;
``(dd) may provide that
such amounts collected are kept
in such account pending the
resolution of any subsequent
appeals;
``(ee) in the case where
the facility successfully
appeals the penalty, may
provide for the return of such
amounts collected (plus
interest) to the facility; and
``(ff) in the case where
all such appeals are
unsuccessful, may provide that
some portion of such amounts
collected may be used to
support activities that benefit
residents, including assistance
to support and protect
residents of a facility that
closes (voluntarily or
involuntarily) or is
decertified (including
offsetting costs of relocating
residents to home and
community-based settings or
another facility), projects
that support resident and
family councils and other
consumer involvement in
assuring quality care in
facilities, and facility
improvement initiatives
approved by the Secretary
(including joint training of
facility staff and surveyors,
technical assistance for
facilities implementing quality
assurance programs, the
appointment of temporary
management firms, and other
activities approved by the
Secretary).''.
(2) Conforming amendment.--Section 1919(h)(5)(8) of the
Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by
inserting ``(ii)(IV),'' after ``(i),''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 6112. NATIONAL INDEPENDENT MONITOR DEMONSTRATION PROJECT.
(a) Establishment.--
(1) In general.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall conduct a demonstration project to develop,
test, and implement an independent monitor program to oversee
interstate and large intrastate chains of skilled nursing
facilities and nursing facilities.
(2) Selection.--The Secretary shall select chains of
skilled nursing facilities and nursing facilities described in
paragraph (1) to participate in the demonstration project under
this section from among those chains that submit an application
to the Secretary at such time, in such manner, and containing
such information as the Secretary may require.
(3) Duration.--The Secretary shall conduct the
demonstration project under this section for a 2-year period.
(4) Implementation.--The Secretary shall implement the
demonstration project under this section not later than 1 year
after the date of the enactment of this Act.
(b) Requirements.--The Secretary shall evaluate chains selected to
participate in the demonstration project under this section based on
criteria selected by the Secretary, including where evidence suggests
that a number of the facilities of the chain are experiencing serious
safety and quality of care problems. Such criteria may include the
evaluation of a chain that includes a number of facilities
participating in the ``Special Focus Facility'' program (or a successor
program) or multiple facilities with a record of repeated serious
safety and quality of care deficiencies.
(c) Responsibilities.--An independent monitor that enters into a
contract with the Secretary to participate in the conduct of the
demonstration project under this section shall--
(1) conduct periodic reviews and prepare root-cause quality
and deficiency analyses of a chain to assess if facilities of
the chain are in compliance with State and Federal laws and
regulations applicable to the facilities;
(2) conduct sustained oversight of the efforts of the
chain, whether publicly or privately held, to achieve
compliance by facilities of the chain with State and Federal
laws and regulations applicable to the facilities;
(3) analyze the management structure, distribution of
expenditures, and nurse staffing levels of facilities of the
chain in relation to resident census, staff turnover rates, and
tenure;
(4) report findings and recommendations with respect to
such reviews, analyses, and oversight to the chain and
facilities of the chain, to the Secretary, and to relevant
States; and
(5) publish the results of such reviews, analyses, and
oversight.
(d) Implementation of Recommendations.--
(1) Receipt of finding by chain.--Not later than 10 days
after receipt of a finding of an independent monitor under
subsection (c)(4), a chain participating in the demonstration
project shall submit to the independent monitor a report--
(A) outlining corrective actions the chain will
take to implement the recommendations in such report;
or
(B) indicating that the chain will not implement
such recommendations, and why it will not do so.
(2) Receipt of report by independent monitor.--Not later
than 10 days after receipt of a report submitted by a chain
under paragraph (1), an independent monitor shall finalize its
recommendations and submit a report to the chain and facilities
of the chain, the Secretary, and the State or States, as
appropriate, containing such final recommendations.
(e) Cost of Appointment.--A chain shall be responsible for a
portion of the costs associated with the appointment of independent
monitors under the demonstration project under this section. The chain
shall pay such portion to the Secretary (in an amount and in accordance
with procedures established by the Secretary).
(f) Waiver Authority.--The Secretary may waive such requirements of
titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et
seq.; 1396 et seq.) as may be necessary for the purpose of carrying out
the demonstration project under this section.
(g) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary to carry out this section.
(h) Definitions.--In this section:
(1) Additional disclosable party.--The term ``additional
disclosable party'' has the meaning given such term in section
1124(c)(5)(A) of the Social Security Act, as added by section
4201(a).
(2) Facility.--The term ``facility'' means a skilled
nursing facility or a nursing facility.
(3) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Assistant
Secretary for Planning and Evaluation.
(5) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(i) Evaluation and Report.--
(1) Evaluation.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall evaluate the demonstration project conducted
under this section.
(2) Report.--Not later than 180 days after the completion
of the demonstration project under this section, the Secretary
shall submit to Congress a report containing the results of the
evaluation conducted under paragraph (1), together with
recommendations--
(A) as to whether the independent monitor program
should be established on a permanent basis;
(B) if the Secretary recommends that such program
be so established, on appropriate procedures and
mechanisms for such establishment; and
(C) for such legislation and administrative action
as the Secretary determines appropriate.
SEC. 6113. NOTIFICATION OF FACILITY CLOSURE.
(a) In General.--Section 1128I of the Social Security Act, as added
and amended by this Act, is amended by adding at the end the following
new subsection:
``(h) Notification of Facility Closure.--
``(1) In general.--Any individual who is the administrator
of a facility must--
``(A) submit to the Secretary, the State long-term
care ombudsman, residents of the facility, and the
legal representatives of such residents or other
responsible parties, written notification of an
impending closure--
``(i) subject to clause (ii), not later
than the date that is 60 days prior to the date
of such closure; and
``(ii) in the case of a facility where the
Secretary terminates the facility's
participation under this title, not later than
the date that the Secretary determines
appropriate;
``(B) ensure that the facility does not admit any
new residents on or after the date on which such
written notification is submitted; and
``(C) include in the notice a plan for the transfer
and adequate relocation of the residents of the
facility by a specified date prior to closure that has
been approved by the State, including assurances that
the residents will be transferred to the most
appropriate facility or other setting in terms of
quality, services, and location, taking into
consideration the needs, choice, and best interests of
each resident.
``(2) Relocation.--
``(A) In general.--The State shall ensure that,
before a facility closes, all residents of the facility
have been successfully relocated to another facility or
an alternative home and community-based setting.
``(B) Continuation of payments until residents
relocated.--The Secretary may, as the Secretary
determines appropriate, continue to make payments under
this title with respect to residents of a facility that
has submitted a notification under paragraph (1) during
the period beginning on the date such notification is
submitted and ending on the date on which the resident
is successfully relocated.
``(3) Sanctions.--Any individual who is the administrator
of a facility that fails to comply with the requirements of
paragraph (1)--
``(A) shall be subject to a civil monetary penalty
of up to $100,000;
``(B) may be subject to exclusion from
participation in any Federal health care program (as
defined in section 1128B(f)); and
``(C) shall be subject to any other penalties that
may be prescribed by law.
``(4) Procedure.--The provisions of section 1128A (other
than subsections (a) and (b) and the second sentence of
subsection (f)) shall apply to a civil money penalty or
exclusion under paragraph (3) in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).''.
(b) Conforming Amendments.--Section 1819(h)(4) of the Social
Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
(1) in the first sentence, by striking ``the Secretary
shall terminate'' and inserting ``the Secretary, subject to
section 1128I(h), shall terminate''; and
(2) in the second sentence, by striking ``subsection
(c)(2)'' and inserting ``subsection (c)(2) and section
1128I(h)''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 6114. NATIONAL DEMONSTRATION PROJECTS ON CULTURE CHANGE AND USE OF
INFORMATION TECHNOLOGY IN NURSING HOMES.
(a) In General.--The Secretary shall conduct 2 demonstration
projects, 1 for the development of best practices in skilled nursing
facilities and nursing facilities that are involved in the culture
change movement (including the development of resources for facilities
to find and access funding in order to undertake culture change) and 1
for the development of best practices in skilled nursing facilities and
nursing facilities for the use of information technology to improve
resident care.
(b) Conduct of Demonstration Projects.--
(1) Grant award.--Under each demonstration project
conducted under this section, the Secretary shall award 1 or
more grants to facility-based settings for the development of
best practices described in subsection (a) with respect to the
demonstration project involved. Such award shall be made on a
competitive basis and may be allocated in 1 lump-sum payment.
(2) Consideration of special needs of residents.--Each
demonstration project conducted under this section shall take
into consideration the special needs of residents of skilled
nursing facilities and nursing facilities who have cognitive
impairment, including dementia.
(c) Duration and Implementation.--
(1) Duration.--The demonstration projects shall each be
conducted for a period not to exceed 3 years.
(2) Implementation.--The demonstration projects shall each
be implemented not later than 1 year after the date of the
enactment of this Act.
(d) Definitions.--In this section:
(1) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(2) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(3) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(e) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary to carry out this section.
(f) Report.--Not later than 9 months after the completion of the
demonstration project, the Secretary shall submit to Congress a report
on such project, together with recommendations for such legislation and
administrative action as the Secretary determines appropriate.
PART III--IMPROVING STAFF TRAINING
SEC. 6121. DEMENTIA AND ABUSE PREVENTION TRAINING.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(f)(2)(A)(i)(I) of the Social
Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by
inserting ``(including, in the case of initial training and, if
the Secretary determines appropriate, in the case of ongoing
training, dementia management training, and patient abuse
prevention training'' before ``, (II)''.
(2) Clarification of definition of nurse aide.--Section
1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i-
3(b)(5)(F)) is amended by adding at the end the following flush
sentence:
``Such term includes an individual who provides such
services through an agency or under a contract with the
facility.''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(f)(2)(A)(i)(I) of the Social
Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by
inserting ``(including, in the case of initial training and, if
the Secretary determines appropriate, in the case of ongoing
training, dementia management training, and patient abuse
prevention training'' before ``, (II)''.
(2) Clarification of definition of nurse aide.--Section
1919(b)(5)(F) of the Social Security Act (42 U.S.C.
1396r(b)(5)(F)) is amended by adding at the end the following
flush sentence:
``Such term includes an individual who provides such
services through an agency or under a contract with the
facility.''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
Subtitle C--Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and
Providers
SEC. 6201. NATIONWIDE PROGRAM FOR NATIONAL AND STATE BACKGROUND CHECKS
ON DIRECT PATIENT ACCESS EMPLOYEES OF LONG-TERM CARE
FACILITIES AND PROVIDERS.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary''), shall establish a
program to identify efficient, effective, and economical procedures for
long term care facilities or providers to conduct background checks on
prospective direct patient access employees on a nationwide basis (in
this subsection, such program shall be referred to as the ``nationwide
program''). Except for the following modifications, the Secretary shall
carry out the nationwide program under similar terms and conditions as
the pilot program under section 307 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-173; 117
Stat. 2257), including the prohibition on hiring abusive workers and
the authorization of the imposition of penalties by a participating
State under subsection (b)(3)(A) and (b)(6), respectively, of such
section 307:
(1) Agreements.--
(A) Newly participating states.--The Secretary
shall enter into agreements with each State--
(i) that the Secretary has not entered into
an agreement with under subsection (c)(1) of
such section 307;
(ii) that agrees to conduct background
checks under the nationwide program on a
Statewide basis; and
(iii) that submits an application to the
Secretary containing such information and at
such time as the Secretary may specify.
(B) Certain previously participating states.--The
Secretary shall enter into agreements with each State--
(i) that the Secretary has entered into an
agreement with under such subsection (c)(1),
but only in the case where such agreement did
not require the State to conduct background
checks under the program established under
subsection (a) of such section 307 on a
Statewide basis;
(ii) that agrees to conduct background
checks under the nationwide program on a
Statewide basis; and
(iii) that submits an application to the
Secretary containing such information and at
such time as the Secretary may specify.
(2) Nonapplication of selection criteria.--The selection
criteria required under subsection (c)(3)(B) of such section
307 shall not apply.
(3) Required fingerprint check as part of criminal history
background check.--The procedures established under subsection
(b)(1) of such section 307 shall--
(A) require that the long-term care facility or
provider (or the designated agent of the long-term care
facility or provider) obtain State and national
criminal history background checks on the prospective
employee through such means as the Secretary determines
appropriate, efficient, and effective that utilize a
search of State-based abuse and neglect registries and
databases, including the abuse and neglect registries
of another State in the case where a prospective
employee previously resided in that State, State
criminal history records, the records of any
proceedings in the State that may contain disqualifying
information about prospective employees (such as
proceedings conducted by State professional licensing
and disciplinary boards and State Medicaid Fraud
Control Units), and Federal criminal history records,
including a fingerprint check using the Integrated
Automated Fingerprint Identification System of the
Federal Bureau of Investigation;
(B) require States to describe and test methods
that reduce duplicative fingerprinting, including
providing for the development of ``rap back''
capability by the State such that, if a direct patient
access employee of a long-term care facility or
provider is convicted of a crime following the initial
criminal history background check conducted with
respect to such employee, and the employee's
fingerprints match the prints on file with the State
law enforcement department, the department will
immediately inform the State and the State will
immediately inform the long-term care facility or
provider which employs the direct patient access
employee of such conviction; and
(C) require that criminal history background checks
conducted under the nationwide program remain valid for
a period of time specified by the Secretary.
(4) State requirements.--An agreement entered into under
paragraph (1) shall require that a participating State--
(A) be responsible for monitoring compliance with
the requirements of the nationwide program;
(B) have procedures in place to--
(i) conduct screening and criminal history
background checks under the nationwide program
in accordance with the requirements of this
section;
(ii) monitor compliance by long-term care
facilities and providers with the procedures
and requirements of the nationwide program;
(iii) as appropriate, provide for a
provisional period of employment by a long-term
care facility or provider of a direct patient
access employee, not to exceed 60 days, pending
completion of the required criminal history
background check and, in the case where the
employee has appealed the results of such
background check, pending completion of the
appeals process, during which the employee
shall be subject to direct on-site supervision
(in accordance with procedures established by
the State to ensure that a long-term care
facility or provider furnishes such direct on-
site supervision);
(iv) provide an independent process by
which a provisional employee or an employee may
appeal or dispute the accuracy of the
information obtained in a background check
performed under the nationwide program,
including the specification of criteria for
appeals for direct patient access employees
found to have disqualifying information which
shall include consideration of the passage of
time, extenuating circumstances, demonstration
of rehabilitation, and relevancy of the
particular disqualifying information with
respect to the current employment of the
individual;
(v) provide for the designation of a single
State agency as responsible for--
(I) overseeing the coordination of
any State and national criminal history
background checks requested by a long-
term care facility or provider (or the
designated agent of the long-term care
facility or provider) utilizing a
search of State and Federal criminal
history records, including a
fingerprint check of such records;
(II) overseeing the design of
appropriate privacy and security
safeguards for use in the review of the
results of any State or national
criminal history background checks
conducted regarding a prospective
direct patient access employee to
determine whether the employee has any
conviction for a relevant crime;
(III) immediately reporting to the
long-term care facility or provider
that requested the criminal history
background check the results of such
review; and
(IV) in the case of an employee
with a conviction for a relevant crime
that is subject to reporting under
section 1128E of the Social Security
Act (42 U.S.C. 1320a-7e), reporting the
existence of such conviction to the
database established under that
section;
(vi) determine which individuals are direct
patient access employees (as defined in
paragraph (6)(B)) for purposes of the
nationwide program;
(vii) as appropriate, specify offenses,
including convictions for violent crimes, for
purposes of the nationwide program; and
(viii) describe and test methods that
reduce duplicative fingerprinting, including
providing for the development of ``rap back''
capability such that, if a direct patient
access employee of a long-term care facility or
provider is convicted of a crime following the
initial criminal history background check
conducted with respect to such employee, and
the employee's fingerprints match the prints on
file with the State law enforcement
department--
(I) the department will immediately
inform the State agency designated
under clause (v) and such agency will
immediately inform the facility or
provider which employs the direct
patient access employee of such
conviction; and
(II) the State will provide, or
will require the facility to provide,
to the employee a copy of the results
of the criminal history background
check conducted with respect to the
employee at no charge in the case where
the individual requests such a copy.
(5) Payments.--
(A) Newly participating states.--
(i) In general.--As part of the application
submitted by a State under paragraph
(1)(A)(iii), the State shall guarantee, with
respect to the costs to be incurred by the
State in carrying out the nationwide program,
that the State will make available (directly or
through donations from public or private
entities) a particular amount of non-Federal
contributions, as a condition of receiving the
Federal match under clause (ii).
(ii) Federal match.--The payment amount to
each State that the Secretary enters into an
agreement with under paragraph (1)(A) shall be
3 times the amount that the State guarantees to
make available under clause (i), except that in
no case may the payment amount exceed
$3,000,000.
(B) Previously participating states.--
(i) In general.--As part of the application
submitted by a State under paragraph
(1)(B)(iii), the State shall guarantee, with
respect to the costs to be incurred by the
State in carrying out the nationwide program,
that the State will make available (directly or
through donations from public or private
entities) a particular amount of non-Federal
contributions, as a condition of receiving the
Federal match under clause (ii).
(ii) Federal match.--The payment amount to
each State that the Secretary enters into an
agreement with under paragraph (1)(B) shall be
3 times the amount that the State guarantees to
make available under clause (i), except that in
no case may the payment amount exceed
$1,500,000.
(6) Definitions.--Under the nationwide program:
(A) Conviction for a relevant crime.--The term
``conviction for a relevant crime'' means any Federal
or State criminal conviction for--
(i) any offense described in section
1128(a) of the Social Security Act (42 U.S.C.
1320a-7); or
(ii) such other types of offenses as a
participating State may specify for purposes of
conducting the program in such State.
(B) Disqualifying information.--The term
``disqualifying information'' means a conviction for a
relevant crime or a finding of patient or resident
abuse.
(C) Finding of patient or resident abuse.--The term
``finding of patient or resident abuse'' means any
substantiated finding by a State agency under section
1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security
Act (42 U.S.C. 1395i-3(g)(1)(C), 1396r(g)(1)(C)) or a
Federal agency that a direct patient access employee
has committed--
(i) an act of patient or resident abuse or
neglect or a misappropriation of patient or
resident property; or
(ii) such other types of acts as a
participating State may specify for purposes of
conducting the program in such State.
(D) Direct patient access employee.--The term
``direct patient access employee'' means any individual
who has access to a patient or resident of a long-term
care facility or provider through employment or through
a contract with such facility or provider and has
duties that involve (or may involve) one-on-one contact
with a patient or resident of the facility or provider,
as determined by the State for purposes of the
nationwide program. Such term does not include a
volunteer unless the volunteer has duties that are
equivalent to the duties of a direct patient access
employee and those duties involve (or may involve) one-
on-one contact with a patient or resident of the long-
term care facility or provider.
(E) Long-term care facility or provider.--The term
``long-term care facility or provider'' means the
following facilities or providers which receive payment
for services under title XVIII or XIX of the Social
Security Act:
(i) A skilled nursing facility (as defined
in section 1819(a) of the Social Security Act
(42 U.S.C. 1395i-3(a))).
(ii) A nursing facility (as defined in
section 1919(a) of such Act (42 U.S.C.
1396r(a))).
(iii) A home health agency.
(iv) A provider of hospice care (as defined
in section 1861(dd)(1) of such Act (42 U.S.C.
1395x(dd)(1))).
(v) A long-term care hospital (as described
in section 1886(d)(1)(B)(iv) of such Act (42
U.S.C. 1395ww(d)(1)(B)(iv))).
(vi) A provider of personal care services.
(vii) A provider of adult day care.
(viii) A residential care provider that
arranges for, or directly provides, long-term
care services, including an assisted living
facility that provides a level of care
established by the Secretary.
(ix) An intermediate care facility for the
mentally retarded (as defined in section
1905(d) of such Act (42 U.S.C. 1396d(d))).
(x) Any other facility or provider of long-
term care services under such titles as the
participating State determines appropriate.
(7) Evaluation and report.--
(A) Evaluation.--
(i) In general.--The Inspector General of
the Department of Health and Human Services
shall conduct an evaluation of the nationwide
program.
(ii) Inclusion of specific topics.--The
evaluation conducted under clause (i) shall
include the following:
(I) A review of the various
procedures implemented by participating
States for long-term care facilities or
providers, including staffing agencies,
to conduct background checks of direct
patient access employees under the
nationwide program and identification
of the most appropriate, efficient, and
effective procedures for conducting
such background checks.
(II) An assessment of the costs of
conducting such background checks
(including start up and administrative
costs).
(III) A determination of the extent
to which conducting such background
checks leads to any unintended
consequences, including a reduction in
the available workforce for long-term
care facilities or providers.
(IV) An assessment of the impact of
the nationwide program on reducing the
number of incidents of neglect, abuse,
and misappropriation of resident
property to the extent practicable.
(V) An evaluation of other aspects
of the nationwide program, as
determined appropriate by the
Secretary.
(B) Report.--Not later than 180 days after the
completion of the nationwide program, the Inspector
General of the Department of Health and Human Services
shall submit a report to Congress containing the
results of the evaluation conducted under subparagraph
(A).
(b) Funding.--
(1) Notification.--The Secretary of Health and Human
Services shall notify the Secretary of the Treasury of the
amount necessary to carry out the nationwide program under this
section for the period of fiscal years 2010 through 2012,
except that in no case shall such amount exceed $160,000,000.
(2) Transfer of funds.--
(A) In general.--Out of any funds in the Treasury
not otherwise appropriated, the Secretary of the
Treasury shall provide for the transfer to the
Secretary of Health and Human Services of the amount
specified as necessary to carry out the nationwide
program under paragraph (1). Such amount shall remain
available until expended.
(B) Reservation of funds for conduct of
evaluation.--The Secretary may reserve not more than
$3,000,000 of the amount transferred under subparagraph
(A) to provide for the conduct of the evaluation under
subsection (a)(7)(A).
Subtitle D--Patient-Centered Outcomes Research
SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH.
(a) In General.--Title XI of the Social Security Act (42 U.S.C.
1301 et seq.) is amended by adding at the end the following new part:
``Part D--Comparative Clinical Effectiveness Research
``comparative clinical effectiveness research
``Sec. 1181. (a) Definitions.--In this section:
``(1) Board.--The term `Board' means the Board of Governors
established under subsection (f).
``(2) Comparative clinical effectiveness research;
research.--
``(A) In general.--The terms `comparative clinical
effectiveness research' and `research' mean research
evaluating and comparing health outcomes and the
clinical effectiveness, risks, and benefits of 2 or
more medical treatments, services, and items described
in subparagraph (B).
``(B) Medical treatments, services, and items
described.--The medical treatments, services, and items
described in this subparagraph are health care
interventions, protocols for treatment, care
management, and delivery, procedures, medical devices,
diagnostic tools, pharmaceuticals (including drugs and
biologicals), integrative health practices, and any
other strategies or items being used in the treatment,
management, and diagnosis of, or prevention of illness
or injury in, individuals.
``(3) Conflict of interest.--The term `conflict of
interest' means an association, including a financial or
personal association, that have the potential to bias or have
the appearance of biasing an individual's decisions in matters
related to the Institute or the conduct of activities under
this section.
``(4) Real conflict of interest.--The term `real conflict
of interest' means any instance where a member of the Board,
the methodology committee established under subsection (d)(6),
or an advisory panel appointed under subsection (d)(4), or a
close relative of such member, has received or could receive
either of the following:
``(A) A direct financial benefit of any amount
deriving from the result or findings of a study
conducted under this section.
``(B) A financial benefit from individuals or
companies that own or manufacture medical treatments,
services, or items to be studied under this section
that in the aggregate exceeds $10,000 per year. For
purposes of the preceding sentence, a financial benefit
includes honoraria, fees, stock, or other financial
benefit and the current value of the member or close
relative's already existing stock holdings, in addition
to any direct financial benefit deriving from the
results or findings of a study conducted under this
section.
``(b) Patient-Centered Outcomes Research Institute.--
``(1) Establishment.--There is authorized to be established
a nonprofit corporation, to be known as the `Patient-Centered
Outcomes Research Institute' (referred to in this section as
the `Institute') which is neither an agency nor establishment
of the United States Government.
``(2) Application of provisions.--The Institute shall be
subject to the provisions of this section, and, to the extent
consistent with this section, to the District of Columbia
Nonprofit Corporation Act.
``(3) Funding of comparative clinical effectiveness
research.--For fiscal year 2010 and each subsequent fiscal
year, amounts in the Patient-Centered Outcomes Research Trust
Fund (referred to in this section as the `PCORTF') under
section 9511 of the Internal Revenue Code of 1986 shall be
available, without further appropriation, to the Institute to
carry out this section.
``(c) Purpose.--The purpose of the Institute is to assist patients,
clinicians, purchasers, and policy-makers in making informed health
decisions by advancing the quality and relevance of evidence concerning
the manner in which diseases, disorders, and other health conditions
can effectively and appropriately be prevented, diagnosed, treated,
monitored, and managed through research and evidence synthesis that
considers variations in patient subpopulations, and the dissemination
of research findings with respect to the relative health outcomes,
clinical effectiveness, and appropriateness of the medical treatments,
services, and items described in subsection (a)(2)(B).
``(d) Duties.--
``(1) Identifying research priorities and establishing
research project agenda.--
``(A) Identifying research priorities.--The
Institute shall identify national priorities for
research, taking into account factors of disease
incidence, prevalence, and burden in the United States
(with emphasis on chronic conditions), gaps in evidence
in terms of clinical outcomes, practice variations and
health disparities in terms of delivery and outcomes of
care, the potential for new evidence to improve patient
health, well-being, and the quality of care, the effect
on national expenditures associated with a health care
treatment, strategy, or health conditions, as well as
patient needs, outcomes, and preferences, the relevance
to patients and clinicians in making informed health
decisions, and priorities in the National Strategy for
quality care established under section 399H of the
Public Health Service Act that are consistent with this
section.
``(B) Establishing research project agenda.--The
Institute shall establish and update a research project
agenda for research to address the priorities
identified under subparagraph (A), taking into
consideration the types of research that might address
each priority and the relative value (determined based
on the cost of conducting research compared to the
potential usefulness of the information produced by
research) associated with the different types of
research, and such other factors as the Institute
determines appropriate.
``(2) Carrying out research project agenda.--
``(A) Research.--The Institute shall carry out the
research project agenda established under paragraph
(1)(B) in accordance with the methodological standards
adopted under paragraph (9) using methods, including
the following:
``(i) Systematic reviews and assessments of
existing and future research and evidence
including original research conducted
subsequent to the date of the enactment of this
section.
``(ii) Primary research, such as randomized
clinical trials, molecularly informed trials,
and observational studies.
``(iii) Any other methodologies recommended
by the methodology committee established under
paragraph (6) that are adopted by the Board
under paragraph (9).
``(B) Contracts for the management of funding and
conduct of research.--
``(i) Contracts.--
``(I) In general.--In accordance
with the research project agenda
established under paragraph (1)(B), the
Institute shall enter into contracts
for the management of funding and
conduct of research in accordance with
the following:
``(aa) Appropriate agencies
and instrumentalities of the
Federal Government.
``(bb) Appropriate academic
research, private sector
research, or study-conducting
entities.
``(II) Preference.--In entering
into contracts under subclause (I), the
Institute shall give preference to the
Agency for Healthcare Research and
Quality and the National Institutes of
Health, but only if the research to be
conducted or managed under such
contract is authorized by the governing
statutes of such Agency or Institutes.
``(ii) Conditions for contracts.--A
contract entered into under this subparagraph
shall require that the agency, instrumentality,
or other entity--
``(I) abide by the transparency and
conflicts of interest requirements
under subsection (h) that apply to the
Institute with respect to the research
managed or conducted under such
contract;
``(II) comply with the
methodological standards adopted under
paragraph (9) with respect to such
research;
``(III) consult with the expert
advisory panels for clinical trials and
rare disease appointed under clauses
(ii) and (iii), respectively, of
paragraph (4)(A);
``(IV) subject to clause (iv),
permit a researcher who conducts
original research under the contract
for the agency, instrumentality, or
other entity to have such research
published in a peer-reviewed journal or
other publication;
``(V) have appropriate processes in
place to manage data privacy and meet
ethical standards for the research;
``(VI) comply with the requirements
of the Institute for making the
information available to the public
under paragraph (8); and
``(VII) comply with other terms and
conditions determined necessary by the
Institute to carry out the research
agenda adopted under paragraph (2).
``(iii) Coverage of copayments or
coinsurance.--A contract entered into under
this subparagraph may allow for the coverage of
copayments or coinsurance, or allow for other
appropriate measures, to the extent that such
coverage or other measures are necessary to
preserve the validity of a research project,
such as in the case where the research project
must be blinded.
``(iv) Requirements for publication of
research.--Any research published under clause
(ii)(IV) shall be within the bounds of and
entirely consistent with the evidence and
findings produced under the contract with the
Institute under this subparagraph. If the
Institute determines that those requirements
are not met, the Institute shall not enter into
another contract with the agency,
instrumentality, or entity which managed or
conducted such research for a period determined
appropriate by the Institute (but not less than
5 years).
``(C) Review and update of evidence.--The Institute
shall review and update evidence on a periodic basis as
appropriate.
``(D) Taking into account potential differences.--
Research shall be designed, as appropriate, to take
into account the potential for differences in the
effectiveness of health care treatments, services, and
items as used with various subpopulations, such as
racial and ethnic minorities, women, age, and groups of
individuals with different comorbidities, genetic and
molecular sub-types, or quality of life preferences and
include members of such subpopulations as subjects in
the research as feasible and appropriate.
``(E) Differences in treatment modalities.--
Research shall be designed, as appropriate, to take
into account different characteristics of treatment
modalities that may affect research outcomes, such as
the phase of the treatment modality in the innovation
cycle and the impact of the skill of the operator of
the treatment modality.
``(3) Data collection.--
``(A) In general.--The Secretary shall, with
appropriate safeguards for privacy, make available to
the Institute such data collected by the Centers for
Medicare & Medicaid Services under the programs under
titles XVIII, XIX, and XXI, as well as provide access
to the data networks developed under section 937(f) of
the Public Health Service Act, as the Institute and its
contractors may require to carry out this section. The
Institute may also request and obtain data from
Federal, State, or private entities, including data
from clinical databases and registries.
``(B) Use of data.--The Institute shall only use
data provided to the Institute under subparagraph (A)
in accordance with laws and regulations governing the
release and use of such data, including applicable
confidentiality and privacy standards.
``(4) Appointing expert advisory panels.--
``(A) Appointment.--
``(i) In general.--The Institute may
appoint permanent or ad hoc expert advisory
panels as determined appropriate to assist in
identifying research priorities and
establishing the research project agenda under
paragraph (1) and for other purposes.
``(ii) Expert advisory panels for clinical
trials.--The Institute shall appoint expert
advisory panels in carrying out randomized
clinical trials under the research project
agenda under paragraph (2)(A)(ii). Such expert
advisory panels shall advise the Institute and
the agency, instrumentality, or entity
conducting the research on the research
question involved and the research design or
protocol, including important patient subgroups
and other parameters of the research. Such
panels shall be available as a resource for
technical questions that may arise during the
conduct of such research.
``(iii) Expert advisory panel for rare
disease.--In the case of a research study for
rare disease, the Institute shall appoint an
expert advisory panel for purposes of assisting
in the design of the research study and
determining the relative value and feasibility
of conducting the research study.
``(B) Composition.--An expert advisory panel
appointed under subparagraph (A) shall include
representatives of practicing and research clinicians,
patients, and experts in scientific and health services
research, health services delivery, and evidence-based
medicine who have experience in the relevant topic, and
as appropriate, experts in integrative health and
primary prevention strategies. The Institute may
include a technical expert of each manufacturer or each
medical technology that is included under the relevant
topic, project, or category for which the panel is
established.
``(5) Supporting patient and consumer representatives.--The
Institute shall provide support and resources to help patient
and consumer representatives effectively participate on the
Board and expert advisory panels appointed by the Institute
under paragraph (4).
``(6) Establishing methodology committee.--
``(A) In general.--The Institute shall establish a
standing methodology committee to carry out the
functions described in subparagraph (C).
``(B) Appointment and composition.--The methodology
committee established under subparagraph (A) shall be
composed of not more than 15 members appointed by the
Comptroller General of the United States. Members
appointed to the methodology committee shall be experts
in their scientific field, such as health services
research, clinical research, comparative clinical
effectiveness research, biostatistics, genomics, and
research methodologies. Stakeholders with such
expertise may be appointed to the methodology
committee. In addition to the members appointed under
the first sentence, the Directors of the National
Institutes of Health and the Agency for Healthcare
Research and Quality (or their designees) shall each be
included as members of the methodology committee.
``(C) Functions.--Subject to subparagraph (D), the
methodology committee shall work to develop and improve
the science and methods of comparative clinical
effectiveness research by, not later than 18 months
after the establishment of the Institute, directly or
through subcontract, developing and periodically
updating the following:
``(i) Methodological standards for
research. Such methodological standards shall
provide specific criteria for internal
validity, generalizability, feasibility, and
timeliness of research and for health outcomes
measures, risk adjustment, and other relevant
aspects of research and assessment with respect
to the design of research. Any methodological
standards developed and updated under this
subclause shall be scientifically based and
include methods by which new information, data,
or advances in technology are considered and
incorporated into ongoing research projects by
the Institute, as appropriate. The process for
developing and updating such standards shall
include input from relevant experts,
stakeholders, and decisionmakers, and shall
provide opportunities for public comment. Such
standards shall also include methods by which
patient subpopulations can be accounted for and
evaluated in different types of research. As
appropriate, such standards shall build on
existing work on methodological standards for
defined categories of health interventions and
for each of the major categories of comparative
clinical effectiveness research methods
(determined as of the date of enactment of the
Patient Protection and Affordable Care Act).
``(ii) A translation table that is designed
to provide guidance and act as a reference for
the Board to determine research methods that
are most likely to address each specific
research question.
``(D) Consultation and conduct of examinations.--
The methodology committee may consult and contract with
the Institute of Medicine of the National Academies and
academic, nonprofit, or other private and governmental
entities with relevant expertise to carry out
activities described in subparagraph (C) and may
consult with relevant stakeholders to carry out such
activities.
``(E) Reports.--The methodology committee shall
submit reports to the Board on the committee's
performance of the functions described in subparagraph
(C). Reports shall contain recommendations for the
Institute to adopt methodological standards developed
and updated by the methodology committee as well as
other actions deemed necessary to comply with such
methodological standards.
``(7) Providing for a peer-review process for primary
research.--
``(A) In general.--The Institute shall ensure that
there is a process for peer review of primary research
described in subparagraph (A)(ii) of paragraph (2) that
is conducted under such paragraph. Under such process--
``(i) evidence from such primary research
shall be reviewed to assess scientific
integrity and adherence to methodological
standards adopted under paragraph (9); and
``(ii) a list of the names of individuals
contributing to any peer-review process during
the preceding year or years shall be made
public and included in annual reports in
accordance with paragraph (10)(D).
``(B) Composition.--Such peer-review process shall
be designed in a manner so as to avoid bias and
conflicts of interest on the part of the reviewers and
shall be composed of experts in the scientific field
relevant to the research under review.
``(C) Use of existing processes.--
``(i) Processes of another entity.--In the
case where the Institute enters into a contract
or other agreement with another entity for the
conduct or management of research under this
section, the Institute may utilize the peer-
review process of such entity if such process
meets the requirements under subparagraphs (A)
and (B).
``(ii) Processes of appropriate medical
journals.--The Institute may utilize the peer-
review process of appropriate medical journals
if such process meets the requirements under
subparagraphs (A) and (B).
``(8) Release of research findings.--
``(A) In general.--The Institute shall, not later
than 90 days after the conduct or receipt of research
findings under this part, make such research findings
available to clinicians, patients, and the general
public. The Institute shall ensure that the research
findings--
``(i) convey the findings of research in a
manner that is comprehensible and useful to
patients and providers in making health care
decisions;
``(ii) fully convey findings and discuss
considerations specific to certain
subpopulations, risk factors, and
comorbidities, as appropriate;
``(iii) include limitations of the research
and what further research may be needed as
appropriate;
``(iv) not be construed as mandates for
practice guidelines, coverage recommendations,
payment, or policy recommendations; and
``(v) not include any data which would
violate the privacy of research participants or
any confidentiality agreements made with
respect to the use of data under this section.
``(B) Definition of research findings.--In this
paragraph, the term `research findings' means the
results of a study or assessment.
``(9) Adoption.--Subject to subsection (h)(1), the
Institute shall adopt the national priorities identified under
paragraph (1)(A), the research project agenda established under
paragraph (1)(B), the methodological standards developed and
updated by the methodology committee under paragraph (6)(C)(i),
and any peer-review process provided under paragraph (7) by
majority vote. In the case where the Institute does not adopt
such processes in accordance with the preceding sentence, the
processes shall be referred to the appropriate staff or entity
within the Institute (or, in the case of the methodological
standards, the methodology committee) for further review.
``(10) Annual reports.--The Institute shall submit an
annual report to Congress and the President, and shall make the
annual report available to the public. Such report shall
contain--
``(A) a description of the activities conducted
under this section, research priorities identified
under paragraph (1)(A) and methodological standards
developed and updated by the methodology committee
under paragraph (6)(C)(i) that are adopted under
paragraph (9) during the preceding year;
``(B) the research project agenda and budget of the
Institute for the following year;
``(C) any administrative activities conducted by
the Institute during the preceding year;
``(D) the names of individuals contributing to any
peer-review process under paragraph (7), without
identifying them with a particular research project;
and
``(E) any other relevant information (including
information on the membership of the Board, expert
advisory panels, methodology committee, and the
executive staff of the Institute, any conflicts of
interest with respect to these individuals, and any
bylaws adopted by the Board during the preceding year).
``(e) Administration.--
``(1) In general.--Subject to paragraph (2), the Board
shall carry out the duties of the Institute.
``(2) Nondelegable duties.--The activities described in
subsections (d)(1) and (d)(9) are nondelegable.
``(f) Board of Governors.--
``(1) In general.--The Institute shall have a Board of
Governors, which shall consist of the following members:
``(A) The Director of Agency for Healthcare
Research and Quality (or the Director's designee).
``(B) The Director of the National Institutes of
Health (or the Director's designee).
``(C) Seventeen members appointed, not later than 6
months after the date of enactment of this section, by
the Comptroller General of the United States as
follows:
``(i) 3 members representing patients and
health care consumers.
``(ii) 5 members representing physicians
and providers, including at least 1 surgeon,
nurse, State-licensed integrative health care
practitioner, and representative of a hospital.
``(iii) 3 members representing private
payers, of whom at least 1 member shall
represent health insurance issuers and at least
1 member shall represent employers who self-
insure employee benefits.
``(iv) 3 members representing
pharmaceutical, device, and diagnostic
manufacturers or developers.
``(v) 1 member representing quality
improvement or independent health service
researchers.
``(vi) 2 members representing the Federal
Government or the States, including at least 1
member representing a Federal health program or
agency.
``(2) Qualifications.--The Board shall represent a broad
range of perspectives and collectively have scientific
expertise in clinical health sciences research, including
epidemiology, decisions sciences, health economics, and
statistics. In appointing the Board, the Comptroller General of
the United States shall consider and disclose any conflicts of
interest in accordance with subsection (h)(4)(B). Members of
the Board shall be recused from relevant Institute activities
in the case where the member (or an immediate family member of
such member) has a real conflict of interest directly related
to the research project or the matter that could affect or be
affected by such participation.
``(3) Terms; vacancies.--A member of the Board shall be
appointed for a term of 6 years, except with respect to the
members first appointed, whose terms of appointment shall be
staggered evenly over 2-year increments. No individual shall be
appointed to the Board for more than 2 terms. Vacancies shall
be filled in the same manner as the original appointment was
made.
``(4) Chairperson and vice-chairperson.--The Comptroller
General of the United States shall designate a Chairperson and
Vice Chairperson of the Board from among the members of the
Board. Such members shall serve as Chairperson or Vice
Chairperson for a period of 3 years.
``(5) Compensation.--Each member of the Board who is not an
officer or employee of the Federal Government shall be entitled
to compensation (equivalent to the rate provided for level IV
of the Executive Schedule under section 5315 of title 5, United
States Code) and expenses incurred while performing the duties
of the Board. An officer or employee of the Federal government
who is a member of the Board shall be exempt from compensation.
``(6) Director and staff; experts and consultants.--The
Board may employ and fix the compensation of an Executive
Director and such other personnel as may be necessary to carry
out the duties of the Institute and may seek such assistance
and support of, or contract with, experts and consultants that
may be necessary for the performance of the duties of the
Institute.
``(7) Meetings and hearings.--The Board shall meet and hold
hearings at the call of the Chairperson or a majority of its
members. Meetings not solely concerning matters of personnel
shall be advertised at least 7 days in advance and open to the
public. A majority of the Board members shall constitute a
quorum, but a lesser number of members may meet and hold
hearings.
``(g) Financial and Governmental Oversight.--
``(1) Contract for audit.--The Institute shall provide for
the conduct of financial audits of the Institute on an annual
basis by a private entity with expertise in conducting
financial audits.
``(2) Review and annual reports.--
``(A) Review.--The Comptroller General of the
United States shall review the following:
``(i) Not less frequently than on an annual
basis, the financial audits conducted under
paragraph (1).
``(ii) Not less frequently than every 5
years, the processes established by the
Institute, including the research priorities
and the conduct of research projects, in order
to determine whether information produced by
such research projects is objective and
credible, is produced in a manner consistent
with the requirements under this section, and
is developed through a transparent process.
``(iii) Not less frequently than every 5
years, the dissemination and training
activities and data networks established under
section 937 of the Public Health Service Act,
including the methods and products used to
disseminate research, the types of training
conducted and supported, and the types and
functions of the data networks established, in
order to determine whether the activities and
data are produced in a manner consistent with
the requirements under such section.
``(iv) Not less frequently than every 5
years, the overall effectiveness of activities
conducted under this section and the
dissemination, training, and capacity building
activities conducted under section 937 of the
Public Health Service Act. Such review shall
include an analysis of the extent to which
research findings are used by health care
decision-makers, the effect of the
dissemination of such findings on reducing
practice variation and disparities in health
care, and the effect of the research conducted
and disseminated on innovation and the health
care economy of the United States.
``(v) Not later than 8 years after the date
of enactment of this section, the adequacy and
use of the funding for the Institute and the
activities conducted under section 937 of the
Public Health Service Act, including a
determination as to whether, based on the
utilization of research findings by public and
private payers, funding sources for the
Patient-Centered Outcomes Research Trust Fund
under section 9511 of the Internal Revenue Code
of 1986 are appropriate and whether such
sources of funding should be continued or
adjusted.
``(B) Annual reports.--Not later than April 1 of
each year, the Comptroller General of the United States
shall submit to Congress a report containing the
results of the review conducted under subparagraph (A)
with respect to the preceding year (or years, if
applicable), together with recommendations for such
legislation and administrative action as the
Comptroller General determines appropriate.
``(h) Ensuring Transparency, Credibility, and Access.--The
Institute shall establish procedures to ensure that the following
requirements for ensuring transparency, credibility, and access are
met:
``(1) Public comment periods.--The Institute shall provide
for a public comment period of not less than 45 days and not
more than 60 days prior to the adoption under subsection (d)(9)
of the national priorities identified under subsection
(d)(1)(A), the research project agenda established under
subsection (d)(1)(B), the methodological standards developed
and updated by the methodology committee under subsection
(d)(6)(C)(i), and the peer-review process provided under
paragraph (7), and after the release of draft findings with
respect to systematic reviews of existing research and
evidence.
``(2) Additional forums.--The Institute shall support
forums to increase public awareness and obtain and incorporate
public input and feedback through media (such as an Internet
website) on research priorities, research findings, and other
duties, activities, or processes the Institute determines
appropriate.
``(3) Public availability.--The Institute shall make
available to the public and disclose through the official
public Internet website of the Institute the following:
``(A) Information contained in research findings as
specified in subsection (d)(9).
``(B) The process and methods for the conduct of
research, including the identity of the entity and the
investigators conducing such research and any conflicts
of interests of such parties, any direct or indirect
links the entity has to industry, and research
protocols, including measures taken, methods of
research and analysis, research results, and such other
information the Institute determines appropriate)
concurrent with the release of research findings.
``(C) Notice of public comment periods under
paragraph (1), including deadlines for public comments.
``(D) Subsequent comments received during each of
the public comment periods.
``(E) In accordance with applicable laws and
processes and as the Institute determines appropriate,
proceedings of the Institute.
``(4) Disclosure of conflicts of interest.--
``(A) In general.--A conflict of interest shall be
disclosed in the following manner:
``(i) By the Institute in appointing
members to an expert advisory panel under
subsection (d)(4), in selecting individuals to
contribute to any peer-review process under
subsection (d)(7), and for employment as
executive staff of the Institute.
``(ii) By the Comptroller General in
appointing members of the methodology committee
under subsection (d)(6);
``(iii) By the Institute in the annual
report under subsection (d)(10), except that,
in the case of individuals contributing to any
such peer review process, such description
shall be in a manner such that those
individuals cannot be identified with a
particular research project.
``(B) Manner of disclosure.--Conflicts of interest
shall be disclosed as described in subparagraph (A) as
soon as practicable on the Internet web site of the
Institute and of the Government Accountability Office.
The information disclosed under the preceding sentence
shall include the type, nature, and magnitude of the
interests of the individual involved, except to the
extent that the individual recuses himself or herself
from participating in the consideration of or any other
activity with respect to the study as to which the
potential conflict exists.
``(i) Rules.--The Institute, its Board or staff, shall be
prohibited from accepting gifts, bequeaths, or donations of services or
property. In addition, the Institute shall be prohibited from
establishing a corporation or generating revenues from activities other
than as provided under this section.
``(j) Rules of Construction.--
``(1) Coverage.--Nothing in this section shall be
construed--
``(A) to permit the Institute to mandate coverage,
reimbursement, or other policies for any public or
private payer; or
``(B) as preventing the Secretary from covering the
routine costs of clinical care received by an
individual entitled to, or enrolled for, benefits under
title XVIII, XIX, or XXI in the case where such
individual is participating in a clinical trial and
such costs would otherwise be covered under such title
with respect to the beneficiary.''.
(b) Dissemination and Building Capacity for Research.--Title IX of
the Public Health Service Act (42 U.S.C. 299 et seq.), as amended by
section 3606, is further amended by inserting after section 936 the
following:
``SEC. 937. DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH.
``(a) In General.--
``(1) Dissemination.--The Office of Communication and
Knowledge Transfer (referred to in this section as the
`Office') at the Agency for Healthcare Research and Quality (or
any other relevant office designated by Agency for Healthcare
Research and Quality), in consultation with the National
Institutes of Health, shall broadly disseminate the research
findings that are published by the Patient Centered Outcomes
Research Institute established under section 1181(b) of the
Social Security Act (referred to in this section as the
`Institute') and other government-funded research relevant to
comparative clinical effectiveness research. The Office shall
create informational tools that organize and disseminate
research findings for physicians, health care providers,
patients, payers, and policy makers. The Office shall also
develop a publicly available resource database that collects
and contains government-funded evidence and research from
public, private, not-for profit, and academic sources.
``(2) Requirements.--The Office shall provide for the
dissemination of the Institute's research findings and
government-funded research relevant to comparative clinical
effectiveness research to physicians, health care providers,
patients, vendors of health information technology focused on
clinical decision support, appropriate professional
associations, and Federal and private health plans. Materials,
forums, and media used to disseminate the findings,
informational tools, and resource databases shall--
``(A) include a description of considerations for
specific subpopulations, the research methodology, and
the limitations of the research, and the names of the
entities, agencies, instrumentalities, and individuals
who conducted any research which was published by the
Institute; and
``(B) not be construed as mandates, guidelines, or
recommendations for payment, coverage, or treatment.
``(b) Incorporation of Research Findings.--The Office, in
consultation with relevant medical and clinical associations, shall
assist users of health information technology focused on clinical
decision support to promote the timely incorporation of research
findings disseminated under subsection (a) into clinical practices and
to promote the ease of use of such incorporation.
``(c) Feedback.--The Office shall establish a process to receive
feedback from physicians, health care providers, patients, and vendors
of health information technology focused on clinical decision support,
appropriate professional associations, and Federal and private health
plans about the value of the information disseminated and the
assistance provided under this section.
``(d) Rule of Construction.--Nothing in this section shall preclude
the Institute from making its research findings publicly available as
required under section 1181(d)(8) of the Social Security Act.
``(e) Training of Researchers.--The Agency for Health Care Research
and Quality, in consultation with the National Institutes of Health,
shall build capacity for comparative clinical effectiveness research by
establishing a grant program that provides for the training of
researchers in the methods used to conduct such research, including
systematic reviews of existing research and primary research such as
clinical trials. At a minimum, such training shall be in methods that
meet the methodological standards adopted under section 1181(d)(9) of
the Social Security Act.
``(f) Building Data for Research.--The Secretary shall provide for
the coordination of relevant Federal health programs to build data
capacity for comparative clinical effectiveness research, including the
development and use of clinical registries and health outcomes research
data networks, in order to develop and maintain a comprehensive,
interoperable data network to collect, link, and analyze data on
outcomes and effectiveness from multiple sources, including electronic
health records.
``(g) Authority To Contract With the Institute.--Agencies and
instrumentalities of the Federal Government may enter into agreements
with the Institute, and accept and retain funds, for the conduct and
support of research described in this part, provided that the research
to be conducted or supported under such agreements is authorized under
the governing statutes of such agencies and instrumentalities.''.
(c) In General.--Part D of title XI of the Social Security Act, as
added by subsection (a), is amended by adding at the end the following
new section:
``limitations on certain uses of comparative clinical effectiveness
research
``Sec. 1182. (a) The Secretary may only use evidence and findings
from research conducted under section 1181 to make a determination
regarding coverage under title XVIII if such use is through an
iterative and transparent process which includes public comment and
considers the effect on subpopulations.
``(b) Nothing in section 1181 shall be construed as--
``(1) superceding or modifying the coverage of items or
services under title XVIII that the Secretary determines are
reasonable and necessary under section 1862(l)(1); or
``(2) authorizing the Secretary to deny coverage of items
or services under such title solely on the basis of comparative
clinical effectiveness research.
``(c)(1) The Secretary shall not use evidence or findings from
comparative clinical effectiveness research conducted under section
1181 in determining coverage, reimbursement, or incentive programs
under title XVIII in a manner that treats extending the life of an
elderly, disabled, or terminally ill individual as of lower value than
extending the life of an individual who is younger, nondisabled, or not
terminally ill.
``(2) Paragraph (1) shall not be construed as preventing the
Secretary from using evidence or findings from such comparative
clinical effectiveness research in determining coverage, reimbursement,
or incentive programs under title XVIII based upon a comparison of the
difference in the effectiveness of alternative treatments in extending
an individual's life due to the individual's age, disability, or
terminal illness.
``(d)(1) The Secretary shall not use evidence or findings from
comparative clinical effectiveness research conducted under section
1181 in determining coverage, reimbursement, or incentive programs
under title XVIII in a manner that precludes, or with the intent to
discourage, an individual from choosing a health care treatment based
on how the individual values the tradeoff between extending the length
of their life and the risk of disability.
``(2)(A) Paragraph (1) shall not be construed to--
``(i) limit the application of differential copayments
under title XVIII based on factors such as cost or type of
service; or
``(ii) prevent the Secretary from using evidence or
findings from such comparative clinical effectiveness research
in determining coverage, reimbursement, or incentive programs
under such title based upon a comparison of the difference in
the effectiveness of alternative health care treatments in
extending an individual's life due to that individual's age,
disability, or terminal illness.
``(3) Nothing in the provisions of, or amendments made by the
Patient Protection and Affordable Care Act, shall be construed to limit
comparative clinical effectiveness research or any other research,
evaluation, or dissemination of information concerning the likelihood
that a health care treatment will result in disability.
``(e) The Patient-Centered Outcomes Research Institute established
under section 1181(b)(1) shall not develop or employ a dollars-per-
quality adjusted life year (or similar measure that discounts the value
of a life because of an individual's disability) as a threshold to
establish what type of health care is cost effective or recommended.
The Secretary shall not utilize such an adjusted life year (or such a
similar measure) as a threshold to determine coverage, reimbursement,
or incentive programs under title XVIII.''.
(d) In General.--Part D of title XI of the Social Security Act, as
added by subsection (a) and amended by subsection (c), is amended by
adding at the end the following new section:
``trust fund transfers to patient-centered outcomes research trust fund
``Sec. 1183. (a) In General.--The Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund under section
1817 and the Federal Supplementary Medical Insurance Trust Fund under
section 1841, in proportion (as estimated by the Secretary) to the
total expenditures during such fiscal year that are made under title
XVIII from the respective trust fund, to the Patient-Centered Outcomes
Research Trust Fund (referred to in this section as the `PCORTF') under
section 9511 of the Internal Revenue Code of 1986, of the following:
``(1) For fiscal year 2013, an amount equal to $1
multiplied by the average number of individuals entitled to
benefits under part A, or enrolled under part B, of title XVIII
during such fiscal year.
``(2) For each of fiscal years 2014, 2015, 2016, 2017,
2018, and 2019, an amount equal to $2 multiplied by the average
number of individuals entitled to benefits under part A, or
enrolled under part B, of title XVIII during such fiscal year.
``(b) Adjustments for Increases in Health Care Spending.--In the
case of any fiscal year beginning after September 30, 2014, the dollar
amount in effect under subsection (a)(2) for such fiscal year shall be
equal to the sum of such dollar amount for the previous fiscal year
(determined after the application of this subsection), plus an amount
equal to the product of--
``(1) such dollar amount for the previous fiscal year,
multiplied by
``(2) the percentage increase in the projected per capita
amount of National Health Expenditures, as most recently
published by the Secretary before the beginning of the fiscal
year.''.
(e) Patient-Centered Outcomes Research Trust Fund; Financing for
Trust Fund.--
(1) Establishment of trust fund.--
(A) In general.--Subchapter A of chapter 98 of the
Internal Revenue Code of 1986 (relating to
establishment of trust funds) is amended by adding at
the end the following new section:
``SEC. 9511. PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND.
``(a) Creation of Trust Fund.--There is established in the Treasury
of the United States a trust fund to be known as the `Patient-Centered
Outcomes Research Trust Fund' (hereafter in this section referred to as
the `PCORTF'), consisting of such amounts as may be appropriated or
credited to such Trust Fund as provided in this section and section
9602(b).
``(b) Transfers to Fund.--
``(1) Appropriation.--There are hereby appropriated to the
Trust Fund the following:
``(A) For fiscal year 2010, $10,000,000.
``(B) For fiscal year 2011, $50,000,000.
``(C) For fiscal year 2012, $150,000,000.
``(D) For fiscal year 2013--
``(i) an amount equivalent to the net
revenues received in the Treasury from the fees
imposed under subchapter B of chapter 34
(relating to fees on health insurance and self-
insured plans) for such fiscal year; and
``(ii) $150,000,000.
``(E) For each of fiscal years 2014, 2015, 2016,
2017, 2018, and 2019--
``(i) an amount equivalent to the net
revenues received in the Treasury from the fees
imposed under subchapter B of chapter 34
(relating to fees on health insurance and self-
insured plans) for such fiscal year; and
``(ii) $150,000,000.
The amounts appropriated under subparagraphs (A), (B),
(C), (D)(ii), and (E)(ii) shall be transferred from the
general fund of the Treasury, from funds not otherwise
appropriated.
``(2) Trust fund transfers.--In addition to the amounts
appropriated under paragraph (1), there shall be credited to
the PCORTF the amounts transferred under section 1183 of the
Social Security Act.
``(3) Limitation on transfers to pcortf.--No amount may be
appropriated or transferred to the PCORTF on and after the date
of any expenditure from the PCORTF which is not an expenditure
permitted under this section. The determination of whether an
expenditure is so permitted shall be made without regard to--
``(A) any provision of law which is not contained
or referenced in this chapter or in a revenue Act, and
``(B) whether such provision of law is a
subsequently enacted provision or directly or
indirectly seeks to waive the application of this
paragraph.
``(c) Trustee.--The Secretary of the Treasury shall be a trustee of
the PCORTF.
``(d) Expenditures From Fund.--
``(1) Amounts available to the patient-centered outcomes
research institute.--Subject to paragraph (2), amounts in the
PCORTF are available, without further appropriation, to the
Patient-Centered Outcomes Research Institute established under
section 1181(b) of the Social Security Act for carrying out
part D of title XI of the Social Security Act (as in effect on
the date of enactment of such Act).
``(2) Transfer of funds.--
``(A) In general.--The trustee of the PCORTF shall
provide for the transfer from the PCORTF of 20 percent
of the amounts appropriated or credited to the PCORTF
for each of fiscal years 2011 through 2019 to the
Secretary of Health and Human Services to carry out
section 937 of the Public Health Service Act.
``(B) Availability.--Amounts transferred under
subparagraph (A) shall remain available until expended.
``(C) Requirements.--Of the amounts transferred
under subparagraph (A) with respect to a fiscal year,
the Secretary of Health and Human Services shall
distribute--
``(i) 80 percent to the Office of
Communication and Knowledge Transfer of the
Agency for Healthcare Research and Quality (or
any other relevant office designated by Agency
for Healthcare Research and Quality) to carry
out the activities described in section 937 of
the Public Health Service Act; and
``(ii) 20 percent to the Secretary to carry
out the activities described in such section
937.
``(e) Net Revenues.--For purposes of this section, the term `net
revenues' means the amount estimated by the Secretary of the Treasury
based on the excess of--
``(1) the fees received in the Treasury under subchapter B
of chapter 34, over
``(2) the decrease in the tax imposed by chapter 1
resulting from the fees imposed by such subchapter.
``(f) Termination.--No amounts shall be available for expenditure
from the PCORTF after September 30, 2019, and any amounts in such Trust
Fund after such date shall be transferred to the general fund of the
Treasury.''.
(B) Clerical amendment.--The table of sections for
subchapter A of chapter 98 of such Code is amended by
adding at the end the following new item:
``Sec. 9511. Patient-centered outcomes research trust fund.''.
(2) Financing for fund from fees on insured and self-
insured health plans.--
(A) General rule.--Chapter 34 of the Internal
Revenue Code of 1986 is amended by adding at the end
the following new subchapter:
``Subchapter B--Insured and Self-Insured Health Plans
``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.
``SEC. 4375. HEALTH INSURANCE.
``(a) Imposition of Fee.--There is hereby imposed on each specified
health insurance policy for each policy year ending after September 30,
2012, a fee equal to the product of $2 ($1 in the case of policy years
ending during fiscal year 2013) multiplied by the average number of
lives covered under the policy.
``(b) Liability for Fee.--The fee imposed by subsection (a) shall
be paid by the issuer of the policy.
``(c) Specified Health Insurance Policy.--For purposes of this
section:
``(1) In general.--Except as otherwise provided in this
section, the term `specified health insurance policy' means any
accident or health insurance policy (including a policy under a
group health plan) issued with respect to individuals residing
in the United States.
``(2) Exemption for certain policies.--The term `specified
health insurance policy' does not include any insurance if
substantially all of its coverage is of excepted benefits
described in section 9832(c).
``(3) Treatment of prepaid health coverage arrangements.--
``(A) In general.--In the case of any arrangement
described in subparagraph (B), such arrangement shall
be treated as a specified health insurance policy, and
the person referred to in such subparagraph shall be
treated as the issuer.
``(B) Description of arrangements.--An arrangement
is described in this subparagraph if under such
arrangement fixed payments or premiums are received as
consideration for any person's agreement to provide or
arrange for the provision of accident or health
coverage to residents of the United States, regardless
of how such coverage is provided or arranged to be
provided.
``(d) Adjustments for Increases in Health Care Spending.--In the
case of any policy year ending in any fiscal year beginning after
September 30, 2014, the dollar amount in effect under subsection (a)
for such policy year shall be equal to the sum of such dollar amount
for policy years ending in the previous fiscal year (determined after
the application of this subsection), plus an amount equal to the
product of--
``(1) such dollar amount for policy years ending in the
previous fiscal year, multiplied by
``(2) the percentage increase in the projected per capita
amount of National Health Expenditures, as most recently
published by the Secretary before the beginning of the fiscal
year.
``(e) Termination.--This section shall not apply to policy years
ending after September 30, 2019.
``SEC. 4376. SELF-INSURED HEALTH PLANS.
``(a) Imposition of Fee.--In the case of any applicable self-
insured health plan for each plan year ending after September 30, 2012,
there is hereby imposed a fee equal to $2 ($1 in the case of plan years
ending during fiscal year 2013) multiplied by the average number of
lives covered under the plan.
``(b) Liability for Fee.--
``(1) In general.--The fee imposed by subsection (a) shall
be paid by the plan sponsor.
``(2) Plan sponsor.--For purposes of paragraph (1) the term
`plan sponsor' means--
``(A) the employer in the case of a plan
established or maintained by a single employer,
``(B) the employee organization in the case of a
plan established or maintained by an employee
organization,
``(C) in the case of--
``(i) a plan established or maintained by 2
or more employers or jointly by 1 or more
employers and 1 or more employee organizations,
``(ii) a multiple employer welfare
arrangement, or
``(iii) a voluntary employees' beneficiary
association described in section 501(c)(9), the
association, committee, joint board of
trustees, or other similar group of
representatives of the parties who establish or
maintain the plan, or
``(D) the cooperative or association described in
subsection (c)(2)(F) in the case of a plan established
or maintained by such a cooperative or association.
``(c) Applicable Self-insured Health Plan.--For purposes of this
section, the term `applicable self-insured health plan' means any plan
for providing accident or health coverage if--
``(1) any portion of such coverage is provided other than
through an insurance policy, and
``(2) such plan is established or maintained--
``(A) by 1 or more employers for the benefit of
their employees or former employees,
``(B) by 1 or more employee organizations for the
benefit of their members or former members,
``(C) jointly by 1 or more employers and 1 or more
employee organizations for the benefit of employees or
former employees,
``(D) by a voluntary employees' beneficiary
association described in section 501(c)(9),
``(E) by any organization described in section
501(c)(6), or
``(F) in the case of a plan not described in the
preceding subparagraphs, by a multiple employer welfare
arrangement (as defined in section 3(40) of Employee
Retirement Income Security Act of 1974), a rural
electric cooperative (as defined in section
3(40)(B)(iv) of such Act), or a rural telephone
cooperative association (as defined in section
3(40)(B)(v) of such Act).
``(d) Adjustments for Increases in Health Care Spending.--In the
case of any plan year ending in any fiscal year beginning after
September 30, 2014, the dollar amount in effect under subsection (a)
for such plan year shall be equal to the sum of such dollar amount for
plan years ending in the previous fiscal year (determined after the
application of this subsection), plus an amount equal to the product
of--
``(1) such dollar amount for plan years ending in the
previous fiscal year, multiplied by
``(2) the percentage increase in the projected per capita
amount of National Health Expenditures, as most recently
published by the Secretary before the beginning of the fiscal
year.
``(e) Termination.--This section shall not apply to plan years
ending after September 30, 2019.
``SEC. 4377. DEFINITIONS AND SPECIAL RULES.
``(a) Definitions.--For purposes of this subchapter--
``(1) Accident and health coverage.--The term `accident and
health coverage' means any coverage which, if provided by an
insurance policy, would cause such policy to be a specified
health insurance policy (as defined in section 4375(c)).
``(2) Insurance policy.--The term `insurance policy' means
any policy or other instrument whereby a contract of insurance
is issued, renewed, or extended.
``(3) United states.--The term `United States' includes any
possession of the United States.
``(b) Treatment of Governmental Entities.--
``(1) In general.--For purposes of this subchapter--
``(A) the term `person' includes any governmental
entity, and
``(B) notwithstanding any other law or rule of law,
governmental entities shall not be exempt from the fees
imposed by this subchapter except as provided in
paragraph (2).
``(2) Treatment of exempt governmental programs.--In the
case of an exempt governmental program, no fee shall be imposed
under section 4375 or section 4376 on any covered life under
such program.
``(3) Exempt governmental program defined.--For purposes of
this subchapter, the term `exempt governmental program' means--
``(A) any insurance program established under title
XVIII of the Social Security Act,
``(B) the medical assistance program established by
title XIX or XXI of the Social Security Act,
``(C) any program established by Federal law for
providing medical care (other than through insurance
policies) to individuals (or the spouses and dependents
thereof) by reason of such individuals being members of
the Armed Forces of the United States or veterans, and
``(D) any program established by Federal law for
providing medical care (other than through insurance
policies) to members of Indian tribes (as defined in
section 4(d) of the Indian Health Care Improvement
Act).
``(c) Treatment as Tax.--For purposes of subtitle F, the fees
imposed by this subchapter shall be treated as if they were taxes.
``(d) No Cover Over to Possessions.--Notwithstanding any other
provision of law, no amount collected under this subchapter shall be
covered over to any possession of the United States.''.
(B) Clerical amendments.--
(i) Chapter 34 of such Code is amended by
striking the chapter heading and inserting the
following:
``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES
``subchapter a. policies issued by foreign insurers
``subchapter b. insured and self-insured health plans
``Subchapter A--Policies Issued By Foreign Insurers''.
(ii) The table of chapters for subtitle D
of such Code is amended by striking the item
relating to chapter 34 and inserting the
following new item:
``Chapter 34--Taxes on Certain Insurance Policies''.
(f) Tax-exempt Status of the Patient-centered Outcomes Research
Institute.--Subsection 501(l) of the Internal Revenue Code of 1986 is
amended by adding at the end the following new paragraph:
``(4) The Patient-Centered Outcomes Research Institute
established under section 1181(b) of the Social Security
Act.''.
SEC. 6302. FEDERAL COORDINATING COUNCIL FOR COMPARATIVE EFFECTIVENESS
RESEARCH.
Notwithstanding any other provision of law, the Federal
Coordinating Council for Comparative Effectiveness Research established
under section 804 of Division A of the American Recovery and
Reinvestment Act of 2009 (42 U.S.C. 299b-8), including the requirement
under subsection (e)(2) of such section, shall terminate on the date of
enactment of this Act.
Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions
SEC. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER
MEDICARE, MEDICAID, AND CHIP.
(a) Medicare.--Section 1866(j) of the Social Security Act (42
U.S.C. 1395cc(j)) is amended--
(1) in paragraph (1)(A), by adding at the end the
following: ``Such process shall include screening of providers
and suppliers in accordance with paragraph (2), a provisional
period of enhanced oversight in accordance with paragraph (3),
disclosure requirements in accordance with paragraph (4), the
imposition of temporary enrollment moratoria in accordance with
paragraph (5), and the establishment of compliance programs in
accordance with paragraph (6).'';
(2) by redesignating paragraph (2) as paragraph (7); and
(3) by inserting after paragraph (1) the following:
``(2) Provider screening.--
``(A) Procedures.--Not later than 180 days after
the date of enactment of this paragraph, the Secretary,
in consultation with the Inspector General of the
Department of Health and Human Services, shall
establish procedures under which screening is conducted
with respect to providers of medical or other items or
services and suppliers under the program under this
title, the Medicaid program under title XIX, and the
CHIP program under title XXI.
``(B) Level of screening.--The Secretary shall
determine the level of screening conducted under this
paragraph according to the risk of fraud, waste, and
abuse, as determined by the Secretary, with respect to
the category of provider of medical or other items or
services or supplier. Such screening--
``(i) shall include a licensure check,
which may include such checks across States;
and
``(ii) may, as the Secretary determines
appropriate based on the risk of fraud, waste,
and abuse described in the preceding sentence,
include--
``(I) a criminal background check;
``(II) fingerprinting;
``(III) unscheduled and unannounced
site visits, including preenrollment
site visits;
``(IV) database checks (including
such checks across States); and
``(V) such other screening as the
Secretary determines appropriate.
``(C) Application fees.--
``(i) Individual providers.--Except as
provided in clause (iii), the Secretary shall
impose a fee on each individual provider of
medical or other items or services or supplier
(such as a physician, physician assistant,
nurse practitioner, or clinical nurse
specialist) with respect to which screening is
conducted under this paragraph in an amount
equal to--
``(I) for 2010, $200; and
``(II) for 2011 and each subsequent
year, the amount determined under this
clause for the preceding year, adjusted
by the percentage change in the
consumer price index for all urban
consumers (all items; United States
city average) for the 12-month period
ending with June of the previous year.
``(ii) Institutional providers.--Except as
provided in clause (iii), the Secretary shall
impose a fee on each institutional provider of
medical or other items or services or supplier
(such as a hospital or skilled nursing
facility) with respect to which screening is
conducted under this paragraph in an amount
equal to--
``(I) for 2010, $500; and
``(II) for 2011 and each subsequent
year, the amount determined under this
clause for the preceding year, adjusted
by the percentage change in the
consumer price index for all urban
consumers (all items; United States
city average) for the 12-month period
ending with June of the previous year.
``(iii) Hardship exception; waiver for
certain medicaid providers.--The Secretary may,
on a case-by-case basis, exempt a provider of
medical or other items or services or supplier
from the imposition of an application fee under
this subparagraph if the Secretary determines
that the imposition of the application fee
would result in a hardship. The Secretary may
waive the application fee under this
subparagraph for providers enrolled in a State
Medicaid program for whom the State
demonstrates that imposition of the fee would
impede beneficiary access to care.
``(iv) Use of funds.--Amounts collected as
a result of the imposition of a fee under this
subparagraph shall be used by the Secretary for
program integrity efforts, including to cover
the costs of conducting screening under this
paragraph and to carry out this subsection and
section 1128J.
``(D) Application and enforcement.--
``(i) New providers of services and
suppliers.--The screening under this paragraph
shall apply, in the case of a provider of
medical or other items or services or supplier
who is not enrolled in the program under this
title, title XIX , or title XXI as of the date
of enactment of this paragraph, on or after the
date that is 1 year after such date of
enactment.
``(ii) Current providers of services and
suppliers.--The screening under this paragraph
shall apply, in the case of a provider of
medical or other items or services or supplier
who is enrolled in the program under this
title, title XIX, or title XXI as of such date
of enactment, on or after the date that is 2
years after such date of enactment.
``(iii) Revalidation of enrollment.--
Effective beginning on the date that is 180
days after such date of enactment, the
screening under this paragraph shall apply with
respect to the revalidation of enrollment of a
provider of medical or other items or services
or supplier in the program under this title,
title XIX, or title XXI.
``(iv) Limitation on enrollment and
revalidation of enrollment.--In no case may a
provider of medical or other items or services
or supplier who has not been screened under
this paragraph be initially enrolled or
reenrolled in the program under this title,
title XIX, or title XXI on or after the date
that is 3 years after such date of enactment.
``(E) Expedited rulemaking.--The Secretary may
promulgate an interim final rule to carry out this
paragraph.
``(3) Provisional period of enhanced oversight for new
providers of services and suppliers.--
``(A) In general.--The Secretary shall establish
procedures to provide for a provisional period of not
less than 30 days and not more than 1 year during which
new providers of medical or other items or services and
suppliers, as the Secretary determines appropriate,
including categories of providers or suppliers, would
be subject to enhanced oversight, such as prepayment
review and payment caps, under the program under this
title, the Medicaid program under title XIX. and the
CHIP program under title XXI.
``(B) Implementation.--The Secretary may establish
by program instruction or otherwise the procedures
under this paragraph.
``(4) Increased disclosure requirements.--
``(A) Disclosure.--A provider of medical or other
items or services or supplier who submits an
application for enrollment or revalidation of
enrollment in the program under this title, title XIX,
or title XXI on or after the date that is 1 year after
the date of enactment of this paragraph shall disclose
(in a form and manner and at such time as determined by
the Secretary) any current or previous affiliation
(directly or indirectly) with a provider of medical or
other items or services or supplier that has
uncollected debt, has been or is subject to a payment
suspension under a Federal health care program (as
defined in section 1128B(f)), has been excluded from
participation under the program under this title, the
Medicaid program under title XIX, or the CHIP program
under title XXI, or has had its billing privileges
denied or revoked.
``(B) Authority to deny enrollment.--If the
Secretary determines that such previous affiliation
poses an undue risk of fraud, waste, or abuse, the
Secretary may deny such application. Such a denial
shall be subject to appeal in accordance with paragraph
(7).
``(5) Authority to adjust payments of providers of services
and suppliers with the same tax identification number for past-
due obligations.--
``(A) In general.--Notwithstanding any other
provision of this title, in the case of an applicable
provider of services or supplier, the Secretary may
make any necessary adjustments to payments to the
applicable provider of services or supplier under the
program under this title in order to satisfy any past-
due obligations described in subparagraph (B)(ii) of an
obligated provider of services or supplier.
``(B) Definitions.--In this paragraph:
``(i) In general.--The term `applicable
provider of services or supplier' means a
provider of services or supplier that has the
same taxpayer identification number assigned
under section 6109 of the Internal Revenue Code
of 1986 as is assigned to the obligated
provider of services or supplier under such
section, regardless of whether the applicable
provider of services or supplier is assigned a
different billing number or national provider
identification number under the program under
this title than is assigned to the obligated
provider of services or supplier.
``(ii) Obligated provider of services or
supplier.--The term `obligated provider of
services or supplier' means a provider of
services or supplier that owes a past-due
obligation under the program under this title
(as determined by the Secretary).
``(6) Temporary moratorium on enrollment of new
providers.--
``(A) In general.--The Secretary may impose a
temporary moratorium on the enrollment of new providers
of services and suppliers, including categories of
providers of services and suppliers, in the program
under this title, under the Medicaid program under
title XIX, or under the CHIP program under title XXI if
the Secretary determines such moratorium is necessary
to prevent or combat fraud, waste, or abuse under
either such program.
``(B) Limitation on review.--There shall be no
judicial review under section 1869, section 1878, or
otherwise, of a temporary moratorium imposed under
subparagraph (A).
``(7) Compliance programs.--
``(A) In general.--On or after the date of
implementation determined by the Secretary under
subparagraph (C), a provider of medical or other items
or services or supplier within a particular industry
sector or category shall, as a condition of enrollment
in the program under this title, title XIX, or title
XXI, establish a compliance program that contains the
core elements established under subparagraph (B) with
respect to that provider or supplier and industry or
category.
``(B) Establishment of core elements.--The
Secretary, in consultation with the Inspector General
of the Department of Health and Human Services, shall
establish core elements for a compliance program under
subparagraph (A) for providers or suppliers within a
particular industry or category.
``(C) Timeline for implementation.--The Secretary
shall determine the timeline for the establishment of
the core elements under subparagraph (B) and the date
of the implementation of subparagraph (A) for providers
or suppliers within a particular industry or category.
The Secretary shall, in determining such date of
implementation, consider the extent to which the
adoption of compliance programs by a provider of
medical or other items or services or supplier is
widespread in a particular industry sector or with
respect to a particular provider or supplier
category.''.
(b) Medicaid.--
(1) State plan amendment.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)), as amended by section
4302(b), is amended--
(A) in subsection (a)--
(i) by striking ``and'' at the end of
paragraph (75);
(ii) by striking the period at the end of
paragraph (76) and inserting a semicolon; and
(iii) by inserting after paragraph (76) the
following:
``(77) provide that the State shall comply with provider
and supplier screening, oversight, and reporting requirements
in accordance with subsection (ii);''; and
(B) by adding at the end the following:
``(ii) Provider and Supplier Screening, Oversight, and Reporting
Requirements.--For purposes of subsection (a)(77), the requirements of
this subsection are the following:
``(1) Screening.--The State complies with the process for
screening providers and suppliers under this title, as
established by the Secretary under section 1886(j)(2).
``(2) Provisional period of enhanced oversight for new
providers and suppliers.--The State complies with procedures to
provide for a provisional period of enhanced oversight for new
providers and suppliers under this title, as established by the
Secretary under section 1886(j)(3).
``(3) Disclosure requirements.--The State requires
providers and suppliers under the State plan or under a waiver
of the plan to comply with the disclosure requirements
established by the Secretary under section 1886(j)(4).
``(4) Temporary moratorium on enrollment of new providers
or suppliers.--
``(A) Temporary moratorium imposed by the
secretary.--
``(i) In general.--Subject to clause (ii),
the State complies with any temporary
moratorium on the enrollment of new providers
or suppliers imposed by the Secretary under
section 1886(j)(6).
``(ii) Exception.--A State shall not be
required to comply with a temporary moratorium
described in clause (i) if the State determines
that the imposition of such temporary
moratorium would adversely impact
beneficiaries' access to medical assistance.
``(B) Moratorium on enrollment of providers and
suppliers.--At the option of the State, the State
imposes, for purposes of entering into participation
agreements with providers or suppliers under the State
plan or under a waiver of the plan, periods of
enrollment moratoria, or numerical caps or other
limits, for providers or suppliers identified by the
Secretary as being at high-risk for fraud, waste, or
abuse as necessary to combat fraud, waste, or abuse,
but only if the State determines that the imposition of
any such period, cap, or other limits would not
adversely impact beneficiaries' access to medical
assistance.
``(5) Compliance programs.--The State requires providers
and suppliers under the State plan or under a waiver of the
plan to establish, in accordance with the requirements of
section 1866(j)(7), a compliance program that contains the core
elements established under subparagraph (B) of that section
1866(j)(7) for providers or suppliers within a particular
industry or category.
``(6) Reporting of adverse provider actions.--The State
complies with the national system for reporting criminal and
civil convictions, sanctions, negative licensure actions, and
other adverse provider actions to the Secretary, through the
Administrator of the Centers for Medicare & Medicaid Services,
in accordance with regulations of the Secretary.
``(7) Enrollment and npi of ordering or referring
providers.--The State requires--
``(A) all ordering or referring physicians or other
professionals to be enrolled under the State plan or
under a waiver of the plan as a participating provider;
and
``(B) the national provider identifier of any
ordering or referring physician or other professional
to be specified on any claim for payment that is based
on an order or referral of the physician or other
professional.
``(8) Other state oversight.--Nothing in this subsection
shall be interpreted to preclude or limit the ability of a
State to engage in provider and supplier screening or enhanced
provider and supplier oversight activities beyond those
required by the Secretary.''.
(2) Disclosure of medicare terminated providers and
suppliers to states.--The Administrator of the Centers for
Medicare & Medicaid Services shall establish a process for
making available to the each State agency with responsibility
for administering a State Medicaid plan (or a waiver of such
plan) under title XIX of the Social Security Act or a child
health plan under title XXI the name, national provider
identifier, and other identifying information for any provider
of medical or other items or services or supplier under the
Medicare program under title XVIII or under the CHIP program
under title XXI that is terminated from participation under
that program within 30 days of the termination (and, with
respect to all such providers or suppliers who are terminated
from the Medicare program on the date of enactment of this Act,
within 90 days of such date).
(3) Conforming amendment.--Section 1902(a)(23) of the
Social Security Act (42 U.S.C. 1396a), is amended by inserting
before the semicolon at the end the following: ``or by a
provider or supplier to which a moratorium under subsection
(ii)(4) is applied during the period of such moratorium''.
(c) CHIP.--Section 2107(e)(1) of the Social Security Act (42 U.S.C.
1397gg(e)(1)), as amended by section 2101(d), is amended--
(1) by redesignating subparagraphs (D) through (M) as
subparagraphs (E) through (N), respectively; and
(2) by inserting after subparagraph (C), the following:
``(D) Subsections (a)(77) and (ii) of section 1902
(relating to provider and supplier screening,
oversight, and reporting requirements).''.
SEC. 6402. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS.
(a) In General.--Part A of title XI of the Social Security Act (42
U.S.C. 1301 et seq.), as amended by sections 6002, 6004, and 6102, is
amended by inserting after section 1128I the following new section:
``SEC. 1128J. MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS.
``(a) Data Matching.--
``(1) Integrated data repository.--
``(A) Inclusion of certain data.--
``(i) In general.--The Integrated Data
Repository of the Centers for Medicare &
Medicaid Services shall include, at a minimum,
claims and payment data from the following:
``(I) The programs under titles
XVIII and XIX (including parts A, B, C,
and D of title XVIII).
``(II) The program under title XXI.
``(III) Health-related programs
administered by the Secretary of
Veterans Affairs.
``(IV) Health-related programs
administered by the Secretary of
Defense.
``(V) The program of old-age,
survivors, and disability insurance
benefits established under title II.
``(VI) The Indian Health Service
and the Contract Health Service
program.
``(ii) Priority for inclusion of certain
data.--Inclusion of the data described in
subclause (I) of such clause in the Integrated
Data Repository shall be a priority. Data
described in subclauses (II) through (VI) of
such clause shall be included in the Integrated
Data Repository as appropriate.
``(B) Data sharing and matching.--
``(i) In general.--The Secretary shall
enter into agreements with the individuals
described in clause (ii) under which such
individuals share and match data in the system
of records of the respective agencies of such
individuals with data in the system of records
of the Department of Health and Human Services
for the purpose of identifying potential fraud,
waste, and abuse under the programs under
titles XVIII and XIX.
``(ii) Individuals described.--The
following individuals are described in this
clause:
``(I) The Commissioner of Social
Security.
``(II) The Secretary of Veterans
Affairs.
``(III) The Secretary of Defense.
``(IV) The Director of the Indian
Health Service.
``(iii) Definition of system of records.--
For purposes of this paragraph, the term
`system of records' has the meaning given such
term in section 552a(a)(5) of title 5, United
States Code.
``(2) Access to claims and payment databases.--For purposes
of conducting law enforcement and oversight activities and to
the extent consistent with applicable information, privacy,
security, and disclosure laws, including the regulations
promulgated under the Health Insurance Portability and
Accountability Act of 1996 and section 552a of title 5, United
States Code, and subject to any information systems security
requirements under such laws or otherwise required by the
Secretary, the Inspector General of the Department of Health
and Human Services and the Attorney General shall have access
to claims and payment data of the Department of Health and
Human Services and its contractors related to titles XVIII,
XIX, and XXI.
``(b) OIG Authority To Obtain Information.--
``(1) In general.--Notwithstanding and in addition to any
other provision of law, the Inspector General of the Department
of Health and Human Services may, for purposes of protecting
the integrity of the programs under titles XVIII and XIX,
obtain information from any individual (including a beneficiary
provided all applicable privacy protections are followed) or
entity that--
``(A) is a provider of medical or other items or
services, supplier, grant recipient, contractor, or
subcontractor; or
``(B) directly or indirectly provides, orders,
manufactures, distributes, arranges for, prescribes,
supplies, or receives medical or other items or
services payable by any Federal health care program (as
defined in section 1128B(f)) regardless of how the item
or service is paid for, or to whom such payment is
made.
``(2) Inclusion of certain information.--Information which
the Inspector General may obtain under paragraph (1) includes
any supporting documentation necessary to validate claims for
payment or payments under title XVIII or XIX, including a
prescribing physician's medical records for an individual who
is prescribed an item or service which is covered under part B
of title XVIII, a covered part D drug (as defined in section
1860D-2(e)) for which payment is made under an MA-PD plan under
part C of such title, or a prescription drug plan under part D
of such title, and any records necessary for evaluation of the
economy, efficiency, and effectiveness of the programs under
titles XVIII and XIX.
``(c) Administrative Remedy for Knowing Participation by
Beneficiary in Health Care Fraud Scheme.--
``(1) In general.--In addition to any other applicable
remedies, if an applicable individual has knowingly
participated in a Federal health care fraud offense or a
conspiracy to commit a Federal health care fraud offense, the
Secretary shall impose an appropriate administrative penalty
commensurate with the offense or conspiracy.
``(2) Applicable individual.--For purposes of paragraph
(1), the term `applicable individual' means an individual--
``(A) entitled to, or enrolled for, benefits under
part A of title XVIII or enrolled under part B of such
title;
``(B) eligible for medical assistance under a State
plan under title XIX or under a waiver of such plan; or
``(C) eligible for child health assistance under a
child health plan under title XXI.
``(d) Reporting and Returning of Overpayments.--
``(1) In general.--If a person has received an overpayment,
the person shall--
``(A) report and return the overpayment to the
Secretary, the State, an intermediary, a carrier, or a
contractor, as appropriate, at the correct address; and
``(B) notify the Secretary, State, intermediary,
carrier, or contractor to whom the overpayment was
returned in writing of the reason for the overpayment.
``(2) Deadline for reporting and returning overpayments.--
An overpayment must be reported and returned under paragraph
(1) by the later of--
``(A) the date which is 60 days after the date on
which the overpayment was identified; or
``(B) the date any corresponding cost report is
due, if applicable.
``(3) Enforcement.--Any overpayment retained by a person
after the deadline for reporting and returning the overpayment
under paragraph (2) is an obligation (as defined in section
3729(b)(3) of title 31, United States Code) for purposes of
section 3729 of such title.
``(4) Definitions.--In this subsection:
``(A) Knowing and knowingly.--The terms `knowing'
and `knowingly' have the meaning given those terms in
section 3729(b) of title 31, United States Code.
``(B) Overpayment.--The term ``overpayment'' means
any funds that a person receives or retains under title
XVIII or XIX to which the person, after applicable
reconciliation, is not entitled under such title.
``(C) Person.--
``(i) In general.--The term `person' means
a provider of services, supplier, medicaid
managed care organization (as defined in
section 1903(m)(1)(A)), Medicare Advantage
organization (as defined in section
1859(a)(1)), or PDP sponsor (as defined in
section 1860D-41(a)(13)).
``(ii) Exclusion.--Such term does not
include a beneficiary.
``(e) Inclusion of National Provider Identifier on All Applications
and Claims.--The Secretary shall promulgate a regulation that requires,
not later than January 1, 2011, all providers of medical or other items
or services and suppliers under the programs under titles XVIII and XIX
that qualify for a national provider identifier to include their
national provider identifier on all applications to enroll in such
programs and on all claims for payment submitted under such
programs.''.
(b) Access to Data.--
(1) Medicare part d.--Section 1860D-15(f)(2) of the Social
Security Act (42 U.S.C. 1395w-116(f)(2)) is amended by striking
``may be used by'' and all that follows through the period at
the end and inserting ``may be used--
``(A) by officers, employees, and contractors of
the Department of Health and Human Services for the
purposes of, and to the extent necessary in--
``(i) carrying out this section; and
``(ii) conducting oversight, evaluation,
and enforcement under this title; and
``(B) by the Attorney General and the Comptroller
General of the United States for the purposes of, and
to the extent necessary in, carrying out health
oversight activities.''.
(2) Data matching.--Section 552a(a)(8)(B) of title 5,
United States Code, is amended--
(A) in clause (vii), by striking ``or'' at the end;
(B) in clause (viii), by inserting ``or'' after the
semicolon; and
(C) by adding at the end the following new clause:
``(ix) matches performed by the Secretary
of Health and Human Services or the Inspector
General of the Department of Health and Human
Services with respect to potential fraud,
waste, and abuse, including matches of a system
of records with non-Federal records;''.
(3) Matching agreements with the commissioner of social
security.--Section 205(r) of the Social Security Act (42 U.S.C.
405(r)) is amended by adding at the end the following new
paragraph:
``(9)(A) The Commissioner of Social Security shall, upon
the request of the Secretary or the Inspector General of the
Department of Health and Human Services--
``(i) enter into an agreement with the Secretary or
such Inspector General for the purpose of matching data
in the system of records of the Social Security
Administration and the system of records of the
Department of Health and Human Services; and
``(ii) include in such agreement safeguards to
assure the maintenance of the confidentiality of any
information disclosed.
``(B) For purposes of this paragraph, the term `system of
records' has the meaning given such term in section 552a(a)(5)
of title 5, United States Code.''.
(c) Withholding of Federal Matching Payments for States That Fail
To Report Enrollee Encounter Data in the Medicaid Statistical
Information System.--Section 1903(i) of the Social Security Act (42
U.S.C. 1396b(i)) is amended--
(1) in paragraph (23), by striking ``or'' at the end;
(2) in paragraph (24), by striking the period at the end
and inserting ``; or''; and
(3) by adding at the end the following new paragraph:.
``(25) with respect to any amounts expended for medical
assistance for individuals for whom the State does not report
enrollee encounter data (as defined by the Secretary) to the
Medicaid Statistical Information System (MSIS) in a timely
manner (as determined by the Secretary).''.
(d) Permissive Exclusions and Civil Monetary Penalties.--
(1) Permissive exclusions.--Section 1128(b) of the Social
Security Act (42 U.S.C. 1320a-7(b)) is amended by adding at the
end the following new paragraph:
``(16) Making false statements or misrepresentation of
material facts.--Any individual or entity that knowingly makes
or causes to be made any false statement, omission, or
misrepresentation of a material fact in any application,
agreement, bid, or contract to participate or enroll as a
provider of services or supplier under a Federal health care
program (as defined in section 1128B(f)), including Medicare
Advantage organizations under part C of title XVIII,
prescription drug plan sponsors under part D of title XVIII,
medicaid managed care organizations under title XIX, and
entities that apply to participate as providers of services or
suppliers in such managed care organizations and such plans.''.
(2) Civil monetary penalties.--
(A) In general.--Section 1128A(a) of the Social
Security Act (42 U.S.C. 1320a-7a(a)) is amended--
(i) in paragraph (1)(D), by striking ``was
excluded'' and all that follows through the
period at the end and inserting ``was excluded
from the Federal health care program (as
defined in section 1128B(f)) under which the
claim was made pursuant to Federal law.'';
(ii) in paragraph (6), by striking ``or''
at the end;
(iii) by inserting after paragraph (7), the
following new paragraphs:
``(8) orders or prescribes a medical or other item or
service during a period in which the person was excluded from a
Federal health care program (as so defined), in the case where
the person knows or should know that a claim for such medical
or other item or service will be made under such a program;
``(9) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a material fact in
any application, bid, or contract to participate or enroll as a
provider of services or a supplier under a Federal health care
program (as so defined), including Medicare Advantage
organizations under part C of title XVIII, prescription drug
plan sponsors under part D of title XVIII, medicaid managed
care organizations under title XIX, and entities that apply to
participate as providers of services or suppliers in such
managed care organizations and such plans;
``(10) knows of an overpayment (as defined in paragraph (4)
of section 1128J(d)) and does not report and return the
overpayment in accordance with such section;'';
(iv) in the first sentence--
(I) by striking the ``or'' after
``prohibited relationship occurs;'';
and
(II) by striking ``act)'' and
inserting ``act; or in cases under
paragraph (9), $50,000 for each false
statement or misrepresentation of a
material fact)''; and
(v) in the second sentence, by striking
``purpose)'' and inserting ``purpose; or in
cases under paragraph (9), an assessment of not
more than 3 times the total amount claimed for
each item or service for which payment was made
based upon the application containing the false
statement or misrepresentation of a material
fact)''.
(B) Clarification of treatment of certain
charitable and other innocuous programs.--Section
1128A(i)(6) of the Social Security Act (42 U.S.C.
1320a-7a(i)(6)) is amended--
(i) in subparagraph (C), by striking ``or''
at the end;
(ii) in subparagraph (D), as redesignated
by section 4331(e) of the Balanced Budget Act
of 1997 (Public Law 105-33), by striking the
period at the end and inserting a semicolon;
(iii) by redesignating subparagraph (D), as
added by section 4523(c) of such Act, as
subparagraph (E) and striking the period at the
end and inserting ``; or''; and
(iv) by adding at the end the following new
subparagraphs:
``(F) any other remuneration which promotes access
to care and poses a low risk of harm to patients and
Federal health care programs (as defined in section
1128B(f) and designated by the Secretary under
regulations);
``(G) the offer or transfer of items or services
for free or less than fair market value by a person,
if--
``(i) the items or services consist of
coupons, rebates, or other rewards from a
retailer;
``(ii) the items or services are offered or
transferred on equal terms available to the
general public, regardless of health insurance
status; and
``(iii) the offer or transfer of the items
or services is not tied to the provision of
other items or services reimbursed in whole or
in part by the program under title XVIII or a
State health care program (as defined in
section 1128(h));
``(H) the offer or transfer of items or services
for free or less than fair market value by a person,
if--
``(i) the items or services are not offered
as part of any advertisement or solicitation;
``(ii) the items or services are not tied
to the provision of other services reimbursed
in whole or in part by the program under title
XVIII or a State health care program (as so
defined);
``(iii) there is a reasonable connection
between the items or services and the medical
care of the individual; and
``(iv) the person provides the items or
services after determining in good faith that
the individual is in financial need; or
``(I) effective on a date specified by the
Secretary (but not earlier than January 1, 2011), the
waiver by a PDP sponsor of a prescription drug plan
under part D of title XVIII or an MA organization
offering an MA-PD plan under part C of such title of
any copayment for the first fill of a covered part D
drug (as defined in section 1860D-2(e)) that is a
generic drug for individuals enrolled in the
prescription drug plan or MA-PD plan, respectively.''.
(e) Testimonial Subpoena Authority in Exclusion-only Cases.--
Section 1128(f) of the Social Security Act (42 U.S.C. 1320a-7(f)) is
amended by adding at the end the following new paragraph:
``(4) The provisions of subsections (d) and (e) of section
205 shall apply with respect to this section to the same extent
as they are applicable with respect to title II. The Secretary
may delegate the authority granted by section 205(d) (as made
applicable to this section) to the Inspector General of the
Department of Health and Human Services for purposes of any
investigation under this section.''.
(f) Health Care Fraud.--
(1) Kickbacks.--Section 1128B of the Social Security Act
(42 U.S.C. 1320a-7b) is amended by adding at the end the
following new subsection:
``(g) In addition to the penalties provided for in this section or
section 1128A, a claim that includes items or services resulting from a
violation of this section constitutes a false or fraudulent claim for
purposes of subchapter III of chapter 37 of title 31, United States
Code.''.
(2) Revising the intent requirement.--Section 1128B of the
Social Security Act (42 U.S.C. 1320a-7b), as amended by
paragraph (1), is amended by adding at the end the following
new subsection:
``(h) With respect to violations of this section, a person need not
have actual knowledge of this section or specific intent to commit a
violation of this section.''.
(g) Surety Bond Requirements.--
(1) Durable medical equipment.--Section 1834(a)(16)(B) of
the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is amended
by inserting ``that the Secretary determines is commensurate
with the volume of the billing of the supplier'' before the
period at the end.
(2) Home health agencies.--Section 1861(o)(7)(C) of the
Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by
inserting ``that the Secretary determines is commensurate with
the volume of the billing of the home health agency'' before
the semicolon at the end.
(3) Requirements for certain other providers of services
and suppliers.--Section 1862 of the Social Security Act (42
U.S.C. 1395y) is amended by adding at the end the following new
subsection:
``(n) Requirement of a Surety Bond for Certain Providers of
Services and Suppliers.--
``(1) In general.--The Secretary may require a provider of
services or supplier described in paragraph (2) to provide the
Secretary on a continuing basis with a surety bond in a form
specified by the Secretary in an amount (not less than $50,000)
that the Secretary determines is commensurate with the volume
of the billing of the provider of services or supplier. The
Secretary may waive the requirement of a bond under the
preceding sentence in the case of a provider of services or
supplier that provides a comparable surety bond under State
law.
``(2) Provider of services or supplier described.--A
provider of services or supplier described in this paragraph is
a provider of services or supplier the Secretary determines
appropriate based on the level of risk involved with respect to
the provider of services or supplier, and consistent with the
surety bond requirements under sections 1834(a)(16)(B) and
1861(o)(7)(C).''.
(h) Suspension of Medicare and Medicaid Payments Pending
Investigation of Credible Allegations of Fraud.--
(1) Medicare.--Section 1862 of the Social Security Act (42
U.S.C. 1395y), as amended by subsection (g)(3), is amended by
adding at the end the following new subsection:
``(o) Suspension of Payments Pending Investigation of Credible
Allegations of Fraud.--
``(1) In general.--The Secretary may suspend payments to a
provider of services or supplier under this title pending an
investigation of a credible allegation of fraud against the
provider of services or supplier, unless the Secretary
determines there is good cause not to suspend such payments.
``(2) Consultation.--The Secretary shall consult with the
Inspector General of the Department of Health and Human
Services in determining whether there is a credible allegation
of fraud against a provider of services or supplier.
``(3) Promulgation of regulations.--The Secretary shall
promulgate regulations to carry out this subsection and section
1903(i)(2)(C).''.
(2) Medicaid.--Section 1903(i)(2) of such Act (42 U.S.C.
1396b(i)(2)) is amended--
(A) in subparagraph (A), by striking ``or'' at the
end; and
(B) by inserting after subparagraph (B), the
following:
``(C) by any individual or entity to whom the State
has failed to suspend payments under the plan during
any period when there is pending an investigation of a
credible allegation of fraud against the individual or
entity, as determined by the State in accordance with
regulations promulgated by the Secretary for purposes
of section 1862(o) and this subparagraph, unless the
State determines in accordance with such regulations
there is good cause not to suspend such payments; or''.
(i) Increased Funding To Fight Fraud and Abuse.--
(1) In general.--Section 1817(k) of the Social Security Act
(42 U.S.C. 1395i(k)) is amended--
(A) by adding at the end the following new
paragraph:
``(7) Additional funding.--In addition to the funds
otherwise appropriated to the Account from the Trust Fund under
paragraphs (3) and (4) and for purposes described in paragraphs
(3)(C) and (4)(A), there are hereby appropriated an additional
$10,000,000 to such Account from such Trust Fund for each of
fiscal years 2011 through 2020. The funds appropriated under
this paragraph shall be allocated in the same proportion as the
total funding appropriated with respect to paragraphs (3)(A)
and (4)(A) was allocated with respect to fiscal year 2010, and
shall be available without further appropriation until
expended.''; and
(B) in paragraph (4)(A), by inserting ``until
expended'' after ``appropriation''.
(2) Indexing of amounts appropriated.--
(A) Departments of health and human services and
justice.--Section 1817(k)(3)(A)(i) of the Social
Security Act (42 U.S.C. 1395i(k)(3)(A)(i)) is amended--
(i) in subclause (III), by inserting
``and'' at the end;
(ii) in subclause (IV)--
(I) by striking ``for each of
fiscal years 2007, 2008, 2009, and
2010'' and inserting ``for each fiscal
year after fiscal year 2006''; and
(II) by striking ``; and'' and
inserting a period; and
(iii) by striking subclause (V).
(B) Office of the inspector general of the
department of health and human services.--Section
1817(k)(3)(A)(ii) of such Act (42 U.S.C.
1395i(k)(3)(A)(ii)) is amended--
(i) in subclause (VIII), by inserting
``and'' at the end;
(ii) in subclause (IX)--
(I) by striking ``for each of
fiscal years 2008, 2009, and 2010'' and
inserting ``for each fiscal year after
fiscal year 2007''; and
(II) by striking ``; and'' and
inserting a period; and
(iii) by striking subclause (X).
(C) Federal bureau of investigation.--Section
1817(k)(3)(B) of the Social Security Act (42 U.S.C.
1395i(k)(3)(B)) is amended--
(i) in clause (vii), by inserting ``and''
at the end;
(ii) in clause (viii)--
(I) by striking ``for each of
fiscal years 2007, 2008, 2009, and
2010'' and inserting ``for each fiscal
year after fiscal year 2006''; and
(II) by striking ``; and'' and
inserting a period; and
(iii) by striking clause (ix).
(D) Medicare integrity program.--Section
1817(k)(4)(C) of the Social Security Act (42 U.S.C.
1395i(k)(4)(C)) is amended by adding at the end the
following new clause:
``(ii) For each fiscal year after 2010, by
the percentage increase in the consumer price
index for all urban consumers (all items;
United States city average) over the previous
year.''.
(j) Medicare Integrity Program and Medicaid Integrity Program.--
(1) Medicare integrity program.--
(A) Requirement to provide performance
statistics.--Section 1893(c) of the Social Security Act
(42 U.S.C. 1395ddd(c)) is amended--
(i) in paragraph (3), by striking ``and''
at the end;
(ii) by redesignating paragraph (4) as
paragraph (5); and
(iii) by inserting after paragraph (3) the
following new paragraph:
``(4) the entity agrees to provide the Secretary and the
Inspector General of the Department of Health and Human
Services with such performance statistics (including the number
and amount of overpayments recovered, the number of fraud
referrals, and the return on investment of such activities by
the entity) as the Secretary or the Inspector General may
request; and''.
(B) Evaluations and annual report.--Section 1893 of
the Social Security Act (42 U.S.C. 1395ddd) is amended
by adding at the end the following new subsection:
``(i) Evaluations and Annual Report.--
``(1) Evaluations.--The Secretary shall conduct evaluations
of eligible entities which the Secretary contracts with under
the Program not less frequently than every 3 years.
``(2) Annual report.--Not later than 180 days after the end
of each fiscal year (beginning with fiscal year 2011), the
Secretary shall submit a report to Congress which identifies--
``(A) the use of funds, including funds transferred
from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Insurance
Trust Fund under section 1841, to carry out this
section; and
``(B) the effectiveness of the use of such
funds.''.
(C) Flexibility in pursuing fraud and abuse.--
Section 1893(a) of the Social Security Act (42 U.S.C.
1395ddd(a)) is amended by inserting ``, or otherwise,''
after ``entities''.
(2) Medicaid integrity program.--
(A) Requirement to provide performance
statistics.--Section 1936(c)(2) of the Social Security
Act (42 U.S.C. 1396u-6(c)(2)) is amended--
(i) by redesignating subparagraph (D) as
subparagraph (E); and
(ii) by inserting after subparagraph (C)
the following new subparagraph:
``(D) The entity agrees to provide the Secretary
and the Inspector General of the Department of Health
and Human Services with such performance statistics
(including the number and amount of overpayments
recovered, the number of fraud referrals, and the
return on investment of such activities by the entity)
as the Secretary or the Inspector General may
request.''.
(B) Evaluations and annual report.--Section 1936(e)
of the Social Security Act (42 U.S.C. 1396u-7(e)) is
amended--
(i) by redesignating paragraph (4) as
paragraph (5); and
(ii) by inserting after paragraph (3) the
following new paragraph:
``(4) Evaluations.--The Secretary shall conduct evaluations
of eligible entities which the Secretary contracts with under
the Program not less frequently than every 3 years.''.
(k) Expanded Application of Hardship Waivers for Exclusions.--
Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 1320a-
7(c)(3)(B)) is amended by striking ``individuals entitled to benefits
under part A of title XVIII or enrolled under part B of such title, or
both'' and inserting ``beneficiaries (as defined in section
1128A(i)(5)) of that program''.
SEC. 6403. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE INTEGRITY
AND PROTECTION DATA BANK AND THE NATIONAL PRACTITIONER
DATA BANK.
(a) Information Reported by Federal Agencies and Health Plans.--
Section 1128E of the Social Security Act (42 U.S.C. 1320a-7e) is
amended--
(1) by striking subsection (a) and inserting the following:
``(a) In General.--The Secretary shall maintain a national health
care fraud and abuse data collection program under this section for the
reporting of certain final adverse actions (not including settlements
in which no findings of liability have been made) against health care
providers, suppliers, or practitioners as required by subsection (b),
with access as set forth in subsection (d), and shall furnish the
information collected under this section to the National Practitioner
Data Bank established pursuant to the Health Care Quality Improvement
Act of 1986 (42 U.S.C. 11101 et seq.).'';
(2) by striking subsection (d) and inserting the following:
``(d) Access to Reported Information.--
``(1) Availability.--The information collected under this
section shall be available from the National Practitioner Data
Bank to the agencies, authorities, and officials which are
provided under section 1921(b) information reported under
section 1921(a).
``(2) Fees for disclosure.--The Secretary may establish or
approve reasonable fees for the disclosure of information under
this section. The amount of such a fee may not exceed the costs
of processing the requests for disclosure and of providing such
information. Such fees shall be available to the Secretary to
cover such costs.'';
(3) by striking subsection (f) and inserting the following:
``(f) Appropriate Coordination.--In implementing this section, the
Secretary shall provide for the maximum appropriate coordination with
part B of the Health Care Quality Improvement Act of 1986 (42 U.S.C.
11131 et seq.) and section 1921.''; and
(4) in subsection (g)--
(A) in paragraph (1)(A)--
(i) in clause (iii)--
(I) by striking ``or State'' each
place it appears;
(II) by redesignating subclauses
(II) and (III) as subclauses (III) and
(IV), respectively; and
(III) by inserting after subclause
(I) the following new subclause:
``(II) any dismissal or closure of
the proceedings by reason of the
provider, supplier, or practitioner
surrendering their license or leaving
the State or jurisdiction''; and
(ii) by striking clause (iv) and inserting
the following:
``(iv) Exclusion from participation in a
Federal health care program (as defined in
section 1128B(f)).'';
(B) in paragraph (3)--
(i) by striking subparagraphs (D) and (E);
and
(ii) by redesignating subparagraph (F) as
subparagraph (D); and
(C) in subparagraph (D) (as so redesignated), by
striking ``or State''.
(b) Information Reported by State Law or Fraud Enforcement
Agencies.--Section 1921 of the Social Security Act (42 U.S.C. 1396r-2)
is amended--
(1) in subsection (a)--
(A) in paragraph (1)--
(i) by striking ``system.--The State'' and
all that follows through the semicolon and
inserting system.--
``(A) Licensing or certification actions.--The
State must have in effect a system of reporting the
following information with respect to formal
proceedings (as defined by the Secretary in
regulations) concluded against a health care
practitioner or entity by a State licensing or
certification agency:'';
(ii) by redesignating subparagraphs (A)
through (D) as clauses (i) through (iv),
respectively, and indenting appropriately;
(iii) in subparagraph (A)(iii) (as so
redesignated)--
(I) by striking ``the license of''
and inserting ``license or the right to
apply for, or renew, a license by'';
and
(II) by inserting
``nonrenewability,'' after ``voluntary
surrender,''; and
(iv) by adding at the end the following new
subparagraph:
``(B) Other final adverse actions.--The State must
have in effect a system of reporting information with
respect to any final adverse action (not including
settlements in which no findings of liability have been
made) taken against a health care provider, supplier,
or practitioner by a State law or fraud enforcement
agency.''; and
(B) in paragraph (2), by striking ``the authority
described in paragraph (1)'' and inserting ``a State
licensing or certification agency or State law or fraud
enforcement agency'';
(2) in subsection (b)--
(A) by striking paragraph (2) and inserting the
following:
``(2) to State licensing or certification agencies and
Federal agencies responsible for the licensing and
certification of health care providers, suppliers, and licensed
health care practitioners;'';
(B) in each of paragraphs (4) and (6), by inserting
``, but only with respect to information provided
pursuant to subsection (a)(1)(A)'' before the comma at
the end;
(C) by striking paragraph (5) and inserting the
following:
``(5) to State law or fraud enforcement agencies,'';
(D) by redesignating paragraphs (7) and (8) as
paragraphs (8) and (9), respectively; and
(E) by inserting after paragraph (6) the following
new paragraph:
``(7) to health plans (as defined in section 1128C(c));'';
(3) by redesignating subsection (d) as subsection (h), and
by inserting after subsection (c) the following new
subsections:
``(d) Disclosure and Correction of Information.--
``(1) Disclosure.--With respect to information reported
pursuant to subsection (a)(1), the Secretary shall--
``(A) provide for disclosure of the information,
upon request, to the health care practitioner who, or
the entity that, is the subject of the information
reported; and
``(B) establish procedures for the case where the
health care practitioner or entity disputes the
accuracy of the information reported.
``(2) Corrections.--Each State licensing or certification
agency and State law or fraud enforcement agency shall report
corrections of information already reported about any formal
proceeding or final adverse action described in subsection (a),
in such form and manner as the Secretary prescribes by
regulation.
``(e) Fees for Disclosure.--The Secretary may establish or approve
reasonable fees for the disclosure of information under this section.
The amount of such a fee may not exceed the costs of processing the
requests for disclosure and of providing such information. Such fees
shall be available to the Secretary to cover such costs.
``(f) Protection From Liability for Reporting.--No person or
entity, including any agency designated by the Secretary in subsection
(b), shall be held liable in any civil action with respect to any
reporting of information as required under this section, without
knowledge of the falsity of the information contained in the report.
``(g) References.--For purposes of this section:
``(1) State licensing or certification agency.--The term
`State licensing or certification agency' includes any
authority of a State (or of a political subdivision thereof)
responsible for the licensing of health care practitioners (or
any peer review organization or private accreditation entity
reviewing the services provided by health care practitioners)
or entities.
``(2) State law or fraud enforcement agency.--The term
`State law or fraud enforcement agency' includes--
``(A) a State law enforcement agency; and
``(B) a State medicaid fraud control unit (as
defined in section 1903(q)).
``(3) Final adverse action.--
``(A) In general.--Subject to subparagraph (B), the
term `final adverse action' includes--
``(i) civil judgments against a health care
provider, supplier, or practitioner in State
court related to the delivery of a health care
item or service;
``(ii) State criminal convictions related
to the delivery of a health care item or
service;
``(iii) exclusion from participation in
State health care programs (as defined in
section 1128(h));
``(iv) any licensing or certification
action described in subsection (a)(1)(A) taken
against a supplier by a State licensing or
certification agency; and
``(v) any other adjudicated actions or
decisions that the Secretary shall establish by
regulation.
``(B) Exception.--Such term does not include any
action with respect to a malpractice claim.''; and
(4) in subsection (h), as so redesignated, by striking
``The Secretary'' and all that follows through the period at
the end and inserting ``In implementing this section, the
Secretary shall provide for the maximum appropriate
coordination with part B of the Health Care Quality Improvement
Act of 1986 (42 U.S.C. 11131 et seq.) and section 1128E.''.
(c) Conforming Amendment.--Section 1128C(a)(1) of the Social
Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended--
(1) in subparagraph (C), by adding ``and'' after the comma
at the end;
(2) in subparagraph (D), by striking ``, and'' and
inserting a period; and
(3) by striking subparagraph (E).
(d) Transition Process; Effective Date.--
(1) In general.--Effective on the date of enactment of this
Act, the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') shall implement a
transition process under which, by not later than the end of
the transition period described in paragraph (5), the Secretary
shall cease operating the Healthcare Integrity and Protection
Data Bank established under section 1128E of the Social
Security Act (as in effect before the effective date specified
in paragraph (6)) and shall transfer all data collected in the
Healthcare Integrity and Protection Data Bank to the National
Practitioner Data Bank established pursuant to the Health Care
Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq.).
During such transition process, the Secretary shall have in
effect appropriate procedures to ensure that data collection
and access to the Healthcare Integrity and Protection Data Bank
and the National Practitioner Data Bank are not disrupted.
(2) Regulations.--The Secretary shall promulgate
regulations to carry out the amendments made by subsections (a)
and (b).
(3) Funding.--
(A) Availability of fees.--Fees collected pursuant
to section 1128E(d)(2) of the Social Security Act prior
to the effective date specified in paragraph (6) for
the disclosure of information in the Healthcare
Integrity and Protection Data Bank shall be available
to the Secretary, without fiscal year limitation, for
payment of costs related to the transition process
described in paragraph (1). Any such fees remaining
after the transition period is complete shall be
available to the Secretary, without fiscal year
limitation, for payment of the costs of operating the
National Practitioner Data Bank.
(B) Availability of additional funds.--In addition
to the fees described in subparagraph (A), any funds
available to the Secretary or to the Inspector General
of the Department of Health and Human Services for a
purpose related to combating health care fraud, waste,
or abuse shall be available to the extent necessary for
operating the Healthcare Integrity and Protection Data
Bank during the transition period, including systems
testing and other activities necessary to ensure that
information formerly reported to the Healthcare
Integrity and Protection Data Bank will be accessible
through the National Practitioner Data Bank after the
end of such transition period.
(4) Special provision for access to the national
practitioner data bank by the department of veterans affairs.--
(A) In general.--Notwithstanding any other
provision of law, during the 1-year period that begins
on the effective date specified in paragraph (6), the
information described in subparagraph (B) shall be
available from the National Practitioner Data Bank to
the Secretary of Veterans Affairs without charge.
(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is the information that would, but for the
amendments made by this section, have been available to
the Secretary of Veterans Affairs from the Healthcare
Integrity and Protection Data Bank.
(5) Transition period defined.--For purposes of this
subsection, the term ``transition period'' means the period
that begins on the date of enactment of this Act and ends on
the later of--
(A) the date that is 1 year after such date of
enactment; or
(B) the effective date of the regulations
promulgated under paragraph (2).
(6) Effective date.--The amendments made by subsections
(a), (b), and (c) shall take effect on the first day after the
final day of the transition period.
SEC. 6404. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO
NOT MORE THAN 12 MONTHS.
(a) Reducing Maximum Period for Submission.--
(1) Part a.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)(1)) is amended--
(A) in paragraph (1), by striking ``period of 3
calendar years'' and all that follows through the
semicolon and inserting ``period ending 1 calendar year
after the date of service;''; and
(B) by adding at the end the following new
sentence: ``In applying paragraph (1), the Secretary
may specify exceptions to the 1 calendar year period
specified in such paragraph.''
(2) Part b.--
(A) Section 1842(b)(3) of such Act (42 U.S.C.
1395u(b)(3)(B)) is amended--
(i) in subparagraph (B), in the flush
language following clause (ii), by striking
``close of the calendar year following the year
in which such service is furnished (deeming any
service furnished in the last 3 months of any
calendar year to have been furnished in the
succeeding calendar year)'' and inserting
``period ending 1 calendar year after the date
of service''; and
(ii) by adding at the end the following new
sentence: ``In applying subparagraph (B), the
Secretary may specify exceptions to the 1
calendar year period specified in such
subparagraph.''
(B) Section 1835(a) of such Act (42 U.S.C.
1395n(a)) is amended--
(i) in paragraph (1), by striking ``period
of 3 calendar years'' and all that follows
through the semicolon and inserting ``period
ending 1 calendar year after the date of
service;''; and
(ii) by adding at the end the following new
sentence: ``In applying paragraph (1), the
Secretary may specify exceptions to the 1
calendar year period specified in such
paragraph.''
(b) Effective Date.--
(1) In general.--The amendments made by subsection (a)
shall apply to services furnished on or after January 1, 2010.
(2) Services furnished before 2010.--In the case of
services furnished before January 1, 2010, a bill or request
for payment under section 1814(a)(1), 1842(b)(3)(B), or 1835(a)
shall be filed not later that December 31, 2010.
SEC. 6405. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED TO BE
MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE PROFESSIONALS.
(a) DME.--Section 1834(a)(11)(B) of the Social Security Act (42
U.S.C. 1395m(a)(11)(B)) is amended by striking ``physician'' and
inserting ``physician enrolled under section 1866(j) or an eligible
professional under section 1848(k)(3)(B) that is enrolled under section
1866(j)''.
(b) Home Health Services.--
(1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C.
1395(a)(2)) is amended in the matter preceding subparagraph (A)
by inserting ``in the case of services described in
subparagraph (C), a physician enrolled under section 1866(j) or
an eligible professional under section 1848(k)(3)(B),'' before
``or, in the case of services''.
(2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C.
1395n(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``, or in the case of services described in
subparagraph (A), a physician enrolled under section 1866(j) or
an eligible professional under section 1848(k)(3)(B),'' after
``a physician''.
(c) Application to Other Items or Services.--The Secretary may
extend the requirement applied by the amendments made by subsections
(a) and (b) to durable medical equipment and home health services
(relating to requiring certifications and written orders to be made by
enrolled physicians and health professions) to all other categories of
items or services under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), including covered part D drugs as defined in
section 1860D-2(e) of such Act (42 U.S.C. 1395w-102), that are ordered,
prescribed, or referred by a physician enrolled under section 1866(j)
of such Act (42 U.S.C. 1395cc(j)) or an eligible professional under
section 1848(k)(3)(B) of such Act (42 U.S.C. 1395w-4(k)(3)(B)).
(d) Effective Date.--The amendments made by this section shall
apply to written orders and certifications made on or after July 1,
2010.
SEC. 6406. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON
REFERRALS TO PROGRAMS AT HIGH RISK OF WASTE AND ABUSE.
(a) Physicians and Other Suppliers.--Section 1842(h) of the Social
Security Act (42 U.S.C. 1395u(h)) is amended by adding at the end the
following new paragraph:
``(9) The Secretary may revoke enrollment, for a period of not more
than one year for each act, for a physician or supplier under section
1866(j) if such physician or supplier fails to maintain and, upon
request of the Secretary, provide access to documentation relating to
written orders or requests for payment for durable medical equipment,
certifications for home health services, or referrals for other items
or services written or ordered by such physician or supplier under this
title, as specified by the Secretary.''.
(b) Providers of Services.--Section 1866(a)(1) of such Act (42
U.S.C. 1395cc) is further amended--
(1) in subparagraph (U), by striking at the end ``and'';
(2) in subparagraph (V), by striking the period at the end
and adding ``; and''; and
(3) by adding at the end the following new subparagraph:
``(W) maintain and, upon request of the Secretary,
provide access to documentation relating to written
orders or requests for payment for durable medical
equipment, certifications for home health services, or
referrals for other items or services written or
ordered by the provider under this title, as specified
by the Secretary.''.
(c) OIG Permissive Exclusion Authority.--Section 1128(b)(11) of the
Social Security Act (42 U.S.C. 1320a-7(b)(11)) is amended by inserting
``, ordering, referring for furnishing, or certifying the need for''
after ``furnishing''.
(d) Effective Date.--The amendments made by this section shall
apply to orders, certifications, and referrals made on or after January
1, 2010.
SEC. 6407. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE
PHYSICIANS MAY CERTIFY ELIGIBILITY FOR HOME HEALTH
SERVICES OR DURABLE MEDICAL EQUIPMENT UNDER MEDICARE.
(a) Condition of Payment for Home Health Services.--
(1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
(A) by striking ``and such services'' and inserting
``such services''; and
(B) by inserting after ``care of a physician'' the
following: ``, and, in the case of a certification made
by a physician after January 1, 2010, prior to making
such certification the physician must document that the
physician himself or herself has had a face-to-face
encounter (including through use of telehealth, subject
to the requirements in section 1834(m), and other than
with respect to encounters that are incident to
services involved) with the individual within a
reasonable timeframe as determined by the Secretary''.
(2) Part b.--Section 1835(a)(2)(A) of the Social Security
Act is amended--
(A) by striking ``and'' before ``(iii)''; and
(B) by inserting after ``care of a physician'' the
following: ``, and (iv) in the case of a certification
after January 1, 2010, prior to making such
certification the physician must document that the
physician has had a face-to-face encounter (including
through use of telehealth and other than with respect
to encounters that are incident to services involved)
with the individual during the 6-month period preceding
such certification, or other reasonable timeframe as
determined by the Secretary''.
(b) Condition of Payment for Durable Medical Equipment.--Section
1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B))
is amended--
(1) by striking ``Order.--The Secretary'' and inserting
``Order.--
``(i) In general.--The Secretary''; and
(2) by adding at the end the following new clause:
``(ii) Requirement for face to face
encounter.--The Secretary shall require that
such an order be written pursuant to the
physician documenting that a physician, a
physician assistant, a nurse practitioner, or a
clinical nurse specialist (as those terms are
defined in section 1861(aa)(5)) has had a face-
to-face encounter (including through use of
telehealth under subsection (m) and other than
with respect to encounters that are incident to
services involved) with the individual involved
during the 6-month period preceding such
written order, or other reasonable timeframe as
determined by the Secretary.''.
(c) Application to Other Areas Under Medicare.--The Secretary may
apply the face-to-face encounter requirement described in the
amendments made by subsections (a) and (b) to other items and services
for which payment is provided under title XVIII of the Social Security
Act based upon a finding that such an decision would reduce the risk of
waste, fraud, or abuse.
(d) Application to Medicaid.--The requirements pursuant to the
amendments made by subsections (a) and (b) shall apply in the case of
physicians making certifications for home health services under title
XIX of the Social Security Act in the same manner and to the same
extent as such requirements apply in the case of physicians making such
certifications under title XVIII of such Act.
SEC. 6408. ENHANCED PENALTIES.
(a) Civil Monetary Penalties for False Statements or Delaying
Inspections.--Section 1128A(a) of the Social Security Act (42 U.S.C.
1320a-7a(a)), as amended by section 5002(d)(2)(A), is amended--
(1) in paragraph (6), by striking ``or'' at the end; and
(2) by inserting after paragraph (7) the following new
paragraphs:
``(8) knowingly makes, uses, or causes to be made or used,
a false record or statement material to a false or fraudulent
claim for payment for items and services furnished under a
Federal health care program; or
``(9) fails to grant timely access, upon reasonable request
(as defined by the Secretary in regulations), to the Inspector
General of the Department of Health and Human Services, for the
purpose of audits, investigations, evaluations, or other
statutory functions of the Inspector General of the Department
of Health and Human Services;''; and
(3) in the first sentence--
(A) by striking ``or in cases under paragraph (7)''
and inserting ``in cases under paragraph (7)''; and
(B) by striking ``act)'' and inserting ``act, in
cases under paragraph (8), $50,000 for each false
record or statement, or in cases under paragraph (9),
$15,000 for each day of the failure described in such
paragraph)''.
(b) Medicare Advantage and Part D Plans.--
(1) Ensuring timely inspections relating to contracts with
ma organizations.--Section 1857(d)(2) of such Act (42 U.S.C.
1395w-27(d)(2)) is amended--
(A) in subparagraph (A), by inserting ``timely''
before ``inspect''; and
(B) in subparagraph (B), by inserting ``timely''
before ``audit and inspect''.
(2) Marketing violations.--Section 1857(g)(1) of the Social
Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(A) in subparagraph (F), by striking ``or'' at the
end;
(B) by inserting after subparagraph (G) the
following new subparagraphs:
``(H) except as provided under subparagraph (C) or
(D) of section 1860D-1(b)(1), enrolls an individual in
any plan under this part without the prior consent of
the individual or the designee of the individual;
``(I) transfers an individual enrolled under this
part from one plan to another without the prior consent
of the individual or the designee of the individual or
solely for the purpose of earning a commission;
``(J) fails to comply with marketing restrictions
described in subsections (h) and (j) of section 1851 or
applicable implementing regulations or guidance; or
``(K) employs or contracts with any individual or
entity who engages in the conduct described in
subparagraphs (A) through (J) of this paragraph;''; and
(C) by adding at the end the following new
sentence: ``The Secretary may provide, in addition to
any other remedies authorized by law, for any of the
remedies described in paragraph (2), if the Secretary
determines that any employee or agent of such
organization, or any provider or supplier who contracts
with such organization, has engaged in any conduct
described in subparagraphs (A) through (K) of this
paragraph.''.
(3) Provision of false information.--Section 1857(g)(2)(A)
of the Social Security Act (42 U.S.C. 1395w-27(g)(2)(A)) is
amended by inserting ``except with respect to a determination
under subparagraph (E), an assessment of not more than the
amount claimed by such plan or plan sponsor based upon the
misrepresentation or falsified information involved,'' after
``for each such determination,''.
(c) Obstruction of Program Audits.--Section 1128(b)(2) of the
Social Security Act (42 U.S.C. 1320a-7(b)(2)) is amended--
(1) in the heading, by inserting ``or audit'' after
``investigation''; and
(2) by striking ``investigation into'' and all that follows
through the period and inserting ``investigation or audit
related to--''
``(i) any offense described in paragraph
(1) or in subsection (a); or
``(ii) the use of funds received, directly
or indirectly, from any Federal health care
program (as defined in section 1128B(f)).''.
(d) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply to acts committed
on or after January 1, 2010.
(2) Exception.--The amendments made by subsection (b)(1)
take effect on the date of enactment of this Act.
SEC. 6409. MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL.
(a) Development of Self-Referral Disclosure Protocol.--
(1) In general.--The Secretary of Health and Human
Services, in cooperation with the Inspector General of the
Department of Health and Human Services, shall establish, not
later than 6 months after the date of the enactment of this
Act, a protocol to enable health care providers of services and
suppliers to disclose an actual or potential violation of
section 1877 of the Social Security Act (42 U.S.C. 1395nn)
pursuant to a self-referral disclosure protocol (in this
section referred to as an ``SRDP''). The SRDP shall include
direction to health care providers of services and suppliers
on--
(A) a specific person, official, or office to whom
such disclosures shall be made; and
(B) instruction on the implication of the SRDP on
corporate integrity agreements and corporate compliance
agreements.
(2) Publication on internet website of srdp information.--
The Secretary of Health and Human Services shall post
information on the public Internet website of the Centers for
Medicare & Medicaid Services to inform relevant stakeholders of
how to disclose actual or potential violations pursuant to an
SRDP.
(3) Relation to advisory opinions.--The SRDP shall be
separate from the advisory opinion process set forth in
regulations implementing section 1877(g) of the Social Security
Act.
(b) Reduction in Amounts Owed.--The Secretary of Health and Human
Services is authorized to reduce the amount due and owing for all
violations under section 1877 of the Social Security Act to an amount
less than that specified in subsection (g) of such section. In
establishing such amount for a violation, the Secretary may consider
the following factors:
(1) The nature and extent of the improper or illegal
practice.
(2) The timeliness of such self-disclosure.
(3) The cooperation in providing additional information
related to the disclosure.
(4) Such other factors as the Secretary considers
appropriate.
(c) Report.--Not later than 18 months after the date on which the
SRDP protocol is established under subsection (a)(1), the Secretary
shall submit to Congress a report on the implementation of this
section. Such report shall include--
(1) the number of health care providers of services and
suppliers making disclosures pursuant to the SRDP;
(2) the amounts collected pursuant to the SRDP;
(3) the types of violations reported under the SRDP; and
(4) such other information as may be necessary to evaluate
the impact of this section.
SEC. 6410. ADJUSTMENTS TO THE MEDICARE DURABLE MEDICAL EQUIPMENT,
PROSTHETICS, ORTHOTICS, AND SUPPLIES COMPETITIVE
ACQUISITION PROGRAM.
(a) Expansion of Round 2 of the DME Competitive Bidding Program.--
Section 1847(a)(1) of the Social Security Act (42 U.S.C. 1395w-3(a)(1))
is amended--
(1) in subparagraph (B)(i)(II), by striking ``70'' and
inserting ``91''; and
(2) in subparagraph (D)(ii)--
(A) in subclause (I), by striking ``and'' at the
end;
(B) by redesignating subclause (II) as subclause
(III); and
(C) by inserting after subclause (I) the following
new subclause:
``(II) the Secretary shall include
the next 21 largest metropolitan
statistical areas by total population
(after those selected under subclause
(I)) for such round; and''.
(b) Requirement to Either Competitively Bid Areas or Use
Competitive Bid Prices by 2016.--Section 1834(a)(1)(F) of the Social
Security Act (42 U.S.C. 1395m(a)(1)(F)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by inserting ``(and, in the case of covered
items furnished on or after January 1, 2016, subject to
clause (iii), shall)'' after ``may''; and
(B) by striking the period at the end and inserting
``; and''; and
(3) by adding at the end the following new clause:
``(iii) in the case of covered items
furnished on or after January 1, 2016, the
Secretary shall continue to make such
adjustments described in clause (ii) as, under
such competitive acquisition programs,
additional covered items are phased in or
information is updated as contracts under
section 1847 are recompeted in accordance with
section 1847(b)(3)(B).''.
SEC. 6411. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM.
(a) Expansion to Medicaid.--
(1) State plan amendment.--Section 1902(a)(42) of the
Social Security Act (42 U.S.C. 1396a(a)(42)) is amended--
(A) by striking ``that the records'' and inserting
``that--
``(A) the records'';
(B) by inserting ``and'' after the semicolon; and
(C) by adding at the end the following:
``(B) not later than December 31, 2010, the State
shall--
``(i) establish a program under which the
State contracts (consistent with State law and
in the same manner as the Secretary enters into
contracts with recovery audit contractors under
section 1893(h), subject to such exceptions or
requirements as the Secretary may require for
purposes of this title or a particular State)
with 1 or more recovery audit contractors for
the purpose of identifying underpayments and
overpayments and recouping overpayments under
the State plan and under any waiver of the
State plan with respect to all services for
which payment is made to any entity under such
plan or waiver; and
``(ii) provide assurances satisfactory to
the Secretary that--
``(I) under such contracts, payment
shall be made to such a contractor only
from amounts recovered;
``(II) from such amounts recovered,
payment--
``(aa) shall be made on a
contingent basis for collecting
overpayments; and
``(bb) may be made in such
amounts as the State may
specify for identifying
underpayments;
``(III) the State has an adequate
process for entities to appeal any
adverse determination made by such
contractors; and
``(IV) such program is carried out
in accordance with such requirements as
the Secretary shall specify,
including--
``(aa) for purposes of
section 1903(a)(7), that
amounts expended by the State
to carry out the program shall
be considered amounts expended
as necessary for the proper and
efficient administration of the
State plan or a waiver of the
plan;
``(bb) that section 1903(d)
shall apply to amounts
recovered under the program;
and
``(cc) that the State and
any such contractors under
contract with the State shall
coordinate such recovery audit
efforts with other contractors
or entities performing audits
of entities receiving payments
under the State plan or waiver
in the State, including efforts
with Federal and State law
enforcement with respect to the
Department of Justice,
including the Federal Bureau of
Investigations, the Inspector
General of the Department of
Health and Human Services, and
the State medicaid fraud
control unit; and''.
(2) Coordination; regulations.--
(A) In general.--The Secretary of Health and Human
Services, acting through the Administrator of the
Centers for Medicare & Medicaid Services, shall
coordinate the expansion of the Recovery Audit
Contractor program to Medicaid with States,
particularly with respect to each State that enters
into a contract with a recovery audit contractor for
purposes of the State's Medicaid program prior to
December 31, 2010.
(B) Regulations.--The Secretary of Health and Human
Services shall promulgate regulations to carry out this
subsection and the amendments made by this subsection,
including with respect to conditions of Federal
financial participation, as specified by the Secretary.
(b) Expansion to Medicare Parts C and D.--Section 1893(h) of the
Social Security Act (42 U.S.C. 1395ddd(h)) is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by striking ``part A or B'' and inserting ``this title'';
(2) in paragraph (2), by striking ``parts A and B'' and
inserting ``this title'';
(3) in paragraph (3), by inserting ``(not later than
December 31, 2010, in the case of contracts relating to
payments made under part C or D)'' after ``2010'';
(4) in paragraph (4), in the matter preceding subparagraph
(A), by striking ``part A or B'' and inserting ``this title'';
and
(5) by adding at the end the following:
``(9) Special rules relating to parts c and d.--The
Secretary shall enter into contracts under paragraph (1) to
require recovery audit contractors to--
``(A) ensure that each MA plan under part C has an
anti-fraud plan in effect and to review the
effectiveness of each such anti-fraud plan;
``(B) ensure that each prescription drug plan under
part D has an anti-fraud plan in effect and to review
the effectiveness of each such anti-fraud plan;
``(C) examine claims for reinsurance payments under
section 1860D-15(b) to determine whether prescription
drug plans submitting such claims incurred costs in
excess of the allowable reinsurance costs permitted
under paragraph (2) of that section; and
``(D) review estimates submitted by prescription
drug plans by private plans with respect to the
enrollment of high cost beneficiaries (as defined by
the Secretary) and to compare such estimates with the
numbers of such beneficiaries actually enrolled by such
plans.''.
(c) Annual Report.--The Secretary of Health and Human Services,
acting through the Administrator of the Centers for Medicare & Medicaid
Services, shall submit an annual report to Congress concerning the
effectiveness of the Recovery Audit Contractor program under Medicaid
and Medicare and shall include such reports recommendations for
expanding or improving the program.
Subtitle F--Additional Medicaid Program Integrity Provisions
SEC. 6501. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID IF
TERMINATED UNDER MEDICARE OR OTHER STATE PLAN.
Section 1902(a)(39) of the Social Security Act (42 U.S.C. 42 U.S.C.
1396a(a)) is amended by inserting after ``1128A,'' the following:
``terminate the participation of any individual or entity in such
program if (subject to such exceptions as are permitted with respect to
exclusion under sections 1128(c)(3)(B) and 1128(d)(3)(B)) participation
of such individual or entity is terminated under title XVIII or any
other State plan under this title,''.
SEC. 6502. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO CERTAIN
OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS.
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as
amended by section 6401(b), is amended by inserting after paragraph
(77) the following:
``(78) provide that the State agency described in paragraph
(9) exclude, with respect to a period, any individual or entity
from participation in the program under the State plan if such
individual or entity owns, controls, or manages an entity that
(or if such entity is owned, controlled, or managed by an
individual or entity that)--
``(A) has unpaid overpayments (as defined by the
Secretary) under this title during such period
determined by the Secretary or the State agency to be
delinquent;
``(B) is suspended or excluded from participation
under or whose participation is terminated under this
title during such period; or
``(C) is affiliated with an individual or entity
that has been suspended or excluded from participation
under this title or whose participation is terminated
under this title during such period;''.
SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES
REQUIRED TO REGISTER UNDER MEDICAID.
(a) In General.--Section 1902(a) of the Social Security Act (42
U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is amended
by inserting after paragraph (78), the following:
``(79) provide that any agent, clearinghouse, or other
alternate payee (as defined by the Secretary) that submits
claims on behalf of a health care provider must register with
the State and the Secretary in a form and manner specified by
the Secretary;''.
SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER
MMIS TO DETECT FRAUD AND ABUSE.
(a) In General.--Section 1903(r)(1)(F) of the Social Security Act
(42 U.S.C. 1396b(r)(1)(F)) is amended by inserting after ``necessary''
the following: ``and including, for data submitted to the Secretary on
or after January 1, 2010, data elements from the automated data system
that the Secretary determines to be necessary for program integrity,
program oversight, and administration, at such frequency as the
Secretary shall determine''.
(b) Managed Care Organizations.--
(1) In general.--Section 1903(m)(2)(A)(xi) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by
inserting ``and for the provision of such data to the State at
a frequency and level of detail to be specified by the
Secretary'' after ``patients''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to contract years beginning on or
after January 1, 2010.
SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR ENTITIES LOCATED
OUTSIDE OF THE UNITED STATES.
Section 1902(a) of the Social Security Act (42 U.S.C. 1396b(a)), as
amended by section 6503, is amended by inserting after paragraph (79)
the following new paragraph:
``(80) provide that the State shall not provide any
payments for items or services provided under the State plan or
under a waiver to any financial institution or entity located
outside of the United States;''.
SEC. 6506. OVERPAYMENTS.
(a) Extension of Period for Collection of Overpayments Due to
Fraud.--
(1) In general.--Section 1903(d)(2) of the Social Security
Act (42 U.S.C. 1396b(d)(2)) is amended--
(A) in subparagraph (C)--
(i) in the first sentence, by striking ``60
days'' and inserting ``1 year''; and
(ii) in the second sentence, by striking
``60 days'' and inserting ``1-year period'';
and
(B) in subparagraph (D)--
(i) in inserting ``(i)'' after ``(D)''; and
(ii) by adding at the end the following:
``(ii) In any case where the State is unable to recover a debt
which represents an overpayment (or any portion thereof) made to a
person or other entity due to fraud within 1 year of discovery because
there is not a final determination of the amount of the overpayment
under an administrative or judicial process (as applicable), including
as a result of a judgment being under appeal, no adjustment shall be
made in the Federal payment to such State on account of such
overpayment (or portion thereof) before the date that is 30 days after
the date on which a final judgment (including, if applicable, a final
determination on an appeal) is made.''.
(2) Effective date.--The amendments made by this subsection
take effect on the date of enactment of this Act and apply to
overpayments discovered on or after that date.
(b) Corrective Action.--The Secretary shall promulgate regulations
that require States to correct Federally identified claims
overpayments, of an ongoing or recurring nature, with new Medicaid
Management Information System (MMIS) edits, audits, or other
appropriate corrective action.
SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE.
Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) is
amended--
(1) in paragraph (1)(B)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by adding ``and'' after the
semi-colon; and
(C) by adding at the end the following new clause:
``(iv) effective for claims filed on or
after October 1, 2010, incorporate compatible
methodologies of the National Correct Coding
Initiative administered by the Secretary (or
any successor initiative to promote correct
coding and to control improper coding leading
to inappropriate payment) and such other
methodologies of that Initiative (or such other
national correct coding methodologies) as the
Secretary identifies in accordance with
paragraph (4);''; and
(2) by adding at the end the following new paragraph:
``(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do
the following:
``(A) Not later than September 1, 2010:
``(i) Identify those methodologies of the National
Correct Coding Initiative administered by the Secretary
(or any successor initiative to promote correct coding
and to control improper coding leading to inappropriate
payment) which are compatible to claims filed under
this title.
``(ii) Identify those methodologies of such
Initiative (or such other national correct coding
methodologies) that should be incorporated into claims
filed under this title with respect to items or
services for which States provide medical assistance
under this title and no national correct coding
methodologies have been established under such
Initiative with respect to title XVIII.
``(iii) Notify States of--
``(I) the methodologies identified under
subparagraphs (A) and (B) (and of any other
national correct coding methodologies
identified under subparagraph (B)); and
``(II) how States are to incorporate such
methodologies into claims filed under this
title.
``(B) Not later than March 1, 2011, submit a report to
Congress that includes the notice to States under clause (iii)
of subparagraph (A) and an analysis supporting the
identification of the methodologies made under clauses (i) and
(ii) of subparagraph (A).''.
SEC. 6508. GENERAL EFFECTIVE DATE.
(a) In General.--Except as otherwise provided in this subtitle,
this subtitle and the amendments made by this subtitle take effect on
January 1, 2011, without regard to whether final regulations to carry
out such amendments and subtitle have been promulgated by that date.
(b) Delay if State Legislation Required.--In the case of a State
plan for medical assistance under title XIX of the Social Security Act
or a child health plan under title XXI of such Act which the Secretary
of Health and Human Services determines requires State legislation
(other than legislation appropriating funds) in order for the plan to
meet the additional requirement imposed by the amendments made by this
subtitle, the State plan or child health plan shall not be regarded as
failing to comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement before the
first day of the first calendar quarter beginning after the close of
the first regular session of the State legislature that begins after
the date of the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative session,
each year of such session shall be deemed to be a separate regular
session of the State legislature.
Subtitle G--Additional Program Integrity Provisions
SEC. 6601. PROHIBITION ON FALSE STATEMENTS AND REPRESENTATIONS.
(a) Prohibition.--Part 5 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is
amended by adding at the end the following:
``SEC. 519. PROHIBITION ON FALSE STATEMENTS AND REPRESENTATIONS.
``No person, in connection with a plan or other arrangement that is
multiple employer welfare arrangement described in section 3(40), shall
make a false statement or false representation of fact, knowing it to
be false, in connection with the marketing or sale of such plan or
arrangement, to any employee, any member of an employee organization,
any beneficiary, any employer, any employee organization, the
Secretary, or any State, or the representative or agent of any such
person, State, or the Secretary, concerning--
``(1) the financial condition or solvency of such plan or
arrangement;
``(2) the benefits provided by such plan or arrangement;
``(3) the regulatory status of such plan or other
arrangement under any Federal or State law governing collective
bargaining, labor management relations, or intern union
affairs; or
``(4) the regulatory status of such plan or other
arrangement regarding exemption from state regulatory authority
under this Act.
This section shall not apply to any plan or arrangement that does not
fall within the meaning of the term `multiple employer welfare
arrangement' under section 3(40)(A).''.
(b) Criminal Penalties.--Section 501 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1131) is amended--
(1) by inserting ``(a)'' before ``Any person''; and
(2) by adding at the end the following:
``(b) Any person that violates section 519 shall upon conviction be
imprisoned not more than 10 years or fined under title 18, United
States Code, or both.''.
(c) Conforming Amendment.--The table of sections for part 5 of
subtitle B of title I of the Employee Retirement Income Security Act of
1974 is amended by adding at the end the following:
``Sec. 519. Prohibition on false statement and representations.''.
SEC. 6602. CLARIFYING DEFINITION.
Section 24(a)(2) of title 18, United States Code, is amended by
inserting ``or section 411, 518, or 511 of the Employee Retirement
Income Security Act of 1974,'' after ``1954 of this title''.
SEC. 6603. DEVELOPMENT OF MODEL UNIFORM REPORT FORM.
Part C of title XXVII of the Public Health Service Act (42 U.S.C.
300gg-91 et seq.) is amended by adding at the end the following:
``SEC. 2794. UNIFORM FRAUD AND ABUSE REFERRAL FORMAT.
``The Secretary shall request the National Association of Insurance
Commissioners to develop a model uniform report form for private health
insurance issuer seeking to refer suspected fraud and abuse to State
insurance departments or other responsible State agencies for
investigation. The Secretary shall request that the National
Association of Insurance Commissioners develop recommendations for
uniform reporting standards for such referrals.''.
SEC. 6604. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND ABUSE.
(a) In General.--Part 5 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), as
amended by section 6601, is further amended by adding at the end the
following:
``SEC. 520. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND ABUSE.
``The Secretary may, for the purpose of identifying, preventing, or
prosecuting fraud and abuse, adopt regulatory standards establishing,
or issue an order relating to a specific person establishing, that a
person engaged in the business of providing insurance through a
multiple employer welfare arrangement described in section 3(40) is
subject to the laws of the States in which such person operates which
regulate insurance in such State, notwithstanding section 514(b)(6) of
this Act or the Liability Risk Retention Act of 1986, and regardless of
whether the law of the State is otherwise preempted under any of such
provisions. This section shall not apply to any plan or arrangement
that does not fall within the meaning of the term `multiple employer
welfare arrangement' under section 3(40)(A).''.
(b) Conforming Amendment.--The table of sections for part 5 of
subtitle B of title I of the Employee Retirement Income Security Act of
1974, as amended by section 6601, is further amended by adding at the
end the following:
``Sec. 520. Applicability of State law to combat fraud and abuse.''.
SEC. 6605. ENABLING THE DEPARTMENT OF LABOR TO ISSUE ADMINISTRATIVE
SUMMARY CEASE AND DESIST ORDERS AND SUMMARY SEIZURES
ORDERS AGAINST PLANS THAT ARE IN FINANCIALLY HAZARDOUS
CONDITION.
(a) In General.--Part 5 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), as
amended by section 6604, is further amended by adding at the end the
following:
``SEC. 521. ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS AND SUMMARY
SEIZURE ORDERS AGAINST MULTIPLE EMPLOYER WELFARE
ARRANGEMENTS IN FINANCIALLY HAZARDOUS CONDITION.
``(a) In General.--The Secretary may issue a cease and desist (ex
parte) order under this title if it appears to the Secretary that the
alleged conduct of a multiple employer welfare arrangement described in
section 3(40), other than a plan or arrangement described in subsection
(g), is fraudulent, or creates an immediate danger to the public safety
or welfare, or is causing or can be reasonably expected to cause
significant, imminent, and irreparable public injury.
``(b) Hearing.--A person that is adversely affected by the issuance
of a cease and desist order under subsection (a) may request a hearing
by the Secretary regarding such order. The Secretary may require that a
proceeding under this section, including all related information and
evidence, be conducted in a confidential manner.
``(c) Burden of Proof.--The burden of proof in any hearing
conducted under subsection (b) shall be on the party requesting the
hearing to show cause why the cease and desist order should be set
aside.
``(d) Determination.--Based upon the evidence presented at a
hearing under subsection (b), the cease and desist order involved may
be affirmed, modified, or set aside by the Secretary in whole or in
part.
``(e) Seizure.--The Secretary may issue a summary seizure order
under this title if it appears that a multiple employer welfare
arrangement is in a financially hazardous condition.
``(f) Regulations.--The Secretary may promulgate such regulations
or other guidance as may be necessary or appropriate to carry out this
section.
``(g) Exception.--This section shall not apply to any plan or
arrangement that does not fall within the meaning of the term `multiple
employer welfare arrangement' under section 3(40)(A).''.
(b) Conforming Amendment.--The table of sections for part 5 of
subtitle B of title I of the Employee Retirement Income Security Act of
1974, as amended by section 6604, is further amended by adding at the
end the following:
``Sec. 521. Administrative summary cease and desist orders and summary
seizure orders against health plans in
financially hazardous condition.''.
SEC. 6606. MEWA PLAN REGISTRATION WITH DEPARTMENT OF LABOR.
Section 101(g) of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1021(g)) is amended--
(1) by striking ``Secretary may'' and inserting ``Secretary
shall''; and
(2) by inserting ``to register with the Secretary prior to
operating in a State and may, by regulation, require such
multiple employer welfare arrangements'' after ``not group
health plans''.
SEC. 6607. PERMITTING EVIDENTIARY PRIVILEGE AND CONFIDENTIAL
COMMUNICATIONS.
Section 504 of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1134) is amended by adding at the end the following:
``(d) The Secretary may promulgate a regulation that provides an
evidentiary privilege for, and provides for the confidentiality of
communications between or among, any of the following entities or their
agents, consultants, or employees:
``(1) A State insurance department.
``(2) A State attorney general.
``(3) The National Association of Insurance Commissioners.
``(4) The Department of Labor.
``(5) The Department of the Treasury.
``(6) The Department of Justice.
``(7) The Department of Health and Human Services.
``(8) Any other Federal or State authority that the
Secretary determines is appropriate for the purposes of
enforcing the provisions of this title.
``(e) The privilege established under subsection (d) shall apply to
communications related to any investigation, audit, examination, or
inquiry conducted or coordinated by any of the agencies. A
communication that is privileged under subsection (d) shall not waive
any privilege otherwise available to the communicating agency or to any
person who provided the information that is communicated.''.
Subtitle H--Elder Justice Act
SEC. 6701. SHORT TITLE OF SUBTITLE.
This subtitle may be cited as the ``Elder Justice Act of 2009''.
SEC. 6702. DEFINITIONS.
Except as otherwise specifically provided, any term that is defined
in section 2011 of the Social Security Act (as added by section
6703(a)) and is used in this subtitle has the meaning given such term
by such section.
SEC. 6703. ELDER JUSTICE.
(a) Elder Justice.--
(1) In general.--Title XX of the Social Security Act (42
U.S.C. 1397 et seq.) is amended--
(A) in the heading, by inserting ``AND ELDER
JUSTICE'' after ``SOCIAL SERVICES'';
(B) by inserting before section 2001 the following:
``Subtitle A--Block Grants to States for Social Services'';
and
(C) by adding at the end the following:
``Subtitle B--Elder Justice
``SEC. 2011. DEFINITIONS.
``In this subtitle:
``(1) Abuse.--The term `abuse' means the knowing infliction
of physical or psychological harm or the knowing deprivation of
goods or services that are necessary to meet essential needs or
to avoid physical or psychological harm.
``(2) Adult protective services.--The term `adult
protective services' means such services provided to adults as
the Secretary may specify and includes services such as--
``(A) receiving reports of adult abuse, neglect, or
exploitation;
``(B) investigating the reports described in
subparagraph (A);
``(C) case planning, monitoring, evaluation, and
other case work and services; and
``(D) providing, arranging for, or facilitating the
provision of medical, social service, economic, legal,
housing, law enforcement, or other protective,
emergency, or support services.
``(3) Caregiver.--The term `caregiver' means an individual
who has the responsibility for the care of an elder, either
voluntarily, by contract, by receipt of payment for care, or as
a result of the operation of law, and means a family member or
other individual who provides (on behalf of such individual or
of a public or private agency, organization, or institution)
compensated or uncompensated care to an elder who needs
supportive services in any setting.
``(4) Direct care.--The term `direct care' means care by an
employee or contractor who provides assistance or long-term
care services to a recipient.
``(5) Elder.--The term `elder' means an individual age 60
or older.
``(6) Elder justice.--The term `elder justice' means--
``(A) from a societal perspective, efforts to--
``(i) prevent, detect, treat, intervene in,
and prosecute elder abuse, neglect, and
exploitation; and
``(ii) protect elders with diminished
capacity while maximizing their autonomy; and
``(B) from an individual perspective, the
recognition of an elder's rights, including the right
to be free of abuse, neglect, and exploitation.
``(7) Eligible entity.--The term `eligible entity' means a
State or local government agency, Indian tribe or tribal
organization, or any other public or private entity that is
engaged in and has expertise in issues relating to elder
justice or in a field necessary to promote elder justice
efforts.
``(8) Exploitation.--The term `exploitation' means the
fraudulent or otherwise illegal, unauthorized, or improper act
or process of an individual, including a caregiver or
fiduciary, that uses the resources of an elder for monetary or
personal benefit, profit, or gain, or that results in depriving
an elder of rightful access to, or use of, benefits, resources,
belongings, or assets.
``(9) Fiduciary.--The term `fiduciary'--
``(A) means a person or entity with the legal
responsibility--
``(i) to make decisions on behalf of and
for the benefit of another person; and
``(ii) to act in good faith and with
fairness; and
``(B) includes a trustee, a guardian, a
conservator, an executor, an agent under a financial
power of attorney or health care power of attorney, or
a representative payee.
``(10) Grant.--The term `grant' includes a contract,
cooperative agreement, or other mechanism for providing
financial assistance.
``(11) Guardianship.--The term `guardianship' means--
``(A) the process by which a State court determines
that an adult individual lacks capacity to make
decisions about self-care or property, and appoints
another individual or entity known as a guardian, as a
conservator, or by a similar term, as a surrogate
decisionmaker;
``(B) the manner in which the court-appointed
surrogate decisionmaker carries out duties to the
individual and the court; or
``(C) the manner in which the court exercises
oversight of the surrogate decisionmaker.
``(12) Indian tribe.--
``(A) In general.--The term `Indian tribe' has the
meaning given such term in section 4 of the Indian
Self-Determination and Education Assistance Act (25
U.S.C. 450b).
``(B) Inclusion of pueblo and rancheria.--The term
`Indian tribe' includes any Pueblo or Rancheria.
``(13) Law enforcement.--The term `law enforcement' means
the full range of potential responders to elder abuse, neglect,
and exploitation including--
``(A) police, sheriffs, detectives, public safety
officers, and corrections personnel;
``(B) prosecutors;
``(C) medical examiners;
``(D) investigators; and
``(E) coroners.
``(14) Long-term care.--
``(A) In general.--The term `long-term care' means
supportive and health services specified by the
Secretary for individuals who need assistance because
the individuals have a loss of capacity for self-care
due to illness, disability, or vulnerability.
``(B) Loss of capacity for self-care.--For purposes
of subparagraph (A), the term `loss of capacity for
self-care' means an inability to engage in 1 or more
activities of daily living, including eating, dressing,
bathing, management of one's financial affairs, and
other activities the Secretary determines appropriate.
``(15) Long-term care facility.--The term `long-term care
facility' means a residential care provider that arranges for,
or directly provides, long-term care.
``(16) Neglect.--The term `neglect' means--
``(A) the failure of a caregiver or fiduciary to
provide the goods or services that are necessary to
maintain the health or safety of an elder; or
``(B) self-neglect.
``(17) Nursing facility.--
``(A) In general.--The term `nursing facility' has
the meaning given such term under section 1919(a).
``(B) Inclusion of skilled nursing facility.--The
term `nursing facility' includes a skilled nursing
facility (as defined in section 1819(a)).
``(18) Self-neglect.--The term `self-neglect' means an
adult's inability, due to physical or mental impairment or
diminished capacity, to perform essential self-care tasks
including--
``(A) obtaining essential food, clothing, shelter,
and medical care;
``(B) obtaining goods and services necessary to
maintain physical health, mental health, or general
safety; or
``(C) managing one's own financial affairs.
``(19) Serious bodily injury.--
``(A) In general.--The term `serious bodily injury'
means an injury--
``(i) involving extreme physical pain;
``(ii) involving substantial risk of death;
``(iii) involving protracted loss or
impairment of the function of a bodily member,
organ, or mental faculty; or
``(iv) requiring medical intervention such
as surgery, hospitalization, or physical
rehabilitation.
``(B) Criminal sexual abuse.--Serious bodily injury
shall be considered to have occurred if the conduct
causing the injury is conduct described in section 2241
(relating to aggravated sexual abuse) or 2242 (relating
to sexual abuse) of title 18, United States Code, or
any similar offense under State law.
``(20) Social.--The term `social', when used with respect
to a service, includes adult protective services.
``(21) State legal assistance developer.--The term `State
legal assistance developer' means an individual described in
section 731 of the Older Americans Act of 1965.
``(22) State long-term care ombudsman.--The term `State
Long-Term Care Ombudsman' means the State Long-Term Care
Ombudsman described in section 712(a)(2) of the Older Americans
Act of 1965.
``SEC. 2012. GENERAL PROVISIONS.
``(a) Protection of Privacy.--In pursuing activities under this
subtitle, the Secretary shall ensure the protection of individual
health privacy consistent with the regulations promulgated under
section 264(c) of the Health Insurance Portability and Accountability
Act of 1996 and applicable State and local privacy regulations.
``(b) Rule of Construction.--Nothing in this subtitle shall be
construed to interfere with or abridge an elder's right to practice his
or her religion through reliance on prayer alone for healing when this
choice--
``(1) is contemporaneously expressed, either orally or in
writing, with respect to a specific illness or injury which the
elder has at the time of the decision by an elder who is
competent at the time of the decision;
``(2) is previously set forth in a living will, health care
proxy, or other advance directive document that is validly
executed and applied under State law; or
``(3) may be unambiguously deduced from the elder's life
history.
``PART I--NATIONAL COORDINATION OF ELDER JUSTICE ACTIVITIES AND
RESEARCH
``Subpart A--Elder Justice Coordinating Council and Advisory Board on
Elder Abuse, Neglect, and Exploitation
``SEC. 2021. ELDER JUSTICE COORDINATING COUNCIL.
``(a) Establishment.--There is established within the Office of the
Secretary an Elder Justice Coordinating Council (in this section
referred to as the `Council').
``(b) Membership.--
``(1) In general.--The Council shall be composed of the
following members:
``(A) The Secretary (or the Secretary's designee).
``(B) The Attorney General (or the Attorney
General's designee).
``(C) The head of each Federal department or agency
or other governmental entity identified by the Chair
referred to in subsection (d) as having
responsibilities, or administering programs, relating
to elder abuse, neglect, and exploitation.
``(2) Requirement.--Each member of the Council shall be an
officer or employee of the Federal Government.
``(c) Vacancies.--Any vacancy in the Council shall not affect its
powers, but shall be filled in the same manner as the original
appointment was made.
``(d) Chair.--The member described in subsection (b)(1)(A) shall be
Chair of the Council.
``(e) Meetings.--The Council shall meet at least 2 times per year,
as determined by the Chair.
``(f) Duties.--
``(1) In general.--The Council shall make recommendations
to the Secretary for the coordination of activities of the
Department of Health and Human Services, the Department of
Justice, and other relevant Federal, State, local, and private
agencies and entities, relating to elder abuse, neglect, and
exploitation and other crimes against elders.
``(2) Report.--Not later than the date that is 2 years
after the date of enactment of the Elder Justice Act of 2009
and every 2 years thereafter, the Council shall submit to the
Committee on Finance of the Senate and the Committee on Ways
and Means and the Committee on Energy and Commerce of the House
of Representatives a report that--
``(A) describes the activities and accomplishments
of, and challenges faced by--
``(i) the Council; and
``(ii) the entities represented on the
Council; and
``(B) makes such recommendations for legislation,
model laws, or other action as the Council determines
to be appropriate.
``(g) Powers of the Council.--
``(1) Information from federal agencies.--Subject to the
requirements of section 2012(a), the Council may secure
directly from any Federal department or agency such information
as the Council considers necessary to carry out this section.
Upon request of the Chair of the Council, the head of such
department or agency shall furnish such information to the
Council.
``(2) Postal services.--The Council may use the United
States mails in the same manner and under the same conditions
as other departments and agencies of the Federal Government.
``(h) Travel Expenses.--The members of the Council shall not
receive compensation for the performance of services for the Council.
The members shall be allowed travel expenses, including per diem in
lieu of subsistence, at rates authorized for employees of agencies
under subchapter I of chapter 57 of title 5, United States Code, while
away from their homes or regular places of business in the performance
of services for the Council. Notwithstanding section 1342 of title 31,
United States Code, the Secretary may accept the voluntary and
uncompensated services of the members of the Council.
``(i) Detail of Government Employees.--Any Federal Government
employee may be detailed to the Council without reimbursement, and such
detail shall be without interruption or loss of civil service status or
privilege.
``(j) Status as Permanent Council.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply to the Council.
``(k) Authorization of Appropriations.--There are authorized to be
appropriated such sums as are necessary to carry out this section.
``SEC. 2022. ADVISORY BOARD ON ELDER ABUSE, NEGLECT, AND EXPLOITATION.
``(a) Establishment.--There is established a board to be known as
the `Advisory Board on Elder Abuse, Neglect, and Exploitation' (in this
section referred to as the `Advisory Board') to create short- and long-
term multidisciplinary strategic plans for the development of the field
of elder justice and to make recommendations to the Elder Justice
Coordinating Council established under section 2021.
``(b) Composition.--The Advisory Board shall be composed of 27
members appointed by the Secretary from among members of the general
public who are individuals with experience and expertise in elder
abuse, neglect, and exploitation prevention, detection, treatment,
intervention, or prosecution.
``(c) Solicitation of Nominations.--The Secretary shall publish a
notice in the Federal Register soliciting nominations for the
appointment of members of the Advisory Board under subsection (b).
``(d) Terms.--
``(1) In general.--Each member of the Advisory Board shall
be appointed for a term of 3 years, except that, of the members
first appointed--
``(A) 9 shall be appointed for a term of 3 years;
``(B) 9 shall be appointed for a term of 2 years;
and
``(C) 9 shall be appointed for a term of 1 year.
``(2) Vacancies.--
``(A) In general.--Any vacancy on the Advisory
Board shall not affect its powers, but shall be filled
in the same manner as the original appointment was
made.
``(B) Filling unexpired term.--An individual chosen
to fill a vacancy shall be appointed for the unexpired
term of the member replaced.
``(3) Expiration of terms.--The term of any member shall
not expire before the date on which the member's successor
takes office.
``(e) Election of Officers.--The Advisory Board shall elect a Chair
and Vice Chair from among its members. The Advisory Board shall elect
its initial Chair and Vice Chair at its initial meeting.
``(f) Duties.--
``(1) Enhance communication on promoting quality of, and
preventing abuse, neglect, and exploitation in, long-term
care.--The Advisory Board shall develop collaborative and
innovative approaches to improve the quality of, including
preventing abuse, neglect, and exploitation in, long-term care.
``(2) Collaborative efforts to develop consensus around the
management of certain quality-related factors.--
``(A) In general.--The Advisory Board shall
establish multidisciplinary panels to address, and
develop consensus on, subjects relating to improving
the quality of long-term care. At least 1 such panel
shall address, and develop consensus on, methods for
managing resident-to-resident abuse in long-term care.
``(B) Activities conducted.--The multidisciplinary
panels established under subparagraph (A) shall examine
relevant research and data, identify best practices
with respect to the subject of the panel, determine the
best way to carry out those best practices in a
practical and feasible manner, and determine an
effective manner of distributing information on such
subject.
``(3) Report.--Not later than the date that is 18 months
after the date of enactment of the Elder Justice Act of 2009,
and annually thereafter, the Advisory Board shall prepare and
submit to the Elder Justice Coordinating Council, the Committee
on Finance of the Senate, and the Committee on Ways and Means
and the Committee on Energy and Commerce of the House of
Representatives a report containing--
``(A) information on the status of Federal, State,
and local public and private elder justice activities;
``(B) recommendations (including recommended
priorities) regarding--
``(i) elder justice programs, research,
training, services, practice, enforcement, and
coordination;
``(ii) coordination between entities
pursuing elder justice efforts and those
involved in related areas that may inform or
overlap with elder justice efforts, such as
activities to combat violence against women and
child abuse and neglect; and
``(iii) activities relating to adult
fiduciary systems, including guardianship and
other fiduciary arrangements;
``(C) recommendations for specific modifications
needed in Federal and State laws (including
regulations) or for programs, research, and training to
enhance prevention, detection, and treatment (including
diagnosis) of, intervention in (including investigation
of), and prosecution of elder abuse, neglect, and
exploitation;
``(D) recommendations on methods for the most
effective coordinated national data collection with
respect to elder justice, and elder abuse, neglect, and
exploitation; and
``(E) recommendations for a multidisciplinary
strategic plan to guide the effective and efficient
development of the field of elder justice.
``(g) Powers of the Advisory Board.--
``(1) Information from federal agencies.--Subject to the
requirements of section 2012(a), the Advisory Board may secure
directly from any Federal department or agency such information
as the Advisory Board considers necessary to carry out this
section. Upon request of the Chair of the Advisory Board, the
head of such department or agency shall furnish such
information to the Advisory Board.
``(2) Sharing of data and reports.--The Advisory Board may
request from any entity pursuing elder justice activities under
the Elder Justice Act of 2009 or an amendment made by that Act,
any data, reports, or recommendations generated in connection
with such activities.
``(3) Postal services.--The Advisory Board may use the
United States mails in the same manner and under the same
conditions as other departments and agencies of the Federal
Government.
``(h) Travel Expenses.--The members of the Advisory Board shall not
receive compensation for the performance of services for the Advisory
Board. The members shall be allowed travel expenses for up to 4
meetings per year, including per diem in lieu of subsistence, at rates
authorized for employees of agencies under subchapter I of chapter 57
of title 5, United States Code, while away from their homes or regular
places of business in the performance of services for the Advisory
Board. Notwithstanding section 1342 of title 31, United States Code,
the Secretary may accept the voluntary and uncompensated services of
the members of the Advisory Board.
``(i) Detail of Government Employees.--Any Federal Government
employee may be detailed to the Advisory Board without reimbursement,
and such detail shall be without interruption or loss of civil service
status or privilege.
``(j) Status as Permanent Advisory Committee.--Section 14 of the
Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the
advisory board.
``(k) Authorization of Appropriations.--There are authorized to be
appropriated such sums as are necessary to carry out this section.
``SEC. 2023. RESEARCH PROTECTIONS.
``(a) Guidelines.--The Secretary shall promulgate guidelines to
assist researchers working in the area of elder abuse, neglect, and
exploitation, with issues relating to human subject protections.
``(b) Definition of Legally Authorized Representative for
Application of Regulations.--For purposes of the application of subpart
A of part 46 of title 45, Code of Federal Regulations, to research
conducted under this subpart, the term `legally authorized
representative' means, unless otherwise provided by law, the individual
or judicial or other body authorized under the applicable law to
consent to medical treatment on behalf of another person.
``SEC. 2024. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated to carry out this
subpart--
``(1) for fiscal year 2011, $6,500,000; and
``(2) for each of fiscal years 2012 through 2014,
$7,000,000.
``Subpart B--Elder Abuse, Neglect, and Exploitation Forensic Centers
``SEC. 2031. ESTABLISHMENT AND SUPPORT OF ELDER ABUSE, NEGLECT, AND
EXPLOITATION FORENSIC CENTERS.
``(a) In General.--The Secretary, in consultation with the Attorney
General, shall make grants to eligible entities to establish and
operate stationary and mobile forensic centers, to develop forensic
expertise regarding, and provide services relating to, elder abuse,
neglect, and exploitation.
``(b) Stationary Forensic Centers.--The Secretary shall make 4 of
the grants described in subsection (a) to institutions of higher
education with demonstrated expertise in forensics or commitment to
preventing or treating elder abuse, neglect, or exploitation, to
establish and operate stationary forensic centers.
``(c) Mobile Centers.--The Secretary shall make 6 of the grants
described in subsection (a) to appropriate entities to establish and
operate mobile forensic centers.
``(d) Authorized Activities.--
``(1) Development of forensic markers and methodologies.--
An eligible entity that receives a grant under this section
shall use funds made available through the grant to assist in
determining whether abuse, neglect, or exploitation occurred
and whether a crime was committed and to conduct research to
describe and disseminate information on--
``(A) forensic markers that indicate a case in
which elder abuse, neglect, or exploitation may have
occurred; and
``(B) methodologies for determining, in such a
case, when and how health care, emergency service,
social and protective services, and legal service
providers should intervene and when the providers
should report the case to law enforcement authorities.
``(2) Development of forensic expertise.--An eligible
entity that receives a grant under this section shall use funds
made available through the grant to develop forensic expertise
regarding elder abuse, neglect, and exploitation in order to
provide medical and forensic evaluation, therapeutic
intervention, victim support and advocacy, case review, and
case tracking.
``(3) Collection of evidence.--The Secretary, in
coordination with the Attorney General, shall use data made
available by grant recipients under this section to develop the
capacity of geriatric health care professionals and law
enforcement to collect forensic evidence, including collecting
forensic evidence relating to a potential determination of
elder abuse, neglect, or exploitation.
``(e) Application.--To be eligible to receive a grant under this
section, an entity shall submit an application to the Secretary at such
time, in such manner, and containing such information as the Secretary
may require.
``(f) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section--
``(1) for fiscal year 2011, $4,000,000;
``(2) for fiscal year 2012, $6,000,000; and
``(3) for each of fiscal years 2013 and 2014, $8,000,000.
``PART II--PROGRAMS TO PROMOTE ELDER JUSTICE
``SEC. 2041. ENHANCEMENT OF LONG-TERM CARE.
``(a) Grants and Incentives for Long-Term Care Staffing.--
``(1) In general.--The Secretary shall carry out
activities, including activities described in paragraphs (2)
and (3), to provide incentives for individuals to train for,
seek, and maintain employment providing direct care in long-
term care.
``(2) Specific programs to enhance training, recruitment,
and retention of staff.--
``(A) Coordination with secretary of labor to
recruit and train long-term care staff.--The Secretary
shall coordinate activities under this subsection with
the Secretary of Labor in order to provide incentives
for individuals to train for and seek employment
providing direct care in long-term care.
``(B) Career ladders and wage or benefit increases
to increase staffing in long-term care.--
``(i) In general.--The Secretary shall make
grants to eligible entities to carry out
programs through which the entities--
``(I) offer, to employees who
provide direct care to residents of an
eligible entity or individuals
receiving community-based long-term
care from an eligible entity,
continuing training and varying levels
of certification, based on observed
clinical care practices and the amount
of time the employees spend providing
direct care; and
``(II) provide, or make
arrangements to provide, bonuses or
other increased compensation or
benefits to employees who achieve
certification under such a program.
``(ii) Application.--To be eligible to
receive a grant under this subparagraph, an
eligible entity shall submit an application to
the Secretary at such time, in such manner, and
containing such information as the Secretary
may require (which may include evidence of
consultation with the State in which the
eligible entity is located with respect to
carrying out activities funded under the
grant).
``(iii) Authority to limit number of
applicants.--Nothing in this subparagraph shall
be construed as prohibiting the Secretary from
limiting the number of applicants for a grant
under this subparagraph.
``(3) Specific programs to improve management practices.--
``(A) In general.--The Secretary shall make grants
to eligible entities to enable the entities to provide
training and technical assistance.
``(B) Authorized activities.--An eligible entity
that receives a grant under subparagraph (A) shall use
funds made available through the grant to provide
training and technical assistance regarding management
practices using methods that are demonstrated to
promote retention of individuals who provide direct
care, such as--
``(i) the establishment of standard human
resource policies that reward high performance,
including policies that provide for improved
wages and benefits on the basis of job reviews;
``(ii) the establishment of motivational
and thoughtful work organization practices;
``(iii) the creation of a workplace culture
that respects and values caregivers and their
needs;
``(iv) the promotion of a workplace culture
that respects the rights of residents of an
eligible entity or individuals receiving
community-based long-term care from an eligible
entity and results in improved care for the
residents or the individuals; and
``(v) the establishment of other programs
that promote the provision of high quality
care, such as a continuing education program
that provides additional hours of training,
including on-the-job training, for employees
who are certified nurse aides.
``(C) Application.--To be eligible to receive a
grant under this paragraph, an eligible entity shall
submit an application to the Secretary at such time, in
such manner, and containing such information as the
Secretary may require (which may include evidence of
consultation with the State in which the eligible
entity is located with respect to carrying out
activities funded under the grant).
``(D) Authority to limit number of applicants.--
Nothing in this paragraph shall be construed as
prohibiting the Secretary from limiting the number of
applicants for a grant under this paragraph.
``(4) Accountability measures.--The Secretary shall develop
accountability measures to ensure that the activities conducted
using funds made available under this subsection benefit
individuals who provide direct care and increase the stability
of the long-term care workforce.
``(5) Definitions.--In this subsection:
``(A) Community-based long-term care.--The term
`community-based long-term care' has the meaning given
such term by the Secretary.
``(B) Eligible entity.--The term `eligible entity'
means the following:
``(i) A long-term care facility.
``(ii) A community-based long-term care
entity (as defined by the Secretary).
``(b) Certified EHR Technology Grant Program.--
``(1) Grants authorized.--The Secretary is authorized to
make grants to long-term care facilities for the purpose of
assisting such entities in offsetting the costs related to
purchasing, leasing, developing, and implementing certified EHR
technology (as defined in section 1848(o)(4)) designed to
improve patient safety and reduce adverse events and health
care complications resulting from medication errors.
``(2) Use of grant funds.--Funds provided under grants
under this subsection may be used for any of the following:
``(A) Purchasing, leasing, and installing computer
software and hardware, including handheld computer
technologies.
``(B) Making improvements to existing computer
software and hardware.
``(C) Making upgrades and other improvements to
existing computer software and hardware to enable e-
prescribing.
``(D) Providing education and training to eligible
long-term care facility staff on the use of such
technology to implement the electronic transmission of
prescription and patient information.
``(3) Application.--
``(A) In general.--To be eligible to receive a
grant under this subsection, a long-term care facility
shall submit an application to the Secretary at such
time, in such manner, and containing such information
as the Secretary may require (which may include
evidence of consultation with the State in which the
long-term care facility is located with respect to
carrying out activities funded under the grant).
``(B) Authority to limit number of applicants.--
Nothing in this subsection shall be construed as
prohibiting the Secretary from limiting the number of
applicants for a grant under this subsection.
``(4) Participation in state health exchanges.--A long-term
care facility that receives a grant under this subsection
shall, where available, participate in activities conducted by
a State or a qualified State-designated entity (as defined in
section 3013(f) of the Public Health Service Act) under a grant
under section 3013 of the Public Health Service Act to
coordinate care and for other purposes determined appropriate
by the Secretary.
``(5) Accountability measures.--The Secretary shall develop
accountability measures to ensure that the activities conducted
using funds made available under this subsection help improve
patient safety and reduce adverse events and health care
complications resulting from medication errors.
``(c) Adoption of Standards for Transactions Involving Clinical
Data by Long-Term Care Facilities.--
``(1) Standards and compatibility.--The Secretary shall
adopt electronic standards for the exchange of clinical data by
long-term care facilities, including, where available,
standards for messaging and nomenclature. Standards adopted by
the Secretary under the preceding sentence shall be compatible
with standards established under part C of title XI, standards
established under subsections (b)(2)(B)(i) and (e)(4) of
section 1860D-4, standards adopted under section 3004 of the
Public Health Service Act, and general health information
technology standards.
``(2) Electronic submission of data to the secretary.--
``(A) In general.--Not later than 10 years after
the date of enactment of the Elder Justice Act of 2009,
the Secretary shall have procedures in place to accept
the optional electronic submission of clinical data by
long-term care facilities pursuant to the standards
adopted under paragraph (1).
``(B) Rule of construction.--Nothing in this
subsection shall be construed to require a long-term
care facility to submit clinical data electronically to
the Secretary.
``(3) Regulations.--The Secretary shall promulgate
regulations to carry out this subsection. Such regulations
shall require a State, as a condition of the receipt of funds
under this part, to conduct such data collection and reporting
as the Secretary determines are necessary to satisfy the
requirements of this subsection.
``(d) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section--
``(1) for fiscal year 2011, $20,000,000;
``(2) for fiscal year 2012, $17,500,000; and
``(3) for each of fiscal years 2013 and 2014, $15,000,000.
``SEC. 2042. ADULT PROTECTIVE SERVICES FUNCTIONS AND GRANT PROGRAMS.
``(a) Secretarial Responsibilities.--
``(1) In general.--The Secretary shall ensure that the
Department of Health and Human Services--
``(A) provides funding authorized by this part to
State and local adult protective services offices that
investigate reports of the abuse, neglect, and
exploitation of elders;
``(B) collects and disseminates data annually
relating to the abuse, exploitation, and neglect of
elders in coordination with the Department of Justice;
``(C) develops and disseminates information on best
practices regarding, and provides training on, carrying
out adult protective services;
``(D) conducts research related to the provision of
adult protective services; and
``(E) provides technical assistance to States and
other entities that provide or fund the provision of
adult protective services, including through grants
made under subsections (b) and (c).
``(2) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
$3,000,000 for fiscal year 2011 and $4,000,000 for each of
fiscal years 2012 through 2014.
``(b) Grants To Enhance the Provision of Adult Protective
Services.--
``(1) Establishment.--There is established an adult
protective services grant program under which the Secretary
shall annually award grants to States in the amounts calculated
under paragraph (2) for the purposes of enhancing adult
protective services provided by States and local units of
government.
``(2) Amount of payment.--
``(A) In general.--Subject to the availability of
appropriations and subparagraphs (B) and (C), the
amount paid to a State for a fiscal year under the
program under this subsection shall equal the amount
appropriated for that year to carry out this subsection
multiplied by the percentage of the total number of
elders who reside in the United States who reside in
that State.
``(B) Guaranteed minimum payment amount.--
``(i) 50 states.--Subject to clause (ii),
if the amount determined under subparagraph (A)
for a State for a fiscal year is less than 0.75
percent of the amount appropriated for such
year, the Secretary shall increase such
determined amount so that the total amount paid
under this subsection to the State for the year
is equal to 0.75 percent of the amount so
appropriated.
``(ii) Territories.--In the case of a State
other than 1 of the 50 States, clause (i) shall
be applied as if each reference to `0.75' were
a reference to `0.1'.
``(C) Pro rata reductions.--The Secretary shall
make such pro rata reductions to the amounts described
in subparagraph (A) as are necessary to comply with the
requirements of subparagraph (B).
``(3) Authorized activities.--
``(A) Adult protective services.--Funds made
available pursuant to this subsection may only be used
by States and local units of government to provide
adult protective services and may not be used for any
other purpose.
``(B) Use by agency.--Each State receiving funds
pursuant to this subsection shall provide such funds to
the agency or unit of State government having legal
responsibility for providing adult protective services
within the State.
``(C) Supplement not supplant.--Each State or local
unit of government shall use funds made available
pursuant to this subsection to supplement and not
supplant other Federal, State, and local public funds
expended to provide adult protective services in the
State.
``(4) State reports.--Each State receiving funds under this
subsection shall submit to the Secretary, at such time and in
such manner as the Secretary may require, a report on the
number of elders served by the grants awarded under this
subsection.
``(5) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
$100,000,000 for each of fiscal years 2011 through 2014.
``(c) State Demonstration Programs.--
``(1) Establishment.--The Secretary shall award grants to
States for the purposes of conducting demonstration programs in
accordance with paragraph (2).
``(2) Demonstration programs.--Funds made available
pursuant to this subsection may be used by States and local
units of government to conduct demonstration programs that
test--
``(A) training modules developed for the purpose of
detecting or preventing elder abuse;
``(B) methods to detect or prevent financial
exploitation of elders;
``(C) methods to detect elder abuse;
``(D) whether training on elder abuse forensics
enhances the detection of elder abuse by employees of
the State or local unit of government; or
``(E) other matters relating to the detection or
prevention of elder abuse.
``(3) Application.--To be eligible to receive a grant under
this subsection, a State shall submit an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
``(4) State reports.--Each State that receives funds under
this subsection shall submit to the Secretary a report at such
time, in such manner, and containing such information as the
Secretary may require on the results of the demonstration
program conducted by the State using funds made available under
this subsection.
``(5) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
$25,000,000 for each of fiscal years 2011 through 2014.
``SEC. 2043. LONG-TERM CARE OMBUDSMAN PROGRAM GRANTS AND TRAINING.
``(a) Grants To Support the Long-Term Care Ombudsman Program.--
``(1) In general.--The Secretary shall make grants to
eligible entities with relevant expertise and experience in
abuse and neglect in long-term care facilities or long-term
care ombudsman programs and responsibilities, for the purpose
of--
``(A) improving the capacity of State long-term
care ombudsman programs to respond to and resolve
complaints about abuse and neglect;
``(B) conducting pilot programs with State long-
term care ombudsman offices or local ombudsman
entities; and
``(C) providing support for such State long-term
care ombudsman programs and such pilot programs (such
as through the establishment of a national long-term
care ombudsman resource center).
``(2) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection--
``(A) for fiscal year 2011, $5,000,000;
``(B) for fiscal year 2012, $7,500,000; and
``(C) for each of fiscal years 2013 and 2014,
$10,000,000.
``(b) Ombudsman Training Programs.--
``(1) In general.--The Secretary shall establish programs
to provide and improve ombudsman training with respect to elder
abuse, neglect, and exploitation for national organizations and
State long-term care ombudsman programs.
``(2) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection, for
each of fiscal years 2011 through 2014, $10,000,000.
``SEC. 2044. PROVISION OF INFORMATION REGARDING, AND EVALUATIONS OF,
ELDER JUSTICE PROGRAMS.
``(a) Provision of Information.--To be eligible to receive a grant
under this part, an applicant shall agree--
``(1) except as provided in paragraph (2), to provide the
eligible entity conducting an evaluation under subsection (b)
of the activities funded through the grant with such
information as the eligible entity may require in order to
conduct such evaluation; or
``(2) in the case of an applicant for a grant under section
2041(b), to provide the Secretary with such information as the
Secretary may require to conduct an evaluation or audit under
subsection (c).
``(b) Use of Eligible Entities To Conduct Evaluations.--
``(1) Evaluations required.--Except as provided in
paragraph (2), the Secretary shall--
``(A) reserve a portion (not less than 2 percent)
of the funds appropriated with respect to each program
carried out under this part; and
``(B) use the funds reserved under subparagraph (A)
to provide assistance to eligible entities to conduct
evaluations of the activities funded under each program
carried out under this part.
``(2) Certified ehr technology grant program not
included.--The provisions of this subsection shall not apply to
the certified EHR technology grant program under section
2041(b).
``(3) Authorized activities.--A recipient of assistance
described in paragraph (1)(B) shall use the funds made
available through the assistance to conduct a validated
evaluation of the effectiveness of the activities funded under
a program carried out under this part.
``(4) Applications.--To be eligible to receive assistance
under paragraph (1)(B), an entity shall submit an application
to the Secretary at such time, in such manner, and containing
such information as the Secretary may require, including a
proposal for the evaluation.
``(5) Reports.--Not later than a date specified by the
Secretary, an eligible entity receiving assistance under
paragraph (1)(B) shall submit to the Secretary, the Committee
on Ways and Means and the Committee on Energy and Commerce of
the House of Representatives, and the Committee on Finance of
the Senate a report containing the results of the evaluation
conducted using such assistance together with such
recommendations as the entity determines to be appropriate.
``(c) Evaluations and Audits of Certified EHR Technology Grant
Program by the Secretary.--
``(1) Evaluations.--The Secretary shall conduct an
evaluation of the activities funded under the certified EHR
technology grant program under section 2041(b). Such evaluation
shall include an evaluation of whether the funding provided
under the grant is expended only for the purposes for which it
is made.
``(2) Audits.--The Secretary shall conduct appropriate
audits of grants made under section 2041(b).
``SEC. 2045. REPORT.
``Not later than October 1, 2014, the Secretary shall submit to the
Elder Justice Coordinating Council established under section 2021, the
Committee on Ways and Means and the Committee on Energy and Commerce of
the House of Representatives, and the Committee on Finance of the
Senate a report--
``(1) compiling, summarizing, and analyzing the information
contained in the State reports submitted under subsections
(b)(4) and (c)(4) of section 2042; and
``(2) containing such recommendations for legislative or
administrative action as the Secretary determines to be
appropriate.
``SEC. 2046. RULE OF CONSTRUCTION.
``Nothing in this subtitle shall be construed as--
``(1) limiting any cause of action or other relief related
to obligations under this subtitle that is available under the
law of any State, or political subdivision thereof; or
``(2) creating a private cause of action for a violation of
this subtitle.''.
(2) Option for state plan under program for temporary
assistance for needy families.--
(A) In general.--Section 402(a)(1)(B) of the Social
Security Act (42 U.S.C. 602(a)(1)(B)) is amended by
adding at the end the following new clause:
``(v) The document shall indicate whether
the State intends to assist individuals to
train for, seek, and maintain employment--
``(I) providing direct care in a
long-term care facility (as such terms
are defined under section 2011); or
``(II) in other occupations related
to elder care determined appropriate by
the State for which the State
identifies an unmet need for service
personnel,
and, if so, shall include an overview of such
assistance.''.
(B) Effective date.--The amendment made by
subparagraph (A) shall take effect on January 1, 2011.
(b) Protecting Residents of Long-Term Care Facilities.--
(1) National training institute for surveyors.--
(A) In general.--The Secretary of Health and Human
Services shall enter into a contract with an entity for
the purpose of establishing and operating a National
Training Institute for Federal and State surveyors.
Such Institute shall provide and improve the training
of surveyors with respect to investigating allegations
of abuse, neglect, and misappropriation of property in
programs and long-term care facilities that receive
payments under title XVIII or XIX of the Social
Security Act.
(B) Activities carried out by the institute.--The
contract entered into under subparagraph (A) shall
require the Institute established and operated under
such contract to carry out the following activities:
(i) Assess the extent to which State
agencies use specialized surveyors for the
investigation of reported allegations of abuse,
neglect, and misappropriation of property in
such programs and long-term care facilities.
(ii) Evaluate how the competencies of
surveyors may be improved to more effectively
investigate reported allegations of such abuse,
neglect, and misappropriation of property, and
provide feedback to Federal and State agencies
on the evaluations conducted.
(iii) Provide a national program of
training, tools, and technical assistance to
Federal and State surveyors on investigating
reports of such abuse, neglect, and
misappropriation of property.
(iv) Develop and disseminate information on
best practices for the investigation of such
abuse, neglect, and misappropriation of
property.
(v) Assess the performance of State
complaint intake systems, in order to ensure
that the intake of complaints occurs 24 hours
per day, 7 days a week (including holidays).
(vi) To the extent approved by the
Secretary of Health and Human Services, provide
a national 24 hours per day, 7 days a week
(including holidays), back-up system to State
complaint intake systems in order to ensure
optimum national responsiveness to complaints
of such abuse, neglect, and misappropriation of
property.
(vii) Analyze and report annually on the
following:
(I) The total number and sources of
complaints of such abuse, neglect, and
misappropriation of property.
(II) The extent to which such
complaints are referred to law
enforcement agencies.
(III) General results of Federal
and State investigations of such
complaints.
(viii) Conduct a national study of the cost
to State agencies of conducting complaint
investigations of skilled nursing facilities
and nursing facilities under sections 1819 and
1919, respectively, of the Social Security Act
(42 U.S.C. 1395i-3; 1396r), and making
recommendations to the Secretary of Health and
Human Services with respect to options to
increase the efficiency and cost-effectiveness
of such investigations.
(C) Authorization.--There are authorized to be
appropriated to carry out this paragraph, for the
period of fiscal years 2011 through 2014, $12,000,000.
(2) Grants to state survey agencies.--
(A) In general.--The Secretary of Health and Human
Services shall make grants to State agencies that
perform surveys of skilled nursing facilities or
nursing facilities under sections 1819 or 1919,
respectively, of the Social Security Act (42 U.S.C.
1395i-3; 1395r).
(B) Use of funds.--A grant awarded under
subparagraph (A) shall be used for the purpose of
designing and implementing complaint investigations
systems that--
(i) promptly prioritize complaints in order
to ensure a rapid response to the most serious
and urgent complaints;
(ii) respond to complaints with optimum
effectiveness and timeliness; and
(iii) optimize the collaboration between
local authorities, consumers, and providers,
including--
(I) such State agency;
(II) the State Long-Term Care
Ombudsman;
(III) local law enforcement
agencies;
(IV) advocacy and consumer
organizations;
(V) State aging units;
(VI) Area Agencies on Aging; and
(VII) other appropriate entities.
(C) Authorization.--There are authorized to be
appropriated to carry out this paragraph, for each of
fiscal years 2011 through 2014, $5,000,000.
(3) Reporting of crimes in federally funded long-term care
facilities.--Part A of title XI of the Social Security Act (42
U.S.C. 1301 et seq.), as amended by section 6005, is amended by
inserting after section 1150A the following new section:
``reporting to law enforcement of crimes occurring in federally funded
long-term care facilities
``Sec. 1150B. (a) Determination and Notification.--
``(1) Determination.--The owner or operator of each long-
term care facility that receives Federal funds under this Act
shall annually determine whether the facility received at least
$10,000 in such Federal funds during the preceding year.
``(2) Notification.--If the owner or operator determines
under paragraph (1) that the facility received at least $10,000
in such Federal funds during the preceding year, such owner or
operator shall annually notify each covered individual (as
defined in paragraph (3)) of that individual's obligation to
comply with the reporting requirements described in subsection
(b).
``(3) Covered individual defined.--In this section, the
term `covered individual' means each individual who is an
owner, operator, employee, manager, agent, or contractor of a
long-term care facility that is the subject of a determination
described in paragraph (1).
``(b) Reporting Requirements.--
``(1) In general.--Each covered individual shall report to
the Secretary and 1 or more law enforcement entities for the
political subdivision in which the facility is located any
reasonable suspicion of a crime (as defined by the law of the
applicable political subdivision) against any individual who is
a resident of, or is receiving care from, the facility.
``(2) Timing.--If the events that cause the suspicion--
``(A) result in serious bodily injury, the
individual shall report the suspicion immediately, but
not later than 2 hours after forming the suspicion; and
``(B) do not result in serious bodily injury, the
individual shall report the suspicion not later than 24
hours after forming the suspicion.
``(c) Penalties.--
``(1) In general.--If a covered individual violates
subsection (b)--
``(A) the covered individual shall be subject to a
civil money penalty of not more than $200,000; and
``(B) the Secretary may make a determination in the
same proceeding to exclude the covered individual from
participation in any Federal health care program (as
defined in section 1128B(f)).
``(2) Increased harm.--If a covered individual violates
subsection (b) and the violation exacerbates the harm to the
victim of the crime or results in harm to another individual--
``(A) the covered individual shall be subject to a
civil money penalty of not more than $300,000; and
``(B) the Secretary may make a determination in the
same proceeding to exclude the covered individual from
participation in any Federal health care program (as
defined in section 1128B(f)).
``(3) Excluded individual.--During any period for which a
covered individual is classified as an excluded individual
under paragraph (1)(B) or (2)(B), a long-term care facility
that employs such individual shall be ineligible to receive
Federal funds under this Act.
``(4) Extenuating circumstances.--
``(A) In general.--The Secretary may take into
account the financial burden on providers with
underserved populations in determining any penalty to
be imposed under this subsection.
``(B) Underserved population defined.--In this
paragraph, the term `underserved population' means the
population of an area designated by the Secretary as an
area with a shortage of elder justice programs or a
population group designated by the Secretary as having
a shortage of such programs. Such areas or groups
designated by the Secretary may include--
``(i) areas or groups that are
geographically isolated (such as isolated in a
rural area);
``(ii) racial and ethnic minority
populations; and
``(iii) populations underserved because of
special needs (such as language barriers,
disabilities, alien status, or age).
``(d) Additional Penalties for Retaliation.--
``(1) In general.--A long-term care facility may not--
``(A) discharge, demote, suspend, threaten, harass,
or deny a promotion or other employment-related benefit
to an employee, or in any other manner discriminate
against an employee in the terms and conditions of
employment because of lawful acts done by the employee;
or
``(B) file a complaint or a report against a nurse
or other employee with the appropriate State
professional disciplinary agency because of lawful acts
done by the nurse or employee,
for making a report, causing a report to be made, or for taking
steps in furtherance of making a report pursuant to subsection
(b)(1).
``(2) Penalties for retaliation.--If a long-term care
facility violates subparagraph (A) or (B) of paragraph (1) the
facility shall be subject to a civil money penalty of not more
than $200,000 or the Secretary may classify the entity as an
excluded entity for a period of 2 years pursuant to section
1128(b), or both.
``(3) Requirement to post notice.--Each long-term care
facility shall post conspicuously in an appropriate location a
sign (in a form specified by the Secretary) specifying the
rights of employees under this section. Such sign shall include
a statement that an employee may file a complaint with the
Secretary against a long-term care facility that violates the
provisions of this subsection and information with respect to
the manner of filing such a complaint.
``(e) Procedure.--The provisions of section 1128A (other than
subsections (a) and (b) and the second sentence of subsection (f))
shall apply to a civil money penalty or exclusion under this section in
the same manner as such provisions apply to a penalty or proceeding
under section 1128A(a).
``(f) Definitions.--In this section, the terms `elder justice',
`long-term care facility', and `law enforcement' have the meanings
given those terms in section 2011.''.
(c) National Nurse Aide Registry.--
(1) Definition of nurse aide.--In this subsection, the term
``nurse aide'' has the meaning given that term in sections
1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act (42
U.S.C. 1395i-3(b)(5)(F); 1396r(b)(5)(F)).
(2) Study and report.--
(A) In general.--The Secretary, in consultation
with appropriate government agencies and private sector
organizations, shall conduct a study on establishing a
national nurse aide registry.
(B) Areas evaluated.--The study conducted under
this subsection shall include an evaluation of--
(i) who should be included in the registry;
(ii) how such a registry would comply with
Federal and State privacy laws and regulations;
(iii) how data would be collected for the
registry;
(iv) what entities and individuals would
have access to the data collected;
(v) how the registry would provide
appropriate information regarding violations of
Federal and State law by individuals included
in the registry;
(vi) how the functions of a national nurse
aide registry would be coordinated with the
nationwide program for national and State
background checks on direct patient access
employees of long-term care facilities and
providers under section 4301; and
(vii) how the information included in State
nurse aide registries developed and maintained
under sections 1819(e)(2) and 1919(e)(2) of the
Social Security Act (42 U.S.C. 1395i-3(e)(2);
1396r(e)(2)(2)) would be provided as part of a
national nurse aide registry.
(C) Considerations.--In conducting the study and
preparing the report required under this subsection,
the Secretary shall take into consideration the
findings and conclusions of relevant reports and other
relevant resources, including the following:
(i) The Department of Health and Human
Services Office of Inspector General Report,
Nurse Aide Registries: State Compliance and
Practices (February 2005).
(ii) The General Accounting Office (now
known as the Government Accountability Office)
Report, Nursing Homes: More Can Be Done to
Protect Residents from Abuse (March 2002).
(iii) The Department of Health and Human
Services Office of the Inspector General
Report, Nurse Aide Registries: Long-Term Care
Facility Compliance and Practices (July 2005).
(iv) The Department of Health and Human
Services Health Resources and Services
Administration Report, Nursing Aides, Home
Health Aides, and Related Health Care
Occupations--National and Local Workforce
Shortages and Associated Data Needs (2004) (in
particular with respect to chapter 7 and
appendix F).
(v) The 2001 Report to CMS from the School
of Rural Public Health, Texas A&M University,
Preventing Abuse and Neglect in Nursing Homes:
The Role of Nurse Aide Registries.
(vi) Information included in State nurse
aide registries developed and maintained under
sections 1819(e)(2) and 1919(e)(2) of the
Social Security Act (42 U.S.C. 1395i-3(e)(2);
1396r(e)(2)(2)).
(D) Report.--Not later than 18 months after the
date of enactment of this Act, the Secretary shall
submit to the Elder Justice Coordinating Council
established under section 2021 of the Social Security
Act, as added by section 1805(a), the Committee on
Finance of the Senate, and the Committee on Ways and
Means and the Committee on Energy and Commerce of the
House of Representatives a report containing the
findings and recommendations of the study conducted
under this paragraph.
(E) Funding limitation.--Funding for the study
conducted under this subsection shall not exceed
$500,000.
(3) Congressional action.--After receiving the report
submitted by the Secretary under paragraph (2)(D), the
Committee on Finance of the Senate and the Committee on Ways
and Means and the Committee on Energy and Commerce of the House
of Representatives shall, as they deem appropriate, take action
based on the recommendations contained in the report.
(4) Authorization of appropriations.--There are authorized
to be appropriated such sums as are necessary for the purpose
of carrying out this subsection.
(d) Conforming Amendments.--
(1) Title xx.--Title XX of the Social Security Act (42
U.S.C. 1397 et seq.), as amended by section 6703(a), is
amended--
(A) in the heading of section 2001, by striking
``title'' and inserting ``subtitle''; and
(B) in subtitle 1, by striking ``this title'' each
place it appears and inserting ``this subtitle''.
(2) Title iv.--Title IV of the Social Security Act (42
U.S.C. 601 et seq.) is amended--
(A) in section 404(d)--
(i) in paragraphs (1)(A), (2)(A), and
(3)(B), by inserting ``subtitle 1 of'' before
``title XX'' each place it appears;
(ii) in the heading of paragraph (2), by
inserting ``subtitle 1 of'' before ``title
xx''; and
(iii) in the heading of paragraph (3)(B),
by inserting ``subtitle 1 of'' before ``title
xx''; and
(B) in sections 422(b), 471(a)(4), 472(h)(1), and
473(b)(2), by inserting ``subtitle 1 of'' before
``title XX'' each place it appears.
(3) Title xi.--Title XI of the Social Security Act (42
U.S.C. 1301 et seq.) is amended--
(A) in section 1128(h)(3)--
(i) by inserting ``subtitle 1 of'' before
``title XX''; and
(ii) by striking ``such title'' and
inserting ``such subtitle''; and
(B) in section 1128A(i)(1), by inserting ``subtitle
1 of'' before ``title XX''.
Subtitle I--Sense of the Senate Regarding Medical Malpractice
SEC. 6801. SENSE OF THE SENATE REGARDING MEDICAL MALPRACTICE.
It is the sense of the Senate that--
(1) health care reform presents an opportunity to address
issues related to medical malpractice and medical liability
insurance;
(2) States should be encouraged to develop and test
alternatives to the existing civil litigation system as a way
of improving patient safety, reducing medical errors,
encouraging the efficient resolution of disputes, increasing
the availability of prompt and fair resolution of disputes, and
improving access to liability insurance, while preserving an
individual's right to seek redress in court; and
(3) Congress should consider establishing a State
demonstration program to evaluate alternatives to the existing
civil litigation system with respect to the resolution of
medical malpractice claims.
TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
Subtitle A--Biologics Price Competition and Innovation
SEC. 7001. SHORT TITLE.
(a) In General.--This subtitle may be cited as the ``Biologics
Price Competition and Innovation Act of 2009''.
(b) Sense of the Senate.--It is the sense of the Senate that a
biosimilars pathway balancing innovation and consumer interests should
be established.
SEC. 7002. APPROVAL PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS.
(a) Licensure of Biological Products as Biosimilar or
Interchangeable.--Section 351 of the Public Health Service Act (42
U.S.C. 262) is amended--
(1) in subsection (a)(1)(A), by inserting ``under this
subsection or subsection (k)'' after ``biologics license''; and
(2) by adding at the end the following:
``(k) Licensure of Biological Products as Biosimilar or
Interchangeable.--
``(1) In general.--Any person may submit an application for
licensure of a biological product under this subsection.
``(2) Content.--
``(A) In general.--
``(i) Required information.--An application
submitted under this subsection shall include
information demonstrating that--
``(I) the biological product is
biosimilar to a reference product based
upon data derived from--
``(aa) analytical studies
that demonstrate that the
biological product is highly
similar to the reference
product notwithstanding minor
differences in clinically
inactive components;
``(bb) animal studies
(including the assessment of
toxicity); and
``(cc) a clinical study or
studies (including the
assessment of immunogenicity
and pharmacokinetics or
pharmacodynamics) that are
sufficient to demonstrate
safety, purity, and potency in
1 or more appropriate
conditions of use for which the
reference product is licensed
and intended to be used and for
which licensure is sought for
the biological product;
``(II) the biological product and
reference product utilize the same
mechanism or mechanisms of action for
the condition or conditions of use
prescribed, recommended, or suggested
in the proposed labeling, but only to
the extent the mechanism or mechanisms
of action are known for the reference
product;
``(III) the condition or conditions
of use prescribed, recommended, or
suggested in the labeling proposed for
the biological product have been
previously approved for the reference
product;
``(IV) the route of administration,
the dosage form, and the strength of
the biological product are the same as
those of the reference product; and
``(V) the facility in which the
biological product is manufactured,
processed, packed, or held meets
standards designed to assure that the
biological product continues to be
safe, pure, and potent.
``(ii) Determination by secretary.--The
Secretary may determine, in the Secretary's
discretion, that an element described in clause
(i)(I) is unnecessary in an application
submitted under this subsection.
``(iii) Additional information.--An
application submitted under this subsection--
``(I) shall include publicly-
available information regarding the
Secretary's previous determination that
the reference product is safe, pure,
and potent; and
``(II) may include any additional
information in support of the
application, including publicly-
available information with respect to
the reference product or another
biological product.
``(B) Interchangeability.--An application (or a
supplement to an application) submitted under this
subsection may include information demonstrating that
the biological product meets the standards described in
paragraph (4).
``(3) Evaluation by secretary.--Upon review of an
application (or a supplement to an application) submitted under
this subsection, the Secretary shall license the biological
product under this subsection if--
``(A) the Secretary determines that the information
submitted in the application (or the supplement) is
sufficient to show that the biological product--
``(i) is biosimilar to the reference
product; or
``(ii) meets the standards described in
paragraph (4), and therefore is interchangeable
with the reference product; and
``(B) the applicant (or other appropriate person)
consents to the inspection of the facility that is the
subject of the application, in accordance with
subsection (c).
``(4) Safety standards for determining
interchangeability.--Upon review of an application submitted
under this subsection or any supplement to such application,
the Secretary shall determine the biological product to be
interchangeable with the reference product if the Secretary
determines that the information submitted in the application
(or a supplement to such application) is sufficient to show
that--
``(A) the biological product--
``(i) is biosimilar to the reference
product; and
``(ii) can be expected to produce the same
clinical result as the reference product in any
given patient; and
``(B) for a biological product that is administered
more than once to an individual, the risk in terms of
safety or diminished efficacy of alternating or
switching between use of the biological product and the
reference product is not greater than the risk of using
the reference product without such alternation or
switch.
``(5) General rules.--
``(A) One reference product per application.--A
biological product, in an application submitted under
this subsection, may not be evaluated against more than
1 reference product.
``(B) Review.--An application submitted under this
subsection shall be reviewed by the division within the
Food and Drug Administration that is responsible for
the review and approval of the application under which
the reference product is licensed.
``(C) Risk evaluation and mitigation strategies.--
The authority of the Secretary with respect to risk
evaluation and mitigation strategies under the Federal
Food, Drug, and Cosmetic Act shall apply to biological
products licensed under this subsection in the same
manner as such authority applies to biological products
licensed under subsection (a).
``(6) Exclusivity for first interchangeable biological
product.--Upon review of an application submitted under this
subsection relying on the same reference product for which a
prior biological product has received a determination of
interchangeability for any condition of use, the Secretary
shall not make a determination under paragraph (4) that the
second or subsequent biological product is interchangeable for
any condition of use until the earlier of--
``(A) 1 year after the first commercial marketing
of the first interchangeable biosimilar biological
product to be approved as interchangeable for that
reference product;
``(B) 18 months after--
``(i) a final court decision on all patents
in suit in an action instituted under
subsection (l)(6) against the applicant that
submitted the application for the first
approved interchangeable biosimilar biological
product; or
``(ii) the dismissal with or without
prejudice of an action instituted under
subsection (l)(6) against the applicant that
submitted the application for the first
approved interchangeable biosimilar biological
product; or
``(C)(i) 42 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has been sued
under subsection (l)(6) and such litigation is still
ongoing within such 42-month period; or
``(ii) 18 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has not been
sued under subsection (l)(6).
For purposes of this paragraph, the term `final court decision'
means a final decision of a court from which no appeal (other
than a petition to the United States Supreme Court for a writ
of certiorari) has been or can be taken.
``(7) Exclusivity for reference product.--
``(A) Effective date of biosimilar application
approval.--Approval of an application under this
subsection may not be made effective by the Secretary
until the date that is 12 years after the date on which
the reference product was first licensed under
subsection (a).
``(B) Filing period.--An application under this
subsection may not be submitted to the Secretary until
the date that is 4 years after the date on which the
reference product was first licensed under subsection
(a).
``(C) First licensure.--Subparagraphs (A) and (B)
shall not apply to a license for or approval of--
``(i) a supplement for the biological
product that is the reference product; or
``(ii) a subsequent application filed by
the same sponsor or manufacturer of the
biological product that is the reference
product (or a licensor, predecessor in
interest, or other related entity) for--
``(I) a change (not including a
modification to the structure of the
biological product) that results in a
new indication, route of
administration, dosing schedule, dosage
form, delivery system, delivery device,
or strength; or
``(II) a modification to the
structure of the biological product
that does not result in a change in
safety, purity, or potency.
``(8) Guidance documents.--
``(A) In general.--The Secretary may, after
opportunity for public comment, issue guidance in
accordance, except as provided in subparagraph (B)(i),
with section 701(h) of the Federal Food, Drug, and
Cosmetic Act with respect to the licensure of a
biological product under this subsection. Any such
guidance may be general or specific.
``(B) Public comment.--
``(i) In general.--The Secretary shall
provide the public an opportunity to comment on
any proposed guidance issued under subparagraph
(A) before issuing final guidance.
``(ii) Input regarding most valuable
guidance.--The Secretary shall establish a
process through which the public may provide
the Secretary with input regarding priorities
for issuing guidance.
``(C) No requirement for application
consideration.--The issuance (or non-issuance) of
guidance under subparagraph (A) shall not preclude the
review of, or action on, an application submitted under
this subsection.
``(D) Requirement for product class-specific
guidance.--If the Secretary issues product class-
specific guidance under subparagraph (A), such guidance
shall include a description of--
``(i) the criteria that the Secretary will
use to determine whether a biological product
is highly similar to a reference product in
such product class; and
``(ii) the criteria, if available, that the
Secretary will use to determine whether a
biological product meets the standards
described in paragraph (4).
``(E) Certain product classes.--
``(i) Guidance.--The Secretary may indicate
in a guidance document that the science and
experience, as of the date of such guidance,
with respect to a product or product class (not
including any recombinant protein) does not
allow approval of an application for a license
as provided under this subsection for such
product or product class.
``(ii) Modification or reversal.--The
Secretary may issue a subsequent guidance
document under subparagraph (A) to modify or
reverse a guidance document under clause (i).
``(iii) No effect on ability to deny
license.--Clause (i) shall not be construed to
require the Secretary to approve a product with
respect to which the Secretary has not
indicated in a guidance document that the
science and experience, as described in clause
(i), does not allow approval of such an
application.
``(l) Patents.--
``(1) Confidential access to subsection (k) application.--
``(A) Application of paragraph.--Unless otherwise
agreed to by a person that submits an application under
subsection (k) (referred to in this subsection as the
`subsection (k) applicant') and the sponsor of the
application for the reference product (referred to in
this subsection as the `reference product sponsor'),
the provisions of this paragraph shall apply to the
exchange of information described in this subsection.
``(B) In general.--
``(i) Provision of confidential
information.--When a subsection (k) applicant
submits an application under subsection (k),
such applicant shall provide to the persons
described in clause (ii), subject to the terms
of this paragraph, confidential access to the
information required to be produced pursuant to
paragraph (2) and any other information that
the subsection (k) applicant determines, in its
sole discretion, to be appropriate (referred to
in this subsection as the `confidential
information').
``(ii) Recipients of information.--The
persons described in this clause are the
following:
``(I) Outside counsel.--One or more
attorneys designated by the reference
product sponsor who are employees of an
entity other than the reference product
sponsor (referred to in this paragraph
as the `outside counsel'), provided
that such attorneys do not engage,
formally or informally, in patent
prosecution relevant or related to the
reference product.
``(II) In-house counsel.--One
attorney that represents the reference
product sponsor who is an employee of
the reference product sponsor, provided
that such attorney does not engage,
formally or informally, in patent
prosecution relevant or related to the
reference product.
``(iii) Patent owner access.--A
representative of the owner of a patent
exclusively licensed to a reference product
sponsor with respect to the reference product
and who has retained a right to assert the
patent or participate in litigation concerning
the patent may be provided the confidential
information, provided that the representative
informs the reference product sponsor and the
subsection (k) applicant of his or her
agreement to be subject to the confidentiality
provisions set forth in this paragraph,
including those under clause (ii).
``(C) Limitation on disclosure.--No person that
receives confidential information pursuant to
subparagraph (B) shall disclose any confidential
information to any other person or entity, including
the reference product sponsor employees, outside
scientific consultants, or other outside counsel
retained by the reference product sponsor, without the
prior written consent of the subsection (k) applicant,
which shall not be unreasonably withheld.
``(D) Use of confidential information.--
Confidential information shall be used for the sole and
exclusive purpose of determining, with respect to each
patent assigned to or exclusively licensed by the
reference product sponsor, whether a claim of patent
infringement could reasonably be asserted if the
subsection (k) applicant engaged in the manufacture,
use, offering for sale, sale, or importation into the
United States of the biological product that is the
subject of the application under subsection (k).
``(E) Ownership of confidential information.--The
confidential information disclosed under this paragraph
is, and shall remain, the property of the subsection
(k) applicant. By providing the confidential
information pursuant to this paragraph, the subsection
(k) applicant does not provide the reference product
sponsor or the outside counsel any interest in or
license to use the confidential information, for
purposes other than those specified in subparagraph
(D).
``(F) Effect of infringement action.--In the event
that the reference product sponsor files a patent
infringement suit, the use of confidential information
shall continue to be governed by the terms of this
paragraph until such time as a court enters a
protective order regarding the information. Upon entry
of such order, the subsection (k) applicant may
redesignate confidential information in accordance with
the terms of that order. No confidential information
shall be included in any publicly-available complaint
or other pleading. In the event that the reference
product sponsor does not file an infringement action by
the date specified in paragraph (6), the reference
product sponsor shall return or destroy all
confidential information received under this paragraph,
provided that if the reference product sponsor opts to
destroy such information, it will confirm destruction
in writing to the subsection (k) applicant.
``(G) Rule of construction.--Nothing in this
paragraph shall be construed--
``(i) as an admission by the subsection (k)
applicant regarding the validity,
enforceability, or infringement of any patent;
or
``(ii) as an agreement or admission by the
subsection (k) applicant with respect to the
competency, relevance, or materiality of any
confidential information.
``(H) Effect of violation.--The disclosure of any
confidential information in violation of this paragraph
shall be deemed to cause the subsection (k) applicant
to suffer irreparable harm for which there is no
adequate legal remedy and the court shall consider
immediate injunctive relief to be an appropriate and
necessary remedy for any violation or threatened
violation of this paragraph.
``(2) Subsection (k) application information.--Not later
than 20 days after the Secretary notifies the subsection (k)
applicant that the application has been accepted for review,
the subsection (k) applicant--
``(A) shall provide to the reference product
sponsor a copy of the application submitted to the
Secretary under subsection (k), and such other
information that describes the process or processes
used to manufacture the biological product that is the
subject of such application; and
``(B) may provide to the reference product sponsor
additional information requested by or on behalf of the
reference product sponsor.
``(3) List and description of patents.--
``(A) List by reference product sponsor.--Not later
than 60 days after the receipt of the application and
information under paragraph (2), the reference product
sponsor shall provide to the subsection (k) applicant--
``(i) a list of patents for which the
reference product sponsor believes a claim of
patent infringement could reasonably be
asserted by the reference product sponsor, or
by a patent owner that has granted an exclusive
license to the reference product sponsor with
respect to the reference product, if a person
not licensed by the reference product sponsor
engaged in the making, using, offering to sell,
selling, or importing into the United States of
the biological product that is the subject of
the subsection (k) application; and
``(ii) an identification of the patents on
such list that the reference product sponsor
would be prepared to license to the subsection
(k) applicant.
``(B) List and description by subsection (k)
applicant.--Not later than 60 days after receipt of the
list under subparagraph (A), the subsection (k)
applicant--
``(i) may provide to the reference product
sponsor a list of patents to which the
subsection (k) applicant believes a claim of
patent infringement could reasonably be
asserted by the reference product sponsor if a
person not licensed by the reference product
sponsor engaged in the making, using, offering
to sell, selling, or importing into the United
States of the biological product that is the
subject of the subsection (k) application;
``(ii) shall provide to the reference
product sponsor, with respect to each patent
listed by the reference product sponsor under
subparagraph (A) or listed by the subsection
(k) applicant under clause (i)--
``(I) a detailed statement that
describes, on a claim by claim basis,
the factual and legal basis of the
opinion of the subsection (k) applicant
that such patent is invalid,
unenforceable, or will not be infringed
by the commercial marketing of the
biological product that is the subject
of the subsection (k) application; or
``(II) a statement that the
subsection (k) applicant does not
intend to begin commercial marketing of
the biological product before the date
that such patent expires; and
``(iii) shall provide to the reference
product sponsor a response regarding each
patent identified by the reference product
sponsor under subparagraph (A)(ii).
``(C) Description by reference product sponsor.--
Not later than 60 days after receipt of the list and
statement under subparagraph (B), the reference product
sponsor shall provide to the subsection (k) applicant a
detailed statement that describes, with respect to each
patent described in subparagraph (B)(ii)(I), on a claim
by claim basis, the factual and legal basis of the
opinion of the reference product sponsor that such
patent will be infringed by the commercial marketing of
the biological product that is the subject of the
subsection (k) application and a response to the
statement concerning validity and enforceability
provided under subparagraph (B)(ii)(I).
``(4) Patent resolution negotiations.--
``(A) In general.--After receipt by the subsection
(k) applicant of the statement under paragraph (3)(C),
the reference product sponsor and the subsection (k)
applicant shall engage in good faith negotiations to
agree on which, if any, patents listed under paragraph
(3) by the subsection (k) applicant or the reference
product sponsor shall be the subject of an action for
patent infringement under paragraph (6).
``(B) Failure to reach agreement.--If, within 15
days of beginning negotiations under subparagraph (A),
the subsection (k) applicant and the reference product
sponsor fail to agree on a final and complete list of
which, if any, patents listed under paragraph (3) by
the subsection (k) applicant or the reference product
sponsor shall be the subject of an action for patent
infringement under paragraph (6), the provisions of
paragraph (5) shall apply to the parties.
``(5) Patent resolution if no agreement.--
``(A) Number of patents.--The subsection (k)
applicant shall notify the reference product sponsor of
the number of patents that such applicant will provide
to the reference product sponsor under subparagraph
(B)(i)(I).
``(B) Exchange of patent lists.--
``(i) In general.--On a date agreed to by
the subsection (k) applicant and the reference
product sponsor, but in no case later than 5
days after the subsection (k) applicant
notifies the reference product sponsor under
subparagraph (A), the subsection (k) applicant
and the reference product sponsor shall
simultaneously exchange--
``(I) the list of patents that the
subsection (k) applicant believes
should be the subject of an action for
patent infringement under paragraph
(6); and
``(II) the list of patents, in
accordance with clause (ii), that the
reference product sponsor believes
should be the subject of an action for
patent infringement under paragraph
(6).
``(ii) Number of patents listed by
reference product sponsor.--
``(I) In general.--Subject to
subclause (II), the number of patents
listed by the reference product sponsor
under clause (i)(II) may not exceed the
number of patents listed by the
subsection (k) applicant under clause
(i)(I).
``(II) Exception.--If a subsection
(k) applicant does not list any patent
under clause (i)(I), the reference
product sponsor may list 1 patent under
clause (i)(II).
``(6) Immediate patent infringement action.--
``(A) Action if agreement on patent list.--If the
subsection (k) applicant and the reference product
sponsor agree on patents as described in paragraph (4),
not later than 30 days after such agreement, the
reference product sponsor shall bring an action for
patent infringement with respect to each such patent.
``(B) Action if no agreement on patent list.--If
the provisions of paragraph (5) apply to the parties as
described in paragraph (4)(B), not later than 30 days
after the exchange of lists under paragraph (5)(B), the
reference product sponsor shall bring an action for
patent infringement with respect to each patent that is
included on such lists.
``(C) Notification and publication of complaint.--
``(i) Notification to secretary.--Not later
than 30 days after a complaint is served to a
subsection (k) applicant in an action for
patent infringement described under this
paragraph, the subsection (k) applicant shall
provide the Secretary with notice and a copy of
such complaint.
``(ii) Publication by secretary.--The
Secretary shall publish in the Federal Register
notice of a complaint received under clause
(i).
``(7) Newly issued or licensed patents.--In the case of a
patent that--
``(A) is issued to, or exclusively licensed by, the
reference product sponsor after the date that the
reference product sponsor provided the list to the
subsection (k) applicant under paragraph (3)(A); and
``(B) the reference product sponsor reasonably
believes that, due to the issuance of such patent, a
claim of patent infringement could reasonably be
asserted by the reference product sponsor if a person
not licensed by the reference product sponsor engaged
in the making, using, offering to sell, selling, or
importing into the United States of the biological
product that is the subject of the subsection (k)
application,
not later than 30 days after such issuance or licensing, the
reference product sponsor shall provide to the subsection (k)
applicant a supplement to the list provided by the reference
product sponsor under paragraph (3)(A) that includes such
patent, not later than 30 days after such supplement is
provided, the subsection (k) applicant shall provide a
statement to the reference product sponsor in accordance with
paragraph (3)(B), and such patent shall be subject to paragraph
(8).
``(8) Notice of commercial marketing and preliminary
injunction.--
``(A) Notice of commercial marketing.--The
subsection (k) applicant shall provide notice to the
reference product sponsor not later than 180 days
before the date of the first commercial marketing of
the biological product licensed under subsection (k).
``(B) Preliminary injunction.--After receiving the
notice under subparagraph (A) and before such date of
the first commercial marketing of such biological
product, the reference product sponsor may seek a
preliminary injunction prohibiting the subsection (k)
applicant from engaging in the commercial manufacture
or sale of such biological product until the court
decides the issue of patent validity, enforcement, and
infringement with respect to any patent that is--
``(i) included in the list provided by the
reference product sponsor under paragraph
(3)(A) or in the list provided by the
subsection (k) applicant under paragraph
(3)(B); and
``(ii) not included, as applicable, on--
``(I) the list of patents described
in paragraph (4); or
``(II) the lists of patents
described in paragraph (5)(B).
``(C) Reasonable cooperation.--If the reference
product sponsor has sought a preliminary injunction
under subparagraph (B), the reference product sponsor
and the subsection (k) applicant shall reasonably
cooperate to expedite such further discovery as is
needed in connection with the preliminary injunction
motion.
``(9) Limitation on declaratory judgment action.--
``(A) Subsection (k) application provided.--If a
subsection (k) applicant provides the application and
information required under paragraph (2)(A), neither
the reference product sponsor nor the subsection (k)
applicant may, prior to the date notice is received
under paragraph (8)(A), bring any action under section
2201 of title 28, United States Code, for a declaration
of infringement, validity, or enforceability of any
patent that is described in clauses (i) and (ii) of
paragraph (8)(B).
``(B) Subsequent failure to act by subsection (k)
applicant.--If a subsection (k) applicant fails to
complete an action required of the subsection (k)
applicant under paragraph (3)(B)(ii), paragraph (5),
paragraph (6)(C)(i), paragraph (7), or paragraph
(8)(A), the reference product sponsor, but not the
subsection (k) applicant, may bring an action under
section 2201 of title 28, United States Code, for a
declaration of infringement, validity, or
enforceability of any patent included in the list
described in paragraph (3)(A), including as provided
under paragraph (7).
``(C) Subsection (k) application not provided.--If
a subsection (k) applicant fails to provide the
application and information required under paragraph
(2)(A), the reference product sponsor, but not the
subsection (k) applicant, may bring an action under
section 2201 of title 28, United States Code, for a
declaration of infringement, validity, or
enforceability of any patent that claims the biological
product or a use of the biological product.''.
(b) Definitions.--Section 351(i) of the Public Health Service Act
(42 U.S.C. 262(i)) is amended--
(1) by striking ``In this section, the term `biological
product' means'' and inserting the following: ``In this
section:
``(1) The term `biological product' means'';
(2) in paragraph (1), as so designated, by inserting
``protein (except any chemically synthesized polypeptide),''
after ``allergenic product,''; and
(3) by adding at the end the following:
``(2) The term `biosimilar' or `biosimilarity', in
reference to a biological product that is the subject of an
application under subsection (k), means--
``(A) that the biological product is highly similar
to the reference product notwithstanding minor
differences in clinically inactive components; and
``(B) there are no clinically meaningful
differences between the biological product and the
reference product in terms of the safety, purity, and
potency of the product.
``(3) The term `interchangeable' or `interchangeability',
in reference to a biological product that is shown to meet the
standards described in subsection (k)(4), means that the
biological product may be substituted for the reference product
without the intervention of the health care provider who
prescribed the reference product.
``(4) The term `reference product' means the single
biological product licensed under subsection (a) against which
a biological product is evaluated in an application submitted
under subsection (k).''.
(c) Conforming Amendments Relating to Patents.--
(1) Patents.--Section 271(e) of title 35, United States
Code, is amended--
(A) in paragraph (2)--
(i) in subparagraph (A), by striking ``or''
at the end;
(ii) in subparagraph (B), by adding ``or''
at the end; and
(iii) by inserting after subparagraph (B)
the following:
``(C)(i) with respect to a patent that is identified in the
list of patents described in section 351(l)(3) of the Public
Health Service Act (including as provided under section
351(l)(7) of such Act), an application seeking approval of a
biological product, or
``(ii) if the applicant for the application fails to
provide the application and information required under section
351(l)(2)(A) of such Act, an application seeking approval of a
biological product for a patent that could be identified
pursuant to section 351(l)(3)(A)(i) of such Act,''; and
(iv) in the matter following subparagraph
(C) (as added by clause (iii)), by striking
``or veterinary biological product'' and
inserting ``, veterinary biological product, or
biological product'';
(B) in paragraph (4)--
(i) in subparagraph (B), by--
(I) striking ``or veterinary
biological product'' and inserting ``,
veterinary biological product, or
biological product''; and
(II) striking ``and'' at the end;
(ii) in subparagraph (C), by--
(I) striking ``or veterinary
biological product'' and inserting ``,
veterinary biological product, or
biological product''; and
(II) striking the period and
inserting ``, and'';
(iii) by inserting after subparagraph (C)
the following:
``(D) the court shall order a permanent injunction
prohibiting any infringement of the patent by the biological
product involved in the infringement until a date which is not
earlier than the date of the expiration of the patent that has
been infringed under paragraph (2)(C), provided the patent is
the subject of a final court decision, as defined in section
351(k)(6) of the Public Health Service Act, in an action for
infringement of the patent under section 351(l)(6) of such Act,
and the biological product has not yet been approved because of
section 351(k)(7) of such Act.''; and
(iv) in the matter following subparagraph
(D) (as added by clause (iii)), by striking
``and (C)'' and inserting ``(C), and (D)''; and
(C) by adding at the end the following:
``(6)(A) Subparagraph (B) applies, in lieu of paragraph (4), in the
case of a patent--
``(i) that is identified, as applicable, in the list of
patents described in section 351(l)(4) of the Public Health
Service Act or the lists of patents described in section
351(l)(5)(B) of such Act with respect to a biological product;
and
``(ii) for which an action for infringement of the patent
with respect to the biological product--
``(I) was brought after the expiration of the 30-
day period described in subparagraph (A) or (B), as
applicable, of section 351(l)(6) of such Act; or
``(II) was brought before the expiration of the 30-
day period described in subclause (I), but which was
dismissed without prejudice or was not prosecuted to
judgment in good faith.
``(B) In an action for infringement of a patent described in
subparagraph (A), the sole and exclusive remedy that may be granted by
a court, upon a finding that the making, using, offering to sell,
selling, or importation into the United States of the biological
product that is the subject of the action infringed the patent, shall
be a reasonable royalty.
``(C) The owner of a patent that should have been included in the
list described in section 351(l)(3)(A) of the Public Health Service
Act, including as provided under section 351(l)(7) of such Act for a
biological product, but was not timely included in such list, may not
bring an action under this section for infringement of the patent with
respect to the biological product.''.
(2) Conforming amendment under title 28.--Section 2201(b)
of title 28, United States Code, is amended by inserting before
the period the following: ``, or section 351 of the Public
Health Service Act''.
(d) Conforming Amendments Under the Federal Food, Drug, and
Cosmetic Act.--
(1) Content and review of applications.--Section
505(b)(5)(B) of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355(b)(5)(B)) is amended by inserting before the period
at the end of the first sentence the following: ``or, with
respect to an applicant for approval of a biological product
under section 351(k) of the Public Health Service Act, any
necessary clinical study or studies''.
(2) New active ingredient.--Section 505B of the Federal
Food, Drug, and Cosmetic Act (21 U.S.C. 355c) is amended by
adding at the end the following:
``(n) New Active Ingredient.--
``(1) Non-interchangeable biosimilar biological product.--A
biological product that is biosimilar to a reference product
under section 351 of the Public Health Service Act, and that
the Secretary has not determined to meet the standards
described in subsection (k)(4) of such section for
interchangeability with the reference product, shall be
considered to have a new active ingredient under this section.
``(2) Interchangeable biosimilar biological product.--A
biological product that is interchangeable with a reference
product under section 351 of the Public Health Service Act
shall not be considered to have a new active ingredient under
this section.''.
(e) Products Previously Approved Under Section 505.--
(1) Requirement to follow section 351.--Except as provided
in paragraph (2), an application for a biological product shall
be submitted under section 351 of the Public Health Service Act
(42 U.S.C. 262) (as amended by this Act).
(2) Exception.--An application for a biological product may
be submitted under section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) if--
(A) such biological product is in a product class
for which a biological product in such product class is
the subject of an application approved under such
section 505 not later than the date of enactment of
this Act; and
(B) such application--
(i) has been submitted to the Secretary of
Health and Human Services (referred to in this
subtitle as the ``Secretary'') before the date
of enactment of this Act; or
(ii) is submitted to the Secretary not
later than the date that is 10 years after the
date of enactment of this Act.
(3) Limitation.--Notwithstanding paragraph (2), an
application for a biological product may not be submitted under
section 505 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355) if there is another biological product approved
under subsection (a) of section 351 of the Public Health
Service Act that could be a reference product with respect to
such application (within the meaning of such section 351) if
such application were submitted under subsection (k) of such
section 351.
(4) Deemed approved under section 351.--An approved
application for a biological product under section 505 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be
deemed to be a license for the biological product under such
section 351 on the date that is 10 years after the date of
enactment of this Act.
(5) Definitions.--For purposes of this subsection, the term
``biological product'' has the meaning given such term under
section 351 of the Public Health Service Act (42 U.S.C. 262)
(as amended by this Act).
(f) Follow-on Biologics User Fees.--
(1) Development of user fees for biosimilar biological
products.--
(A) In general.--Beginning not later than October
1, 2010, the Secretary shall develop recommendations to
present to Congress with respect to the goals, and
plans for meeting the goals, for the process for the
review of biosimilar biological product applications
submitted under section 351(k) of the Public Health
Service Act (as added by this Act) for the first 5
fiscal years after fiscal year 2012. In developing such
recommendations, the Secretary shall consult with--
(i) the Committee on Health, Education,
Labor, and Pensions of the Senate;
(ii) the Committee on Energy and Commerce
of the House of Representatives;
(iii) scientific and academic experts;
(iv) health care professionals;
(v) representatives of patient and consumer
advocacy groups; and
(vi) the regulated industry.
(B) Public review of recommendations.--After
negotiations with the regulated industry, the Secretary
shall--
(i) present the recommendations developed
under subparagraph (A) to the Congressional
committees specified in such subparagraph;
(ii) publish such recommendations in the
Federal Register;
(iii) provide for a period of 30 days for
the public to provide written comments on such
recommendations;
(iv) hold a meeting at which the public may
present its views on such recommendations; and
(v) after consideration of such public
views and comments, revise such recommendations
as necessary.
(C) Transmittal of recommendations.--Not later than
January 15, 2012, the Secretary shall transmit to
Congress the revised recommendations under subparagraph
(B), a summary of the views and comments received under
such subparagraph, and any changes made to the
recommendations in response to such views and comments.
(2) Establishment of user fee program.--It is the sense of
the Senate that, based on the recommendations transmitted to
Congress by the Secretary pursuant to paragraph (1)(C),
Congress should authorize a program, effective on October 1,
2012, for the collection of user fees relating to the
submission of biosimilar biological product applications under
section 351(k) of the Public Health Service Act (as added by
this Act).
(3) Transitional provisions for user fees for biosimilar
biological products.--
(A) Application of the prescription drug user fee
provisions.--Section 735(1)(B) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 379g(1)(B)) is
amended by striking ``section 351'' and inserting
``subsection (a) or (k) of section 351''.
(B) Evaluation of costs of reviewing biosimilar
biological product applications.--During the period
beginning on the date of enactment of this Act and
ending on October 1, 2010, the Secretary shall collect
and evaluate data regarding the costs of reviewing
applications for biological products submitted under
section 351(k) of the Public Health Service Act (as
added by this Act) during such period.
(C) Audit.--
(i) In general.--On the date that is 2
years after first receiving a user fee
applicable to an application for a biological
product under section 351(k) of the Public
Health Service Act (as added by this Act), and
on a biennial basis thereafter until October 1,
2013, the Secretary shall perform an audit of
the costs of reviewing such applications under
such section 351(k). Such an audit shall
compare--
(I) the costs of reviewing such
applications under such section 351(k)
to the amount of the user fee
applicable to such applications; and
(II)(aa) such ratio determined
under subclause (I); to
(bb) the ratio of the costs of
reviewing applications for biological
products under section 351(a) of such
Act (as amended by this Act) to the
amount of the user fee applicable to
such applications under such section
351(a).
(ii) Alteration of user fee.--If the audit
performed under clause (i) indicates that the
ratios compared under subclause (II) of such
clause differ by more than 5 percent, then the
Secretary shall alter the user fee applicable
to applications submitted under such section
351(k) to more appropriately account for the
costs of reviewing such applications.
(iii) Accounting standards.--The Secretary
shall perform an audit under clause (i) in
conformance with the accounting principles,
standards, and requirements prescribed by the
Comptroller General of the United States under
section 3511 of title 31, United State Code, to
ensure the validity of any potential
variability.
(4) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection such sums as
may be necessary for each of fiscal years 2010 through 2012.
(g) Pediatric Studies of Biological Products.--
(1) In general.--Section 351 of the Public Health Service
Act (42 U.S.C. 262) is amended by adding at the end the
following:
``(m) Pediatric Studies.--
``(1) Application of certain provisions.--The provisions of
subsections (a), (d), (e), (f), (i), (j), (k), (l), (p), and
(q) of section 505A of the Federal Food, Drug, and Cosmetic Act
shall apply with respect to the extension of a period under
paragraphs (2) and (3) to the same extent and in the same
manner as such provisions apply with respect to the extension
of a period under subsection (b) or (c) of section 505A of the
Federal Food, Drug, and Cosmetic Act.
``(2) Market exclusivity for new biological products.--If,
prior to approval of an application that is submitted under
subsection (a), the Secretary determines that information
relating to the use of a new biological product in the
pediatric population may produce health benefits in that
population, the Secretary makes a written request for pediatric
studies (which shall include a timeframe for completing such
studies), the applicant agrees to the request, such studies are
completed using appropriate formulations for each age group for
which the study is requested within any such timeframe, and the
reports thereof are submitted and accepted in accordance with
section 505A(d)(3) of the Federal Food, Drug, and Cosmetic
Act--
``(A) the periods for such biological product
referred to in subsection (k)(7) are deemed to be 4
years and 6 months rather than 4 years and 12 years and
6 months rather than 12 years; and
``(B) if the biological product is designated under
section 526 for a rare disease or condition, the period
for such biological product referred to in section
527(a) is deemed to be 7 years and 6 months rather than
7 years.
``(3) Market exclusivity for already-marketed biological
products.--If the Secretary determines that information
relating to the use of a licensed biological product in the
pediatric population may produce health benefits in that
population and makes a written request to the holder of an
approved application under subsection (a) for pediatric studies
(which shall include a timeframe for completing such studies),
the holder agrees to the request, such studies are completed
using appropriate formulations for each age group for which the
study is requested within any such timeframe, and the reports
thereof are submitted and accepted in accordance with section
505A(d)(3) of the Federal Food, Drug, and Cosmetic Act--
``(A) the periods for such biological product
referred to in subsection (k)(7) are deemed to be 4
years and 6 months rather than 4 years and 12 years and
6 months rather than 12 years; and
``(B) if the biological product is designated under
section 526 for a rare disease or condition, the period
for such biological product referred to in section
527(a) is deemed to be 7 years and 6 months rather than
7 years.
``(4) Exception.--The Secretary shall not extend a period
referred to in paragraph (2)(A), (2)(B), (3)(A), or (3)(B) if
the determination under section 505A(d)(3) is made later than 9
months prior to the expiration of such period.''.
(2) Studies regarding pediatric research.--
(A) Program for pediatric study of drugs.--
Subsection (a)(1) of section 409I of the Public Health
Service Act (42 U.S.C. 284m) is amended by inserting
``, biological products,'' after ``including drugs''.
(B) Institute of medicine study.--Section 505A(p)
of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
355b(p)) is amended by striking paragraphs (4) and (5)
and inserting the following:
``(4) review and assess the number and importance of
biological products for children that are being tested as a
result of the amendments made by the Biologics Price
Competition and Innovation Act of 2009 and the importance for
children, health care providers, parents, and others of
labeling changes made as a result of such testing;
``(5) review and assess the number, importance, and
prioritization of any biological products that are not being
tested for pediatric use; and
``(6) offer recommendations for ensuring pediatric testing
of biological products, including consideration of any
incentives, such as those provided under this section or
section 351(m) of the Public Health Service Act.''.
(h) Orphan Products.--If a reference product, as defined in section
351 of the Public Health Service Act (42 U.S.C. 262) (as amended by
this Act) has been designated under section 526 of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 360bb) for a rare disease or
condition, a biological product seeking approval for such disease or
condition under subsection (k) of such section 351 as biosimilar to, or
interchangeable with, such reference product may be licensed by the
Secretary only after the expiration for such reference product of the
later of--
(1) the 7-year period described in section 527(a) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360cc(a)); and
(2) the 12-year period described in subsection (k)(7) of
such section 351.
SEC. 7003. SAVINGS.
(a) Determination.--The Secretary of the Treasury, in consultation
with the Secretary of Health and Human Services, shall for each fiscal
year determine the amount of savings to the Federal Government as a
result of the enactment of this subtitle.
(b) Use.--Notwithstanding any other provision of this subtitle (or
an amendment made by this subtitle), the savings to the Federal
Government generated as a result of the enactment of this subtitle
shall be used for deficit reduction.
Subtitle B--More Affordable Medicines for Children and Underserved
Communities
SEC. 7101. EXPANDED PARTICIPATION IN 340B PROGRAM.
(a) Expansion of Covered Entities Receiving Discounted Prices.--
Section 340B(a)(4) of the Public Health Service Act (42 U.S.C.
256b(a)(4)) is amended by adding at the end the following:
``(M) A children's hospital excluded from the
Medicare prospective payment system pursuant to section
1886(d)(1)(B)(iii) of the Social Security Act, or a
free-standing cancer hospital excluded from the
Medicare prospective payment system pursuant to section
1886(d)(1)(B)(v) of the Social Security Act, that would
meet the requirements of subparagraph (L), including
the disproportionate share adjustment percentage
requirement under clause (ii) of such subparagraph, if
the hospital were a subsection (d) hospital as defined
by section 1886(d)(1)(B) of the Social Security Act.
``(N) An entity that is a critical access hospital
(as determined under section 1820(c)(2) of the Social
Security Act), and that meets the requirements of
subparagraph (L)(i).
``(O) An entity that is a rural referral center, as
defined by section 1886(d)(5)(C)(i) of the Social
Security Act, or a sole community hospital, as defined
by section 1886(d)(5)(C)(iii) of such Act, and that
both meets the requirements of subparagraph (L)(i) and
has a disproportionate share adjustment percentage
equal to or greater than 8 percent.''.
(b) Extension of Discount to Inpatient Drugs.--Section 340B of the
Public Health Service Act (42 U.S.C. 256b) is amended--
(1) in paragraphs (2), (5), (7), and (9) of subsection (a),
by striking ``outpatient'' each place it appears; and
(2) in subsection (b)--
(A) by striking ``Other Definition'' and all that
follows through ``In this section'' and inserting the
following: ``Other Definitions.--
``(1) In general.--In this section''; and
(B) by adding at the end the following new
paragraph:
``(2) Covered drug.--In this section, the term `covered
drug'--
``(A) means a covered outpatient drug (as defined
in section 1927(k)(2) of the Social Security Act); and
``(B) includes, notwithstanding paragraph (3)(A) of
section 1927(k) of such Act, a drug used in connection
with an inpatient or outpatient service provided by a
hospital described in subparagraph (L), (M), (N), or
(O) of subsection (a)(4) that is enrolled to
participate in the drug discount program under this
section.''.
(c) Prohibition on Group Purchasing Arrangements.--Section 340B(a)
of the Public Health Service Act (42 U.S.C. 256b(a)) is amended--
(1) in paragraph (4)(L)--
(A) in clause (i), by adding ``and'' at the end;
(B) in clause (ii), by striking ``; and'' and
inserting a period; and
(C) by striking clause (iii); and
(2) in paragraph (5), as amended by subsection (b)--
(A) by redesignating subparagraphs (C) and (D) as
subparagraphs (D) and (E); respectively; and
(B) by inserting after subparagraph (B), the
following:
``(C) Prohibition on group purchasing
arrangements.--
``(i) In general.--A hospital described in
subparagraph (L), (M), (N), or (O) of paragraph
(4) shall not obtain covered outpatient drugs
through a group purchasing organization or
other group purchasing arrangement, except as
permitted or provided for pursuant to clauses
(ii) or (iii).
``(ii) Inpatient drugs.--Clause (i) shall
not apply to drugs purchased for inpatient use.
``(iii) Exceptions.--The Secretary shall
establish reasonable exceptions to clause (i)--
``(I) with respect to a covered
outpatient drug that is unavailable to
be purchased through the program under
this section due to a drug shortage
problem, manufacturer noncompliance, or
any other circumstance beyond the
hospital's control;
``(II) to facilitate generic
substitution when a generic covered
outpatient drug is available at a lower
price; or
``(III) to reduce in other ways the
administrative burdens of managing both
inventories of drugs subject to this
section and inventories of drugs that
are not subject to this section, so
long as the exceptions do not create a
duplicate discount problem in violation
of subparagraph (A) or a diversion
problem in violation of subparagraph
(B).
``(iv) Purchasing arrangements for
inpatient drugs.--The Secretary shall ensure
that a hospital described in subparagraph (L),
(M), (N), or (O) of subsection (a)(4) that is
enrolled to participate in the drug discount
program under this section shall have multiple
options for purchasing covered drugs for
inpatients, including by utilizing a group
purchasing organization or other group
purchasing arrangement, establishing and
utilizing its own group purchasing program,
purchasing directly from a manufacturer, and
any other purchasing arrangements that the
Secretary determines is appropriate to ensure
access to drug discount pricing under this
section for inpatient drugs taking into account
the particular needs of small and rural
hospitals.''.
(d) Medicaid Credits on Inpatient Drugs.--Section 340B of the
Public Health Service Act (42 U.S.C. 256b) is amended by striking
subsection (c) and inserting the following:
``(c) Medicaid Credit.--Not later than 90 days after the date of
filing of the hospital's most recently filed Medicare cost report, the
hospital shall issue a credit as determined by the Secretary to the
State Medicaid program for inpatient covered drugs provided to Medicaid
recipients.''.
(e) Effective Dates.--
(1) In general.--The amendments made by this section and
section 7102 shall take effect on January 1, 2010, and shall
apply to drugs purchased on or after January 1, 2010.
(2) Effectiveness.--The amendments made by this section and
section 7102 shall be effective and shall be taken into account
in determining whether a manufacturer is deemed to meet the
requirements of section 340B(a) of the Public Health Service
Act (42 U.S.C. 256b(a)), notwithstanding any other provision of
law.
SEC. 7102. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.
(a) Integrity Improvements.--Subsection (d) of section 340B of the
Public Health Service Act (42 U.S.C. 256b) is amended to read as
follows:
``(d) Improvements in Program Integrity.--
``(1) Manufacturer compliance.--
``(A) In general.--From amounts appropriated under
paragraph (4), the Secretary shall provide for
improvements in compliance by manufacturers with the
requirements of this section in order to prevent
overcharges and other violations of the discounted
pricing requirements specified in this section.
``(B) Improvements.--The improvements described in
subparagraph (A) shall include the following:
``(i) The development of a system to enable
the Secretary to verify the accuracy of ceiling
prices calculated by manufacturers under
subsection (a)(1) and charged to covered
entities, which shall include the following:
``(I) Developing and publishing
through an appropriate policy or
regulatory issuance, precisely defined
standards and methodology for the
calculation of ceiling prices under
such subsection.
``(II) Comparing regularly the
ceiling prices calculated by the
Secretary with the quarterly pricing
data that is reported by manufacturers
to the Secretary.
``(III) Performing spot checks of
sales transactions by covered entities.
``(IV) Inquiring into the cause of
any pricing discrepancies that may be
identified and either taking, or
requiring manufacturers to take, such
corrective action as is appropriate in
response to such price discrepancies.
``(ii) The establishment of procedures for
manufacturers to issue refunds to covered
entities in the event that there is an
overcharge by the manufacturers, including the
following:
``(I) Providing the Secretary with
an explanation of why and how the
overcharge occurred, how the refunds
will be calculated, and to whom the
refunds will be issued.
``(II) Oversight by the Secretary
to ensure that the refunds are issued
accurately and within a reasonable
period of time, both in routine
instances of retroactive adjustment to
relevant pricing data and exceptional
circumstances such as erroneous or
intentional overcharging for covered
drugs.
``(iii) The provision of access through the
Internet website of the Department of Health
and Human Services to the applicable ceiling
prices for covered drugs as calculated and
verified by the Secretary in accordance with
this section, in a manner (such as through the
use of password protection) that limits such
access to covered entities and adequately
assures security and protection of privileged
pricing data from unauthorized re-disclosure.
``(iv) The development of a mechanism by
which--
``(I) rebates and other discounts
provided by manufacturers to other
purchasers subsequent to the sale of
covered drugs to covered entities are
reported to the Secretary; and
``(II) appropriate credits and
refunds are issued to covered entities
if such discounts or rebates have the
effect of lowering the applicable
ceiling price for the relevant quarter
for the drugs involved.
``(v) Selective auditing of manufacturers
and wholesalers to ensure the integrity of the
drug discount program under this section.
``(vi) The imposition of sanctions in the
form of civil monetary penalties, which--
``(I) shall be assessed according
to standards established in regulations
to be promulgated by the Secretary not
later than 180 days after the date of
enactment of the Patient Protection and
Affordable Care Act;
``(II) shall not exceed $5,000 for
each instance of overcharging a covered
entity that may have occurred; and
``(III) shall apply to any
manufacturer with an agreement under
this section that knowingly and
intentionally charges a covered entity
a price for purchase of a drug that
exceeds the maximum applicable price
under subsection (a)(1).
``(2) Covered entity compliance.--
``(A) In general.--From amounts appropriated under
paragraph (4), the Secretary shall provide for
improvements in compliance by covered entities with the
requirements of this section in order to prevent
diversion and violations of the duplicate discount
provision and other requirements specified under
subsection (a)(5).
``(B) Improvements.--The improvements described in
subparagraph (A) shall include the following:
``(i) The development of procedures to
enable and require covered entities to
regularly update (at least annually) the
information on the Internet website of the
Department of Health and Human Services
relating to this section.
``(ii) The development of a system for the
Secretary to verify the accuracy of information
regarding covered entities that is listed on
the website described in clause (i).
``(iii) The development of more detailed
guidance describing methodologies and options
available to covered entities for billing
covered drugs to State Medicaid agencies in a
manner that avoids duplicate discounts pursuant
to subsection (a)(5)(A).
``(iv) The establishment of a single,
universal, and standardized identification
system by which each covered entity site can be
identified by manufacturers, distributors,
covered entities, and the Secretary for
purposes of facilitating the ordering,
purchasing, and delivery of covered drugs under
this section, including the processing of
chargebacks for such drugs.
``(v) The imposition of sanctions, in
appropriate cases as determined by the
Secretary, additional to those to which covered
entities are subject under subsection
(a)(5)(E), through one or more of the following
actions:
``(I) Where a covered entity
knowingly and intentionally violates
subsection (a)(5)(B), the covered
entity shall be required to pay a
monetary penalty to a manufacturer or
manufacturers in the form of interest
on sums for which the covered entity is
found liable under subsection
(a)(5)(E), such interest to be
compounded monthly and equal to the
current short term interest rate as
determined by the Federal Reserve for
the time period for which the covered
entity is liable.
``(II) Where the Secretary
determines a violation of subsection
(a)(5)(B) was systematic and egregious
as well as knowing and intentional,
removing the covered entity from the
drug discount program under this
section and disqualifying the entity
from re-entry into such program for a
reasonable period of time to be
determined by the Secretary.
``(III) Referring matters to
appropriate Federal authorities within
the Food and Drug Administration, the
Office of Inspector General of
Department of Health and Human
Services, or other Federal agencies for
consideration of appropriate action
under other Federal statutes, such as
the Prescription Drug Marketing Act (21
U.S.C. 353).
``(3) Administrative dispute resolution process.--
``(A) In general.--Not later than 180 days after
the date of enactment of the Patient Protection and
Affordable Care Act, the Secretary shall promulgate
regulations to establish and implement an
administrative process for the resolution of claims by
covered entities that they have been overcharged for
drugs purchased under this section, and claims by
manufacturers, after the conduct of audits as
authorized by subsection (a)(5)(D), of violations of
subsections (a)(5)(A) or (a)(5)(B), including
appropriate procedures for the provision of remedies
and enforcement of determinations made pursuant to such
process through mechanisms and sanctions described in
paragraphs (1)(B) and (2)(B).
``(B) Deadlines and procedures.--Regulations
promulgated by the Secretary under subparagraph (A)
shall--
``(i) designate or establish a decision-
making official or decision-making body within
the Department of Health and Human Services to
be responsible for reviewing and finally
resolving claims by covered entities that they
have been charged prices for covered drugs in
excess of the ceiling price described in
subsection (a)(1), and claims by manufacturers
that violations of subsection (a)(5)(A) or
(a)(5)(B) have occurred;
``(ii) establish such deadlines and
procedures as may be necessary to ensure that
claims shall be resolved fairly, efficiently,
and expeditiously;
``(iii) establish procedures by which a
covered entity may discover and obtain such
information and documents from manufacturers
and third parties as may be relevant to
demonstrate the merits of a claim that charges
for a manufacturer's product have exceeded the
applicable ceiling price under this section,
and may submit such documents and information
to the administrative official or body
responsible for adjudicating such claim;
``(iv) require that a manufacturer conduct
an audit of a covered entity pursuant to
subsection (a)(5)(D) as a prerequisite to
initiating administrative dispute resolution
proceedings against a covered entity;
``(v) permit the official or body
designated under clause (i), at the request of
a manufacturer or manufacturers, to consolidate
claims brought by more than one manufacturer
against the same covered entity where, in the
judgment of such official or body,
consolidation is appropriate and consistent
with the goals of fairness and economy of
resources; and
``(vi) include provisions and procedures to
permit multiple covered entities to jointly
assert claims of overcharges by the same
manufacturer for the same drug or drugs in one
administrative proceeding, and permit such
claims to be asserted on behalf of covered
entities by associations or organizations
representing the interests of such covered
entities and of which the covered entities are
members.
``(C) Finality of administrative resolution.--The
administrative resolution of a claim or claims under
the regulations promulgated under subparagraph (A)
shall be a final agency decision and shall be binding
upon the parties involved, unless invalidated by an
order of a court of competent jurisdiction.
``(4) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
such sums as may be necessary for fiscal year 2010 and each
succeeding fiscal year.''.
(b) Conforming Amendments.--Section 340B(a) of the Public Health
Service Act (42 U.S.C. 256b(a)) is amended--
(1) in subsection (a)(1), by adding at the end the
following: ``Each such agreement shall require that the
manufacturer furnish the Secretary with reports, on a quarterly
basis, of the price for each covered drug subject to the
agreement that, according to the manufacturer, represents the
maximum price that covered entities may permissibly be required
to pay for the drug (referred to in this section as the
`ceiling price'), and shall require that the manufacturer offer
each covered entity covered drugs for purchase at or below the
applicable ceiling price if such drug is made available to any
other purchaser at any price.''; and
(2) in the first sentence of subsection (a)(5)(E), as
redesignated by section 7101(c), by inserting ``after audit as
described in subparagraph (D) and'' after ``finds,''.
SEC. 7103. GAO STUDY TO MAKE RECOMMENDATIONS ON IMPROVING THE 340B
PROGRAM.
(a) Report.--Not later than 18 months after the date of enactment
of this Act, the Comptroller General of the United States shall submit
to Congress a report that examines whether those individuals served by
the covered entities under the program under section 340B of the Public
Health Service Act (42 U.S.C. 256b) (referred to in this section as the
``340B program'') are receiving optimal health care services.
(b) Recommendations.--The report under subsection (a) shall include
recommendations on the following:
(1) Whether the 340B program should be expanded since it is
anticipated that the 47,000,000 individuals who are uninsured
as of the date of enactment of this Act will have health care
coverage once this Act is implemented.
(2) Whether mandatory sales of certain products by the 340B
program could hinder patients access to those therapies through
any provider.
(3) Whether income from the 340B program is being used by
the covered entities under the program to further the program
objectives.
TITLE VIII--CLASS ACT
SEC. 8001. SHORT TITLE OF TITLE.
This title may be cited as the ``Community Living Assistance
Services and Supports Act'' or the ``CLASS Act''.
SEC. 8002. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE PROGRAM FOR
PURCHASING COMMUNITY LIVING ASSISTANCE SERVICES AND
SUPPORT.
(a) Establishment of CLASS Program.--
(1) In general.--The Public Health Service Act (42 U.S.C.
201 et seq.), as amended by section 4302(a), is amended by
adding at the end the following:
``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS
``SEC. 3201. PURPOSE.
``The purpose of this title is to establish a national voluntary
insurance program for purchasing community living assistance services
and supports in order to--
``(1) provide individuals with functional limitations with
tools that will allow them to maintain their personal and
financial independence and live in the community through a new
financing strategy for community living assistance services and
supports;
``(2) establish an infrastructure that will help address
the Nation's community living assistance services and supports
needs;
``(3) alleviate burdens on family caregivers; and
``(4) address institutional bias by providing a financing
mechanism that supports personal choice and independence to
live in the community.
``SEC. 3202. DEFINITIONS.
``In this title:
``(1) Active enrollee.--The term `active enrollee' means an
individual who is enrolled in the CLASS program in accordance
with section 3204 and who has paid any premiums due to maintain
such enrollment.
``(2) Actively employed.--The term `actively employed'
means an individual who--
``(A) is reporting for work at the individual's
usual place of employment or at another location to
which the individual is required to travel because of
the individual's employment (or in the case of an
individual who is a member of the uniformed services,
is on active duty and is physically able to perform the
duties of the individual's position); and
``(B) is able to perform all the usual and
customary duties of the individual's employment on the
individual's regular work schedule.
``(3) Activities of daily living.--The term `activities of
daily living' means each of the following activities specified
in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986:
``(A) Eating.
``(B) Toileting.
``(C) Transferring.
``(D) Bathing.
``(E) Dressing.
``(F) Continence.
``(4) CLASS program.--The term `CLASS program' means the
program established under this title.
``(5) Eligibility assessment system.--The term `Eligibility
Assessment System' means the entity established by the
Secretary under section 3205(a)(2) to make functional
eligibility determinations for the CLASS program.
``(6) Eligible beneficiary.--
``(A) In general.--The term `eligible beneficiary'
means any individual who is an active enrollee in the
CLASS program and, as of the date described in
subparagraph (B)--
``(i) has paid premiums for enrollment in
such program for at least 60 months;
``(ii) has earned, with respect to at least
3 calendar years that occur during the first 60
months for which the individual has paid
premiums for enrollment in the program, at
least an amount equal to the amount of wages
and self-employment income which an individual
must have in order to be credited with a
quarter of coverage under section 213(d) of the
Social Security Act for the year; and
``(iii) has paid premiums for enrollment in
such program for at least 24 consecutive
months, if a lapse in premium payments of more
than 3 months has occurred during the period
that begins on the date of the individual's
enrollment and ends on the date of such
determination.
``(B) Date described.--For purposes of subparagraph
(A), the date described in this subparagraph is the
date on which the individual is determined to have a
functional limitation described in section
3203(a)(1)(C) that is expected to last for a continuous
period of more than 90 days.
``(C) Regulations.--The Secretary shall promulgate
regulations specifying exceptions to the minimum
earnings requirements under subparagraph (A)(ii) for
purposes of being considered an eligible beneficiary
for certain populations.
``(7) Hospital; nursing facility; intermediate care
facility for the mentally retarded; institution for mental
diseases.--The terms `hospital', `nursing facility',
`intermediate care facility for the mentally retarded', and
`institution for mental diseases' have the meanings given such
terms for purposes of Medicaid.
``(8) CLASS independence advisory council.--The term `CLASS
Independence Advisory Council' or `Council' means the Advisory
Council established under section 3207 to advise the Secretary.
``(9) CLASS independence benefit plan.--The term `CLASS
Independence Benefit Plan' means the benefit plan developed and
designated by the Secretary in accordance with section 3203.
``(10) CLASS independence fund.--The term `CLASS
Independence Fund' or `Fund' means the fund established under
section 3206.
``(11) Medicaid.--The term `Medicaid' means the program
established under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
``(12) Poverty line.--The term `poverty line' has the
meaning given that term in section 2110(c)(5) of the Social
Security Act (42 U.S.C. 1397jj(c)(5)).
``(13) Protection and advocacy system.--The term
`Protection and Advocacy System' means the system for each
State established under section 143 of the Developmental
Disabilities Assistance and Bill of Rights Act of 2000 (42
U.S.C. 15043).
``SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN.
``(a) Process for Development.--
``(1) In general.--The Secretary, in consultation with
appropriate actuaries and other experts, shall develop at least
3 actuarially sound benefit plans as alternatives for
consideration for designation by the Secretary as the CLASS
Independence Benefit Plan under which eligible beneficiaries
shall receive benefits under this title. Each of the plan
alternatives developed shall be designed to provide eligible
beneficiaries with the benefits described in section 3205
consistent with the following requirements:
``(A) Premiums.--
``(i) In general.--Beginning with the first
year of the CLASS program, and for each year
thereafter, subject to clauses (ii) and (iii),
the Secretary shall establish all premiums to
be paid by enrollees for the year based on an
actuarial analysis of the 75-year costs of the
program that ensures solvency throughout such
75-year period.
``(ii) Nominal premium for poorest
individuals and full-time students.--
``(I) In general.--The monthly
premium for enrollment in the CLASS
program shall not exceed the applicable
dollar amount per month determined
under subclause (II) for--
``(aa) any individual whose
income does not exceed the
poverty line; and
``(bb) any individual who
has not attained age 22, and is
actively employed during any
period in which the individual
is a full-time student (as
determined by the Secretary).
``(II) Applicable dollar amount.--
The applicable dollar amount described
in this subclause is the amount equal
to $5, increased by the percentage
increase in the consumer price index
for all urban consumers (U.S. city
average) for each year occurring after
2009 and before such year.
``(iii) Class independence fund reserves.--
At such time as the CLASS program has been in
operation for 10 years, the Secretary shall
establish all premiums to be paid by enrollees
for the year based on an actuarial analysis
that accumulated reserves in the CLASS
Independence Fund would not decrease in that
year. At such time as the Secretary determines
the CLASS program demonstrates a sustained
ability to finance expected yearly expenses
with expected yearly premiums and interest
credited to the CLASS Independence Fund, the
Secretary may decrease the required amount of
CLASS Independence Fund reserves.
``(B) Vesting period.--A 5-year vesting period for
eligibility for benefits.
``(C) Benefit triggers.--A benefit trigger for
provision of benefits that requires a determination
that an individual has a functional limitation, as
certified by a licensed health care practitioner,
described in any of the following clauses that is
expected to last for a continuous period of more than
90 days:
``(i) The individual is determined to be
unable to perform at least the minimum number
(which may be 2 or 3) of activities of daily
living as are required under the plan for the
provision of benefits without substantial
assistance (as defined by the Secretary) from
another individual.
``(ii) The individual requires substantial
supervision to protect the individual from
threats to health and safety due to substantial
cognitive impairment.
``(iii) The individual has a level of
functional limitation similar (as determined
under regulations prescribed by the Secretary)
to the level of functional limitation described
in clause (i) or (ii).
``(D) Cash benefit.--Payment of a cash benefit that
satisfies the following requirements:
``(i) Minimum required amount.--The benefit
amount provides an eligible beneficiary with
not less than an average of $50 per day (as
determined based on the reasonably expected
distribution of beneficiaries receiving
benefits at various benefit levels).
``(ii) Amount scaled to functional
ability.--The benefit amount is varied based on
a scale of functional ability, with not less
than 2, and not more than 6, benefit level
amounts.
``(iii) Daily or weekly.--The benefit is
paid on a daily or weekly basis.
``(iv) No lifetime or aggregate limit.--The
benefit is not subject to any lifetime or
aggregate limit.
``(E) Coordination with supplemental coverage
obtained through the exchange.--The benefits allow for
coordination with any supplemental coverage purchased
through an Exchange established under section 1311 of
the Patient Protection and Affordable Care Act.
``(2) Review and recommendation by the class independence
advisory council.--The CLASS Independence Advisory Council
shall--
``(A) evaluate the alternative benefit plans
developed under paragraph (1); and
``(B) recommend for designation as the CLASS
Independence Benefit Plan for offering to the public
the plan that the Council determines best balances
price and benefits to meet enrollees' needs in an
actuarially sound manner, while optimizing the
probability of the long-term sustainability of the
CLASS program.
``(3) Designation by the secretary.--Not later than October
1, 2012, the Secretary, taking into consideration the
recommendation of the CLASS Independence Advisory Council under
paragraph (2)(B), shall designate a benefit plan as the CLASS
Independence Benefit Plan. The Secretary shall publish such
designation, along with details of the plan and the reasons for
the selection by the Secretary, in a final rule that allows for
a period of public comment.
``(b) Additional Premium Requirements.--
``(1) Adjustment of premiums.--
``(A) In general.--Except as provided in
subparagraphs (B), (C), (D), and (E), the amount of the
monthly premium determined for an individual upon such
individual's enrollment in the CLASS program shall
remain the same for as long as the individual is an
active enrollee in the program.
``(B) Recalculated premium if required for program
solvency.--
``(i) In general.--Subject to clause (ii),
if the Secretary determines, based on the most
recent report of the Board of Trustees of the
CLASS Independence Fund, the advice of the
CLASS Independence Advisory Council, and the
annual report of the Inspector General of the
Department of Health and Human Services, and
waste, fraud, and abuse, or such other
information as the Secretary determines
appropriate, that the monthly premiums and
income to the CLASS Independence Fund for a
year are projected to be insufficient with
respect to the 20-year period that begins with
that year, the Secretary shall adjust the
monthly premiums for individuals enrolled in
the CLASS program as necessary (but maintaining
a nominal premium for enrollees whose income is
below the poverty line or who are full-time
students actively employed).
``(ii) Exemption from increase.--Any
increase in a monthly premium imposed as result
of a determination described in clause (i)
shall not apply with respect to the monthly
premium of any active enrollee who--
``(I) has attained age 65;
``(II) has paid premiums for
enrollment in the program for at least
20 years; and
``(III) is not actively employed.
``(C) Recalculated premium if reenrollment after
more than a 3-month lapse.--
``(i) In general.--The reenrollment of an
individual after a 90-day period during which
the individual failed to pay the monthly
premium required to maintain the individual's
enrollment in the CLASS program shall be
treated as an initial enrollment for purposes
of age-adjusting the premium for enrollment in
the program.
``(ii) Credit for prior months if
reenrolled within 5 years.--An individual who
reenrolls in the CLASS program after such a 90-
day period and before the end of the 5-year
period that begins with the first month for
which the individual failed to pay the monthly
premium required to maintain the individual's
enrollment in the program shall be--
``(I) credited with any months of
paid premiums that accrued prior to the
individual's lapse in enrollment; and
``(II) notwithstanding the total
amount of any such credited months,
required to satisfy section
3202(6)(A)(ii) before being eligible to
receive benefits.
``(D) No longer status as a full-time student.--An
individual subject to a nominal premium on the basis of
being described in subsection (a)(1)(A)(ii)(I)(bb) who
ceases to be described in that subsection, beginning
with the first month following the month in which the
individual ceases to be so described, shall be subject
to the same monthly premium as the monthly premium that
applies to an individual of the same age who first
enrolls in the program under the most similar
circumstances as the individual (such as the first year
of eligibility for enrollment in the program or in a
subsequent year).
``(E) Penalty for reenollment after 5-year lapse.--
In the case of an individual who reenrolls in the CLASS
program after the end of the 5-year period described in
subparagraph (C)(ii), the monthly premium required for
the individual shall be the age-adjusted premium that
would be applicable to an initially enrolling
individual who is the same age as the reenrolling
individual, increased by the greater of--
``(i) an amount that the Secretary
determines is actuarially sound for each month
that occurs during the period that begins with
the first month for which the individual failed
to pay the monthly premium required to maintain
the individual's enrollment in the CLASS
program and ends with the month preceding the
month in which the reenollment is effective; or
``(ii) 1 percent of the applicable age-
adjusted premium for each such month occurring
in such period.
``(2) Administrative expenses.--In determining the monthly
premiums for the CLASS program the Secretary may factor in
costs for administering the program, not to exceed for any year
in which the program is in effect under this title, an amount
equal to 3 percent of all premiums paid during the year.
``(3) No underwriting requirements.--No underwriting (other
than on the basis of age in accordance with subparagraphs (D)
and (E) of paragraph (1)) shall be used to--
``(A) determine the monthly premium for enrollment
in the CLASS program; or
``(B) prevent an individual from enrolling in the
program.
``(c) Self-attestation and Verification of Income.--The Secretary
shall establish procedures to--
``(1) permit an individual who is eligible for the nominal
premium required under subsection (a)(1)(A)(ii), as part of
their automatic enrollment in the CLASS program, to self-attest
that their income does not exceed the poverty line or that
their status as a full-time student who is actively employed;
``(2) verify, using procedures similar to the procedures
used by the Commissioner of Social Security under section
1631(e)(1)(B)(ii) of the Social Security Act and consistent
with the requirements applicable to the conveyance of data and
information under section 1942 of such Act, the validity of
such self-attestation; and
``(3) require an individual to confirm, on at least an
annual basis, that their income does not exceed the poverty
line or that they continue to maintain such status.
``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.
``(a) Automatic Enrollment.--
``(1) In general.--Subject to paragraph (2), the Secretary,
in coordination with the Secretary of the Treasury, shall
establish procedures under which each individual described in
subsection (c) may be automatically enrolled in the CLASS
program by an employer of such individual in the same manner as
an employer may elect to automatically enroll employees in a
plan under section 401(k), 403(b), or 457 of the Internal
Revenue Code of 1986.
``(2) Alternative enrollment procedures.--The procedures
established under paragraph (1) shall provide for an
alternative enrollment process for an individual described in
subsection (c) in the case of such an individual--
``(A) who is self-employed;
``(B) who has more than 1 employer; or
``(C) whose employer does not elect to participate
in the automatic enrollment process established by the
Secretary.
``(3) Administration.--
``(A) In general.--The Secretary and the Secretary
of the Treasury shall, by regulation, establish
procedures to ensure that an individual is not
automatically enrolled in the CLASS program by more
than 1 employer.
``(B) Form.--Enrollment in the CLASS program shall
be made in such manner as the Secretary may prescribe
in order to ensure ease of administration.
``(b) Election to Opt-Out.--An individual described in subsection
(c) may elect to waive enrollment in the CLASS program at any time in
such form and manner as the Secretary and the Secretary of the Treasury
shall prescribe.
``(c) Individual Described.--For purposes of enrolling in the CLASS
program, an individual described in this paragraph is an individual--
``(1) who has attained age 18;
``(2) who--
``(A) receives wages on which there is imposed a
tax under section 3201(a) of the Internal Revenue Code
of 1986; or
``(B) derives self-employment income on which there
is imposed a tax under section 1401(a) of the Internal
Revenue Code of 1986;
``(3) who is actively employed; and
``(4) who is not--
``(A) a patient in a hospital or nursing facility,
an intermediate care facility for the mentally
retarded, or an institution for mental diseases and
receiving medical assistance under Medicaid; or
``(B) confined in a jail, prison, other penal
institution or correctional facility, or by court order
pursuant to conviction of a criminal offense or in
connection with a verdict or finding described in
section 202(x)(1)(A)(ii) of the Social Security Act (42
U.S.C. 402(x)(1)(A)(ii)).
``(d) Rule of Construction.--Nothing in this title shall be
construed as requiring an active enrollee to continue to satisfy
subparagraph (B) or (C) of subsection (c)(1) in order to maintain
enrollment in the CLASS program.
``(e) Payment.--
``(1) Payroll deduction.--An amount equal to the monthly
premium for the enrollment in the CLASS program of an
individual shall be deducted from the wages or self-employment
income of such individual in accordance with such procedures as
the Secretary, in coordination with the Secretary of the
Treasury, shall establish for employers who elect to deduct and
withhold such premiums on behalf of enrolled employees.
``(2) Alternative payment mechanism.--The Secretary, in
coordination with the Secretary of the Treasury, shall
establish alternative procedures for the payment of monthly
premiums by an individual enrolled in the CLASS program--
``(A) who does not have an employer who elects to
deduct and withhold premiums in accordance with
subparagraph (A); or
``(B) who does not earn wages or derive self-
employment income.
``(f) Transfer of Premiums Collected.--
``(1) In general.--During each calendar year the Secretary
of the Treasury shall deposit into the CLASS Independence Fund
a total amount equal, in the aggregate, to 100 percent of the
premiums collected during that year.
``(2) Transfers based on estimates.--The amount deposited
pursuant to paragraph (1) shall be transferred in at least
monthly payments to the CLASS Independence Fund on the basis of
estimates by the Secretary and certified to the Secretary of
the Treasury of the amounts collected in accordance with
subparagraphs (A) and (B) of paragraph (5). Proper adjustments
shall be made in amounts subsequently transferred to the Fund
to the extent prior estimates were in excess of, or were less
than, actual amounts collected.
``(g) Other Enrollment and Disenrollment Opportunities.--The
Secretary, in coordination with the Secretary of the Treasury, shall
establish procedures under which--
``(1) an individual who, in the year of the individual's
initial eligibility to enroll in the CLASS program, has elected
to waive enrollment in the program, is eligible to elect to
enroll in the program, in such form and manner as the
Secretaries shall establish, only during an open enrollment
period established by the Secretaries that is specific to the
individual and that may not occur more frequently than
biennially after the date on which the individual first elected
to waive enrollment in the program; and
``(2) an individual shall only be permitted to disenroll
from the program (other than for nonpayment of premiums) during
an annual disenrollment period established by the Secretaries
and in such form and manner as the Secretaries shall establish.
``SEC. 3205. BENEFITS.
``(a) Determination of Eligibility.--
``(1) Application for receipt of benefits.--The Secretary
shall establish procedures under which an active enrollee shall
apply for receipt of benefits under the CLASS Independence
Benefit Plan.
``(2) Eligibility assessments.--
``(A) In general.--Not later than January 1, 2012,
the Secretary shall--
``(i) establish an Eligibility Assessment
System (other than a service with which the
Commissioner of Social Security has entered
into an agreement, with respect to any State,
to make disability determinations for purposes
of title II or XVI of the Social Security Act)
to provide for eligibility assessments of
active enrollees who apply for receipt of
benefits;
``(ii) enter into an agreement with the
Protection and Advocacy System for each State
to provide advocacy services in accordance with
subsection (d); and
``(iii) enter into an agreement with public
and private entities to provide advice and
assistance counseling in accordance with
subsection (e).
``(B) Regulations.--The Secretary shall promulgate
regulations to develop an expedited nationally
equitable eligibility determination process, as
certified by a licensed health care practitioner, an
appeals process, and a redetermination process, as
certified by a licensed health care practitioner,
including whether an active enrollee is eligible for a
cash benefit under the program and if so, the amount of
the cash benefit (in accordance the sliding scale
established under the plan).
``(C) Presumptive eligibility for certain
institutionalized enrollees planning to discharge.--An
active enrollee shall be deemed presumptively eligible
if the enrollee--
``(i) has applied for, and attests is
eligible for, the maximum cash benefit
available under the sliding scale established
under the CLASS Independence Benefit Plan;
``(ii) is a patient in a hospital (but only
if the hospitalization is for long-term care),
nursing facility, intermediate care facility
for the mentally retarded, or an institution
for mental diseases; and
``(iii) is in the process of, or about to
begin the process of, planning to discharge
from the hospital, facility, or institution, or
within 60 days from the date of discharge from
the hospital, facility, or institution.
``(D) Appeals.--The Secretary shall establish
procedures under which an applicant for benefits under
the CLASS Independence Benefit Plan shall be guaranteed
the right to appeal an adverse determination.
``(b) Benefits.--An eligible beneficiary shall receive the
following benefits under the CLASS Independence Benefit Plan:
``(1) Cash benefit.--A cash benefit established by the
Secretary in accordance with the requirements of section
3203(a)(1)(D) that--
``(A) the first year in which beneficiaries receive
the benefits under the plan, is not less than the
average dollar amount specified in clause (i) of such
section; and
``(B) for any subsequent year, is not less than the
average per day dollar limit applicable under this
subparagraph for the preceding year, increased by the
percentage increase in the consumer price index for all
urban consumers (U.S. city average) over the previous
year.
``(2) Advocacy services.--Advocacy services in accordance
with subsection (d).
``(3) Advice and assistance counseling.--Advice and
assistance counseling in accordance with subsection (e).
``(4) Administrative expenses.--Advocacy services and
advise and assistance counseling services under paragraphs (2)
and (3) of this subsection shall be included as administrative
expenses under section 3203(b)(3).
``(c) Payment of Benefits.--
``(1) Life independence account.--
``(A) In general.--The Secretary shall establish
procedures for administering the provision of benefits
to eligible beneficiaries under the CLASS Independence
Benefit Plan, including the payment of the cash benefit
for the beneficiary into a Life Independence Account
established by the Secretary on behalf of each eligible
beneficiary.
``(B) Use of cash benefits.--Cash benefits paid
into a Life Independence Account of an eligible
beneficiary shall be used to purchase nonmedical
services and supports that the beneficiary needs to
maintain his or her independence at home or in another
residential setting of their choice in the community,
including (but not limited to) home modifications,
assistive technology, accessible transportation,
homemaker services, respite care, personal assistance
services, home care aides, and nursing support. Nothing
in the preceding sentence shall prevent an eligible
beneficiary from using cash benefits paid into a Life
Independence Account for obtaining assistance with
decision making concerning medical care, including the
right to accept or refuse medical or surgical treatment
and the right to formulate advance directives or other
written instructions recognized under State law, such
as a living will or durable power of attorney for
health care, in the case that an injury or illness
causes the individual to be unable to make health care
decisions.
``(C) Electronic management of funds.--The
Secretary shall establish procedures for--
``(i) crediting an account established on
behalf of a beneficiary with the beneficiary's
cash daily benefit;
``(ii) allowing the beneficiary to access
such account through debit cards; and
``(iii) accounting for withdrawals by the
beneficiary from such account.
``(D) Primary payor rules for beneficiaries who are
enrolled in medicaid.--In the case of an eligible
beneficiary who is enrolled in Medicaid, the following
payment rules shall apply:
``(i) Institutionalized beneficiary.--If
the beneficiary is a patient in a hospital,
nursing facility, intermediate care facility
for the mentally retarded, or an institution
for mental diseases, the beneficiary shall
retain an amount equal to 5 percent of the
beneficiary's daily or weekly cash benefit (as
applicable) (which shall be in addition to the
amount of the beneficiary's personal needs
allowance provided under Medicaid), and the
remainder of such benefit shall be applied
toward the facility's cost of providing the
beneficiary's care, and Medicaid shall provide
secondary coverage for such care.
``(ii) Beneficiaries receiving home and
community-based services.--
``(I) 50 percent of benefit
retained by beneficiary.--Subject to
subclause (II), if a beneficiary is
receiving medical assistance under
Medicaid for home and community based
services, the beneficiary shall retain
an amount equal to 50 percent of the
beneficiary's daily or weekly cash
benefit (as applicable), and the
remainder of the daily or weekly cash
benefit shall be applied toward the
cost to the State of providing such
assistance (and shall not be used to
claim Federal matching funds under
Medicaid), and Medicaid shall provide
secondary coverage for the remainder of
any costs incurred in providing such
assistance.
``(II) Requirement for state
offset.--A State shall be paid the
remainder of a beneficiary's daily or
weekly cash benefit under subclause (I)
only if the State home and community-
based waiver under section 1115 of the
Social Security Act (42 U.S.C. 1315) or
subsection (c) or (d) of section 1915
of such Act (42 U.S.C. 1396n), or the
State plan amendment under subsection
(i) of such section does not include a
waiver of the requirements of section
1902(a)(1) of the Social Security Act
(relating to statewideness) or of
section 1902(a)(10)(B) of such Act
(relating to comparability) and the
State offers at a minimum case
management services, personal care
services, habilitation services, and
respite care under such a waiver or
State plan amendment.
``(III) Definition of home and
community-based services.--In this
clause, the term `home and community-
based services' means any services
which may be offered under a home and
community-based waiver authorized for a
State under section 1115 of the Social
Security Act (42 U.S.C. 1315) or
subsection (c) or (d) of section 1915
of such Act (42 U.S.C. 1396n) or under
a State plan amendment under subsection
(i) of such section.
``(iii) Beneficiaries enrolled in programs
of all-inclusive care for the elderly (pace).--
``(I) In general.--Subject to
subclause (II), if a beneficiary is
receiving medical assistance under
Medicaid for PACE program services
under section 1934 of the Social
Security Act (42 U.S.C. 1396u-4), the
beneficiary shall retain an amount
equal to 50 percent of the
beneficiary's daily or weekly cash
benefit (as applicable), and the
remainder of the daily or weekly cash
benefit shall be applied toward the
cost to the State of providing such
assistance (and shall not be used to
claim Federal matching funds under
Medicaid), and Medicaid shall provide
secondary coverage for the remainder of
any costs incurred in providing such
assistance.
``(II) Institutionalized recipients
of pace program services.--If a
beneficiary receiving assistance under
Medicaid for PACE program services is a
patient in a hospital, nursing
facility, intermediate care facility
for the mentally retarded, or an
institution for mental diseases, the
beneficiary shall be treated as in
institutionalized beneficiary under
clause (i).
``(2) Authorized representatives.--
``(A) In general.--The Secretary shall establish
procedures to allow access to a beneficiary's cash
benefits by an authorized representative of the
eligible beneficiary on whose behalf such benefits are
paid.
``(B) Quality assurance and protection against
fraud and abuse.--The procedures established under
subparagraph (A) shall ensure that authorized
representatives of eligible beneficiaries comply with
standards of conduct established by the Secretary,
including standards requiring that such representatives
provide quality services on behalf of such
beneficiaries, do not have conflicts of interest, and
do not misuse benefits paid on behalf of such
beneficiaries or otherwise engage in fraud or abuse.
``(3) Commencement of benefits.--Benefits shall be paid to,
or on behalf of, an eligible beneficiary beginning with the
first month in which an application for such benefits is
approved.
``(4) Rollover option for lump-sum payment.--An eligible
beneficiary may elect to--
``(A) defer payment of their daily or weekly
benefit and to rollover any such deferred benefits from
month-to-month, but not from year-to-year; and
``(B) receive a lump-sum payment of such deferred
benefits in an amount that may not exceed the lesser
of--
``(i) the total amount of the accrued
deferred benefits; or
``(ii) the applicable annual benefit.
``(5) Period for determination of annual benefits.--
``(A) In general.--The applicable period for
determining with respect to an eligible beneficiary the
applicable annual benefit and the amount of any accrued
deferred benefits is the 12-month period that commences
with the first month in which the beneficiary began to
receive such benefits, and each 12-month period
thereafter.
``(B) Inclusion of increased benefits.--The
Secretary shall establish procedures under which cash
benefits paid to an eligible beneficiary that increase
or decrease as a result of a change in the functional
status of the beneficiary before the end of a 12-month
benefit period shall be included in the determination
of the applicable annual benefit paid to the eligible
beneficiary.
``(C) Recoupment of unpaid, accrued benefits.--
``(i) In general.--The Secretary, in
coordination with the Secretary of the
Treasury, shall recoup any accrued benefits in
the event of--
``(I) the death of a beneficiary;
or
``(II) the failure of a beneficiary
to elect under paragraph (4)(B) to
receive such benefits as a lump-sum
payment before the end of the 12-month
period in which such benefits accrued.
``(ii) Payment into class independence
fund.--Any benefits recouped in accordance with
clause (i) shall be paid into the CLASS
Independence Fund and used in accordance with
section 3206.
``(6) Requirement to recertify eligibility for receipt of
benefits.--An eligible beneficiary shall periodically, as
determined by the Secretary--
``(A) recertify by submission of medical evidence
the beneficiary's continued eligibility for receipt of
benefits; and
``(B) submit records of expenditures attributable
to the aggregate cash benefit received by the
beneficiary during the preceding year.
``(7) Supplement, not supplant other health care
benefits.--Subject to the Medicaid payment rules under
paragraph (1)(D), benefits received by an eligible beneficiary
shall supplement, but not supplant, other health care benefits
for which the beneficiary is eligible under Medicaid or any
other Federally funded program that provides health care
benefits or assistance.
``(d) Advocacy Services.--An agreement entered into under
subsection (a)(2)(A)(ii) shall require the Protection and Advocacy
System for the State to--
``(1) assign, as needed, an advocacy counselor to each
eligible beneficiary that is covered by such agreement and who
shall provide an eligible beneficiary with--
``(A) information regarding how to access the
appeals process established for the program;
``(B) assistance with respect to the annual
recertification and notification required under
subsection (c)(6); and
``(C) such other assistance with obtaining services
as the Secretary, by regulation, shall require; and
``(2) ensure that the System and such counselors comply
with the requirements of subsection (h).
``(e) Advice and Assistance Counseling.--An agreement entered into
under subsection (a)(2)(A)(iii) shall require the entity to assign, as
requested by an eligible beneficiary that is covered by such agreement,
an advice and assistance counselor who shall provide an eligible
beneficiary with information regarding--
``(1) accessing and coordinating long-term services and
supports in the most integrated setting;
``(2) possible eligibility for other benefits and services;
``(3) development of a service and support plan;
``(4) information about programs established under the
Assistive Technology Act of 1998 and the services offered under
such programs;
``(5) available assistance with decision making concerning
medical care, including the right to accept or refuse medical
or surgical treatment and the right to formulate advance
directives or other written instructions recognized under State
law, such as a living will or durable power of attorney for
health care, in the case that an injury or illness causes the
individual to be unable to make health care decisions; and
``(6) such other services as the Secretary, by regulation,
may require.
``(f) No Effect on Eligibility for Other Benefits.--Benefits paid
to an eligible beneficiary under the CLASS program shall be disregarded
for purposes of determining or continuing the beneficiary's eligibility
for receipt of benefits under any other Federal, State, or locally
funded assistance program, including benefits paid under titles II,
XVI, XVIII, XIX, or XXI of the Social Security Act (42 U.S.C. 401 et
seq., 1381 et seq., 1395 et seq., 1396 et seq., 1397aa et seq.), under
the laws administered by the Secretary of Veterans Affairs, under low-
income housing assistance programs, or under the supplemental nutrition
assistance program established under the Food and Nutrition Act of 2008
(7 U.S.C. 2011 et seq.).
``(g) Rule of Construction.--Nothing in this title shall be
construed as prohibiting benefits paid under the CLASS Independence
Benefit Plan from being used to compensate a family caregiver for
providing community living assistance services and supports to an
eligible beneficiary.
``(h) Protection Against Conflict of Interests.--The Secretary
shall establish procedures to ensure that the Eligibility Assessment
System, the Protection and Advocacy System for a State, advocacy
counselors for eligible beneficiaries, and any other entities that
provide services to active enrollees and eligible beneficiaries under
the CLASS program comply with the following:
``(1) If the entity provides counseling or planning
services, such services are provided in a manner that fosters
the best interests of the active enrollee or beneficiary.
``(2) The entity has established operating procedures that
are designed to avoid or minimize conflicts of interest between
the entity and an active enrollee or beneficiary.
``(3) The entity provides information about all services
and options available to the active enrollee or beneficiary, to
the best of its knowledge, including services available through
other entities or providers.
``(4) The entity assists the active enrollee or beneficiary
to access desired services, regardless of the provider.
``(5) The entity reports the number of active enrollees and
beneficiaries provided with assistance by age, disability, and
whether such enrollees and beneficiaries received services from
the entity or another entity.
``(6) If the entity provides counseling or planning
services, the entity ensures that an active enrollee or
beneficiary is informed of any financial interest that the
entity has in a service provider.
``(7) The entity provides an active enrollee or beneficiary
with a list of available service providers that can meet the
needs of the active enrollee or beneficiary.
``SEC. 3206. CLASS INDEPENDENCE FUND.
``(a) Establishment of CLASS Independence Fund.--There is
established in the Treasury of the United States a trust fund to be
known as the `CLASS Independence Fund'. The Secretary of the Treasury
shall serve as Managing Trustee of such Fund. The Fund shall consist of
all amounts derived from payments into the Fund under sections 3204(f)
and 3205(c)(5)(C)(ii), and remaining after investment of such amounts
under subsection (b), including additional amounts derived as income
from such investments. The amounts held in the Fund are appropriated
and shall remain available without fiscal year limitation--
``(1) to be held for investment on behalf of individuals
enrolled in the CLASS program;
``(2) to pay the administrative expenses related to the
Fund and to investment under subsection (b); and
``(3) to pay cash benefits to eligible beneficiaries under
the CLASS Independence Benefit Plan.
``(b) Investment of Fund Balance.--The Secretary of the Treasury
shall invest and manage the CLASS Independence Fund in the same manner,
and to the same extent, as the Federal Supplementary Medical Insurance
Trust Fund may be invested and managed under subsections (c), (d), and
(e) of section 1841(d) of the Social Security Act (42 U.S.C. 1395t).
``(c) Board of Trustees.--
``(1) In general.--With respect to the CLASS Independence
Fund, there is hereby created a body to be known as the Board
of Trustees of the CLASS Independence Fund (hereinafter in this
section referred to as the `Board of Trustees') composed of the
Secretary of the Treasury, the Secretary of Labor, and the
Secretary of Health and Human Services, all ex officio, and of
two members of the public (both of whom may not be from the
same political party), who shall be nominated by the President
for a term of 4 years and subject to confirmation by the
Senate. A member of the Board of Trustees serving as a member
of the public and nominated and confirmed to fill a vacancy
occurring during a term shall be nominated and confirmed only
for the remainder of such term. An individual nominated and
confirmed as a member of the public may serve in such position
after the expiration of such member's term until the earlier of
the time at which the member's successor takes office or the
time at which a report of the Board is first issued under
paragraph (2) after the expiration of the member's term. The
Secretary of the Treasury shall be the Managing Trustee of the
Board of Trustees. The Board of Trustees shall meet not less
frequently than once each calendar year. A person serving on
the Board of Trustees shall not be considered to be a fiduciary
and shall not be personally liable for actions taken in such
capacity with respect to the Trust Fund.
``(2) Duties.--
``(A) In general.--It shall be the duty of the
Board of Trustees to do the following:
``(i) Hold the CLASS Independence Fund.
``(ii) Report to the Congress not later
than the first day of April of each year on the
operation and status of the CLASS Independence
Fund during the preceding fiscal year and on
its expected operation and status during the
current fiscal year and the next 2 fiscal
years.
``(iii) Report immediately to the Congress
whenever the Board is of the opinion that the
amount of the CLASS Independence Fund is not
actuarially sound in regards to the projection
under section 3203(b)(1)(B)(i).
``(iv) Review the general policies followed
in managing the CLASS Independence Fund, and
recommend changes in such policies, including
necessary changes in the provisions of law
which govern the way in which the CLASS
Independence Fund is to be managed.
``(B) Report.--The report provided for in
subparagraph (A)(ii) shall--
``(i) include--
``(I) a statement of the assets of,
and the disbursements made from, the
CLASS Independence Fund during the
preceding fiscal year;
``(II) an estimate of the expected
income to, and disbursements to be made
from, the CLASS Independence Fund
during the current fiscal year and each
of the next 2 fiscal years;
``(III) a statement of the
actuarial status of the CLASS
Independence Fund for the current
fiscal year, each of the next 2 fiscal
years, and as projected over the 75-
year period beginning with the current
fiscal year; and
``(IV) an actuarial opinion by the
Chief Actuary of the Centers for
Medicare & Medicaid Services certifying
that the techniques and methodologies
used are generally accepted within the
actuarial profession and that the
assumptions and cost estimates used are
reasonable; and
``(ii) be printed as a House document of
the session of the Congress to which the report
is made.
``(C) Recommendations.--If the Board of Trustees
determines that enrollment trends and expected future
benefit claims on the CLASS Independence Fund are not
actuarially sound in regards to the projection under
section 3203(b)(1)(B)(i) and are unlikely to be
resolved with reasonable premium increases or through
other means, the Board of Trustees shall include in the
report provided for in subparagraph (A)(ii)
recommendations for such legislative action as the
Board of Trustees determine to be appropriate,
including whether to adjust monthly premiums or impose
a temporary moratorium on new enrollments.
``SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL.
``(a) Establishment.--There is hereby created an Advisory Committee
to be known as the `CLASS Independence Advisory Council'.
``(b) Membership.--
``(1) In general.--The CLASS Independence Advisory Council
shall be composed of not more than 15 individuals, not
otherwise in the employ of the United States--
``(A) who shall be appointed by the President
without regard to the civil service laws and
regulations; and
``(B) a majority of whom shall be representatives
of individuals who participate or are likely to
participate in the CLASS program, and shall include
representatives of older and younger workers,
individuals with disabilities, family caregivers of
individuals who require services and supports to
maintain their independence at home or in another
residential setting of their choice in the community,
individuals with expertise in long-term care or
disability insurance, actuarial science, economics, and
other relevant disciplines, as determined by the
Secretary.
``(2) Terms.--
``(A) In general.--The members of the CLASS
Independence Advisory Council shall serve overlapping
terms of 3 years (unless appointed to fill a vacancy
occurring prior to the expiration of a term, in which
case the individual shall serve for the remainder of
the term).
``(B) Limitation.--A member shall not be eligible
to serve for more than 2 consecutive terms.
``(3) Chair.--The President shall, from time to time,
appoint one of the members of the CLASS Independence Advisory
Council to serve as the Chair.
``(c) Duties.--The CLASS Independence Advisory Council shall advise
the Secretary on matters of general policy in the administration of the
CLASS program established under this title and in the formulation of
regulations under this title including with respect to--
``(1) the development of the CLASS Independence Benefit
Plan under section 3203;
``(2) the determination of monthly premiums under such
plan; and
``(3) the financial solvency of the program.
``(d) Application of FACA.--The Federal Advisory Committee Act (5
U.S.C. App.), other than section 14 of that Act, shall apply to the
CLASS Independence Advisory Council.
``(e) Authorization of Appropriations.--
``(1) In general.--There are authorized to be appropriated
to the CLASS Independence Advisory Council to carry out its
duties under this section, such sums as may be necessary for
fiscal year 2011 and for each fiscal year thereafter.
``(2) Availability.--Any sums appropriated under the
authorization contained in this section shall remain available,
without fiscal year limitation, until expended.
``SEC. 3208. SOLVENCY AND FISCAL INDEPENDENCE; REGULATIONS; ANNUAL
REPORT.
``(a) Solvency.--The Secretary shall regularly consult with the
Board of Trustees of the CLASS Independence Fund and the CLASS
Independence Advisory Council, for purposes of ensuring that enrollees
premiums are adequate to ensure the financial solvency of the CLASS
program, both with respect to fiscal years occurring in the near-term
and fiscal years occurring over 20- and 75-year periods, taking into
account the projections required for such periods under subsections
(a)(1)(A)(i) and (b)(1)(B)(i) of section 3202.
``(b) No Taxpayer Funds Used To Pay Benefits.--No taxpayer funds
shall be used for payment of benefits under a CLASS Independent Benefit
Plan. For purposes of this subsection, the term `taxpayer funds' means
any Federal funds from a source other than premiums deposited by CLASS
program participants in the CLASS Independence Fund and any associated
interest earnings.
``(c) Regulations.--The Secretary shall promulgate such regulations
as are necessary to carry out the CLASS program in accordance with this
title. Such regulations shall include provisions to prevent fraud and
abuse under the program.
``(d) Annual Report.--Beginning January 1, 2014, the Secretary
shall submit an annual report to Congress on the CLASS program. Each
report shall include the following:
``(1) The total number of enrollees in the program.
``(2) The total number of eligible beneficiaries during the
fiscal year.
``(3) The total amount of cash benefits provided during the
fiscal year.
``(4) A description of instances of fraud or abuse
identified during the fiscal year.
``(5) Recommendations for such administrative or
legislative action as the Secretary determines is necessary to
improve the program, ensure the solvency of the program, or to
prevent the occurrence of fraud or abuse.
``SEC. 3209. INSPECTOR GENERAL'S REPORT.
``The Inspector General of the Department of Health and Human
Services shall submit an annual report to the Secretary and Congress
relating to the overall progress of the CLASS program and of the
existence of waste, fraud, and abuse in the CLASS program. Each such
report shall include findings in the following areas:
``(1) The eligibility determination process.
``(2) The provision of cash benefits.
``(3) Quality assurance and protection against waste,
fraud, and abuse.
``(4) Recouping of unpaid and accrued benefits.
``SEC. 3210. TAX TREATMENT OF PROGRAM.
``The CLASS program shall be treated for purposes of the Internal
Revenue Code of 1986 in the same manner as a qualified long-term care
insurance contract for qualified long-term care services.''.
(2) Conforming amendments to medicaid.--Section 1902(a) of
the Social Security Act (42 U.S.C. 1396a(a)), as amended by
section 6505, is amended by inserting after paragraph (80) the
following:
``(81) provide that the State will comply with such
regulations regarding the application of primary and secondary
payor rules with respect to individuals who are eligible for
medical assistance under this title and are eligible
beneficiaries under the CLASS program established under title
XXXII of the Public Health Service Act as the Secretary shall
establish; and''.
(b) Assurance of Adequate Infrastructure for the Provision of
Personal Care Attendant Workers.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)), as amended by subsection (a)(2), is
amended by inserting after paragraph (81) the following:
``(82) provide that, not later than 2 years after the date
of enactment of the Community Living Assistance Services and
Supports Act, each State shall--
``(A) assess the extent to which entities such as
providers of home care, home health services, home and
community service providers, public authorities created
to provide personal care services to individuals
eligible for medical assistance under the State plan,
and nonprofit organizations, are serving or have the
capacity to serve as fiscal agents for, employers of,
and providers of employment-related benefits for,
personal care attendant workers who provide personal
care services to individuals receiving benefits under
the CLASS program established under title XXXII of the
Public Health Service Act, including in rural and
underserved areas;
``(B) designate or create such entities to serve as
fiscal agents for, employers of, and providers of
employment-related benefits for, such workers to ensure
an adequate supply of the workers for individuals
receiving benefits under the CLASS program, including
in rural and underserved areas; and
``(C) ensure that the designation or creation of
such entities will not negatively alter or impede
existing programs, models, methods, or administration
of service delivery that provide for consumer
controlled or self-directed home and community services
and further ensure that such entities will not impede
the ability of individuals to direct and control their
home and community services, including the ability to
select, manage, dismiss, co-employ, or employ such
workers or inhibit such individuals from relying on
family members for the provision of personal care
services.''.
(c) Personal Care Attendants Workforce Advisory Panel.--
(1) Establishment.--Not later than 90 days after the date
of enactment of this Act, the Secretary of Health and Human
Services shall establish a Personal Care Attendants Workforce
Advisory Panel for the purpose of examining and advising the
Secretary and Congress on workforce issues related to personal
care attendant workers, including with respect to the adequacy
of the number of such workers, the salaries, wages, and
benefits of such workers, and access to the services provided
by such workers.
(2) Membership.--In appointing members to the Personal Care
Attendants Workforce Advisory Panel, the Secretary shall ensure
that such members include the following:
(A) Individuals with disabilities of all ages.
(B) Senior individuals.
(C) Representatives of individuals with
disabilities.
(D) Representatives of senior individuals.
(E) Representatives of workforce and labor
organizations.
(F) Representatives of home and community-based
service providers.
(G) Representatives of assisted living providers.
(d) Inclusion of Information on Supplemental Coverage in the
National Clearinghouse for Long-term Care Information; Extension of
Funding.--Section 6021(d) of the Deficit Reduction Act of 2005 (42
U.S.C. 1396p note) is amended--
(1) in paragraph (2)(A)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period at the
end and inserting ``; and''; and
(C) by adding at the end the following:
``(iv) include information regarding the
CLASS program established under title XXXII of
the Public Health Service Act and coverage
available for purchase through a Exchange
established under section 1311 of the Patient
Protection and Affordable Care Act that is
supplemental coverage to the benefits provided
under a CLASS Independence Benefit Plan under
that program, and information regarding how
benefits provided under a CLASS Independence
Benefit Plan differ from disability insurance
benefits.''; and
(2) in paragraph (3), by striking ``2010'' and inserting
``2015''.
(e) Effective Date.--The amendments made by subsections (a), (b),
and (d) take effect on January 1, 2011.
(f) Rule of Construction.--Nothing in this title or the amendments
made by this title are intended to replace or displace public or
private disability insurance benefits, including such benefits that are
for income replacement.
TITLE IX--REVENUE PROVISIONS
Subtitle A--Revenue Offset Provisions
SEC. 9001. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED HEALTH COVERAGE.
(a) In General.--Chapter 43 of the Internal Revenue Code of 1986,
as amended by section 1513, is amended by adding at the end the
following:
``SEC. 4980I. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED HEALTH
COVERAGE.
``(a) Imposition of Tax.--If--
``(1) an employee is covered under any applicable employer-
sponsored coverage of an employer at any time during a taxable
period, and
``(2) there is any excess benefit with respect to the
coverage,
there is hereby imposed a tax equal to 40 percent of the excess
benefit.
``(b) Excess Benefit.--For purposes of this section--
``(1) In general.--The term `excess benefit' means, with
respect to any applicable employer-sponsored coverage made
available by an employer to an employee during any taxable
period, the sum of the excess amounts determined under
paragraph (2) for months during the taxable period.
``(2) Monthly excess amount.--The excess amount determined
under this paragraph for any month is the excess (if any) of--
``(A) the aggregate cost of the applicable
employer-sponsored coverage of the employee for the
month, over
``(B) an amount equal to \1/12\ of the annual
limitation under paragraph (3) for the calendar year in
which the month occurs.
``(3) Annual limitation.--For purposes of this subsection--
``(A) In general.--The annual limitation under this
paragraph for any calendar year is the dollar limit
determined under subparagraph (C) for the calendar
year.
``(B) Applicable annual limitation.--The annual
limitation which applies for any month shall be
determined on the basis of the type of coverage (as
determined under subsection (f)(1)) provided to the
employee by the employer as of the beginning of the
month.
``(C) Applicable dollar limit.--Except as provided
in subparagraph (D)--
``(i) 2013.--In the case of 2013, the
dollar limit under this subparagraph is--
``(I) in the case of an employee
with self-only coverage, $8,500, and
``(II) in the case of an employee
with coverage other than self-only
coverage, $23,000.
``(ii) Exception for certain individuals.--
In the case of an individual who is a qualified
retiree or who participates in a plan sponsored
by an employer the majority of whose employees
are engaged in a high-risk profession or
employed to repair or install electrical or
telecommunications lines--
``(I) the dollar amount in clause
(i)(I) (determined after the
application of subparagraph (D)) shall
be increased by $1,350, and
``(II) the dollar amount in clause
(i)(II) (determined after the
application of subparagraph (D)) shall
be increased by $3,000.
``(iii) Subsequent years.--In the case of
any calendar year after 2013, each of the
dollar amounts under clauses (i) and (ii) shall
be increased to the amount equal to such amount
as in effect for the calendar year preceding
such year, increased by an amount equal to the
product of--
``(I) such amount as so in effect,
multiplied by
``(II) the cost-of-living
adjustment determined under section
1(f)(3) for such year (determined by
substituting the calendar year that is
2 years before such year for `1992' in
subparagraph (B) thereof), increased by
1 percentage point.
If any amount determined under this clause is
not a multiple of $50, such amount shall be
rounded to the nearest multiple of $50.
``(D) Transition rule for states with highest
coverage costs.--
``(i) In general.--If an employee is a
resident of a high cost State on the first day
of any month beginning in 2013, 2014, or 2015,
the annual limitation under this paragraph for
such month with respect to such employee shall
be an amount equal to the applicable percentage
of the annual limitation (determined without
regard to this subparagraph or subparagraph
(C)(ii)).
``(ii) Applicable percentage.--The
applicable percentage is 120 percent for 2013,
110 percent for 2014, and 105 percent for 2015.
``(iii) High cost state.--The term `high
cost State' means each of the 17 States which
the Secretary of Health and Human Services, in
consultation with the Secretary, estimates had
the highest average cost during 2012 for
employer-sponsored coverage under health plans.
The Secretary's estimate shall be made on the
basis of aggregate premiums paid in the State
for such health plans, determined using the
most recent data available as of August 31,
2012.
``(c) Liability To Pay Tax.--
``(1) In general.--Each coverage provider shall pay the tax
imposed by subsection (a) on its applicable share of the excess
benefit with respect to an employee for any taxable period.
``(2) Coverage provider.--For purposes of this subsection,
the term `coverage provider' means each of the following:
``(A) Health insurance coverage.--If the applicable
employer-sponsored coverage consists of coverage under
a group health plan which provides health insurance
coverage, the health insurance issuer.
``(B) HSA and msa contributions.--If the applicable
employer-sponsored coverage consists of coverage under
an arrangement under which the employer makes
contributions described in subsection (b) or (d) of
section 106, the employer.
``(C) Other coverage.--In the case of any other
applicable employer-sponsored coverage, the person that
administers the plan benefits.
``(3) Applicable share.--For purposes of this subsection, a
coverage provider's applicable share of an excess benefit for
any taxable period is the amount which bears the same ratio to
the amount of such excess benefit as--
``(A) the cost of the applicable employer-sponsored
coverage provided by the provider to the employee
during such period, bears to
``(B) the aggregate cost of all applicable
employer-sponsored coverage provided to the employee by
all coverage providers during such period.
``(4) Responsibility to calculate tax and applicable
shares.--
``(A) In general.--Each employer shall--
``(i) calculate for each taxable period the
amount of the excess benefit subject to the tax
imposed by subsection (a) and the applicable
share of such excess benefit for each coverage
provider, and
``(ii) notify, at such time and in such
manner as the Secretary may prescribe, the
Secretary and each coverage provider of the
amount so determined for the provider.
``(B) Special rule for multiemployer plans.--In the
case of applicable employer-sponsored coverage made
available to employees through a multiemployer plan (as
defined in section 414(f)), the plan sponsor shall make
the calculations, and provide the notice, required
under subparagraph (A).
``(d) Applicable Employer-Sponsored Coverage; Cost.--For purposes
of this section--
``(1) Applicable employer-sponsored coverage.--
``(A) In general.--The term `applicable employer-
sponsored coverage' means, with respect to any
employee, coverage under any group health plan made
available to the employee by an employer which is
excludable from the employee's gross income under
section 106, or would be so excludable if it were
employer-provided coverage (within the meaning of such
section 106).
``(B) Exceptions.--The term `applicable employer-
sponsored coverage' shall not include--
``(i) any coverage (whether through
insurance or otherwise) described in section
9832(c)(1)(A) or for long-term care, or
``(ii) any coverage described in section
9832(c)(3) the payment for which is not
excludable from gross income and for which a
deduction under section 162(l) is not
allowable.
``(C) Coverage includes employee paid portion.--
Coverage shall be treated as applicable employer-
sponsored coverage without regard to whether the
employer or employee pays for the coverage.
``(D) Self-employed individual.--In the case of an
individual who is an employee within the meaning of
section 401(c)(1), coverage under any group health plan
providing health insurance coverage shall be treated as
applicable employer-sponsored coverage if a deduction
is allowable under section 162(l) with respect to all
or any portion of the cost of the coverage.
``(E) Governmental plans included.--Applicable
employer-sponsored coverage shall include coverage
under any group health plan established and maintained
primarily for its civilian employees by the Government
of the United States, by the government of any State or
political subdivision thereof, or by any agency or
instrumentality of any such government.
``(2) Determination of cost.--
``(A) In general.--The cost of applicable employer-
sponsored coverage shall be determined under rules
similar to the rules of section 4980B(f)(4), except
that in determining such cost, any portion of the cost
of such coverage which is attributable to the tax
imposed under this section shall not be taken into
account and the amount of such cost shall be calculated
separately for self-only coverage and other coverage.
In the case of applicable employer-sponsored coverage
which provides coverage to retired employees, the plan
may elect to treat a retired employee who has not
attained the age of 65 and a retired employee who has
attained the age of 65 as similarly situated
beneficiaries.
``(B) Health fsas.--In the case of applicable
employer-sponsored coverage consisting of coverage
under a flexible spending arrangement (as defined in
section 106(c)(2)), the cost of the coverage shall be
equal to the sum of--
``(i) the amount of employer contributions
under any salary reduction election under the
arrangement, plus
``(ii) the amount determined under
subparagraph (A) with respect to any
reimbursement under the arrangement in excess
of the contributions described in clause (i).
``(C) Archer msas and hsas.--In the case of
applicable employer-sponsored coverage consisting of
coverage under an arrangement under which the employer
makes contributions described in subsection (b) or (d)
of section 106, the cost of the coverage shall be equal
to the amount of employer contributions under the
arrangement.
``(D) Allocation on a monthly basis.--If cost is
determined on other than a monthly basis, the cost
shall be allocated to months in a taxable period on
such basis as the Secretary may prescribe.
``(e) Penalty for Failure To Properly Calculate Excess Benefit.--
``(1) In general.--If, for any taxable period, the tax
imposed by subsection (a) exceeds the tax determined under such
subsection with respect to the total excess benefit calculated
by the employer or plan sponsor under subsection (c)(4)--
``(A) each coverage provider shall pay the tax on
its applicable share (determined in the same manner as
under subsection (c)(4)) of the excess, but no penalty
shall be imposed on the provider with respect to such
amount, and
``(B) the employer or plan sponsor shall, in
addition to any tax imposed by subsection (a), pay a
penalty in an amount equal to such excess, plus
interest at the underpayment rate determined under
section 6621 for the period beginning on the due date
for the payment of tax imposed by subsection (a) to
which the excess relates and ending on the date of
payment of the penalty.
``(2) Limitations on penalty.--
``(A) Penalty not to apply where failure not
discovered exercising reasonable diligence.--No penalty
shall be imposed by paragraph (1)(B) on any failure to
properly calculate the excess benefit during any period
for which it is established to the satisfaction of the
Secretary that the employer or plan sponsor neither
knew, nor exercising reasonable diligence would have
known, that such failure existed.
``(B) Penalty not to apply to failures corrected
within 30 days.--No penalty shall be imposed by
paragraph (1)(B) on any such failure if--
``(i) such failure was due to reasonable
cause and not to willful neglect, and
``(ii) such failure is corrected during the
30-day period beginning on the 1st date that
the employer knew, or exercising reasonable
diligence would have known, that such failure
existed.
``(C) Waiver by secretary.--In the case of any such
failure which is due to reasonable cause and not to
willful neglect, the Secretary may waive part or all of
the penalty imposed by paragraph (1), to the extent
that the payment of such penalty would be excessive or
otherwise inequitable relative to the failure involved.
``(f) Other Definitions and Special Rules.--For purposes of this
section--
``(1) Coverage determinations.--
``(A) In general.--Except as provided in
subparagraph (B), an employee shall be treated as
having self-only coverage with respect to any
applicable employer-sponsored coverage of an employer.
``(B) Minimum essential coverage.--An employee
shall be treated as having coverage other than self-
only coverage only if the employee is enrolled in
coverage other than self-only coverage in a group
health plan which provides minimum essential coverage
(as defined in section 5000A(f)) to the employee and at
least one other beneficiary, and the benefits provided
under such minimum essential coverage do not vary based
on whether any individual covered under such coverage
is the employee or another beneficiary.
``(2) Qualified retiree.--The term `qualified retiree'
means any individual who--
``(A) is receiving coverage by reason of being a
retiree,
``(B) has attained age 55, and
``(C) is not entitled to benefits or eligible for
enrollment under the Medicare program under title XVIII
of the Social Security Act.
``(3) Employees engaged in high-risk profession.--The term
`employees engaged in a high-risk profession' means law
enforcement officers (as such term is defined in section 1204
of the Omnibus Crime Control and Safe Streets Act of 1968),
employees in fire protection activities (as such term is
defined in section 3(y) of the Fair Labor Standards Act of
1938), individuals who provide out-of-hospital emergency
medical care (including emergency medical technicians,
paramedics, and first-responders), and individuals engaged in
the construction, mining, agriculture (not including food
processing), forestry, and fishing industries. Such term
includes an employee who is retired from a high-risk profession
described in the preceding sentence, if such employee satisfied
the requirements of such sentence for a period of not less than
20 years during the employee's employment.
``(4) Group health plan.--The term `group health plan' has
the meaning given such term by section 5000(b)(1).
``(5) Health insurance coverage; health insurance issuer.--
``(A) Health insurance coverage.--The term `health
insurance coverage' has the meaning given such term by
section 9832(b)(1) (applied without regard to
subparagraph (B) thereof, except as provided by the
Secretary in regulations).
``(B) Health insurance issuer.--The term `health
insurance issuer' has the meaning given such term by
section 9832(b)(2).
``(6) Person that administers the plan benefits.--The term
`person that administers the plan benefits' shall include the
plan sponsor if the plan sponsor administers benefits under the
plan.
``(7) Plan sponsor.--The term `plan sponsor' has the
meaning given such term in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974.
``(8) Taxable period.--The term `taxable period' means the
calendar year or such shorter period as the Secretary may
prescribe. The Secretary may have different taxable periods for
employers of varying sizes.
``(9) Aggregation rules.--All employers treated as a single
employer under subsection (b), (c), (m), or (o) of section 414
shall be treated as a single employer.
``(10) Denial of deduction.--For denial of a deduction for
the tax imposed by this section, see section 275(a)(6).
``(g) Regulations.--The Secretary shall prescribe such regulations
as may be necessary to carry out this section.''.
(b) Clerical Amendment.--The table of sections for chapter 43 of
such Code, as amended by section 1513, is amended by adding at the end
the following new item:
``Sec. 4980I. Excise tax on high cost employer-sponsored health
coverage.''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
SEC. 9002. INCLUSION OF COST OF EMPLOYER-SPONSORED HEALTH COVERAGE ON
W-2.
(a) In General.--Section 6051(a) of the Internal Revenue Code of
1986 (relating to receipts for employees) is amended by striking
``and'' at the end of paragraph (12), by striking the period at the end
of paragraph (13) and inserting ``, and'', and by adding after
paragraph (13) the following new paragraph:
``(14) the aggregate cost (determined under rules similar
to the rules of section 4980B(f)(4)) of applicable employer-
sponsored coverage (as defined in section 4980I(d)(1)), except
that this paragraph shall not apply to--
``(A) coverage to which paragraphs (11) and (12)
apply, or
``(B) the amount of any salary reduction
contributions to a flexible spending arrangement
(within the meaning of section 125).''.
(b) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2010.
SEC. 9003. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR PRESCRIBED
DRUG OR INSULIN.
(a) HSAs.--Subparagraph (A) of section 223(d)(2) of the Internal
Revenue Code of 1986 is amended by adding at the end the following:
``Such term shall include an amount paid for medicine or a drug only if
such medicine or drug is a prescribed drug (determined without regard
to whether such drug is available without a prescription) or is
insulin.''.
(b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of the
Internal Revenue Code of 1986 is amended by adding at the end the
following: ``Such term shall include an amount paid for medicine or a
drug only if such medicine or drug is a prescribed drug (determined
without regard to whether such drug is available without a
prescription) or is insulin.''.
(c) Health Flexible Spending Arrangements and Health Reimbursement
Arrangements.--Section 106 of the Internal Revenue Code of 1986 is
amended by adding at the end the following new subsection:
``(f) Reimbursements for Medicine Restricted to Prescribed Drugs
and Insulin.--For purposes of this section and section 105,
reimbursement for expenses incurred for a medicine or a drug shall be
treated as a reimbursement for medical expenses only if such medicine
or drug is a prescribed drug (determined without regard to whether such
drug is available without a prescription) or is insulin.''.
(d) Effective Dates.--
(1) Distributions from savings accounts.--The amendments
made by subsections (a) and (b) shall apply to amounts paid
with respect to taxable years beginning after December 31,
2010.
(2) Reimbursements.--The amendment made by subsection (c)
shall apply to expenses incurred with respect to taxable years
beginning after December 31, 2010.
SEC. 9004. INCREASE IN ADDITIONAL TAX ON DISTRIBUTIONS FROM HSAS AND
ARCHER MSAS NOT USED FOR QUALIFIED MEDICAL EXPENSES.
(a) HSAs.--Section 223(f)(4)(A) of the Internal Revenue Code of
1986 is amended by striking ``10 percent'' and inserting ``20
percent''.
(b) Archer MSAs.--Section 220(f)(4)(A) of the Internal Revenue Code
of 1986 is amended by striking ``15 percent'' and inserting ``20
percent''.
(c) Effective Date.--The amendments made by this section shall
apply to distributions made after December 31, 2010.
SEC. 9005. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS UNDER
CAFETERIA PLANS.
(a) In General.--Section 125 of the Internal Revenue Code of 1986
is amended--
(1) by redesignating subsections (i) and (j) as subsections
(j) and (k), respectively, and
(2) by inserting after subsection (h) the following new
subsection:
``(i) Limitation on Health Flexible Spending Arrangements.--For
purposes of this section, if a benefit is provided under a cafeteria
plan through employer contributions to a health flexible spending
arrangement, such benefit shall not be treated as a qualified benefit
unless the cafeteria plan provides that an employee may not elect for
any taxable year to have salary reduction contributions in excess of
$2,500 made to such arrangement.''.
(b) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2010.
SEC. 9006. EXPANSION OF INFORMATION REPORTING REQUIREMENTS.
(a) In General.--Section 6041 of the Internal Revenue Code of 1986
is amended by adding at the end the following new subsections:
``(h) Application to Corporations.--Notwithstanding any regulation
prescribed by the Secretary before the date of the enactment of this
subsection, for purposes of this section the term `person' includes any
corporation that is not an organization exempt from tax under section
501(a).
``(i) Regulations.--The Secretary may prescribe such regulations
and other guidance as may be appropriate or necessary to carry out the
purposes of this section, including rules to prevent duplicative
reporting of transactions.''.
(b) Payments for Property and Other Gross Proceeds.--Subsection (a)
of section 6041 of the Internal Revenue Code of 1986 is amended--
(1) by inserting ``amounts in consideration for property,''
after ``wages,'',
(2) by inserting ``gross proceeds,'' after ``emoluments, or
other'', and
(3) by inserting ``gross proceeds,'' after ``setting forth
the amount of such''.
(c) Effective Date.--The amendments made by this section shall
apply to payments made after December 31, 2011.
SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS.
(a) Requirements To Qualify as Section 501(c)(3) Charitable
Hospital Organization.--Section 501 of the Internal Revenue Code of
1986 (relating to exemption from tax on corporations, certain trusts,
etc.) is amended by redesignating subsection (r) as subsection (s) and
by inserting after subsection (q) the following new subsection:
``(r) Additional Requirements for Certain Hospitals.--
``(1) In general.--A hospital organization to which this
subsection applies shall not be treated as described in
subsection (c)(3) unless the organization--
``(A) meets the community health needs assessment
requirements described in paragraph (3),
``(B) meets the financial assistance policy
requirements described in paragraph (4),
``(C) meets the requirements on charges described
in paragraph (5), and
``(D) meets the billing and collection requirement
described in paragraph (6).
``(2) Hospital organizations to which subsection applies.--
``(A) In general.--This subsection shall apply to--
``(i) an organization which operates a
facility which is required by a State to be
licensed, registered, or similarly recognized
as a hospital, and
``(ii) any other organization which the
Secretary determines has the provision of
hospital care as its principal function or
purpose constituting the basis for its
exemption under subsection (c)(3) (determined
without regard to this subsection).
``(B) Organizations with more than 1 hospital
facility.--If a hospital organization operates more
than 1 hospital facility--
``(i) the organization shall meet the
requirements of this subsection separately with
respect to each such facility, and
``(ii) the organization shall not be
treated as described in subsection (c)(3) with
respect to any such facility for which such
requirements are not separately met.
``(3) Community health needs assessments.--
``(A) In general.--An organization meets the
requirements of this paragraph with respect to any
taxable year only if the organization--
``(i) has conducted a community health
needs assessment which meets the requirements
of subparagraph (B) in such taxable year or in
either of the 2 taxable years immediately
preceding such taxable year, and
``(ii) has adopted an implementation
strategy to meet the community health needs
identified through such assessment.
``(B) Community health needs assessment.--A
community health needs assessment meets the
requirements of this paragraph if such community health
needs assessment--
``(i) takes into account input from persons
who represent the broad interests of the
community served by the hospital facility,
including those with special knowledge of or
expertise in public health, and
``(ii) is made widely available to the
public.
``(4) Financial assistance policy.--An organization meets
the requirements of this paragraph if the organization
establishes the following policies:
``(A) Financial assistance policy.--A written
financial assistance policy which includes--
``(i) eligibility criteria for financial
assistance, and whether such assistance
includes free or discounted care,
``(ii) the basis for calculating amounts
charged to patients,
``(iii) the method for applying for
financial assistance,
``(iv) in the case of an organization which
does not have a separate billing and
collections policy, the actions the
organization may take in the event of non-
payment, including collections action and
reporting to credit agencies, and
``(v) measures to widely publicize the
policy within the community to be served by the
organization.
``(B) Policy relating to emergency medical care.--A
written policy requiring the organization to provide,
without discrimination, care for emergency medical
conditions (within the meaning of section 1867 of the
Social Security Act (42 U.S.C. 1395dd)) to individuals
regardless of their eligibility under the financial
assistance policy described in subparagraph (A).
``(5) Limitation on charges.--An organization meets the
requirements of this paragraph if the organization--
``(A) limits amounts charged for emergency or other
medically necessary care provided to individuals
eligible for assistance under the financial assistance
policy described in paragraph (4)(A) to not more than
the lowest amounts charged to individuals who have
insurance covering such care, and
``(B) prohibits the use of gross charges.
``(6) Billing and collection requirements.--An organization
meets the requirement of this paragraph only if the
organization does not engage in extraordinary collection
actions before the organization has made reasonable efforts to
determine whether the individual is eligible for assistance
under the financial assistance policy described in paragraph
(4)(A).
``(7) Regulatory authority.--The Secretary shall issue such
regulations and guidance as may be necessary to carry out the
provisions of this subsection, including guidance relating to
what constitutes reasonable efforts to determine the
eligibility of a patient under a financial assistance policy
for purposes of paragraph (6).''.
(b) Excise Tax for Failures To Meet Hospital Exemption
Requirements.--
(1) In general.--Subchapter D of chapter 42 of the Internal
Revenue Code of 1986 (relating to failure by certain charitable
organizations to meet certain qualification requirements) is
amended by adding at the end the following new section:
``SEC. 4959. TAXES ON FAILURES BY HOSPITAL ORGANIZATIONS.
``If a hospital organization to which section 501(r) applies fails
to meet the requirement of section 501(r)(3) for any taxable year,
there is imposed on the organization a tax equal to $50,000.''.
(2) Conforming amendment.--The table of sections for
subchapter D of chapter 42 of such Code is amended by adding at
the end the following new item:
``Sec. 4959. Taxes on failures by hospital organizations.''.
(c) Mandatory Review of Tax Exemption for Hospitals.--The Secretary
of the Treasury or the Secretary's delegate shall review at least once
every 3 years the community benefit activities of each hospital
organization to which section 501(r) of the Internal Revenue Code of
1986 (as added by this section) applies.
(d) Additional Reporting Requirements.--
(1) Community health needs assessments and audited
financial statements.--Section 6033(b) of the Internal Revenue
Code of 1986 (relating to certain organizations described in
section 501(c)(3)) is amended by striking ``and'' at the end of
paragraph (14), by redesignating paragraph (15) as paragraph
(16), and by inserting after paragraph (14) the following new
paragraph:
``(15) in the case of an organization to which the
requirements of section 501(r) apply for the taxable year--
``(A) a description of how the organization is
addressing the needs identified in each community
health needs assessment conducted under section
501(r)(3) and a description of any such needs that are
not being addressed together with the reasons why such
needs are not being addressed, and
``(B) the audited financial statements of such
organization (or, in the case of an organization the
financial statements of which are included in a
consolidated financial statement with other
organizations, such consolidated financial
statement).''.
(2) Taxes.--Section 6033(b)(10) of such Code is amended by
striking ``and'' at the end of subparagraph (B), by inserting
``and'' at the end of subparagraph (C), and by adding at the
end the following new subparagraph:
``(D) section 4959 (relating to taxes on failures
by hospital organizations),''.
(e) Reports.--
(1) Report on levels of charity care.--The Secretary of the
Treasury, in consultation with the Secretary of Health and
Human Services, shall submit to the Committees on Ways and
Means, Education and Labor, and Energy and Commerce of the
House of Representatives and to the Committees on Finance and
Health, Education, Labor, and Pensions of the Senate an annual
report on the following:
(A) Information with respect to private tax-exempt,
taxable, and government-owned hospitals regarding--
(i) levels of charity care provided,
(ii) bad debt expenses,
(iii) unreimbursed costs for services
provided with respect to means-tested
government programs, and
(iv) unreimbursed costs for services
provided with respect to non-means tested
government programs.
(B) Information with respect to private tax-exempt
hospitals regarding costs incurred for community
benefit activities.
(2) Report on trends.--
(A) Study.--The Secretary of the Treasury, in
consultation with the Secretary of Health and Human
Services, shall conduct a study on trends in the
information required to be reported under paragraph
(1).
(B) Report.--Not later than 5 years after the date
of the enactment of this Act, the Secretary of the
Treasury, in consultation with the Secretary of Health
and Human Services, shall submit a report on the study
conducted under subparagraph (A) to the Committees on
Ways and Means, Education and Labor, and Energy and
Commerce of the House of Representatives and to the
Committees on Finance and Health, Education, Labor, and
Pensions of the Senate.
(f) Effective Dates.--
(1) In general.--Except as provided in paragraphs (2) and
(3), the amendments made by this section shall apply to taxable
years beginning after the date of the enactment of this Act.
(2) Community health needs assessment.--The requirements of
section 501(r)(3) of the Internal Revenue Code of 1986, as
added by subsection (a), shall apply to taxable years beginning
after the date which is 2 years after the date of the enactment
of this Act.
(3) Excise tax.--The amendments made by subsection (b)
shall apply to failures occurring after the date of the
enactment of this Act.
SEC. 9008. IMPOSITION OF ANNUAL FEE ON BRANDED PRESCRIPTION
PHARMACEUTICAL MANUFACTURERS AND IMPORTERS.
(a) Imposition of Fee.--
(1) In general.--Each covered entity engaged in the
business of manufacturing or importing branded prescription
drugs shall pay to the Secretary of the Treasury not later than
the annual payment date of each calendar year beginning after
2009 a fee in an amount determined under subsection (b).
(2) Annual payment date.--For purposes of this section, the
term ``annual payment date'' means with respect to any calendar
year the date determined by the Secretary, but in no event
later than September 30 of such calendar year.
(b) Determination of Fee Amount.--
(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal to
an amount that bears the same ratio to $2,300,000,000 as--
(A) the covered entity's branded prescription drug
sales taken into account during the preceding calendar
year, bear to
(B) the aggregate branded prescription drug sales
of all covered entities taken into account during such
preceding calendar year.
(2) Sales taken into account.--For purposes of paragraph
(1), the branded prescription drug sales taken into account
during any calendar year with respect to any covered entity
shall be determined in accordance with the following table:
With respect to a covered entity's
aggregate branded prescription drug The percentage of such sales
sales during the calendar year that taken into account is:
are:
Not more than $5,000,000............. 0 percent
More than $5,000,000 but not more 10 percent
than $125,000,000.
More than $125,000,000 but not more 40 percent
than $225,000,000.
More than $225,000,000 but not more 75 percent
than $400,000,000.
More than $400,000,000............... 100 percent.
(3) Secretarial determination.--The Secretary of the
Treasury shall calculate the amount of each covered entity's
fee for any calendar year under paragraph (1). In calculating
such amount, the Secretary of the Treasury shall determine such
covered entity's branded prescription drug sales on the basis
of reports submitted under subsection (g) and through the use
of any other source of information available to the Secretary
of the Treasury.
(c) Transfer of Fees to Medicare Part B Trust Fund.--There is
hereby appropriated to the Federal Supplementary Medical Insurance
Trust Fund established under section 1841 of the Social Security Act an
amount equal to the fees received by the Secretary of the Treasury
under subsection (a).
(d) Covered Entity.--
(1) In general.--For purposes of this section, the term
``covered entity'' means any manufacturer or importer with
gross receipts from branded prescription drug sales.
(2) Controlled groups.--
(A) In general.--For purposes of this subsection,
all persons treated as a single employer under
subsection (a) or (b) of section 52 of the Internal
Revenue Code of 1986 or subsection (m) or (o) of
section 414 of such Code shall be treated as a single
covered entity.
(B) Inclusion of foreign corporations.--For
purposes of subparagraph (A), in applying subsections
(a) and (b) of section 52 of such Code to this section,
section 1563 of such Code shall be applied without
regard to subsection (b)(2)(C) thereof.
(e) Branded Prescription Drug Sales.--For purposes of this
section--
(1) In general.--The term ``branded prescription drug
sales'' means sales of branded prescription drugs to any
specified government program or pursuant to coverage under any
such program.
(2) Branded prescription drugs.--
(A) In general.--The term ``branded prescription
drug'' means--
(i) any prescription drug the application
for which was submitted under section 505(b) of
the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355(b)), or
(ii) any biological product the license for
which was submitted under section 351(a) of the
Public Health Service Act (42 U.S.C. 262(a)).
(B) Prescription drug.--For purposes of
subparagraph (A)(i), the term ``prescription drug''
means any drug which is subject to section 503(b) of
the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
353(b)).
(3) Exclusion of orphan drug sales.--The term ``branded
prescription drug sales'' shall not include sales of any drug
or biological product with respect to which a credit was
allowed for any taxable year under section 45C of the Internal
Revenue Code of 1986. The preceding sentence shall not apply
with respect to any such drug or biological product after the
date on which such drug or biological product is approved by
the Food and Drug Administration for marketing for any
indication other than the treatment of the rare disease or
condition with respect to which such credit was allowed.
(4) Specified government program.--The term ``specified
government program'' means--
(A) the Medicare Part D program under part D of
title XVIII of the Social Security Act,
(B) the Medicare Part B program under part B of
title XVIII of the Social Security Act,
(C) the Medicaid program under title XIX of the
Social Security Act,
(D) any program under which branded prescription
drugs are procured by the Department of Veterans
Affairs,
(E) any program under which branded prescription
drugs are procured by the Department of Defense, or
(F) the TRICARE retail pharmacy program under
section 1074g of title 10, United States Code.
(f) Tax Treatment of Fees.--The fees imposed by this section--
(1) for purposes of subtitle F of the Internal Revenue Code
of 1986, shall be treated as excise taxes with respect to which
only civil actions for refund under procedures of such subtitle
shall apply, and
(2) for purposes of section 275 of such Code, shall be
considered to be a tax described in section 275(a)(6).
(g) Reporting Requirement.--Not later than the date determined by
the Secretary of the Treasury following the end of any calendar year,
the Secretary of Health and Human Services, the Secretary of Veterans
Affairs, and the Secretary of Defense shall report to the Secretary of
the Treasury, in such manner as the Secretary of the Treasury
prescribes, the total branded prescription drug sales for each covered
entity with respect to each specified government program under such
Secretary's jurisdiction using the following methodology:
(1) Medicare part d program.--The Secretary of Health and
Human Services shall report, for each covered entity and for
each branded prescription drug of the covered entity covered by
the Medicare Part D program, the product of--
(A) the per-unit ingredient cost, as reported to
the Secretary of Health and Human Services by
prescription drug plans and Medicare Advantage
prescription drug plans, minus any per-unit rebate,
discount, or other price concession provided by the
covered entity, as reported to the Secretary of Health
and Human Services by the prescription drug plans and
Medicare Advantage prescription drug plans, and
(B) the number of units of the branded prescription
drug paid for under the Medicare Part D program.
(2) Medicare part b program.--The Secretary of Health and
Human Services shall report, for each covered entity and for
each branded prescription drug of the covered entity covered by
the Medicare Part B program under section 1862(a) of the Social
Security Act, the product of--
(A) the per-unit average sales price (as defined in
section 1847A(c) of the Social Security Act) or the
per-unit Part B payment rate for a separately paid
branded prescription drug without a reported average
sales price, and
(B) the number of units of the branded prescription
drug paid for under the Medicare Part B program.
The Centers for Medicare and Medicaid Services shall establish
a process for determining the units and the allocated price for
purposes of this section for those branded prescription drugs
that are not separately payable or for which National Drug
Codes are not reported.
(3) Medicaid program.--The Secretary of Health and Human
Services shall report, for each covered entity and for each
branded prescription drug of the covered entity covered under
the Medicaid program, the product of--
(A) the per-unit ingredient cost paid to pharmacies
by States for the branded prescription drug dispensed
to Medicaid beneficiaries, minus any per-unit rebate
paid by the covered entity under section 1927 of the
Social Security Act and any State supplemental rebate,
and
(B) the number of units of the branded prescription
drug paid for under the Medicaid program.
(4) Department of veterans affairs programs.--The Secretary
of Veterans Affairs shall report, for each covered entity and
for each branded prescription drug of the covered entity the
total amount paid for each such branded prescription drug
procured by the Department of Veterans Affairs for its
beneficiaries.
(5) Department of defense programs and tricare.--The
Secretary of Defense shall report, for each covered entity and
for each branded prescription drug of the covered entity, the
sum of--
(A) the total amount paid for each such branded
prescription drug procured by the Department of Defense
for its beneficiaries, and
(B) for each such branded prescription drug
dispensed under the TRICARE retail pharmacy program,
the product of--
(i) the per-unit ingredient cost, minus any
per-unit rebate paid by the covered entity, and
(ii) the number of units of the branded
prescription drug dispensed under such program.
(h) Secretary.--For purposes of this section, the term
``Secretary'' includes the Secretary's delegate.
(i) Guidance.--The Secretary of the Treasury shall publish guidance
necessary to carry out the purposes of this section.
(j) Application of Section.--This section shall apply to any
branded prescription drug sales after December 31, 2008.
(k) Conforming Amendment.--Section 1841(a) of the Social Security
Act is amended by inserting ``or section 9008(c) of the Patient
Protection and Affordable Care Act of 2009'' after ``this part''.
SEC. 9009. IMPOSITION OF ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS AND
IMPORTERS.
(a) Imposition of Fee.--
(1) In general.--Each covered entity engaged in the
business of manufacturing or importing medical devices shall
pay to the Secretary not later than the annual payment date of
each calendar year beginning after 2009 a fee in an amount
determined under subsection (b).
(2) Annual payment date.--For purposes of this section, the
term ``annual payment date'' means with respect to any calendar
year the date determined by the Secretary, but in no event
later than September 30 of such calendar year.
(b) Determination of Fee Amount.--
(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal to
an amount that bears the same ratio to $2,000,000,000 as--
(A) the covered entity's gross receipts from
medical device sales taken into account during the
preceding calendar year, bear to
(B) the aggregate gross receipts of all covered
entities from medical device sales taken into account
during such preceding calendar year.
(2) Gross receipts from sales taken into account.--For
purposes of paragraph (1), the gross receipts from medical
device sales taken into account during any calendar year with
respect to any covered entity shall be determined in accordance
with the following table:
With respect to a covered entity's
aggregate gross receipts from medical The percentage of gross
device sales during the calendar year receipts taken into account is:
that are:
Not more than $5,000,000............. 0 percent
More than $5,000,000 but not more 50 percent
than $25,000,000.
More than $25,000,000................ 100 percent.
(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such amount,
the Secretary shall determine such covered entity's gross
receipts from medical device sales on the basis of reports
submitted by the covered entity under subsection (f) and
through the use of any other source of information available to
the Secretary.
(c) Covered Entity.--
(1) In general.--For purposes of this section, the term
``covered entity'' means any manufacturer or importer with
gross receipts from medical device sales.
(2) Controlled groups.--
(A) In general.--For purposes of this subsection,
all persons treated as a single employer under
subsection (a) or (b) of section 52 of the Internal
Revenue Code of 1986 or subsection (m) or (o) of
section 414 of such Code shall be treated as a single
covered entity.
(B) Inclusion of foreign corporations.--For
purposes of subparagraph (A), in applying subsections
(a) and (b) of section 52 of such Code to this section,
section 1563 of such Code shall be applied without
regard to subsection (b)(2)(C) thereof.
(d) Medical Device Sales.--For purposes of this section--
(1) In general.--The term ``medical device sales'' means
sales for use in the United States of any medical device, other
than the sales of a medical device that--
(A) has been classified in class II under section
513 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 360c) and is primarily sold to consumers at
retail for not more than $100 per unit, or
(B) has been classified in class I under such
section.
(2) United states.--For purposes of paragraph (1), the term
``United States'' means the several States, the District of
Columbia, the Commonwealth of Puerto Rico, and the possessions
of the United States.
(3) Medical device.--For purposes of paragraph (1), the
term ``medical device'' means any device (as defined in section
201(h) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
321(h))) intended for humans.
(e) Tax Treatment of Fees.--The fees imposed by this section--
(1) for purposes of subtitle F of the Internal Revenue Code
of 1986, shall be treated as excise taxes with respect to which
only civil actions for refund under procedures of such subtitle
shall apply, and
(2) for purposes of section 275 of such Code, shall be
considered to be a tax described in section 275(a)(6).
(f) Reporting Requirement.--
(1) In general.--Not later than the date determined by the
Secretary following the end of any calendar year, each covered
entity shall report to the Secretary, in such manner as the
Secretary prescribes, the gross receipts from medical device
sales of such covered entity during such calendar year.
(2) Penalty for failure to report.--
(A) In general.--In the case of any failure to make
a report containing the information required by
paragraph (1) on the date prescribed therefor
(determined with regard to any extension of time for
filing), unless it is shown that such failure is due to
reasonable cause, there shall be paid by the covered
entity failing to file such report, an amount equal
to--
(i) $10,000, plus
(ii) the lesser of--
(I) an amount equal to $1,000,
multiplied by the number of days during
which such failure continues, or
(II) the amount of the fee imposed
by this section for which such report
was required.
(B) Treatment of penalty.--The penalty imposed
under subparagraph (A)--
(i) shall be treated as a penalty for
purposes of subtitle F of the Internal Revenue
Code of 1986,
(ii) shall be paid on notice and demand by
the Secretary and in the same manner as tax
under such Code, and
(iii) with respect to which only civil
actions for refund under procedures of such
subtitle F shall apply.
(g) Secretary.--For purposes of this section, the term
``Secretary'' means the Secretary of the Treasury or the Secretary's
delegate.
(h) Guidance.--The Secretary shall publish guidance necessary to
carry out the purposes of this section, including identification of
medical devices described in subsection (d)(1)(A) and with respect to
the treatment of gross receipts from sales of medical devices to
another covered entity or to another entity by reason of the
application of subsection (c)(2).
(i) Application of Section.--This section shall apply to any
medical device sales after December 31, 2008.
SEC. 9010. IMPOSITION OF ANNUAL FEE ON HEALTH INSURANCE PROVIDERS.
(a) Imposition of Fee.--
(1) In general.--Each covered entity engaged in the
business of providing health insurance shall pay to the
Secretary not later than the annual payment date of each
calendar year beginning after 2009 a fee in an amount
determined under subsection (b).
(2) Annual payment date.--For purposes of this section, the
term ``annual payment date'' means with respect to any calendar
year the date determined by the Secretary, but in no event
later than September 30 of such calendar year.
(b) Determination of Fee Amount.--
(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal to
an amount that bears the same ratio to $6,700,000,000 as--
(A) the sum of--
(i) the covered entity's net premiums
written with respect to health insurance for
any United States health risk that are taken
into account during the preceding calendar
year, plus
(ii) 200 percent of the covered entity's
third party administration agreement fees that
are taken into account during the preceding
calendar year, bears to
(B) the sum of--
(i) the aggregate net premiums written with
respect to such health insurance of all covered
entities that are taken into account during
such preceding calendar year, plus
(ii) 200 percent of the aggregate third
party administration agreement fees of all
covered entities that are taken into account
during such preceding calendar year.
(2) Amounts taken into account.--For purposes of paragraph
(1)--
(A) Net premiums written.--The net premiums written
with respect to health insurance for any United States
health risk that are taken into account during any
calendar year with respect to any covered entity shall
be determined in accordance with the following table:
With respect to a covered entity's net The percentage of net premiums
premiums written during the calendar written that are taken into
year that are: account is:
Not more than $25,000,000............ 0 percent
More than $25,000,000 but not more 50 percent
than $50,000,000.
More than $50,000,000................ 100 percent.
(B) Third party administration agreement fees.--The
third party administration agreement fees that are
taken into account during any calendar year with
respect to any covered entity shall be determined in
accordance with the following table:
With respect to a covered entity's The percentage of third party
third party administration agreement administration agreement fees
fees during the calendar year that are: that are taken into account is:
Not more than $5,000,000............. 0 percent
More than $5,000,000 but not more 50 percent
than $10,000,000.
More than $10,000,000................ 100 percent.
(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such amount,
the Secretary shall determine such covered entity's net
premiums written with respect to any United States health risk
and third party administration agreement fees on the basis of
reports submitted by the covered entity under subsection (g)
and through the use of any other source of information
available to the Secretary.
(c) Covered Entity.--
(1) In general.--For purposes of this section, the term
``covered entity'' means any entity which provides health
insurance for any United States health risk.
(2) Exclusion.--Such term does not include--
(A) any employer to the extent that such employer
self-insures its employees' health risks, or
(B) any governmental entity (except to the extent
such an entity provides health insurance coverage
through the community health insurance option under
section 1323).
(3) Controlled groups.--
(A) In general.--For purposes of this subsection,
all persons treated as a single employer under
subsection (a) or (b) of section 52 of the Internal
Revenue Code of 1986 or subsection (m) or (o) of
section 414 of such Code shall be treated as a single
covered entity (or employer for purposes of paragraph
(2)).
(B) Inclusion of foreign corporations.--For
purposes of subparagraph (A), in applying subsections
(a) and (b) of section 52 of such Code to this section,
section 1563 of such Code shall be applied without
regard to subsection (b)(2)(C) thereof.
(d) United States Health Risk.--For purposes of this section, the
term ``United States health risk'' means the health risk of any
individual who is--
(1) a United States citizen,
(2) a resident of the United States (within the meaning of
section 7701(b)(1)(A) of the Internal Revenue Code of 1986), or
(3) located in the United States, with respect to the
period such individual is so located.
(e) Third Party Administration Agreement Fees.--For purposes of
this section, the term ``third party administration agreement fees''
means, with respect to any covered entity, amounts received from an
employer which are in excess of payments made by such covered entity
for health benefits under an arrangement under which such employer
self-insures the United States health risk of its employees.
(f) Tax Treatment of Fees.--The fees imposed by this section--
(1) for purposes of subtitle F of the Internal Revenue Code
of 1986, shall be treated as excise taxes with respect to which
only civil actions for refund under procedures of such subtitle
shall apply, and
(2) for purposes of section 275 of such Code shall be
considered to be a tax described in section 275(a)(6).
(g) Reporting Requirement.--
(1) In general.--Not later than the date determined by the
Secretary following the end of any calendar year, each covered
entity shall report to the Secretary, in such manner as the
Secretary prescribes, the covered entity's net premiums written
with respect to health insurance for any United States health
risk and third party administration agreement fees for such
calendar year.
(2) Penalty for failure to report.--
(A) In general.--In the case of any failure to make
a report containing the information required by
paragraph (1) on the date prescribed therefor
(determined with regard to any extension of time for
filing), unless it is shown that such failure is due to
reasonable cause, there shall be paid by the covered
entity failing to file such report, an amount equal
to--
(i) $10,000, plus
(ii) the lesser of--
(I) an amount equal to $1,000,
multiplied by the number of days during
which such failure continues, or
(II) the amount of the fee imposed
by this section for which such report
was required.
(B) Treatment of penalty.--The penalty imposed
under subparagraph (A)--
(i) shall be treated as a penalty for
purposes of subtitle F of the Internal Revenue
Code of 1986,
(ii) shall be paid on notice and demand by
the Secretary and in the same manner as tax
under such Code, and
(iii) with respect to which only civil
actions for refund under procedures of such
subtitle F shall apply.
(h) Additional Definitions.--For purposes of this section--
(1) Secretary.--The term ``Secretary'' means the Secretary
of the Treasury or the Secretary's delegate.
(2) United states.--The term ``United States'' means the
several States, the District of Columbia, the Commonwealth of
Puerto Rico, and the possessions of the United States.
(3) Health insurance.--The term ``health insurance'' shall
not include insurance for long-term care or disability.
(i) Guidance.--The Secretary shall publish guidance necessary to
carry out the purposes of this section.
(j) Application of Section.--This section shall apply to any net
premiums written after December 31, 2008, with respect to health
insurance for any United States health risk, and any third party
administration agreement fees received after such date.
SEC. 9011. STUDY AND REPORT OF EFFECT ON VETERANS HEALTH CARE.
(a) In General.--The Secretary of Veterans Affairs shall conduct a
study on the effect (if any) of the provisions of sections 9008, 9009,
and 9010 on--
(1) the cost of medical care provided to veterans, and
(2) veterans' access to medical devices and branded
prescription drugs.
(b) Report.--The Secretary of Veterans Affairs shall report the
results of the study under subsection (a) to the Committee on Ways and
Means of the House of Representatives and to the Committee on Finance
of the Senate not later than December 31, 2012.
SEC. 9012. ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE TO MEDICARE
PART D SUBSIDY.
(a) In General.--Section 139A of the Internal Revenue Code of 1986
is amended by striking the second sentence.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after December 31, 2010.
SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL EXPENSES.
(a) In General.--Subsection (a) of section 213 of the Internal
Revenue Code of 1986 is amended by striking ``7.5 percent'' and
inserting ``10 percent''.
(b) Temporary Waiver of Increase for Certain Seniors.--Section 213
of the Internal Revenue Code of 1986 is amended by adding at the end
the following new subsection:
``(f) Special Rule for 2013, 2014, 2015, and 2016.--In the case of
any taxable year beginning after December 31, 2012, and ending before
January 1, 2017, subsection (a) shall be applied with respect to a
taxpayer by substituting `7.5 percent' for `10 percent' if such
taxpayer or such taxpayer's spouse has attained age 65 before the close
of such taxable year.''.
(c) Conforming Amendment.--Section 56(b)(1)(B) of the Internal
Revenue Code of 1986 is amended by striking ``by substituting `10
percent' for `7.5 percent''' and inserting ``without regard to
subsection (f) of such section''.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
SEC. 9014. LIMITATION ON EXCESSIVE REMUNERATION PAID BY CERTAIN HEALTH
INSURANCE PROVIDERS.
(a) In General.--Section 162(m) of the Internal Revenue Code of
1986 is amended by adding at the end the following new subparagraph:
``(6) Special rule for application to certain health
insurance providers.--
``(A) In general.--No deduction shall be allowed
under this chapter--
``(i) in the case of applicable individual
remuneration which is for any disqualified
taxable year beginning after December 31, 2012,
and which is attributable to services performed
by an applicable individual during such taxable
year, to the extent that the amount of such
remuneration exceeds $500,000, or
``(ii) in the case of deferred deduction
remuneration for any taxable year beginning
after December 31, 2012, which is attributable
to services performed by an applicable
individual during any disqualified taxable year
beginning after December 31, 2009, to the
extent that the amount of such remuneration
exceeds $500,000 reduced (but not below zero)
by the sum of--
``(I) the applicable individual
remuneration for such disqualified
taxable year, plus
``(II) the portion of the deferred
deduction remuneration for such
services which was taken into account
under this clause in a preceding
taxable year (or which would have been
taken into account under this clause in
a preceding taxable year if this clause
were applied by substituting `December
31, 2009' for `December 31, 2012' in
the matter preceding subclause (I)).
``(B) Disqualified taxable year.--For purposes of
this paragraph, the term `disqualified taxable year'
means, with respect to any employer, any taxable year
for which such employer is a covered health insurance
provider.
``(C) Covered health insurance provider.--For
purposes of this paragraph--
``(i) In general.--The term `covered health
insurance provider' means--
``(I) with respect to taxable years
beginning after December 31, 2009, and
before January 1, 2013, any employer
which is a health insurance issuer (as
defined in section 9832(b)(2)) and
which receives premiums from providing
health insurance coverage (as defined
in section 9832(b)(1)), and
``(II) with respect to taxable
years beginning after December 31,
2012, any employer which is a health
insurance issuer (as defined in section
9832(b)(2)) and with respect to which
not less than 25 percent of the gross
premiums received from providing health
insurance coverage (as defined in
section 9832(b)(1)) is from minimum
essential coverage (as defined in
section 5000A(f)).
``(ii) Aggregation rules.--Two or more
persons who are treated as a single employer
under subsection (b), (c), (m), or (o) of
section 414 shall be treated as a single
employer, except that in applying section
1563(a) for purposes of any such subsection,
paragraphs (2) and (3) thereof shall be
disregarded.
``(D) Applicable individual remuneration.--For
purposes of this paragraph, the term `applicable
individual remuneration' means, with respect to any
applicable individual for any disqualified taxable
year, the aggregate amount allowable as a deduction
under this chapter for such taxable year (determined
without regard to this subsection) for remuneration (as
defined in paragraph (4) without regard to
subparagraphs (B), (C), and (D) thereof) for services
performed by such individual (whether or not during the
taxable year). Such term shall not include any deferred
deduction remuneration with respect to services
performed during the disqualified taxable year.
``(E) Deferred deduction remuneration.--For
purposes of this paragraph, the term `deferred
deduction remuneration' means remuneration which would
be applicable individual remuneration for services
performed in a disqualified taxable year but for the
fact that the deduction under this chapter (determined
without regard to this paragraph) for such remuneration
is allowable in a subsequent taxable year.
``(F) Applicable individual.--For purposes of this
paragraph, the term `applicable individual' means, with
respect to any covered health insurance provider for
any disqualified taxable year, any individual--
``(i) who is an officer, director, or
employee in such taxable year, or
``(ii) who provides services for or on
behalf of such covered health insurance
provider during such taxable year.
``(G) Coordination.--Rules similar to the rules of
subparagraphs (F) and (G) of paragraph (4) shall apply
for purposes of this paragraph.
``(H) Regulatory authority.--The Secretary may
prescribe such guidance, rules, or regulations as are
necessary to carry out the purposes of this
paragraph.''.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after December 31, 2009, with respect to
services performed after such date.
SEC. 9015. ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-INCOME TAXPAYERS.
(a) FICA.--
(1) In general.--Section 3101(b) of the Internal Revenue
Code of 1986 is amended--
(A) by striking ``In addition'' and inserting the
following:
``(1) In general.--In addition'',
(B) by striking ``the following percentages of
the'' and inserting ``1.45 percent of the'',
(C) by striking ``(as defined in section 3121(b))--
'' and all that follows and inserting ``(as defined in
section 3121(b)).'', and
(D) by adding at the end the following new
paragraph:
``(2) Additional tax.--In addition to the tax imposed by
paragraph (1) and the preceding subsection, there is hereby
imposed on every taxpayer (other than a corporation, estate, or
trust) a tax equal to 0.5 percent of wages which are received
with respect to employment (as defined in section 3121(b))
during any taxable year beginning after December 31, 2012, and
which are in excess of--
``(A) in the case of a joint return, $250,000, and
``(B) in any other case, $200,000.''.
(2) Collection of tax.--Section 3102 of the Internal
Revenue Code of 1986 is amended by adding at the end the
following new subsection:
``(f) Special Rules for Additional Tax.--
``(1) In general.--In the case of any tax imposed by
section 3101(b)(2), subsection (a) shall only apply to the
extent to which the taxpayer receives wages from the employer
in excess of $200,000, and the employer may disregard the
amount of wages received by such taxpayer's spouse.
``(2) Collection of amounts not withheld.--To the extent
that the amount of any tax imposed by section 3101(b)(2) is not
collected by the employer, such tax shall be paid by the
employee.
``(3) Tax paid by recipient.--If an employer, in violation
of this chapter, fails to deduct and withhold the tax imposed
by section 3101(b)(2) and thereafter the tax is paid by the
employee, the tax so required to be deducted and withheld shall
not be collected from the employer, but this paragraph shall in
no case relieve the employer from liability for any penalties
or additions to tax otherwise applicable in respect of such
failure to deduct and withhold.''.
(b) SECA.--
(1) In general.--Section 1401(b) of the Internal Revenue
Code of 1986 is amended--
(A) by striking ``In addition'' and inserting the
following:
``(1) In general.--In addition'', and
(B) by adding at the end the following new
paragraph:
``(2) Additional tax.--
``(A) In general.--In addition to the tax imposed
by paragraph (1) and the preceding subsection, there is
hereby imposed on every taxpayer (other than a
corporation, estate, or trust) for each taxable year
beginning after December 31, 2012, a tax equal to 0.5
percent of the self-employment income for such taxable
year which is in excess of--
``(i) in the case of a joint return,
$250,000, and
``(ii) in any other case, $200,000.
``(B) Coordination with fica.--The amounts under
clauses (i) and (ii) of subparagraph (A) shall be
reduced (but not below zero) by the amount of wages
taken into account in determining the tax imposed under
section 3121(b)(2) with respect to the taxpayer.''.
(2) No deduction for additional tax.--
(A) In general.--Section 164(f) of such Code is
amended by inserting ``(other than the taxes imposed by
section 1401(b)(2))'' after ``section 1401)''.
(B) Deduction for net earnings from self-
employment.--Subparagraph (B) of section 1402(a)(12) is
amended by inserting ``(determined without regard to
the rate imposed under paragraph (2) of section
1401(b))'' after ``for such year''.
(c) Effective Date.--The amendments made by this section shall
apply with respect to remuneration received, and taxable years
beginning, after December 31, 2012.
SEC. 9016. MODIFICATION OF SECTION 833 TREATMENT OF CERTAIN HEALTH
ORGANIZATIONS.
(a) In General.--Subsection (c) of section 833 of the Internal
Revenue Code of 1986 is amended by adding at the end the following new
paragraph:
``(5) Nonapplication of section in case of low medical loss
ratio.--Notwithstanding the preceding paragraphs, this section
shall not apply to any organization unless such organization's
percentage of total premium revenue expended on reimbursement
for clinical services provided to enrollees under its policies
during such taxable year (as reported under section 2718 of the
Public Health Service Act) is not less than 85 percent.''.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after December 31, 2009.
SEC. 9017. EXCISE TAX ON ELECTIVE COSMETIC MEDICAL PROCEDURES.
(a) In General.--Subtitle D of the Internal Revenue Code of 1986,
as amended by this Act, is amended by adding at the end the following
new chapter:
``CHAPTER 49--ELECTIVE COSMETIC MEDICAL PROCEDURES
``Sec. 5000B. Imposition of tax on elective cosmetic medical
procedures.
``SEC. 5000B. IMPOSITION OF TAX ON ELECTIVE COSMETIC MEDICAL
PROCEDURES.
``(a) In General.--There is hereby imposed on any cosmetic surgery
and medical procedure a tax equal to 5 percent of the amount paid for
such procedure (determined without regard to this section), whether
paid by insurance or otherwise.
``(b) Cosmetic Surgery and Medical Procedure.--For purposes of this
section, the term `cosmetic surgery and medical procedure' means any
cosmetic surgery (as defined in section 213(d)(9)(B)) or other similar
procedure which--
``(1) is performed by a licensed medical professional, and
``(2) is not necessary to ameliorate a deformity arising
from, or directly related to, a congenital abnormality, a
personal injury resulting from an accident or trauma, or
disfiguring disease.
``(c) Payment of Tax.--
``(1) In general.--The tax imposed by this section shall be
paid by the individual on whom the procedure is performed.
``(2) Collection.--Every person receiving a payment for
procedures on which a tax is imposed under subsection (a) shall
collect the amount of the tax from the individual on whom the
procedure is performed and remit such tax quarterly to the
Secretary at such time and in such manner as provided by the
Secretary.
``(3) Secondary liability.--Where any tax imposed by
subsection (a) is not paid at the time payments for cosmetic
surgery and medical procedures are made, then to the extent
that such tax is not collected, such tax shall be paid by the
person who performs the procedure.''.
(b) Clerical Amendment.--The table of chapters for subtitle D of
the Internal Revenue Code of 1986, as amended by this Act, is amended
by inserting after the item relating to chapter 48 the following new
item:
``Chapter 49--Elective Cosmetic Medical Procedures''.
(c) Effective Date.--The amendments made by this section shall
apply to procedures performed on or after January 1, 2010.
Subtitle B--Other Provisions
SEC. 9021. EXCLUSION OF HEALTH BENEFITS PROVIDED BY INDIAN TRIBAL
GOVERNMENTS.
(a) In General.--Part III of subchapter B of chapter 1 of the
Internal Revenue Code of 1986 is amended by inserting after section
139C the following new section:
``SEC. 139D. INDIAN HEALTH CARE BENEFITS.
``(a) General Rule.--Except as otherwise provided in this section,
gross income does not include the value of any qualified Indian health
care benefit.
``(b) Qualified Indian Health Care Benefit.--For purposes of this
section, the term `qualified Indian health care benefit' means--
``(1) any health service or benefit provided or purchased,
directly or indirectly, by the Indian Health Service through a
grant to or a contract or compact with an Indian tribe or
tribal organization, or through a third-party program funded by
the Indian Health Service,
``(2) medical care provided or purchased by, or amounts to
reimburse for such medical care provided by, an Indian tribe or
tribal organization for, or to, a member of an Indian tribe,
including a spouse or dependent of such a member,
``(3) coverage under accident or health insurance (or an
arrangement having the effect of accident or health insurance),
or an accident or health plan, provided by an Indian tribe or
tribal organization for medical care to a member of an Indian
tribe, include a spouse or dependent of such a member, and
``(4) any other medical care provided by an Indian tribe or
tribal organization that supplements, replaces, or substitutes
for a program or service relating to medical care provided by
the Federal government to Indian tribes or members of such a
tribe.
``(c) Definitions.--For purposes of this section--
``(1) Indian tribe.--The term `Indian tribe' has the
meaning given such term by section 45A(c)(6).
``(2) Tribal organization.--The term `tribal organization'
has the meaning given such term by section 4(l) of the Indian
Self-Determination and Education Assistance Act.
``(3) Medical care.--The term `medical care' has the same
meaning as when used in section 213.
``(4) Accident or health insurance; accident or health
plan.--The terms `accident or health insurance' and `accident
or health plan' have the same meaning as when used in section
105.
``(5) Dependent.--The term `dependent' has the meaning
given such term by section 152, determined without regard to
subsections (b)(1), (b)(2), and (d)(1)(B) thereof.
``(d) Denial of Double Benefit.--Subsection (a) shall not apply to
the amount of any qualified Indian health care benefit which is not
includible in gross income of the beneficiary of such benefit under any
other provision of this chapter, or to the amount of any such benefit
for which a deduction is allowed to such beneficiary under any other
provision of this chapter.''.
(b) Clerical Amendment.--The table of sections for part III of
subchapter B of chapter 1 of the Internal Revenue Code of 1986 is
amended by inserting after the item relating to section 139C the
following new item:
``Sec. 139D. Indian health care benefits.''.
(c) Effective Date.--The amendments made by this section shall
apply to benefits and coverage provided after the date of the enactment
of this Act.
(d) No Inference.--Nothing in the amendments made by this section
shall be construed to create an inference with respect to the exclusion
from gross income of--
(1) benefits provided by an Indian tribe or tribal
organization that are not within the scope of this section, and
(2) benefits provided prior to the date of the enactment of
this Act.
SEC. 9022. ESTABLISHMENT OF SIMPLE CAFETERIA PLANS FOR SMALL
BUSINESSES.
(a) In General.--Section 125 of the Internal Revenue Code of 1986
(relating to cafeteria plans), as amended by this Act, is amended by
redesignating subsections (j) and (k) as subsections (k) and (l),
respectively, and by inserting after subsection (i) the following new
subsection:
``(j) Simple Cafeteria Plans for Small Businesses.--
``(1) In general.--An eligible employer maintaining a
simple cafeteria plan with respect to which the requirements of
this subsection are met for any year shall be treated as
meeting any applicable nondiscrimination requirement during
such year.
``(2) Simple cafeteria plan.--For purposes of this
subsection, the term `simple cafeteria plan' means a cafeteria
plan--
``(A) which is established and maintained by an
eligible employer, and
``(B) with respect to which the contribution
requirements of paragraph (3), and the eligibility and
participation requirements of paragraph (4), are met.
``(3) Contribution requirements.--
``(A) In general.--The requirements of this
paragraph are met if, under the plan the employer is
required, without regard to whether a qualified
employee makes any salary reduction contribution, to
make a contribution to provide qualified benefits under
the plan on behalf of each qualified employee in an
amount equal to--
``(i) a uniform percentage (not less than 2
percent) of the employee's compensation for the
plan year, or
``(ii) an amount which is not less than the
lesser of--
``(I) 6 percent of the employee's
compensation for the plan year, or
``(II) twice the amount of the
salary reduction contributions of each
qualified employee.
``(B) Matching contributions on behalf of highly
compensated and key employees.--The requirements of
subparagraph (A)(ii) shall not be treated as met if,
under the plan, the rate of contributions with respect
to any salary reduction contribution of a highly
compensated or key employee at any rate of contribution
is greater than that with respect to an employee who is
not a highly compensated or key employee.
``(C) Additional contributions.--Subject to
subparagraph (B), nothing in this paragraph shall be
treated as prohibiting an employer from making
contributions to provide qualified benefits under the
plan in addition to contributions required under
subparagraph (A).
``(D) Definitions.--For purposes of this
paragraph--
``(i) Salary reduction contribution.--The
term `salary reduction contribution' means,
with respect to a cafeteria plan, any amount
which is contributed to the plan at the
election of the employee and which is not
includible in gross income by reason of this
section.
``(ii) Qualified employee.--The term
`qualified employee' means, with respect to a
cafeteria plan, any employee who is not a
highly compensated or key employee and who is
eligible to participate in the plan.
``(iii) Highly compensated employee.--The
term `highly compensated employee' has the
meaning given such term by section 414(q).
``(iv) Key employee.--The term `key
employee' has the meaning given such term by
section 416(i).
``(4) Minimum eligibility and participation requirements.--
``(A) In general.--The requirements of this
paragraph shall be treated as met with respect to any
year if, under the plan--
``(i) all employees who had at least 1,000
hours of service for the preceding plan year
are eligible to participate, and
``(ii) each employee eligible to
participate in the plan may, subject to terms
and conditions applicable to all participants,
elect any benefit available under the plan.
``(B) Certain employees may be excluded.--For
purposes of subparagraph (A)(i), an employer may elect
to exclude under the plan employees--
``(i) who have not attained the age of 21
before the close of a plan year,
``(ii) who have less than 1 year of service
with the employer as of any day during the plan
year,
``(iii) who are covered under an agreement
which the Secretary of Labor finds to be a
collective bargaining agreement if there is
evidence that the benefits covered under the
cafeteria plan were the subject of good faith
bargaining between employee representatives and
the employer, or
``(iv) who are described in section
410(b)(3)(C) (relating to nonresident aliens
working outside the United States).
A plan may provide a shorter period of service or
younger age for purposes of clause (i) or (ii).
``(5) Eligible employer.--For purposes of this subsection--
``(A) In general.--The term `eligible employer'
means, with respect to any year, any employer if such
employer employed an average of 100 or fewer employees
on business days during either of the 2 preceding
years. For purposes of this subparagraph, a year may
only be taken into account if the employer was in
existence throughout the year.
``(B) Employers not in existence during preceding
year.--If an employer was not in existence throughout
the preceding year, the determination under
subparagraph (A) shall be based on the average number
of employees that it is reasonably expected such
employer will employ on business days in the current
year.
``(C) Growing employers retain treatment as small
employer.--
``(i) In general.--If--
``(I) an employer was an eligible
employer for any year (a `qualified
year'), and
``(II) such employer establishes a
simple cafeteria plan for its employees
for such year,
then, notwithstanding the fact the employer
fails to meet the requirements of subparagraph
(A) for any subsequent year, such employer
shall be treated as an eligible employer for
such subsequent year with respect to employees
(whether or not employees during a qualified
year) of any trade or business which was
covered by the plan during any qualified year.
``(ii) Exception.--This subparagraph shall
cease to apply if the employer employs an
average of 200 or more employees on business
days during any year preceding any such
subsequent year.
``(D) Special rules.--
``(i) Predecessors.--Any reference in this
paragraph to an employer shall include a
reference to any predecessor of such employer.
``(ii) Aggregation rules.--All persons
treated as a single employer under subsection
(a) or (b) of section 52, or subsection (n) or
(o) of section 414, shall be treated as one
person.
``(6) Applicable nondiscrimination requirement.--For
purposes of this subsection, the term `applicable
nondiscrimination requirement' means any requirement under
subsection (b) of this section, section 79(d), section 105(h),
or paragraph (2), (3), (4), or (8) of section 129(d).
``(7) Compensation.--The term `compensation' has the
meaning given such term by section 414(s).''.
(b) Effective Date.--The amendments made by this section shall
apply to years beginning after December 31, 2010.
SEC. 9023. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.
(a) In General.--Subpart E of part IV of subchapter A of chapter 1
of the Internal Revenue Code of 1986 is amended by inserting after
section 48C the following new section:
``SEC. 48D. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.
``(a) In General.--For purposes of section 46, the qualifying
therapeutic discovery project credit for any taxable year is an amount
equal to 50 percent of the qualified investment for such taxable year
with respect to any qualifying therapeutic discovery project of an
eligible taxpayer.
``(b) Qualified Investment.--
``(1) In general.--For purposes of subsection (a), the
qualified investment for any taxable year is the aggregate
amount of the costs paid or incurred in such taxable year for
expenses necessary for and directly related to the conduct of a
qualifying therapeutic discovery project.
``(2) Limitation.--The amount which is treated as qualified
investment for all taxable years with respect to any qualifying
therapeutic discovery project shall not exceed the amount
certified by the Secretary as eligible for the credit under
this section.
``(3) Exclusions.--The qualified investment for any taxable
year with respect to any qualifying therapeutic discovery
project shall not take into account any cost--
``(A) for remuneration for an employee described in
section 162(m)(3),
``(B) for interest expenses,
``(C) for facility maintenance expenses,
``(D) which is identified as a service cost under
section 1.263A-1(e)(4) of title 26, Code of Federal
Regulations, or
``(E) for any other expense as determined by the
Secretary as appropriate to carry out the purposes of
this section.
``(4) Certain progress expenditure rules made applicable.--
In the case of costs described in paragraph (1) that are paid
for property of a character subject to an allowance for
depreciation, rules similar to the rules of subsections (c)(4)
and (d) of section 46 (as in effect on the day before the date
of the enactment of the Revenue Reconciliation Act of 1990)
shall apply for purposes of this section.
``(5) Application of subsection.--An investment shall be
considered a qualified investment under this subsection only if
such investment is made in a taxable year beginning in 2009 or
2010.
``(c) Definitions.--
``(1) Qualifying therapeutic discovery project.--The term
`qualifying therapeutic discovery project' means a project
which is designed--
``(A) to treat or prevent diseases or conditions by
conducting pre-clinical activities, clinical trials,
and clinical studies, or carrying out research
protocols, for the purpose of securing approval of a
product under section 505(b) of the Federal Food, Drug,
and Cosmetic Act or section 351(a) of the Public Health
Service Act,
``(B) to diagnose diseases or conditions or to
determine molecular factors related to diseases or
conditions by developing molecular diagnostics to guide
therapeutic decisions, or
``(C) to develop a product, process, or technology
to further the delivery or administration of
therapeutics.
``(2) Eligible taxpayer.--
``(A) In general.--The term `eligible taxpayer'
means a taxpayer which employs not more than 250
employees in all businesses of the taxpayer at the time
of the submission of the application under subsection
(d)(2).
``(B) Aggregation rules.--All persons treated as a
single employer under subsection (a) or (b) of section
52, or subsection (m) or (o) of section 414, shall be
so treated for purposes of this paragraph.
``(3) Facility maintenance expenses.--The term `facility
maintenance expenses' means costs paid or incurred to maintain
a facility, including--
``(A) mortgage or rent payments,
``(B) insurance payments,
``(C) utility and maintenance costs, and
``(D) costs of employment of maintenance personnel.
``(d) Qualifying Therapeutic Discovery Project Program.--
``(1) Establishment.--
``(A) In general.--Not later than 60 days after the
date of the enactment of this section, the Secretary,
in consultation with the Secretary of Health and Human
Services, shall establish a qualifying therapeutic
discovery project program to consider and award
certifications for qualified investments eligible for
credits under this section to qualifying therapeutic
discovery project sponsors.
``(B) Limitation.--The total amount of credits that
may be allocated under the program shall not exceed
$1,000,000,000 for the 2-year period beginning with
2009.
``(2) Certification.--
``(A) Application period.--Each applicant for
certification under this paragraph shall submit an
application containing such information as the
Secretary may require during the period beginning on
the date the Secretary establishes the program under
paragraph (1).
``(B) Time for review of applications.--The
Secretary shall take action to approve or deny any
application under subparagraph (A) within 30 days of
the submission of such application.
``(C) Multi-year applications.--An application for
certification under subparagraph (A) may include a
request for an allocation of credits for more than 1 of
the years described in paragraph (1)(B).
``(3) Selection criteria.--In determining the qualifying
therapeutic discovery projects with respect to which qualified
investments may be certified under this section, the
Secretary--
``(A) shall take into consideration only those
projects that show reasonable potential--
``(i) to result in new therapies--
``(I) to treat areas of unmet
medical need, or
``(II) to prevent, detect, or treat
chronic or acute diseases and
conditions,
``(ii) to reduce long-term health care
costs in the United States, or
``(iii) to significantly advance the goal
of curing cancer within the 30-year period
beginning on the date the Secretary establishes
the program under paragraph (1), and
``(B) shall take into consideration which projects
have the greatest potential--
``(i) to create and sustain (directly or
indirectly) high quality, high-paying jobs in
the United States, and
``(ii) to advance United States
competitiveness in the fields of life,
biological, and medical sciences.
``(4) Disclosure of allocations.--The Secretary shall, upon
making a certification under this subsection, publicly disclose
the identity of the applicant and the amount of the credit with
respect to such applicant.
``(e) Special Rules.--
``(1) Basis adjustment.--For purposes of this subtitle, if
a credit is allowed under this section for an expenditure
related to property of a character subject to an allowance for
depreciation, the basis of such property shall be reduced by
the amount of such credit.
``(2) Denial of double benefit.--
``(A) Bonus depreciation.--A credit shall not be
allowed under this section for any investment for which
bonus depreciation is allowed under section 168(k),
1400L(b)(1), or 1400N(d)(1).
``(B) Deductions.--No deduction under this subtitle
shall be allowed for the portion of the expenses
otherwise allowable as a deduction taken into account
in determining the credit under this section for the
taxable year which is equal to the amount of the credit
determined for such taxable year under subsection (a)
attributable to such portion. This subparagraph shall
not apply to expenses related to property of a
character subject to an allowance for depreciation the
basis of which is reduced under paragraph (1), or which
are described in section 280C(g).
``(C) Credit for research activities.--
``(i) In general.--Except as provided in
clause (ii), any expenses taken into account
under this section for a taxable year shall not
be taken into account for purposes of
determining the credit allowable under section
41 or 45C for such taxable year.
``(ii) Expenses included in determining
base period research expenses.--Any expenses
for any taxable year which are qualified
research expenses (within the meaning of
section 41(b)) shall be taken into account in
determining base period research expenses for
purposes of applying section 41 to subsequent
taxable years.
``(f) Coordination With Department of Treasury Grants.--In the case
of any investment with respect to which the Secretary makes a grant
under section 9023(e) of the Patient Protection and Affordable Care Act
of 2009--
``(1) Denial of credit.--No credit shall be determined
under this section with respect to such investment for the
taxable year in which such grant is made or any subsequent
taxable year.
``(2) Recapture of credits for progress expenditures made
before grant.--If a credit was determined under this section
with respect to such investment for any taxable year ending
before such grant is made--
``(A) the tax imposed under subtitle A on the
taxpayer for the taxable year in which such grant is
made shall be increased by so much of such credit as
was allowed under section 38,
``(B) the general business carryforwards under
section 39 shall be adjusted so as to recapture the
portion of such credit which was not so allowed, and
``(C) the amount of such grant shall be determined
without regard to any reduction in the basis of any
property of a character subject to an allowance for
depreciation by reason of such credit.
``(3) Treatment of grants.--Any such grant shall not be
includible in the gross income of the taxpayer.''.
(b) Inclusion as Part of Investment Credit.--Section 46 of the
Internal Revenue Code of 1986 is amended--
(1) by adding a comma at the end of paragraph (2),
(2) by striking the period at the end of paragraph (5) and
inserting ``, and'', and
(3) by adding at the end the following new paragraph:
``(6) the qualifying therapeutic discovery project
credit.''.
(c) Conforming Amendments.--
(1) Section 49(a)(1)(C) of the Internal Revenue Code of
1986 is amended--
(A) by striking ``and'' at the end of clause (iv),
(B) by striking the period at the end of clause (v)
and inserting ``, and'', and
(C) by adding at the end the following new clause:
``(vi) the basis of any property to which
paragraph (1) of section 48D(e) applies which
is part of a qualifying therapeutic discovery
project under such section 48D.''.
(2) Section 280C of such Code is amended by adding at the
end the following new subsection:
``(g) Qualifying Therapeutic Discovery Project Credit.--
``(1) In general.--No deduction shall be allowed for that
portion of the qualified investment (as defined in section
48D(b)) otherwise allowable as a deduction for the taxable year
which--
``(A) would be qualified research expenses (as
defined in section 41(b)), basic research expenses (as
defined in section 41(e)(2)), or qualified clinical
testing expenses (as defined in section 45C(b)) if the
credit under section 41 or section 45C were allowed
with respect to such expenses for such taxable year,
and
``(B) is equal to the amount of the credit
determined for such taxable year under section 48D(a),
reduced by--
``(i) the amount disallowed as a deduction
by reason of section 48D(e)(2)(B), and
``(ii) the amount of any basis reduction
under section 48D(e)(1).
``(2) Similar rule where taxpayer capitalizes rather than
deducts expenses.--In the case of expenses described in
paragraph (1)(A) taken into account in determining the credit
under section 48D for the taxable year, if--
``(A) the amount of the portion of the credit
determined under such section with respect to such
expenses, exceeds
``(B) the amount allowable as a deduction for such
taxable year for such expenses (determined without
regard to paragraph (1)),
the amount chargeable to capital account for the taxable year
for such expenses shall be reduced by the amount of such
excess.
``(3) Controlled groups.--Paragraph (3) of subsection (b)
shall apply for purposes of this subsection.''.
(d) Clerical Amendment.--The table of sections for subpart E of
part IV of subchapter A of chapter 1 of the Internal Revenue Code of
1986 is amended by inserting after the item relating to section 48C the
following new item:
``Sec. 48D. Qualifying therapeutic discovery project credit.''.
(e) Grants for Qualified Investments in Therapeutic Discovery
Projects in Lieu of Tax Credits.--
(1) In general.--Upon application, the Secretary of the
Treasury shall, subject to the requirements of this subsection,
provide a grant to each person who makes a qualified investment
in a qualifying therapeutic discovery project in the amount of
50 percent of such investment. No grant shall be made under
this subsection with respect to any investment unless such
investment is made during a taxable year beginning in 2009 or
2010.
(2) Application.--
(A) In general.--At the stated election of the
applicant, an application for certification under
section 48D(d)(2) of the Internal Revenue Code of 1986
for a credit under such section for the taxable year of
the applicant which begins in 2009 shall be considered
to be an application for a grant under paragraph (1)
for such taxable year.
(B) Taxable years beginning in 2010.--An
application for a grant under paragraph (1) for a
taxable year beginning in 2010 shall be submitted--
(i) not earlier than the day after the last
day of such taxable year, and
(ii) not later than the due date (including
extensions) for filing the return of tax for
such taxable year.
(C) Information to be submitted.--An application
for a grant under paragraph (1) shall include such
information and be in such form as the Secretary may
require to state the amount of the credit allowable
(but for the receipt of a grant under this subsection)
under section 48D for the taxable year for the
qualified investment with respect to which such
application is made.
(3) Time for payment of grant.--
(A) In general.--The Secretary of the Treasury
shall make payment of the amount of any grant under
paragraph (1) during the 30-day period beginning on the
later of--
(i) the date of the application for such
grant, or
(ii) the date the qualified investment for
which the grant is being made is made.
(B) Regulations.--In the case of investments of an
ongoing nature, the Secretary shall issue regulations
to determine the date on which a qualified investment
shall be deemed to have been made for purposes of this
paragraph.
(4) Qualified investment.--For purposes of this subsection,
the term ``qualified investment'' means a qualified investment
that is certified under section 48D(d) of the Internal Revenue
Code of 1986 for purposes of the credit under such section 48D.
(5) Application of certain rules.--
(A) In general.--In making grants under this
subsection, the Secretary of the Treasury shall apply
rules similar to the rules of section 50 of the
Internal Revenue Code of 1986. In applying such rules,
any increase in tax under chapter 1 of such Code by
reason of an investment ceasing to be a qualified
investment shall be imposed on the person to whom the
grant was made.
(B) Special rules.--
(i) Recapture of excessive grant amounts.--
If the amount of a grant made under this
subsection exceeds the amount allowable as a
grant under this subsection, such excess shall
be recaptured under subparagraph (A) as if the
investment to which such excess portion of the
grant relates had ceased to be a qualified
investment immediately after such grant was
made.
(ii) Grant information not treated as
return information.--In no event shall the
amount of a grant made under paragraph (1), the
identity of the person to whom such grant was
made, or a description of the investment with
respect to which such grant was made be treated
as return information for purposes of section
6103 of the Internal Revenue Code of 1986.
(6) Exception for certain non-taxpayers.--The Secretary of
the Treasury shall not make any grant under this subsection
to--
(A) any Federal, State, or local government (or any
political subdivision, agency, or instrumentality
thereof),
(B) any organization described in section 501(c) of
the Internal Revenue Code of 1986 and exempt from tax
under section 501(a) of such Code,
(C) any entity referred to in paragraph (4) of
section 54(j) of such Code, or
(D) any partnership or other pass-thru entity any
partner (or other holder of an equity or profits
interest) of which is described in subparagraph (A),
(B) or (C).
In the case of a partnership or other pass-thru entity
described in subparagraph (D), partners and other holders of
any equity or profits interest shall provide to such
partnership or entity such information as the Secretary of the
Treasury may require to carry out the purposes of this
paragraph.
(7) Secretary.--Any reference in this subsection to the
Secretary of the Treasury shall be treated as including the
Secretary's delegate.
(8) Other terms.--Any term used in this subsection which is
also used in section 48D of the Internal Revenue Code of 1986
shall have the same meaning for purposes of this subsection as
when used in such section.
(9) Denial of double benefit.--No credit shall be allowed
under section 46(6) of the Internal Revenue Code of 1986 by
reason of section 48D of such Code for any investment for which
a grant is awarded under this subsection.
(10) Appropriations.--There is hereby appropriated to the
Secretary of the Treasury such sums as may be necessary to
carry out this subsection.
(11) Termination.--The Secretary of the Treasury shall not
make any grant to any person under this subsection unless the
application of such person for such grant is received before
January 1, 2013.
(12) Protecting middle class families from tax increases.--
It is the sense of the Senate that the Senate should reject any
procedural maneuver that would raise taxes on middle class
families, such as a motion to commit the pending legislation to
the Committee on Finance, which is designed to kill legislation
that provides tax cuts for American workers and families,
including the affordability tax credit and the small business
tax credit.
(f) Effective Date.--The amendments made by subsections (a) through
(d) of this section shall apply to amounts paid or incurred after
December 31, 2008, in taxable years beginning after such date.
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
Subtitle A--Provisions Relating to Title I
SEC. 10101. AMENDMENTS TO SUBTITLE A.
(a) Section 2711 of the Public Health Service Act, as added by
section 1001(5) of this Act, is amended to read as follows:
``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
``(a) Prohibition.--
``(1) In general.--A group health plan and a health
insurance issuer offering group or individual health insurance
coverage may not establish--
``(A) lifetime limits on the dollar value of
benefits for any participant or beneficiary; or
``(B) except as provided in paragraph (2), annual
limits on the dollar value of benefits for any
participant or beneficiary.
``(2) Annual limits prior to 2014.--With respect to plan
years beginning prior to January 1, 2014, a group health plan
and a health insurance issuer offering group or individual
health insurance coverage may only establish a restricted
annual limit on the dollar value of benefits for any
participant or beneficiary with respect to the scope of
benefits that are essential health benefits under section
1302(b) of the Patient Protection and Affordable Care Act, as
determined by the Secretary. In defining the term `restricted
annual limit' for purposes of the preceding sentence, the
Secretary shall ensure that access to needed services is made
available with a minimal impact on premiums.
``(b) Per Beneficiary Limits.--Subsection (a) shall not be
construed to prevent a group health plan or health insurance coverage
from placing annual or lifetime per beneficiary limits on specific
covered benefits that are not essential health benefits under section
1302(b) of the Patient Protection and Affordable Care Act, to the
extent that such limits are otherwise permitted under Federal or State
law.''.
(b) Section 2715(a) of the Public Health Service Act, as added by
section 1001(5) of this Act, is amended by striking ``and providing to
enrollees'' and inserting ``and providing to applicants, enrollees, and
policyholders or certificate holders''.
(c) Subpart II of part A of title XXVII of the Public Health
Service Act, as added by section 1001(5), is amended by inserting after
section 2715, the following:
``SEC. 2715A. PROVISION OF ADDITIONAL INFORMATION.
``A group health plan and a health insurance issuer offering group
or individual health insurance coverage shall comply with the
provisions of section 1311(e)(3) of the Patient Protection and
Affordable Care Act, except that a plan or coverage that is not offered
through an Exchange shall only be required to submit the information
required to the Secretary and the State insurance commissioner, and
make such information available to the public.''.
(d) Section 2716 of the Public Health Service Act, as added by
section 1001(5) of this Act, is amended to read as follows:
``SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR OF HIGHLY
COMPENSATED INDIVIDUALS.
``(a) In General.--A group health plan (other than a self-insured
plan) shall satisfy the requirements of section 105(h)(2) of the
Internal Revenue Code of 1986 (relating to prohibition on
discrimination in favor of highly compensated individuals).
``(b) Rules and Definitions.--For purposes of this section--
``(1) Certain rules to apply.--Rules similar to the rules
contained in paragraphs (3), (4), and (8) of section 105(h) of
such Code shall apply.
``(2) Highly compensated individual.--The term `highly
compensated individual' has the meaning given such term by
section 105(h)(5) of such Code.''.
(e) Section 2717 of the Public Health Service Act, as added by
section 1001(5) of this Act, is amended--
(1) by redesignating subsections (c) and (d) as subsections
(d) and (e), respectively; and
(2) by inserting after subsection (b), the following:
``(c) Protection of Second Amendment Gun Rights.--
``(1) Wellness and prevention programs.--A wellness and
health promotion activity implemented under subsection
(a)(1)(D) may not require the disclosure or collection of any
information relating to--
``(A) the presence or storage of a lawfully-
possessed firearm or ammunition in the residence or on
the property of an individual; or
``(B) the lawful use, possession, or storage of a
firearm or ammunition by an individual.
``(2) Limitation on data collection.--None of the
authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made by that
Act shall be construed to authorize or may be used for the
collection of any information relating to--
``(A) the lawful ownership or possession of a
firearm or ammunition;
``(B) the lawful use of a firearm or ammunition; or
``(C) the lawful storage of a firearm or
ammunition.
``(3) Limitation on databases or data banks.--None of the
authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made by that
Act shall be construed to authorize or may be used to maintain
records of individual ownership or possession of a firearm or
ammunition.
``(4) Limitation on determination of premium rates or
eligibility for health insurance.--A premium rate may not be
increased, health insurance coverage may not be denied, and a
discount, rebate, or reward offered for participation in a
wellness program may not be reduced or withheld under any
health benefit plan issued pursuant to or in accordance with
the Patient Protection and Affordable Care Act or an amendment
made by that Act on the basis of, or on reliance upon--
``(A) the lawful ownership or possession of a
firearm or ammunition; or
``(B) the lawful use or storage of a firearm or
ammunition.
``(5) Limitation on data collection requirements for
individuals.--No individual shall be required to disclose any
information under any data collection activity authorized under
the Patient Protection and Affordable Care Act or an amendment
made by that Act relating to--
``(A) the lawful ownership or possession of a
firearm or ammunition; or
``(B) the lawful use, possession, or storage of a
firearm or ammunition.''.
(f) Section 2718 of the Public Health Service Act, as added by
section 1001(5), is amended to read as follows:
``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.
``(a) Clear Accounting for Costs.--A health insurance issuer
offering group or individual health insurance coverage (including a
grandfathered health plan) shall, with respect to each plan year,
submit to the Secretary a report concerning the ratio of the incurred
loss (or incurred claims) plus the loss adjustment expense (or change
in contract reserves) to earned premiums. Such report shall include the
percentage of total premium revenue, after accounting for collections
or receipts for risk adjustment and risk corridors and payments of
reinsurance, that such coverage expends--
``(1) on reimbursement for clinical services provided to
enrollees under such coverage;
``(2) for activities that improve health care quality; and
``(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding Federal
and State taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section available
to the public on the Internet website of the Department of Health and
Human Services.
``(b) Ensuring That Consumers Receive Value for Their Premium
Payments.--
``(1) Requirement to provide value for premium payments.--
``(A) Requirement.--Beginning not later than
January 1, 2011, a health insurance issuer offering
group or individual health insurance coverage
(including a grandfathered health plan) shall, with
respect to each plan year, provide an annual rebate to
each enrollee under such coverage, on a pro rata basis,
if the ratio of the amount of premium revenue expended
by the issuer on costs described in paragraphs (1) and
(2) of subsection (a) to the total amount of premium
revenue (excluding Federal and State taxes and
licensing or regulatory fees and after accounting for
payments or receipts for risk adjustment, risk
corridors, and reinsurance under sections 1341, 1342,
and 1343 of the Patient Protection and Affordable Care
Act) for the plan year (except as provided in
subparagraph (B)(ii)), is less than--
``(i) with respect to a health insurance
issuer offering coverage in the large group
market, 85 percent, or such higher percentage
as a State may by regulation determine; or
``(ii) with respect to a health insurance
issuer offering coverage in the small group
market or in the individual market, 80 percent,
or such higher percentage as a State may by
regulation determine, except that the Secretary
may adjust such percentage with respect to a
State if the Secretary determines that the
application of such 80 percent may destabilize
the individual market in such State.
``(B) Rebate amount.--
``(i) Calculation of amount.--The total
amount of an annual rebate required under this
paragraph shall be in an amount equal to the
product of--
``(I) the amount by which the
percentage described in clause (i) or
(ii) of subparagraph (A) exceeds the
ratio described in such subparagraph;
and
``(II) the total amount of premium
revenue (excluding Federal and State
taxes and licensing or regulatory fees
and after accounting for payments or
receipts for risk adjustment, risk
corridors, and reinsurance under
sections 1341, 1342, and 1343 of the
Patient Protection and Affordable Care
Act) for such plan year.
``(ii) Calculation based on average
ratio.--Beginning on January 1, 2014, the
determination made under subparagraph (A) for
the year involved shall be based on the
averages of the premiums expended on the costs
described in such subparagraph and total
premium revenue for each of the previous 3
years for the plan.
``(2) Consideration in setting percentages.--In determining
the percentages under paragraph (1), a State shall seek to
ensure adequate participation by health insurance issuers,
competition in the health insurance market in the State, and
value for consumers so that premiums are used for clinical
services and quality improvements.
``(3) Enforcement.--The Secretary shall promulgate
regulations for enforcing the provisions of this section and
may provide for appropriate penalties.
``(c) Definitions.--Not later than December 31, 2010, and subject
to the certification of the Secretary, the National Association of
Insurance Commissioners shall establish uniform definitions of the
activities reported under subsection (a) and standardized methodologies
for calculating measures of such activities, including definitions of
which activities, and in what regard such activities, constitute
activities described in subsection (a)(2). Such methodologies shall be
designed to take into account the special circumstances of smaller
plans, different types of plans, and newer plans.
``(d) Adjustments.--The Secretary may adjust the rates described in
subsection (b) if the Secretary determines appropriate on account of
the volatility of the individual market due to the establishment of
State Exchanges.
``(e) Standard Hospital Charges.--Each hospital operating within
the United States shall for each year establish (and update) and make
public (in accordance with guidelines developed by the Secretary) a
list of the hospital's standard charges for items and services provided
by the hospital, including for diagnosis-related groups established
under section 1886(d)(4) of the Social Security Act.''.
(g) Section 2719 of the Public Health Service Act, as added by
section 1001(4) of this Act, is amended to read as follows:
``SEC. 2719. APPEALS PROCESS.
``(a) Internal Claims Appeals.--
``(1) In general.--A group health plan and a health
insurance issuer offering group or individual health insurance
coverage shall implement an effective appeals process for
appeals of coverage determinations and claims, under which the
plan or issuer shall, at a minimum--
``(A) have in effect an internal claims appeal
process;
``(B) provide notice to enrollees, in a culturally
and linguistically appropriate manner, of available
internal and external appeals processes, and the
availability of any applicable office of health
insurance consumer assistance or ombudsman established
under section 2793 to assist such enrollees with the
appeals processes; and
``(C) allow an enrollee to review their file, to
present evidence and testimony as part of the appeals
process, and to receive continued coverage pending the
outcome of the appeals process.
``(2) Established processes.--To comply with paragraph
(1)--
``(A) a group health plan and a health insurance
issuer offering group health coverage shall provide an
internal claims and appeals process that initially
incorporates the claims and appeals procedures
(including urgent claims) set forth at section
2560.503-1 of title 29, Code of Federal Regulations, as
published on November 21, 2000 (65 Fed. Reg. 70256),
and shall update such process in accordance with any
standards established by the Secretary of Labor for
such plans and issuers; and
``(B) a health insurance issuer offering individual
health coverage, and any other issuer not subject to
subparagraph (A), shall provide an internal claims and
appeals process that initially incorporates the claims
and appeals procedures set forth under applicable law
(as in existence on the date of enactment of this
section), and shall update such process in accordance
with any standards established by the Secretary of
Health and Human Services for such issuers.
``(b) External Review.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage--
``(1) shall comply with the applicable State external
review process for such plans and issuers that, at a minimum,
includes the consumer protections set forth in the Uniform
External Review Model Act promulgated by the National
Association of Insurance Commissioners and is binding on such
plans; or
``(2) shall implement an effective external review process
that meets minimum standards established by the Secretary
through guidance and that is similar to the process described
under paragraph (1)--
``(A) if the applicable State has not established
an external review process that meets the requirements
of paragraph (1); or
``(B) if the plan is a self-insured plan that is
not subject to State insurance regulation (including a
State law that establishes an external review process
described in paragraph (1)).
``(c) Secretary Authority.--The Secretary may deem the external
review process of a group health plan or health insurance issuer, in
operation as of the date of enactment of this section, to be in
compliance with the applicable process established under subsection
(b), as determined appropriate by the Secretary.''.
(h) Subpart II of part A of title XVIII of the Public Health
Service Act, as added by section 1001(5) of this Act, is amended by
inserting after section 2719 the following:
``SEC. 2719A. PATIENT PROTECTIONS.
``(a) Choice of Health Care Professional.--If a group health plan,
or a health insurance issuer offering group or individual health
insurance coverage, requires or provides for designation by a
participant, beneficiary, or enrollee of a participating primary care
provider, then the plan or issuer shall permit each participant,
beneficiary, and enrollee to designate any participating primary care
provider who is available to accept such individual.
``(b) Coverage of Emergency Services.--
``(1) In general.--If a group health plan, or a health
insurance issuer offering group or individual health insurance
issuer, provides or covers any benefits with respect to
services in an emergency department of a hospital, the plan or
issuer shall cover emergency services (as defined in paragraph
(2)(B))--
``(A) without the need for any prior authorization
determination;
``(B) whether the health care provider furnishing
such services is a participating provider with respect
to such services;
``(C) in a manner so that, if such services are
provided to a participant, beneficiary, or enrollee--
``(i) by a nonparticipating health care
provider with or without prior authorization;
or
``(ii)(I) such services will be provided
without imposing any requirement under the plan
for prior authorization of services or any
limitation on coverage where the provider of
services does not have a contractual
relationship with the plan for the providing of
services that is more restrictive than the
requirements or limitations that apply to
emergency department services received from
providers who do have such a contractual
relationship with the plan; and
``(II) if such services are provided out-
of-network, the cost-sharing requirement
(expressed as a copayment amount or coinsurance
rate) is the same requirement that would apply
if such services were provided in-network;
``(D) without regard to any other term or condition
of such coverage (other than exclusion or coordination
of benefits, or an affiliation or waiting period,
permitted under section 2701 of this Act, section 701
of the Employee Retirement Income Security Act of 1974,
or section 9801 of the Internal Revenue Code of 1986,
and other than applicable cost-sharing).
``(2) Definitions.--In this subsection:
``(A) Emergency medical condition.--The term
`emergency medical condition' means a medical condition
manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of
immediate medical attention to result in a condition
described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
``(B) Emergency services.--The term `emergency
services' means, with respect to an emergency medical
condition--
``(i) a medical screening examination (as
required under section 1867 of the Social
Security Act) that is within the capability of
the emergency department of a hospital,
including ancillary services routinely
available to the emergency department to
evaluate such emergency medical condition, and
``(ii) within the capabilities of the staff
and facilities available at the hospital, such
further medical examination and treatment as
are required under section 1867 of such Act to
stabilize the patient.
``(C) Stabilize.--The term `to stabilize', with
respect to an emergency medical condition (as defined
in subparagraph (A)), has the meaning give in section
1867(e)(3) of the Social Security Act (42 U.S.C.
1395dd(e)(3)).
``(c) Access to Pediatric Care.--
``(1) Pediatric care.--In the case of a person who has a
child who is a participant, beneficiary, or enrollee under a
group health plan, or health insurance coverage offered by a
health insurance issuer in the group or individual market, if
the plan or issuer requires or provides for the designation of
a participating primary care provider for the child, the plan
or issuer shall permit such person to designate a physician
(allopathic or osteopathic) who specializes in pediatrics as
the child's primary care provider if such provider participates
in the network of the plan or issuer.
``(2) Construction.--Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage with
respect to coverage of pediatric care.
``(d) Patient Access to Obstetrical and Gynecological Care.--
``(1) General rights.--
``(A) Direct access.--A group health plan, or
health insurance issuer offering group or individual
health insurance coverage, described in paragraph (2)
may not require authorization or referral by the plan,
issuer, or any person (including a primary care
provider described in paragraph (2)(B)) in the case of
a female participant, beneficiary, or enrollee who
seeks coverage for obstetrical or gynecological care
provided by a participating health care professional
who specializes in obstetrics or gynecology. Such
professional shall agree to otherwise adhere to such
plan's or issuer's policies and procedures, including
procedures regarding referrals and obtaining prior
authorization and providing services pursuant to a
treatment plan (if any) approved by the plan or issuer.
``(B) Obstetrical and gynecological care.--A group
health plan or health insurance issuer described in
paragraph (2) shall treat the provision of obstetrical
and gynecological care, and the ordering of related
obstetrical and gynecological items and services,
pursuant to the direct access described under
subparagraph (A), by a participating health care
professional who specializes in obstetrics or
gynecology as the authorization of the primary care
provider.
``(2) Application of paragraph.--A group health plan, or
health insurance issuer offering group or individual health
insurance coverage, described in this paragraph is a group
health plan or coverage that--
``(A) provides coverage for obstetric or
gynecologic care; and
``(B) requires the designation by a participant,
beneficiary, or enrollee of a participating primary
care provider.
``(3) Construction.--Nothing in paragraph (1) shall be
construed to--
``(A) waive any exclusions of coverage under the
terms and conditions of the plan or health insurance
coverage with respect to coverage of obstetrical or
gynecological care; or
``(B) preclude the group health plan or health
insurance issuer involved from requiring that the
obstetrical or gynecological provider notify the
primary care health care professional or the plan or
issuer of treatment decisions.''.
(i) Section 2794 of the Public Health Service Act, as added by
section 1003 of this Act, is amended--
(1) in subsection (c)(1)--
(A) in subparagraph (A), by striking ``and'' at the
end;
(B) in subparagraph (B), by striking the period and
inserting ``; and''; and
(C) by adding at the end the following:
``(C) in establishing centers (consistent with
subsection (d)) at academic or other nonprofit
institutions to collect medical reimbursement
information from health insurance issuers, to analyze
and organize such information, and to make such
information available to such issuers, health care
providers, health researchers, health care policy
makers, and the general public.''; and
(2) by adding at the end the following:
``(d) Medical Reimbursement Data Centers.--
``(1) Functions.--A center established under subsection
(c)(1)(C) shall--
``(A) develop fee schedules and other database
tools that fairly and accurately reflect market rates
for medical services and the geographic differences in
those rates;
``(B) use the best available statistical methods
and data processing technology to develop such fee
schedules and other database tools;
``(C) regularly update such fee schedules and other
database tools to reflect changes in charges for
medical services;
``(D) make health care cost information readily
available to the public through an Internet website
that allows consumers to understand the amounts that
health care providers in their area charge for
particular medical services; and
``(E) regularly publish information concerning the
statistical methodologies used by the center to analyze
health charge data and make such data available to
researchers and policy makers.
``(2) Conflicts of interest.--A center established under
subsection (c)(1)(C) shall adopt by-laws that ensures that the
center (and all members of the governing board of the center)
is independent and free from all conflicts of interest. Such
by-laws shall ensure that the center is not controlled or
influenced by, and does not have any corporate relation to, any
individual or entity that may make or receive payments for
health care services based on the center's analysis of health
care costs.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to permit a center established under
subsection (c)(1)(C) to compel health insurance issuers to
provide data to the center.''.
SEC. 10102. AMENDMENTS TO SUBTITLE B.
(a) Section 1102(a)(2)(B) of this Act is amended--
(1) in the matter preceding clause (i), by striking ``group
health benefits plan'' and inserting ``group benefits plan
providing health benefits''; and
(2) in clause (i)(I), by inserting ``or any agency or
instrumentality of any of the foregoing'' before the closed
parenthetical.
(b) Section 1103(a) of this Act is amended--
(1) in paragraph (1), by inserting ``, or small business
in,'' after ``residents of any''; and
(2) by striking paragraph (2) and inserting the following:
``(2) Connecting to affordable coverage.--An Internet
website established under paragraph (1) shall, to the extent
practicable, provide ways for residents of, and small
businesses in, any State to receive information on at least the
following coverage options:
``(A) Health insurance coverage offered by health
insurance issuers, other than coverage that provides
reimbursement only for the treatment or mitigation of--
``(i) a single disease or condition; or
``(ii) an unreasonably limited set of
diseases or conditions (as determined by the
Secretary).
``(B) Medicaid coverage under title XIX of the
Social Security Act.
``(C) Coverage under title XXI of the Social
Security Act.
``(D) A State health benefits high risk pool, to
the extent that such high risk pool is offered in such
State; and
``(E) Coverage under a high risk pool under section
1101.
``(F) Coverage within the small group market for
small businesses and their employees, including
reinsurance for early retirees under section 1102, tax
credits available under section 45R of the Internal
Revenue Code of 1986 (as added by section 1421), and
other information specifically for small businesses
regarding affordable health care options.''.
SEC. 10103. AMENDMENTS TO SUBTITLE C.
(a) Section 2701(a)(5) of the Public Health Service Act, as added
by section 1201(4) of this Act, is amended by inserting ``(other than
self-insured group health plans offered in such market)'' after ``such
market''.
(b) Section 2708 of the Public Health Service Act, as added by
section 1201(4) of this Act, is amended by striking ``or individual''.
(c) Subpart I of part A of title XXVII of the Public Health Service
Act, as added by section 1201(4) of this Act, is amended by inserting
after section 2708, the following:
``SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED
CLINICAL TRIALS.
``(a) Coverage.--
``(1) In general.--If a group health plan or a health
insurance issuer offering group or individual health insurance
coverage provides coverage to a qualified individual, then such
plan or issuer--
``(A) may not deny the individual participation in
the clinical trial referred to in subsection (b)(2);
``(B) subject to subsection (c), may not deny (or
limit or impose additional conditions on) the coverage
of routine patient costs for items and services
furnished in connection with participation in the
trial; and
``(C) may not discriminate against the individual
on the basis of the individual's participation in such
trial.
``(2) Routine patient costs.--
``(A) Inclusion.--For purposes of paragraph (1)(B),
subject to subparagraph (B), routine patient costs
include all items and services consistent with the
coverage provided in the plan (or coverage) that is
typically covered for a qualified individual who is not
enrolled in a clinical trial.
``(B) Exclusion.--For purposes of paragraph (1)(B),
routine patient costs does not include--
``(i) the investigational item, device, or
service, itself;
``(ii) items and services that are provided
solely to satisfy data collection and analysis
needs and that are not used in the direct
clinical management of the patient; or
``(iii) a service that is clearly
inconsistent with widely accepted and
established standards of care for a particular
diagnosis.
``(3) Use of in-network providers.--If one or more
participating providers is participating in a clinical trial,
nothing in paragraph (1) shall be construed as preventing a
plan or issuer from requiring that a qualified individual
participate in the trial through such a participating provider
if the provider will accept the individual as a participant in
the trial.
``(4) Use of out-of-network.--Notwithstanding paragraph
(3), paragraph (1) shall apply to a qualified individual
participating in an approved clinical trial that is conducted
outside the State in which the qualified individual resides.
``(b) Qualified Individual Defined.--For purposes of subsection
(a), the term `qualified individual' means an individual who is a
participant or beneficiary in a health plan or with coverage described
in subsection (a)(1) and who meets the following conditions:
``(1) The individual is eligible to participate in an
approved clinical trial according to the trial protocol with
respect to treatment of cancer or other life-threatening
disease or condition.
``(2) Either--
``(A) the referring health care professional is a
participating health care provider and has concluded
that the individual's participation in such trial would
be appropriate based upon the individual meeting the
conditions described in paragraph (1); or
``(B) the participant or beneficiary provides
medical and scientific information establishing that
the individual's participation in such trial would be
appropriate based upon the individual meeting the
conditions described in paragraph (1).
``(c) Limitations on Coverage.--This section shall not be construed
to require a group health plan, or a health insurance issuer offering
group or individual health insurance coverage, to provide benefits for
routine patient care services provided outside of the plan's (or
coverage's) health care provider network unless out-of-network benefits
are otherwise provided under the plan (or coverage).
``(d) Approved Clinical Trial Defined.--
``(1) In general.--In this section, the term `approved
clinical trial' means a phase I, phase II, phase III, or phase
IV clinical trial that is conducted in relation to the
prevention, detection, or treatment of cancer or other life-
threatening disease or condition and is described in any of the
following subparagraphs:
``(A) Federally funded trials.--The study or
investigation is approved or funded (which may include
funding through in-kind contributions) by one or more
of the following:
``(i) The National Institutes of Health.
``(ii) The Centers for Disease Control and
Prevention.
``(iii) The Agency for Health Care Research
and Quality.
``(iv) The Centers for Medicare & Medicaid
Services.
``(v) cooperative group or center of any of
the entities described in clauses (i) through
(iv) or the Department of Defense or the
Department of Veterans Affairs.
``(vi) A qualified non-governmental
research entity identified in the guidelines
issued by the National Institutes of Health for
center support grants.
``(vii) Any of the following if the
conditions described in paragraph (2) are met:
``(I) The Department of Veterans
Affairs.
``(II) The Department of Defense.
``(III) The Department of Energy.
``(B) The study or investigation is conducted under
an investigational new drug application reviewed by the
Food and Drug Administration.
``(C) The study or investigation is a drug trial
that is exempt from having such an investigational new
drug application.
``(2) Conditions for departments.--The conditions described
in this paragraph, for a study or investigation conducted by a
Department, are that the study or investigation has been
reviewed and approved through a system of peer review that the
Secretary determines--
``(A) to be comparable to the system of peer review
of studies and investigations used by the National
Institutes of Health, and
``(B) assures unbiased review of the highest
scientific standards by qualified individuals who have
no interest in the outcome of the review.
``(e) Life-threatening Condition Defined.--In this section, the
term `life-threatening condition' means any disease or condition from
which the likelihood of death is probable unless the course of the
disease or condition is interrupted.
``(f) Construction.--Nothing in this section shall be construed to
limit a plan's or issuer's coverage with respect to clinical trials.
``(g) Application to FEHBP.--Notwithstanding any provision of
chapter 89 of title 5, United States Code, this section shall apply to
health plans offered under the program under such chapter.
``(h) Preemption.--Notwithstanding any other provision of this Act,
nothing in this section shall preempt State laws that require a
clinical trials policy for State regulated health insurance plans that
is in addition to the policy required under this section.''.
(d) Section 1251(a) of this Act is amended--
(1) in paragraph (2), by striking ``With'' and inserting
``Except as provided in paragraph (3), with''; and
(2) by adding at the end the following:
``(3) Application of certain provisions.--The provisions of
sections 2715 and 2718 of the Public Health Service Act (as
added by subtitle A) shall apply to grandfathered health plans
for plan years beginning on or after the date of enactment of
this Act.''.
(e) Section 1253 of this Act is amended insert before the period
the following: ``, except that--
``(1) section 1251 shall take effect on the date of
enactment of this Act; and
``(2) the provisions of section 2704 of the Public Health
Service Act (as amended by section 1201), as they apply to
enrollees who are under 19 years of age, shall become effective
for plan years beginning on or after the date that is 6 months
after the date of enactment of this Act.''.
(f) Subtitle C of title I of this Act is amended--
(1) by redesignating section 1253 as section 1255; and
(2) by inserting after section 1252, the following:
``SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS.
``Not later than 1 year after the date of enactment of this Act,
and annually thereafter, the Secretary of Labor shall prepare an
aggregate annual report, using data collected from the Annual Return/
Report of Employee Benefit Plan (Department of Labor Form 5500), that
shall include general information on self-insured group health plans
(including plan type, number of participants, benefits offered, funding
arrangements, and benefit arrangements) as well as data from the
financial filings of self-insured employers (including information on
assets, liabilities, contributions, investments, and expenses). The
Secretary shall submit such reports to the appropriate committees of
Congress.
``SEC. 1254. STUDY OF LARGE GROUP MARKET.
``(a) In General.--The Secretary of Health and Human Services shall
conduct a study of the fully-insured and self-insured group health plan
markets to--
``(1) compare the characteristics of employers (including
industry, size, and other characteristics as determined
appropriate by the Secretary), health plan benefits, financial
solvency, capital reserve levels, and the risks of becoming
insolvent; and
``(2) determine the extent to which new insurance market
reforms are likely to cause adverse selection in the large
group market or to encourage small and midsize employers to
self-insure.
``(b) Collection of Information.--In conducting the study under
subsection (a), the Secretary, in coordination with the Secretary of
Labor, shall collect information and analyze--
``(1) the extent to which self-insured group health plans
can offer less costly coverage and, if so, whether lower costs
are due to more efficient plan administration and lower
overhead or to the denial of claims and the offering very
limited benefit packages;
``(2) claim denial rates, plan benefit fluctuations (to
evaluate the extent that plans scale back health benefits
during economic downturns), and the impact of the limited
recourse options on consumers; and
``(3) any potential conflict of interest as it relates to
the health care needs of self-insured enrollees and self-
insured employer's financial contribution or profit margin, and
the impact of such conflict on administration of the health
plan.
``(c) Report.--Not later than 1 year after the date of enactment of
this Act, the Secretary shall submit to the appropriate committees of
Congress a report concerning the results of the study conducted under
subsection (a).''.
SEC. 10104. AMENDMENTS TO SUBTITLE D.
(a) Section 1301(a) of this Act is amended by striking paragraph
(2) and inserting the following:
``(2) Inclusion of co-op plans and multi-state qualified
health plans.--Any reference in this title to a qualified
health plan shall be deemed to include a qualified health plan
offered through the CO-OP program under section 1322, and a
multi-State plan under section 1334, unless specifically
provided for otherwise.
``(3) Treatment of qualified direct primary care medical
home plans.--The Secretary of Health and Human Services shall
permit a qualified health plan to provide coverage through a
qualified direct primary care medical home plan that meets
criteria established by the Secretary, so long as the qualified
health plan meets all requirements that are otherwise
applicable and the services covered by the medical home plan
are coordinated with the entity offering the qualified health
plan.
``(4) Variation based on rating area.--A qualified health
plan, including a multi-State qualified health plan, may as
appropriate vary premiums by rating area (as defined in section
2701(a)(2) of the Public Health Service Act).''.
(b) Section 1302 of this Act is amended--
(1) in subsection (d)(2)(B), by striking ``may issue'' and
inserting ``shall issue''; and
(2) by adding at the end the following:
``(g) Payments to Federally-qualified Health Centers.--If any item
or service covered by a qualified health plan is provided by a
Federally-qualified health center (as defined in section 1905(l)(2)(B)
of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)) to an enrollee of
the plan, the offeror of the plan shall pay to the center for the item
or service an amount that is not less than the amount of payment that
would have been paid to the center under section 1902(bb) of such Act
(42 U.S.C. 1396a(bb)) for such item or service.''.
(c) Section 1303 of this Act is amended to read as follows:
``SEC. 1303. SPECIAL RULES.
``(a) State Opt-out of Abortion Coverage.--
``(1) In general.--A State may elect to prohibit abortion
coverage in qualified health plans offered through an Exchange
in such State if such State enacts a law to provide for such
prohibition.
``(2) Termination of opt out.--A State may repeal a law
described in paragraph (1) and provide for the offering of such
services through the Exchange.
``(b) Special Rules Relating to Coverage of Abortion Services.--
``(1) Voluntary choice of coverage of abortion services.--
``(A) In general.--Notwithstanding any other
provision of this title (or any amendment made by this
title)--
``(i) nothing in this title (or any
amendment made by this title), shall be
construed to require a qualified health plan to
provide coverage of services described in
subparagraph (B)(i) or (B)(ii) as part of its
essential health benefits for any plan year;
and
``(ii) subject to subsection (a), the
issuer of a qualified health plan shall
determine whether or not the plan provides
coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of such benefits for
the plan year.
``(B) Abortion services.--
``(i) Abortions for which public funding is
prohibited.--The services described in this
clause are abortions for which the expenditure
of Federal funds appropriated for the
Department of Health and Human Services is not
permitted, based on the law as in effect as of
the date that is 6 months before the beginning
of the plan year involved.
``(ii) Abortions for which public funding
is allowed.--The services described in this
clause are abortions for which the expenditure
of Federal funds appropriated for the
Department of Health and Human Services is
permitted, based on the law as in effect as of
the date that is 6 months before the beginning
of the plan year involved.
``(2) Prohibition on the use of federal funds.--
``(A) In general.--If a qualified health plan
provides coverage of services described in paragraph
(1)(B)(i), the issuer of the plan shall not use any
amount attributable to any of the following for
purposes of paying for such services:
``(i) The credit under section 36B of the
Internal Revenue Code of 1986 (and the amount
(if any) of the advance payment of the credit
under section 1412 of the Patient Protection
and Affordable Care Act).
``(ii) Any cost-sharing reduction under
section 1402 of the Patient Protection and
Affordable Care Act (and the amount (if any) of
the advance payment of the reduction under
section 1412 of the Patient Protection and
Affordable Care Act).
``(B) Establishment of allocation accounts.--In the
case of a plan to which subparagraph (A) applies, the
issuer of the plan shall--
``(i) collect from each enrollee in the
plan (without regard to the enrollee's age,
sex, or family status) a separate payment for
each of the following:
``(I) an amount equal to the
portion of the premium to be paid
directly by the enrollee for coverage
under the plan of services other than
services described in paragraph
(1)(B)(i) (after reduction for credits
and cost-sharing reductions described
in subparagraph (A)); and
``(II) an amount equal to the
actuarial value of the coverage of
services described in paragraph
(1)(B)(i), and
``(ii) shall deposit all such separate
payments into separate allocation accounts as
provided in subparagraph (C).
In the case of an enrollee whose premium for coverage
under the plan is paid through employee payroll
deposit, the separate payments required under this
subparagraph shall each be paid by a separate deposit.
``(C) Segregation of funds.--
``(i) In general.--The issuer of a plan to
which subparagraph (A) applies shall establish
allocation accounts described in clause (ii)
for enrollees receiving amounts described in
subparagraph (A).
``(ii) Allocation accounts.--The issuer of
a plan to which subparagraph (A) applies shall
deposit--
``(I) all payments described in
subparagraph (B)(i)(I) into a separate
account that consists solely of such
payments and that is used exclusively
to pay for services other than services
described in paragraph (1)(B)(i); and
``(II) all payments described in
subparagraph (B)(i)(II) into a separate
account that consists solely of such
payments and that is used exclusively
to pay for services described in
paragraph (1)(B)(i).
``(D) Actuarial value.--
``(i) In general.--The issuer of a
qualified health plan shall estimate the basic
per enrollee, per month cost, determined on an
average actuarial basis, for including coverage
under the qualified health plan of the services
described in paragraph (1)(B)(i).
``(ii) Considerations.--In making such
estimate, the issuer--
``(I) may take into account the
impact on overall costs of the
inclusion of such coverage, but may not
take into account any cost reduction
estimated to result from such services,
including prenatal care, delivery, or
postnatal care;
``(II) shall estimate such costs as
if such coverage were included for the
entire population covered; and
``(III) may not estimate such a
cost at less than $1 per enrollee, per
month.
``(E) Ensuring compliance with segregation
requirements.--
``(i) In general.--Subject to clause (ii),
State health insurance commissioners shall
ensure that health plans comply with the
segregation requirements in this subsection
through the segregation of plan funds in
accordance with applicable provisions of
generally accepted accounting requirements,
circulars on funds management of the Office of
Management and Budget, and guidance on
accounting of the Government Accountability
Office.
``(ii) Clarification.--Nothing in clause
(i) shall prohibit the right of an individual
or health plan to appeal such action in courts
of competent jurisdiction.
``(3) Rules relating to notice.--
``(A) Notice.--A qualified health plan that
provides for coverage of the services described in
paragraph (1)(B)(i) shall provide a notice to
enrollees, only as part of the summary of benefits and
coverage explanation, at the time of enrollment, of
such coverage.
``(B) Rules relating to payments.--The notice
described in subparagraph (A), any advertising used by
the issuer with respect to the plan, any information
provided by the Exchange, and any other information
specified by the Secretary shall provide information
only with respect to the total amount of the combined
payments for services described in paragraph (1)(B)(i)
and other services covered by the plan.
``(4) No discrimination on basis of provision of
abortion.--No qualified health plan offered through an Exchange
may discriminate against any individual health care provider or
health care facility because of its unwillingness to provide,
pay for, provide coverage of, or refer for abortions
``(c) Application of State and Federal Laws Regarding Abortion.--
``(1) No preemption of state laws regarding abortion.--
Nothing in this Act shall be construed to preempt or otherwise
have any effect on State laws regarding the prohibition of (or
requirement of) coverage, funding, or procedural requirements
on abortions, including parental notification or consent for
the performance of an abortion on a minor.
``(2) No effect on federal laws regarding abortion.--
``(A) In general.--Nothing in this Act shall be
construed to have any effect on Federal laws
regarding--
``(i) conscience protection;
``(ii) willingness or refusal to provide
abortion; and
``(iii) discrimination on the basis of the
willingness or refusal to provide, pay for,
cover, or refer for abortion or to provide or
participate in training to provide abortion.
``(3) No effect on federal civil rights law.--Nothing in
this subsection shall alter the rights and obligations of
employees and employers under title VII of the Civil Rights Act
of 1964.
``(d) Application of Emergency Services Laws.--Nothing in this Act
shall be construed to relieve any health care provider from providing
emergency services as required by State or Federal law, including
section 1867 of the Social Security Act (popularly known as
`EMTALA').''.
(d) Section 1304 of this Act is amended by adding at the end the
following:
``(e) Educated Health Care Consumers.--The term `educated health
care consumer' means an individual who is knowledgeable about the
health care system, and has background or experience in making informed
decisions regarding health, medical, and scientific matters.''.
(e) Section 1311(d) of this Act is amended--
(1) in paragraph (3)(B), by striking clause (ii) and
inserting the following:
``(ii) State must assume cost.--A State
shall make payments--
``(I) to an individual enrolled in
a qualified health plan offered in such
State; or
``(II) on behalf of an individual
described in subclause (I) directly to
the qualified health plan in which such
individual is enrolled;
to defray the cost of any additional benefits
described in clause (i).''; and
(2) in paragraph (6)(A), by inserting ``educated'' before
``health care''.
(f) Section 1311(e) of this Act is amended--
(1) in paragraph (2), by striking ``may'' in the second
sentence and inserting ``shall''; and
(2) by adding at the end the following:
``(3) Transparency in coverage.--
``(A) In general.--The Exchange shall require
health plans seeking certification as qualified health
plans to submit to the Exchange, the Secretary, the
State insurance commissioner, and make available to the
public, accurate and timely disclosure of the following
information:
``(i) Claims payment policies and
practices.
``(ii) Periodic financial disclosures.
``(iii) Data on enrollment.
``(iv) Data on disenrollment.
``(v) Data on the number of claims that are
denied.
``(vi) Data on rating practices.
``(vii) Information on cost-sharing and
payments with respect to any out-of-network
coverage.
``(viii) Information on enrollee and
participant rights under this title.
``(ix) Other information as determined
appropriate by the Secretary.
``(B) Use of plain language.--The information
required to be submitted under subparagraph (A) shall
be provided in plain language. The term `plain
language' means language that the intended audience,
including individuals with limited English proficiency,
can readily understand and use because that language is
concise, well-organized, and follows other best
practices of plain language writing. The Secretary and
the Secretary of Labor shall jointly develop and issue
guidance on best practices of plain language writing.
``(C) Cost sharing transparency.--The Exchange
shall require health plans seeking certification as
qualified health plans to permit individuals to learn
the amount of cost-sharing (including deductibles,
copayments, and coinsurance) under the individual's
plan or coverage that the individual would be
responsible for paying with respect to the furnishing
of a specific item or service by a participating
provider in a timely manner upon the request of the
individual. At a minimum, such information shall be
made available to such individual through an Internet
website and such other means for individuals without
access to the Internet.
``(D) Group health plans.--The Secretary of Labor
shall update and harmonize the Secretary's rules
concerning the accurate and timely disclosure to
participants by group health plans of plan disclosure,
plan terms and conditions, and periodic financial
disclosure with the standards established by the
Secretary under subparagraph (A).''.
(g) Section 1311(g)(1) of this Act is amended--
(1) in subparagraph (C), by striking ``; and'' and
inserting a semicolon;
(2) in subparagraph (D), by striking the period and
inserting ``; and''; and
(3) by adding at the end the following:
``(E) the implementation of activities to reduce
health and health care disparities, including through
the use of language services, community outreach, and
cultural competency trainings.''.
(h) Section 1311(i)(2)((B) of this Act is amended by striking
``small business development centers'' and inserting ``resource
partners of the Small Business Administration''.
(i) Section 1312 of this Act is amended--
(1) in subsection (a)(1), by inserting ``and for which such
individual is eligible'' before the period;
(2) in subsection (e)--
(A) in paragraph (1), by inserting ``and
employers'' after ``enroll individuals''; and
(B) by striking the flush sentence at the end; and
(3) in subsection (f)(1)(A)(ii), by striking the
parenthetical.
(j)(1) Subparagraph (B) of section 1313(a)(6) of this Act is hereby
deemed null, void, and of no effect.
(2) Section 3730(e) of title 31, United States Code, is amended by
striking paragraph (4) and inserting the following:
``(4)(A) The court shall dismiss an action or claim under
this section, unless opposed by the Government, if
substantially the same allegations or transactions as alleged
in the action or claim were publicly disclosed--
``(i) in a Federal criminal, civil, or
administrative hearing in which the Government or its
agent is a party;
``(ii) in a congressional, Government
Accountability Office, or other Federal report,
hearing, audit, or investigation; or
``(iii) from the news media,
unless the action is brought by the Attorney General or the
person bringing the action is an original source of the
information.
``(B) For purposes of this paragraph, ``original source''
means an individual who either (i) prior to a public disclosure
under subsection (e)(4)(a), has voluntarily disclosed to the
Government the information on which allegations or transactions
in a claim are based, or (2) who has knowledge that is
independent of and materially adds to the publicly disclosed
allegations or transactions, and who has voluntarily provided
the information to the Government before filing an action under
this section.''.
(k) Section 1313(b) of this Act is amended--
(1) in paragraph (3), by striking ``and'' at the end;
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following:
``(4) a survey of the cost and affordability of health care
insurance provided under the Exchanges for owners and employees
of small business concerns (as defined under section 3 of the
Small Business Act (15 U.S.C. 632)), including data on
enrollees in Exchanges and individuals purchasing health
insurance coverage outside of Exchanges; and''.
(l) Section 1322(b) of this Act is amended--
(1) by redesignating paragraph (3) as paragraph (4); and
(2) by inserting after paragraph (2), the following:
``(3) Repayment of loans and grants.--Not later than July
1, 2013, and prior to awarding loans and grants under the CO-OP
program, the Secretary shall promulgate regulations with
respect to the repayment of such loans and grants in a manner
that is consistent with State solvency regulations and other
similar State laws that may apply. In promulgating such
regulations, the Secretary shall provide that such loans shall
be repaid within 5 years and such grants shall be repaid within
15 years, taking into consideration any appropriate State
reserve requirements, solvency regulations, and requisite
surplus note arrangements that must be constructed in a State
to provide for such repayment prior to awarding such loans and
grants.''.
(m) Part III of subtitle D of title I of this Act is amended by
striking section 1323.
(n) Section 1324(a) of this Act is amended by striking ``, a
community health'' and all that follows through ``1333(b)'' and
inserting ``, or a multi-State qualified health plan under section
1334''.
(o) Section 1331 of this Act is amended--
(1) in subsection (d)(3)(A)(i), by striking ``85'' and
inserting ``95''; and
(2) in subsection (e)(1)(B), by inserting before the
semicolon the following: ``, or, in the case of an alien
lawfully present in the United States, whose income is not
greater than 133 percent of the poverty line for the size of
the family involved but who is not eligible for the Medicaid
program under title XIX of the Social Security Act by reason of
such alien status''.
(p) Section 1333 of this Act is amended by striking subsection (b).
(q) Part IV of subtitle D of title I of this Act is amended by
adding at the end the following:
``SEC. 1334. MULTI-STATE PLANS.
``(a) Oversight by the Office of Personnel Management.--
``(1) In general.--The Director of the Office of Personnel
Management (referred to in this section as the `Director')
shall enter into contracts with health insurance issuers (which
may include a group of health insurance issuers affiliated
either by common ownership and control or by the common use of
a nationally licensed service mark), without regard to section
5 of title 41, United States Code, or other statutes requiring
competitive bidding, to offer at least 2 multi-State qualified
health plans through each Exchange in each State. Such plans
shall provide individual, or in the case of small employers,
group coverage.
``(2) Terms.--Each contract entered into under paragraph
(1) shall be for a uniform term of at least 1 year, but may be
made automatically renewable from term to term in the absence
of notice of termination by either party. In entering into such
contracts, the Director shall ensure that health benefits
coverage is provided in accordance with the types of coverage
provided for under section 2701(a)(1)(A)(i) of the Public
Health Service Act.
``(3) Non-profit entities.--In entering into contracts
under paragraph (1), the Director shall ensure that at least
one contract is entered into with a non-profit entity.
``(4) Administration.--The Director shall implement this
subsection in a manner similar to the manner in which the
Director implements the contracting provisions with respect to
carriers under the Federal employees health benefit program
under chapter 89 of title 5, United States Code, including
(through negotiating with each multi-state plan)--
``(A) a medical loss ratio;
``(B) a profit margin;
``(C) the premiums to be charged; and
``(D) such other terms and conditions of coverage
as are in the interests of enrollees in such plans.
``(5) Authority to protect consumers.--The Director may
prohibit the offering of any multi-State health plan that does
not meet the terms and conditions defined by the Director with
respect to the elements described in subparagraphs (A) through
(D) of paragraph (4).
``(6) Assured availability of varied coverage.--In entering
into contracts under this subsection, the Director shall ensure
that with respect to multi-State qualified health plans offered
in an Exchange, there is at least one such plan that does not
provide coverage of services described in section
1303(b)(1)(B)(i).
``(7) Withdrawal.--Approval of a contract under this
subsection may be withdrawn by the Director only after notice
and opportunity for hearing to the issuer concerned without
regard to subchapter II of chapter 5 and chapter 7 of title 5,
United States Code.
``(b) Eligibility.--A health insurance issuer shall be eligible to
enter into a contract under subsection (a)(1) if such issuer--
``(1) agrees to offer a multi-State qualified health plan
that meets the requirements of subsection (c) in each Exchange
in each State;
``(2) is licensed in each State and is subject to all
requirements of State law not inconsistent with this section,
including the standards and requirements that a State imposes
that do not prevent the application of a requirement of part A
of title XXVII of the Public Health Service Act or a
requirement of this title;
``(3) otherwise complies with the minimum standards
prescribed for carriers offering health benefits plans under
section 8902(e) of title 5, United States Code, to the extent
that such standards do not conflict with a provision of this
title; and
``(4) meets such other requirements as determined
appropriate by the Director, in consultation with the
Secretary.
``(c) Requirements for Multi-State Qualified Health Plan.--
``(1) In general.--A multi-State qualified health plan
meets the requirements of this subsection if, in the
determination of the Director--
``(A) the plan offers a benefits package that is
uniform in each State and consists of the essential
benefits described in section 1302;
``(B) the plan meets all requirements of this title
with respect to a qualified health plan, including
requirements relating to the offering of the bronze,
silver, and gold levels of coverage and catastrophic
coverage in each State Exchange;
``(C) except as provided in paragraph (5), the
issuer provides for determinations of premiums for
coverage under the plan on the basis of the rating
requirements of part A of title XXVII of the Public
Health Service Act; and
``(D) the issuer offers the plan in all geographic
regions, and in all States that have adopted adjusted
community rating before the date of enactment of this
Act.
``(2) States may offer additional benefits.--Nothing in
paragraph (1)(A) shall preclude a State from requiring that
benefits in addition to the essential health benefits required
under such paragraph be provided to enrollees of a multi-State
qualified health plan offered in such State.
``(3) Credits.--
``(A) In general.--An individual enrolled in a
multi-State qualified health plan under this section
shall be eligible for credits under section 36B of the
Internal Revenue Code of 1986 and cost sharing
assistance under section 1402 in the same manner as an
individual who is enrolled in a qualified health plan.
``(B) No additional federal cost.--A requirement by
a State under paragraph (2) that benefits in addition
to the essential health benefits required under
paragraph (1)(A) be provided to enrollees of a multi-
State qualified health plan shall not affect the amount
of a premium tax credit provided under section 36B of
the Internal Revenue Code of 1986 with respect to such
plan.
``(4) State must assume cost.--A State shall make
payments--
``(A) to an individual enrolled in a multi-State
qualified health plan offered in such State; or
``(B) on behalf of an individual described in
subparagraph (A) directly to the multi-State qualified
health plan in which such individual is enrolled;
to defray the cost of any additional benefits described in
paragraph (2).
``(5) Application of certain state rating requirements.--
With respect to a multi-State qualified health plan that is
offered in a State with age rating requirements that are lower
than 3:1, the State may require that Exchanges operating in
such State only permit the offering of such multi-State
qualified health plans if such plans comply with the State's
more protective age rating requirements.
``(d) Plans Deemed To Be Certified.--A multi-State qualified health
plan that is offered under a contract under subsection (a) shall be
deemed to be certified by an Exchange for purposes of section
1311(d)(4)(A).
``(e) Phase-in.--Notwithstanding paragraphs (1) and (2) of
subsection (b), the Director shall enter into a contract with a health
insurance issuer for the offering of a multi-State qualified health
plan under subsection (a) if--
``(1) with respect to the first year for which the issuer
offers such plan, such issuer offers the plan in at least 60
percent of the States;
``(2) with respect to the second such year, such issuer
offers the plan in at least 70 percent of the States;
``(3) with respect to the third such year, such issuer
offers the plan in at least 85 percent of the States; and
``(4) with respect to each subsequent year, such issuer
offers the plan in all States.
``(f) Applicability.--The requirements under chapter 89 of title 5,
United States Code, applicable to health benefits plans under such
chapter shall apply to multi-State qualified health plans provided for
under this section to the extent that such requirements do not conflict
with a provision of this title.
``(g) Continued Support for FEHBP.--
``(1) Maintenance of effort.--Nothing in this section shall
be construed to permit the Director to allocate fewer financial
or personnel resources to the functions of the Office of
Personnel Management related to the administration of the
Federal Employees Health Benefit Program under chapter 89 of
title 5, United States Code.
``(2) Separate risk pool.--Enrollees in multi-State
qualified health plans under this section shall be treated as a
separate risk pool apart from enrollees in the Federal
Employees Health Benefit Program under chapter 89 of title 5,
United States Code.
``(3) Authority to establish separate entities.--The
Director may establish such separate units or offices within
the Office of Personnel Management as the Director determines
to be appropriate to ensure that the administration of multi-
State qualified health plans under this section does not
interfere with the effective administration of the Federal
Employees Health Benefit Program under chapter 89 of title 5,
United States Code.
``(4) Effective oversight.--The Director may appoint such
additional personnel as may be necessary to enable the Director
to carry out activities under this section.
``(5) Assurance of separate program.--In carrying out this
section, the Director shall ensure that the program under this
section is separate from the Federal Employees Health Benefit
Program under chapter 89 of title 5, United States Code.
Premiums paid for coverage under a multi-State qualified health
plan under this section shall not be considered to be Federal
funds for any purposes.
``(6) FEHBP plans not required to participate.--Nothing in
this section shall require that a carrier offering coverage
under the Federal Employees Health Benefit Program under
chapter 89 of title 5, United States Code, also offer a multi-
State qualified health plan under this section.
``(h) Advisory Board.--The Director shall establish an advisory
board to provide recommendations on the activities described in this
section. A significant percentage of the members of such board shall be
comprised of enrollees in a multi-State qualified health plan, or
representatives of such enrollees.
``(i) Authorization of Appropriations.--There is authorized to be
appropriated, such sums as may be necessary to carry out this
section.''.
(r) Section 1341 of this Act is amended--
(1) in the section heading, by striking ``and small group
markets'' and inserting ``market'';
(2) in subsection (b)(2)(B), by striking ``paragraph
(1)(A)'' and inserting ``paragraph (1)(B)''; and
(3) in subsection (c)(1)(A), by striking ``and small group
markets'' and inserting ``market''.
SEC. 10105. AMENDMENTS TO SUBTITLE E.
(a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986,
as added by section 1401(a) of this Act, is amended by striking ``is in
excess of'' and inserting ``equals or exceeds''.
(b) Section 36B(c)(1)(A) of the Internal Revenue Code of 1986, as
added by section 1401(a) of this Act, is amended by inserting ``equals
or'' before ``exceeds''.
(c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code of 1986,
as added by section 1401(a) of this Act, is amended by striking
``subsection (b)(3)(A)(ii)'' and inserting ``subsection
(b)(3)(A)(iii)''.
(d) Section 1401(d) of this Act is amended by adding at the end the
following:
``(3) Section 6211(b)(4)(A) of the Internal Revenue Code of
1986 is amended by inserting `36B,' after `36A,'.''.
(e)(1) Subparagraph (B) of section 45R(d)(3) of the Internal
Revenue Code of 1986, as added by section 1421(a) of this Act, is
amended to read as follows:
``(B) Dollar amount.--For purposes of paragraph
(1)(B) and subsection (c)(2)--
``(i) 2010, 2011, 2012, and 2013.--The
dollar amount in effect under this paragraph
for taxable years beginning in 2010, 2011,
2012, or 2013 is $25,000.
``(ii) Subsequent years.--In the case of a
taxable year beginning in a calendar year after
2013, the dollar amount in effect under this
paragraph shall be equal to $25,000, multiplied
by the cost-of-living adjustment under section
1(f)(3) for the calendar year, determined by
substituting `calendar year 2012' for `calendar
year 1992' in subparagraph (B) thereof.''.
(2) Subsection (g) of section 45R of the Internal Revenue Code of
1986, as added by section 1421(a) of this Act, is amended by striking
``2011'' both places it appears and inserting ``2010, 2011''.
(3) Section 280C(h) of the Internal Revenue Code of 1986, as added
by section 1421(d)(1) of this Act, is amended by striking ``2011'' and
inserting ``2010, 2011''.
(4) Section 1421(f) of this Act is amended by striking ``2010''
both places it appears and inserting ``2009''.
(5) The amendments made by this subsection shall take effect as if
included in the enactment of section 1421 of this Act.
(f) Part I of subtitle E of title I of this Act is amended by
adding at the end of subpart B, the following:
``SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL.
``(a) In General.--The Secretary shall conduct a study to examine
the feasibility and implication of adjusting the application of the
Federal poverty level under this subtitle (and the amendments made by
this subtitle) for different geographic areas so as to reflect the
variations in cost-of-living among different areas within the United
States. If the Secretary determines that an adjustment is feasible, the
study should include a methodology to make such an adjustment. Not
later than January 1, 2013, the Secretary shall submit to Congress a
report on such study and shall include such recommendations as the
Secretary determines appropriate.
``(b) Inclusion of Territories.--
``(1) In general.--The Secretary shall ensure that the
study under subsection (a) covers the territories of the United
States and that special attention is paid to the disparity that
exists among poverty levels and the cost of living in such
territories and to the impact of such disparity on efforts to
expand health coverage and ensure health care.
``(2) Territories defined.--In this subsection, the term
`territories of the United States' includes the Commonwealth of
Puerto Rico, the United States Virgin Islands, Guam, the
Northern Mariana Islands, and any other territory or possession
of the United States.''.
SEC. 10106. AMENDMENTS TO SUBTITLE F.
(a) Section 1501(a)(2) of this Act is amended to read as follows:
``(2) Effects on the national economy and interstate
commerce.--The effects described in this paragraph are the
following:
``(A) The requirement regulates activity that is
commercial and economic in nature: economic and
financial decisions about how and when health care is
paid for, and when health insurance is purchased. In
the absence of the requirement, some individuals would
make an economic and financial decision to forego
health insurance coverage and attempt to self-insure,
which increases financial risks to households and
medical providers.
``(B) Health insurance and health care services are
a significant part of the national economy. National
health spending is projected to increase from
$2,500,000,000,000, or 17.6 percent of the economy, in
2009 to $4,700,000,000,000 in 2019. Private health
insurance spending is projected to be $854,000,000,000
in 2009, and pays for medical supplies, drugs, and
equipment that are shipped in interstate commerce.
Since most health insurance is sold by national or
regional health insurance companies, health insurance
is sold in interstate commerce and claims payments flow
through interstate commerce.
``(C) The requirement, together with the other
provisions of this Act, will add millions of new
consumers to the health insurance market, increasing
the supply of, and demand for, health care services,
and will increase the number and share of Americans who
are insured.
``(D) The requirement achieves near-universal
coverage by building upon and strengthening the private
employer-based health insurance system, which covers
176,000,000 Americans nationwide. In Massachusetts, a
similar requirement has strengthened private employer-
based coverage: despite the economic downturn, the
number of workers offered employer-based coverage has
actually increased.
``(E) The economy loses up to $207,000,000,000 a
year because of the poorer health and shorter lifespan
of the uninsured. By significantly reducing the number
of the uninsured, the requirement, together with the
other provisions of this Act, will significantly reduce
this economic cost.
``(F) The cost of providing uncompensated care to
the uninsured was $43,000,000,000 in 2008. To pay for
this cost, health care providers pass on the cost to
private insurers, which pass on the cost to families.
This cost-shifting increases family premiums by on
average over $1,000 a year. By significantly reducing
the number of the uninsured, the requirement, together
with the other provisions of this Act, will lower
health insurance premiums.
``(G) 62 percent of all personal bankruptcies are
caused in part by medical expenses. By significantly
increasing health insurance coverage, the requirement,
together with the other provisions of this Act, will
improve financial security for families.
``(H) Under the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health
Service Act (42 U.S.C. 201 et seq.), and this Act, the
Federal Government has a significant role in regulating
health insurance. The requirement is an essential part
of this larger regulation of economic activity, and the
absence of the requirement would undercut Federal
regulation of the health insurance market.
``(I) Under sections 2704 and 2705 of the Public
Health Service Act (as added by section 1201 of this
Act), if there were no requirement, many individuals
would wait to purchase health insurance until they
needed care. By significantly increasing health
insurance coverage, the requirement, together with the
other provisions of this Act, will minimize this
adverse selection and broaden the health insurance risk
pool to include healthy individuals, which will lower
health insurance premiums. The requirement is essential
to creating effective health insurance markets in which
improved health insurance products that are guaranteed
issue and do not exclude coverage of pre-existing
conditions can be sold.
``(J) Administrative costs for private health
insurance, which were $90,000,000,000 in 2006, are 26
to 30 percent of premiums in the current individual and
small group markets. By significantly increasing health
insurance coverage and the size of purchasing pools,
which will increase economies of scale, the
requirement, together with the other provisions of this
Act, will significantly reduce administrative costs and
lower health insurance premiums. The requirement is
essential to creating effective health insurance
markets that do not require underwriting and eliminate
its associated administrative costs.''.
(b)(1) Section 5000A(b)(1) of the Internal Revenue Code of 1986, as
added by section 1501(b) of this Act, is amended to read as follows:
``(1) In general.--If a taxpayer who is an applicable
individual, or an applicable individual for whom the taxpayer
is liable under paragraph (3), fails to meet the requirement of
subsection (a) for 1 or more months, then, except as provided
in subsection (e), there is hereby imposed on the taxpayer a
penalty with respect to such failures in the amount determined
under subsection (c).''.
(2) Paragraphs (1) and (2) of section 5000A(c) of the
Internal Revenue Code of 1986, as so added, are amended to read
as follows:
``(1) In general.--The amount of the penalty imposed by
this section on any taxpayer for any taxable year with respect
to failures described in subsection (b)(1) shall be equal to
the lesser of--
``(A) the sum of the monthly penalty amounts
determined under paragraph (2) for months in the
taxable year during which 1 or more such failures
occurred, or
``(B) an amount equal to the national average
premium for qualified health plans which have a bronze
level of coverage, provide coverage for the applicable
family size involved, and are offered through Exchanges
for plan years beginning in the calendar year with or
within which the taxable year ends.
``(2) Monthly penalty amounts.--For purposes of paragraph
(1)(A), the monthly penalty amount with respect to any taxpayer
for any month during which any failure described in subsection
(b)(1) occurred is an amount equal to \1/12\ of the greater of
the following amounts:
``(A) Flat dollar amount.--An amount equal to the
lesser of--
``(i) the sum of the applicable dollar
amounts for all individuals with respect to
whom such failure occurred during such month,
or
``(ii) 300 percent of the applicable dollar
amount (determined without regard to paragraph
(3)(C)) for the calendar year with or within
which the taxable year ends.
``(B) Percentage of income.--An amount equal to the
following percentage of the taxpayer's household income
for the taxable year:
``(i) 0.5 percent for taxable years
beginning in 2014.
``(ii) 1.0 percent for taxable years
beginning in 2015.
``(iii) 2.0 percent for taxable years
beginning after 2015.''.
(3) Section 5000A(c)(3) of the Internal Revenue Code of 1986, as
added by section 1501(b) of this Act, is amended by striking ``$350''
and inserting ``$495''.
(c) Section 5000A(d)(2)(A) of the Internal Revenue Code of 1986, as
added by section 1501(b) of this Act, is amended to read as follows:
``(A) Religious conscience exemption.--Such term
shall not include any individual for any month if such
individual has in effect an exemption under section
1311(d)(4)(H) of the Patient Protection and Affordable
Care Act which certifies that such individual is--
``(i) a member of a recognized religious
sect or division thereof which is described in
section 1402(g)(1), and
``(ii) an adherent of established tenets or
teachings of such sect or division as described
in such section.''.
(d) Section 5000A(e)(1)(C) of the Internal Revenue Code of 1986, as
added by section 1501(b) of this Act, is amended to read as follows:
``(C) Special rules for individuals related to
employees.--For purposes of subparagraph (B)(i), if an
applicable individual is eligible for minimum essential
coverage through an employer by reason of a
relationship to an employee, the determination under
subparagraph (A) shall be made by reference to required
contribution of the employee.''.
(e) Section 4980H(b) of the Internal Revenue Code of 1986, as added
by section 1513(a) of this Act, is amended to read as follows:
``(b) Large Employers With Waiting Periods Exceeding 60 Days.--
``(1) In general.--In the case of any applicable large
employer which requires an extended waiting period to enroll in
any minimum essential coverage under an employer-sponsored plan
(as defined in section 5000A(f)(2)), there is hereby imposed on
the employer an assessable payment of $600 for each full-time
employee of the employer to whom the extended waiting period
applies.
``(2) Extended waiting period.--The term `extended waiting
period' means any waiting period (as defined in section
2701(b)(4) of the Public Health Service Act) which exceeds 60
days.''.
(f)(1) Subparagraph (A) of section 4980H(d)(4) of the Internal
Revenue Code of 1986, as added by section 1513(a) of this Act, is
amended by inserting ``, with respect to any month,'' after ``means''.
(2) Section 4980H(d)(2) of the Internal Revenue Code of 1986, as
added by section 1513(a) of this Act, is amended by adding at the end
the following:
``(D) Application to construction industry
employers.--In the case of any employer the substantial
annual gross receipts of which are attributable to the
construction industry--
``(i) subparagraph (A) shall be applied by
substituting `who employed an average of at
least 5 full-time employees on business days
during the preceding calendar year and whose
annual payroll expenses exceed $250,000 for
such preceding calendar year' for `who employed
an average of at least 50 full-time employees
on business days during the preceding calendar
year', and
``(ii) subparagraph (B) shall be applied by
substituting `5' for `50'.''.
(3) The amendment made by paragraph (2) shall apply to months
beginning after December 31, 2013.
(g) Section 6056(b) of the Internal Revenue Code of 1986, as added
by section 1514(a) of the Act, is amended by adding at the end the
following new flush sentence:
``The Secretary shall have the authority to review the accuracy of the
information provided under this subsection, including the applicable
large employer's share under paragraph (2)(C)(iv).''.
SEC. 10107. AMENDMENTS TO SUBTITLE G.
(a) Section 1562 of this Act is amended, in the amendment made by
subsection (a)(2)(B)(iii), by striking ``subpart 1'' and inserting
``subparts I and II''; and
(b) Subtitle G of title I of this Act is amended--
(1) by redesignating section 1562 (as amended) as section
1563; and
(2) by inserting after section 1561 the following:
``SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF COVERAGE AND
ENROLLMENT BY HEALTH INSURANCE ISSUERS AND GROUP HEALTH
PLANS.
``(a) In General.--The Comptroller General of the United States
(referred to in this section as the `Comptroller General') shall
conduct a study of the incidence of denials of coverage for medical
services and denials of applications to enroll in health insurance
plans, as described in subsection (b), by group health plans and health
insurance issuers.
``(b) Data.--
``(1) In general.--In conducting the study described in
subsection (a), the Comptroller General shall consider samples
of data concerning the following:
``(A)(i) denials of coverage for medical services
to a plan enrollees, by the types of services for which
such coverage was denied; and
``(ii) the reasons such coverage was denied; and
``(B)(i) incidents in which group health plans and
health insurance issuers deny the application of an
individual to enroll in a health insurance plan offered
by such group health plan or issuer; and
``(ii) the reasons such applications are denied.
``(2) Scope of data.--
``(A) Favorably resolved disputes.--The data that
the Comptroller General considers under paragraph (1)
shall include data concerning denials of coverage for
medical services and denials of applications for
enrollment in a plan by a group health plan or health
insurance issuer, where such group health plan or
health insurance issuer later approves such coverage or
application.
``(B) All health plans.--The study under this
section shall consider data from varied group health
plans and health insurance plans offered by health
insurance issuers, including qualified health plans and
health plans that are not qualified health plans.
``(c) Report.--Not later than one year after the date of enactment
of this Act, the Comptroller General shall submit to the Secretaries of
Health and Human Services and Labor a report describing the results of
the study conducted under this section.
``(d) Publication of Report.--The Secretaries of Health and Human
Services and Labor shall make the report described in subsection (c)
available to the public on an Internet website.
``SEC. 1563. SMALL BUSINESS PROCUREMENT.
``Part 19 of the Federal Acquisition Regulation, section 15 of the
Small Business Act (15 U.S.C. 644), and any other applicable laws or
regulations establishing procurement requirements relating to small
business concerns (as defined in section 3 of the Small Business Act
(15 U.S.C. 632)) may not be waived with respect to any contract awarded
under any program or other authority under this Act or an amendment
made by this Act.''.
SEC. 10108. FREE CHOICE VOUCHERS.
(a) In General.--An offering employer shall provide free choice
vouchers to each qualified employee of such employer.
(b) Offering Employer.--For purposes of this section, the term
``offering employer'' means any employer who--
(1) offers minimum essential coverage to its employees
consisting of coverage through an eligible employer-sponsored
plan; and
(2) pays any portion of the costs of such plan.
(c) Qualified Employee.--For purposes of this section--
(1) In general.--The term ``qualified employee'' means,
with respect to any plan year of an offering employer, any
employee--
(A) whose required contribution (as determined
under section 5000A(e)(1)(B)) for minimum essential
coverage through an eligible employer-sponsored plan--
(i) exceeds 8 percent of such employee's
household income for the taxable year described
in section 1412(b)(1)(B) which ends with or
within in the plan year; and
(ii) does not exceed 9.8 percent of such
employee's household income for such taxable
year;
(B) whose household income for such taxable year is
not greater than 400 percent of the poverty line for a
family of the size involved; and
(C) who does not participate in a health plan
offered by the offering employer.
(2) Indexing.--In the case of any calendar year beginning
after 2014, the Secretary shall adjust the 8 percent under
paragraph (1)(A)(i) and 9.8 percent under paragraph (1)(A)(ii)
for the calendar year to reflect the rate of premium growth
between the preceding calendar year and 2013 over the rate of
income growth for such period.
(d) Free Choice Voucher.--
(1) Amount.--
(A) In general.--The amount of any free choice
voucher provided under subsection (a) shall be equal to
the monthly portion of the cost of the eligible
employer-sponsored plan which would have been paid by
the employer if the employee were covered under the
plan with respect to which the employer pays the
largest portion of the cost of the plan. Such amount
shall be equal to the amount the employer would pay for
an employee with self-only coverage unless such
employee elects family coverage (in which case such
amount shall be the amount the employer would pay for
family coverage).
(B) Determination of cost.--The cost of any health
plan shall be determined under the rules similar to the
rules of section 2204 of the Public Health Service Act,
except that such amount shall be adjusted for age and
category of enrollment in accordance with regulations
established by the Secretary.
(2) Use of vouchers.--An Exchange shall credit the amount
of any free choice voucher provided under subsection (a) to the
monthly premium of any qualified health plan in the Exchange in
which the qualified employee is enrolled and the offering
employer shall pay any amounts so credited to the Exchange.
(3) Payment of excess amounts.--If the amount of the free
choice voucher exceeds the amount of the premium of the
qualified health plan in which the qualified employee is
enrolled for such month, such excess shall be paid to the
employee.
(e) Other Definitions.--Any term used in this section which is also
used in section 5000A of the Internal Revenue Code of 1986 shall have
the meaning given such term under such section 5000A.
(f) Exclusion From Income for Employee.--
(1) In general.--Part III of subchapter B of chapter 1 of
the Internal Revenue Code of 1986 is amended by inserting after
section 139C the following new section:
``SEC. 139D. FREE CHOICE VOUCHERS.
``Gross income shall not include the amount of any free choice
voucher provided by an employer under section 10108 of the Patient
Protection and Affordable Care Act to the extent that the amount of
such voucher does not exceed the amount paid for a qualified health
plan (as defined in section 1301 of such Act) by the taxpayer.''.
(2) Clerical amendment.--The table of sections for part III
of subchapter B of chapter 1 of such Code is amended by
inserting after the item relating to section 139C the following
new item:
``Sec. 139D. Free choice vouchers.''.
(3) Effective date.--The amendments made by this subsection
shall apply to vouchers provided after December 31, 2013.
(g) Deduction Allowed to Employer.--
(1) In general.--Section 162(a) of the Internal Revenue
Code of 1986 is amended by adding at the end the following new
sentence: ``For purposes of paragraph (1), the amount of a free
choice voucher provided under section 10108 of the Patient
Protection and Affordable Care Act shall be treated as an
amount for compensation for personal services actually
rendered.''.
(2) Effective date.--The amendments made by this subsection
shall apply to vouchers provided after December 31, 2013.
(h) Voucher Taken Into Account in Determining Premium Credit.--
(1) In general.--Subsection (c)(2) of section 36B of the
Internal Revenue Code of 1986, as added by section 1401, is
amended by adding at the end the following new subparagraph:
``(D) Exception for individual receiving free
choice vouchers.--The term `coverage month' shall not
include any month in which such individual has a free
choice voucher provided under section 10108 of the
Patient Protection and Affordable Care Act.''.
(2) Effective date.--The amendment made by this subsection
shall apply to taxable years beginning after December 31, 2013.
(i) Coordination With Employer Responsibilities.--
(1) Shared responsibility penalty.--
(A) In general.--Subsection (c) of section 4980H of
the Internal Revenue Code of 1986, as added by section
1513, is amended by adding at the end the following new
paragraph:
``(3) Special rules for employers providing free choice
vouchers.--No assessable payment shall be imposed under
paragraph (1) for any month with respect to any employee to
whom the employer provides a free choice voucher under section
10108 of the Patient Protection and Affordable Care Act for
such month.''.
(B) Effective date.--The amendment made by this
paragraph shall apply to months beginning after
December 31, 2013.
(2) Notification requirement.--Section 18B(a)(3) of the
Fair Labor Standards Act of 1938, as added by section 1512, is
amended--
(A) by inserting ``and the employer does not offer
a free choice voucher'' after ``Exchange''; and
(B) by striking ``will lose'' and inserting ``may
lose''.
(j) Employer Reporting.--
(1) In general.--Subsection (a) of section 6056 of the
Internal Revenue Code of 1986, as added by section 1514, is
amended by inserting ``and every offering employer'' before
``shall''.
(2) Offering employers.--Subsection (f) of section 6056 of
such Code, as added by section 1514, is amended to read as
follows:
``(f) Definitions.--For purposes of this section--
``(1) Offering employer.--
``(A) In general.--The term `offering employer'
means any offering employer (as defined in section
10108(b) of the Patient Protection and Affordable Care
Act) if the required contribution (within the meaning
of section 5000A(e)(1)(B)(i)) of any employee exceeds 8
percent of the wages (as defined in section 3121(a))
paid to such employee by such employer.
``(B) Indexing.--In the case of any calendar year
beginning after 2014, the 8 percent under subparagraph
(A) shall be adjusted for the calendar year to reflect
the rate of premium growth between the preceding
calendar year and 2013 over the rate of income growth
for such period.
``(2) Other definitions.--Any term used in this section
which is also used in section 4980H shall have the meaning
given such term by section 4980H.''.
(3) Conforming amendments.--
(A) The heading of section 6056 of such Code, as
added by section 1514, is amended by striking ``large''
and inserting ``certain''.
(B) Section 6056(b)(2)(C) of such Code is amended--
(i) by inserting ``in the case of an
applicable large employer,'' before ``the
length'' in clause (i);
(ii) by striking ``and'' at the end of
clause (iii);
(iii) by striking ``applicable large
employer'' in clause (iv) and inserting
``employer'';
(iv) by inserting ``and'' at the end of
clause (iv); and
(v) by inserting at the end the following
new clause:
``(v) in the case of an offering employer,
the option for which the employer pays the
largest portion of the cost of the plan and the
portion of the cost paid by the employer in
each of the enrollment categories under such
option,''.
(C) Section 6056(d)(2) of such Code is amended by
inserting ``or offering employer'' after ``applicable
large employer''.
(D) Section 6056(e) of such Code is amended by
inserting ``or offering employer'' after ``applicable
large employer''.
(E) Section 6724(d)(1)(B)(xxv) of such Code, as
added by section 1514, is amended by striking ``large''
and inserting ``certain''.
(F) Section 6724(d)(2)(HH) of such Code, as added
by section 1514, is amended by striking ``large'' and
inserting ``certain''.
(G) The table of sections for subpart D of part III
of subchapter A of chapter 1 of such Code, as amended
by section 1514, is amended by striking ``Large
employers'' in the item relating to section 6056 and
inserting ``Certain employers''.
(4) Effective date.--The amendments made by this subsection
shall apply to periods beginning after December 31, 2013.
SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND ADMINISTRATIVE
TRANSACTIONS.
(a) Additional Transaction Standards and Operating Rules.--
(1) Development of additional transaction standards and
operating rules.--Section 1173(a) of the Social Security Act
(42 U.S.C. 1320d-2(a)), as amended by section 1104(b)(2), is
amended--
(A) in paragraph (1)(B), by inserting before the
period the following: ``, and subject to the
requirements under paragraph (5)''; and
(B) by adding at the end the following new
paragraph:
``(5) Consideration of standardization of activities and
items.--
``(A) In general.--For purposes of carrying out
paragraph (1)(B), the Secretary shall solicit, not
later than January 1, 2012, and not less than every 3
years thereafter, input from entities described in
subparagraph (B) on--
``(i) whether there could be greater
uniformity in financial and administrative
activities and items, as determined appropriate
by the Secretary; and
``(ii) whether such activities should be
considered financial and administrative
transactions (as described in paragraph (1)(B))
for which the adoption of standards and
operating rules would improve the operation of
the health care system and reduce
administrative costs.
``(B) Solicitation of input.--For purposes of
subparagraph (A), the Secretary shall seek input from--
``(i) the National Committee on Vital and
Health Statistics, the Health Information
Technology Policy Committee, and the Health
Information Technology Standards Committee; and
``(ii) standard setting organizations and
stakeholders, as determined appropriate by the
Secretary.''.
(b) Activities and Items for Initial Consideration.--For purposes
of section 1173(a)(5) of the Social Security Act, as added by
subsection (a), the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') shall, not later than January
1, 2012, seek input on activities and items relating to the following
areas:
(1) Whether the application process, including the use of a
uniform application form, for enrollment of health care
providers by health plans could be made electronic and
standardized.
(2) Whether standards and operating rules described in
section 1173 of the Social Security Act should apply to the
health care transactions of automobile insurance, worker's
compensation, and other programs or persons not described in
section 1172(a) of such Act (42 U.S.C. 1320d-1(a)).
(3) Whether standardized forms could apply to financial
audits required by health plans, Federal and State agencies
(including State auditors, the Office of the Inspector General
of the Department of Health and Human Services, and the Centers
for Medicare & Medicaid Services), and other relevant entities
as determined appropriate by the Secretary.
(4) Whether there could be greater transparency and
consistency of methodologies and processes used to establish
claim edits used by health plans (as described in section
1171(5) of the Social Security Act (42 U.S.C. 1320d(5))).
(5) Whether health plans should be required to publish
their timeliness of payment rules.
(c) ICD Coding Crosswalks.--
(1) ICD-9 to icd-10 crosswalk.--The Secretary shall task
the ICD-9-CM Coordination and Maintenance Committee to convene
a meeting, not later than January 1, 2011, to receive input
from appropriate stakeholders (including health plans, health
care providers, and clinicians) regarding the crosswalk between
the Ninth and Tenth Revisions of the International
Classification of Diseases (ICD-9 and ICD-10, respectively)
that is posted on the website of the Centers for Medicare &
Medicaid Services, and make recommendations about appropriate
revisions to such crosswalk.
(2) Revision of crosswalk.--For purposes of the crosswalk
described in paragraph (1), the Secretary shall make
appropriate revisions and post any such revised crosswalk on
the website of the Centers for Medicare & Medicaid Services.
(3) Use of revised crosswalk.--For purposes of paragraph
(2), any revised crosswalk shall be treated as a code set for
which a standard has been adopted by the Secretary for purposes
of section 1173(c)(1)(B) of the Social Security Act (42 U.S.C.
1320d-2(c)(1)(B)).
(4) Subsequent crosswalks.--For subsequent revisions of the
International Classification of Diseases that are adopted by
the Secretary as a standard code set under section 1173(c) of
the Social Security Act (42 U.S.C. 1320d-2(c)), the Secretary
shall, after consultation with the appropriate stakeholders,
post on the website of the Centers for Medicare & Medicaid
Services a crosswalk between the previous and subsequent
version of the International Classification of Diseases not
later than the date of implementation of such subsequent
revision.
Subtitle B--Provisions Relating to Title II
PART I--MEDICAID AND CHIP
SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE II OF THIS
ACT.
(a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Security Act (42
U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section 2004(a), is amended
to read as follows:
``(IX) who--
``(aa) are under 26 years
of age;
``(bb) are not described in
or enrolled under any of
subclauses (I) through (VII) of
this clause or are described in
any of such subclauses but have
income that exceeds the level
of income applicable under the
State plan for eligibility to
enroll for medical assistance
under such subclause;
``(cc) were in foster care
under the responsibility of the
State on the date of attaining
18 years of age or such higher
age as the State has elected
under section 475(8)(B)(iii);
and
``(dd) were enrolled in the
State plan under this title or
under a waiver of the plan
while in such foster care;''.
(2) Section 1902(a)(10) of the Social Security Act (42 U.S.C.
1396a(a)(10), as amended by section 2001(a)(5)(A), is amended in the
matter following subparagraph (G), by striking ``and (XV)'' and
inserting ``(XV)'', and by inserting ``and (XVI) if an individual is
described in subclause (IX) of subparagraph (A)(i) and is also
described in subclause (VIII) of that subparagraph, the medical
assistance shall be made available to the individual through subclause
(IX) instead of through subclause (VIII)'' before the semicolon.
(3) Section 2004(d) of this Act is amended by striking ``2019'' and
inserting ``2014''.
(b) Section 1902(k)(2) of the Social Security Act (42 U.S.C.
1396a(k)(2)), as added by section 2001(a)(4)(A), is amended by striking
``January 1, 2011'' and inserting ``April 1, 2010''.
(c) Section 1905 of the Social Security Act (42 U.S.C. 1396d), as
amended by sections 2001(a)(3), 2001(a)(5)(C), 2006, and 4107(a)(2), is
amended--
(1) in subsection (a), in the matter preceding paragraph
(1), by inserting in clause (xiv), ``or 1902(a)(10)(A)(i)(IX)''
before the comma;
(2) in subsection (b), in the first sentence, by inserting
``, (z),'' before ``and (aa)'';
(3) in subsection (y)--
(A) in paragraph (1)(B)(ii)(II), in the first
sentence, by inserting ``includes inpatient hospital
services,'' after ``100 percent of the poverty line,
that''; and
(B) in paragraph (2)(A), by striking ``on the date
of enactment of the Patient Protection and Affordable
Care Act'' and inserting ``as of December 1, 2009'';
(4) by inserting after subsection (y) the following:
``(z) Equitable Support for Certain States.--
``(1)(A) During the period that begins on January 1, 2014,
and ends on September 30, 2019, notwithstanding subsection (b),
the Federal medical assistance percentage otherwise determined
under subsection (b) with respect to a fiscal year occurring
during that period shall be increased by 2.2 percentage points
for any State described in subparagraph (B) for amounts
expended for medical assistance for individuals who are not
newly eligible (as defined in subsection (y)(2)) individuals
described in subclause (VIII) of section 1902(a)(10)(A)(i).
``(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that--
``(i) is an expansion State described in subsection
(y)(1)(B)(ii)(II);
``(ii) the Secretary determines will not receive
any payments under this title on the basis of an
increased Federal medical assistance percentage under
subsection (y) for expenditures for medical assistance
for newly eligible individuals (as so defined); and
``(iii) has not been approved by the Secretary to
divert a portion of the DSH allotment for a State to
the costs of providing medical assistance or other
health benefits coverage under a waiver that is in
effect on July 2009.
``(2)(A) During the period that begins on January 1, 2014, and ends
on December 31, 2016, notwithstanding subsection (b), the Federal
medical assistance percentage otherwise determined under subsection (b)
with respect to all or any portion of a fiscal year occurring during
that period shall be increased by .5 percentage point for a State
described in subparagraph (B) for amounts expended for medical
assistance under the State plan under this title or under a waiver of
that plan during that period.
``(B) For purposes of subparagraph (A), a State described in this
subparagraph is a State that--
``(i) is described in clauses (i) and (ii) of paragraph
(1)(B); and
``(ii) is the State with the highest percentage of its
population insured during 2008, based on the Current Population
Survey.
``(3) Notwithstanding subsection (b) and paragraphs (1) and (2) of
this subsection, the Federal medical assistance percentage otherwise
determined under subsection (b) with respect to all or any portion of a
fiscal year that begins on or after January 1, 2017, for the State of
Nebraska, with respect to amounts expended for newly eligible
individuals described in subclause (VIII) of section 1902(a)(10)(A)(i),
shall be determined as provided for under subsection (y)(1)(A)
(notwithstanding the period provided for in such paragraph).
``(4) The increase in the Federal medical assistance percentage for
a State under paragraphs (1), (2), or (3) shall apply only for purposes
of this title and shall not apply with respect to--
``(A) disproportionate share hospital payments described in
section 1923;
``(B) payments under title IV;
``(C) payments under title XXI; and
``(D) payments under this title that are based on the
enhanced FMAP described in section 2105(b).'';
(5) in subsection (aa), is amended by striking ``without
regard to this subsection and subsection (y)'' and inserting
``without regard to this subsection, subsection (y), subsection
(z), and section 10202 of the Patient Protection and Affordable
Care Act'' each place it appears;
(6) by adding after subsection (bb), the following:
``(cc) Requirement for Certain States.--Notwithstanding subsections
(y), (z), and (aa), in the case of a State that requires political
subdivisions within the State to contribute toward the non-Federal
share of expenditures required under the State plan under section
1902(a)(2), the State shall not be eligible for an increase in its
Federal medical assistance percentage under such subsections if it
requires that political subdivisions pay a greater percentage of the
non-Federal share of such expenditures, or a greater percentage of the
non-Federal share of payments under section 1923, than the respective
percentages that would have been required by the State under the State
plan under this title, State law, or both, as in effect on December 31,
2009, and without regard to any such increase. Voluntary contributions
by a political subdivision to the non-Federal share of expenditures
under the State plan under this title or to the non-Federal share of
payments under section 1923, shall not be considered to be required
contributions for purposes of this subsection. The treatment of
voluntary contributions, and the treatment of contributions required by
a State under the State plan under this title, or State law, as
provided by this subsection, shall also apply to the increases in the
Federal medical assistance percentage under section 5001 of the
American Recovery and Reinvestment Act of 2009.''.
(d) Section 1108(g)(4)(B) of the Social Security Act (42 U.S.C.
1308(g)(4)(B)), as added by section 2005(b), is amended by striking
``income eligibility level in effect for that population under title
XIX or under a waiver'' and inserting ``the highest income eligibility
level in effect for parents under the commonwealth's or territory's
State plan under title XIX or under a waiver of the plan''.
(e)(1) Section 1923(f) of the Social Security Act (42 U.S.C. 1396r-
4(f)), as amended by section 2551, is amended--
(A) in paragraph (6)--
(i) by striking the paragraph heading and inserting
the following: ``Allotment adjustments''; and
(ii) in subparagraph (B), by adding at the end the
following:
``(iii) Allotment for 2d, 3rd, and 4th
quarter of fiscal year 2012, fiscal year 2013,
and succeeding fiscal years.--Notwithstanding
the table set forth in paragraph (2) or
paragraph (7):
``(I) 2d, 3rd, and 4th quarter of
fiscal year 2012.--The DSH allotment
for Hawaii for the 2d, 3rd, and 4th
quarters of fiscal year 2012 shall be
$7,500,000.
``(II) Treatment as a low-dsh state
for fiscal year 2013 and succeeding
fiscal years.--With respect to fiscal
year 2013, and each fiscal year
thereafter, the DSH allotment for
Hawaii shall be increased in the same
manner as allotments for low DSH States
are increased for such fiscal year
under clause (iii) of paragraph (5)(B).
``(III) Certain hospital
payments.--The Secretary may not impose
a limitation on the total amount of
payments made to hospitals under the
QUEST section 1115 Demonstration
Project except to the extent that such
limitation is necessary to ensure that
a hospital does not receive payments in
excess of the amounts described in
subsection (g), or as necessary to
ensure that such payments under the
waiver and such payments pursuant to
the allotment provided in this clause
do not, in the aggregate in any year,
exceed the amount that the Secretary
determines is equal to the Federal
medical assistance percentage component
attributable to disproportionate share
hospital payment adjustments for such
year that is reflected in the budget
neutrality provision of the QUEST
Demonstration Project.''; and
(B) in paragraph (7)--
(i) in subparagraph (A), in the matter preceding
clause (i), by striking ``subparagraph (E)'' and
inserting ``subparagraphs (E) and (G)'';
(ii) in subparagraph (B)--
(I) in clause (i), by striking subclauses
(I) and (II), and inserting the following:
``(I) if the State is a low DSH
State described in paragraph (5)(B) and
has spent not more than 99.90 percent
of the DSH allotments for the State on
average for the period of fiscal years
2004 through 2008, as of September 30,
2009, the applicable percentage is
equal to 25 percent;
``(II) if the State is a low DSH
State described in paragraph (5)(B) and
has spent more than 99.90 percent of
the DSH allotments for the State on
average for the period of fiscal years
2004 through 2008, as of September 30,
2009, the applicable percentage is
equal to 17.5 percent;
``(III) if the State is not a low
DSH State described in paragraph (5)(B)
and has spent not more than 99.90
percent of the DSH allotments for the
State on average for the period of
fiscal years 2004 through 2008, as of
September 30, 2009, the applicable
percentage is equal to 50 percent; and
``(IV) if the State is not a low
DSH State described in paragraph (5)(B)
and has spent more than 99.90 percent
of the DSH allotments for the State on
average for the period of fiscal years
2004 through 2008, as of September 30,
2009, the applicable percentage is
equal to 35 percent.'';
(II) in clause (ii), by striking subclauses
(I) and (II), and inserting the following:
``(I) if the State is a low DSH
State described in paragraph (5)(B) and
has spent not more than 99.90 percent
of the DSH allotments for the State on
average for the period of fiscal years
2004 through 2008, as of September 30,
2009, the applicable percentage is
equal to the product of the percentage
reduction in uncovered individuals for
the fiscal year from the preceding
fiscal year and 27.5 percent;
``(II) if the State is a low DSH
State described in paragraph (5)(B) and
has spent more than 99.90 percent of
the DSH allotments for the State on
average for the period of fiscal years
2004 through 2008, as of September 30,
2009, the applicable percentage is
equal to the product of the percentage
reduction in uncovered individuals for
the fiscal year from the preceding
fiscal year and 20 percent;
``(III) if the State is not a low
DSH State described in paragraph (5)(B)
and has spent not more than 99.90
percent of the DSH allotments for the
State on average for the period of
fiscal years 2004 through 2008, as of
September 30, 2009, the applicable
percentage is equal to the product of
the percentage reduction in uncovered
individuals for the fiscal year from
the preceding fiscal year and 55
percent; and
``(IV) if the State is not a low
DSH State described in paragraph (5)(B)
and has spent more than 99.90 percent
of the DSH allotments for the State on
average for the period of fiscal years
2004 through 2008, as of September 30,
2009, the applicable percentage is
equal to the product of the percentage
reduction in uncovered individuals for
the fiscal year from the preceding
fiscal year and 40 percent.'';
(III) in subparagraph (E), by striking ``35
percent'' and inserting ``50 percent''; and
(IV) by adding at the end the following:
``(G) Nonapplication.--The preceding provisions of
this paragraph shall not apply to the DSH allotment
determined for the State of Hawaii for a fiscal year
under paragraph (6).''.
(f) Section 2551 of this Act is amended by striking subsection (b).
(g) Section 2105(d)(3)(B) of the Social Security Act (42 U.S.C.
1397ee(d)(3)(B)), as added by section 2101(b)(1), is amended by adding
at the end the following: ``For purposes of eligibility for premium
assistance for the purchase of a qualified health plan under section
36B of the Internal Revenue Code of 1986 and reduced cost-sharing under
section 1402 of the Patient Protection and Affordable Care Act,
children described in the preceding sentence shall be deemed to be
ineligible for coverage under the State child health plan.''.
(h) Clause (i) of subparagraph (C) of section 513(b)(2) of the
Social Security Act, as added by section 2953 of this Act, is amended
to read as follows:
``(i) Healthy relationships, including
marriage and family interactions.''.
(i) Section 1115 of the Social Security Act (42 U.S.C. 1315) is
amended by inserting after subsection (c) the following:
``(d)(1) An application or renewal of any experimental, pilot, or
demonstration project undertaken under subsection (a) to promote the
objectives of title XIX or XXI in a State that would result in an
impact on eligibility, enrollment, benefits, cost-sharing, or financing
with respect to a State program under title XIX or XXI (in this
subsection referred to as a `demonstration project') shall be
considered by the Secretary in accordance with the regulations required
to be promulgated under paragraph (2).
``(2) Not later than 180 days after the date of enactment of this
subsection, the Secretary shall promulgate regulations relating to
applications for, and renewals of, a demonstration project that provide
for--
``(A) a process for public notice and comment at the State
level, including public hearings, sufficient to ensure a
meaningful level of public input;
``(B) requirements relating to--
``(i) the goals of the program to be implemented or
renewed under the demonstration project;
``(ii) the expected State and Federal costs and
coverage projections of the demonstration project; and
``(iii) the specific plans of the State to ensure
that the demonstration project will be in compliance
with title XIX or XXI;
``(C) a process for providing public notice and comment
after the application is received by the Secretary, that is
sufficient to ensure a meaningful level of public input;
``(D) a process for the submission to the Secretary of
periodic reports by the State concerning the implementation of
the demonstration project; and
``(E) a process for the periodic evaluation by the
Secretary of the demonstration project.
``(3) The Secretary shall annually report to Congress concerning
actions taken by the Secretary with respect to applications for
demonstration projects under this section.''.
(j) Subtitle F of title III of this Act is amended by adding at the
end the following:
``SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION.
``(a) Study.--
``(1) In general.--The Comptroller General of the United
States shall conduct a study of whether the development,
recognition, or implementation of any guideline or other
standards under a provision described in paragraph (2) would
result in the establishment of a new cause of action or claim.
``(2) Provisions described.--The provisions described in
this paragraph include the following:
``(A) Section 2701 (adult health quality measures).
``(B) Section 2702 (payment adjustments for health
care acquired conditions).
``(C) Section 3001 (Hospital Value-Based Purchase
Program).
``(D) Section 3002 (improvements to the Physician
Quality Reporting Initiative).
``(E) Section 3003 (improvements to the Physician
Feedback Program).
``(F) Section 3007 (value based payment modifier
under physician fee schedule).
``(G) Section 3008 (payment adjustment for
conditions acquired in hospitals).
``(H) Section 3013 (quality measure development).
``(I) Section 3014 (quality measurement).
``(J) Section 3021 (Establishment of Center for
Medicare and Medicaid Innovation).
``(K) Section 3025 (hospital readmission reduction
program).
``(L) Section 3501 (health care delivery system
research, quality improvement).
``(M) Section 4003 (Task Force on Clinical and
Preventive Services).
``(N) Section 4301 (research to optimize deliver of
public health services).
``(b) Report.--Not later than 2 years after the date of enactment
of this Act, the Comptroller General of the United States shall submit
to the appropriate committees of Congress, a report containing the
findings made by the Comptroller General under the study under
subsection (a).''.
SEC. 10202. INCENTIVES FOR STATES TO OFFER HOME AND COMMUNITY-BASED
SERVICES AS A LONG-TERM CARE ALTERNATIVE TO NURSING
HOMES.
(a) State Balancing Incentive Payments Program.--Notwithstanding
section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)), in the
case of a balancing incentive payment State, as defined in subsection
(b), that meets the conditions described in subsection (c), during the
balancing incentive period, the Federal medical assistance percentage
determined for the State under section 1905(b) of such Act and, if
applicable, increased under subsection (z) or (aa) shall be increased
by the applicable percentage points determined under subsection (d)
with respect to eligible medical assistance expenditures described in
subsection (e).
(b) Balancing Incentive Payment State.--A balancing incentive
payment State is a State--
(1) in which less than 50 percent of the total expenditures
for medical assistance under the State Medicaid program for a
fiscal year for long-term services and supports (as defined by
the Secretary under subsection (f))(1)) are for non-
institutionally-based long-term services and supports described
in subsection (f)(1)(B);
(2) that submits an application and meets the conditions
described in subsection (c); and
(3) that is selected by the Secretary to participate in the
State balancing incentive payment program established under
this section.
(c) Conditions.--The conditions described in this subsection are
the following:
(1) Application.--The State submits an application to the
Secretary that includes, in addition to such other information
as the Secretary shall require--
(A) a proposed budget that details the State's plan
to expand and diversify medical assistance for non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B) under the State
Medicaid program during the balancing incentive period
and achieve the target spending percentage applicable
to the State under paragraph (2), including through
structural changes to how the State furnishes such
assistance, such as through the establishment of a ``no
wrong door--single entry point system'', optional
presumptive eligibility, case management services, and
the use of core standardized assessment instruments,
and that includes a description of the new or expanded
offerings of such services that the State will provide
and the projected costs of such services; and
(B) in the case of a State that proposes to expand
the provision of home and community-based services
under its State Medicaid program through a State plan
amendment under section 1915(i) of the Social Security
Act, at the option of the State, an election to
increase the income eligibility for such services from
150 percent of the poverty line to such higher
percentage as the State may establish for such purpose,
not to exceed 300 percent of the supplemental security
income benefit rate established by section 1611(b)(1)
of the Social Security Act (42 U.S.C. 1382(b)(1)).
(2) Target spending percentages.--
(A) In the case of a balancing incentive payment
State in which less than 25 percent of the total
expenditures for long-term services and supports under
the State Medicaid program for fiscal year 2009 are for
home and community-based services, the target spending
percentage for the State to achieve by not later than
October 1, 2015, is that 25 percent of the total
expenditures for long-term services and supports under
the State Medicaid program are for home and community-
based services.
(B) In the case of any other balancing incentive
payment State, the target spending percentage for the
State to achieve by not later than October 1, 2015, is
that 50 percent of the total expenditures for long-term
services and supports under the State Medicaid program
are for home and community-based services.
(3) Maintenance of eligibility requirements.--The State
does not apply eligibility standards, methodologies, or
procedures for determining eligibility for medical assistance
for non-institutionally-based long-term services and supports
described in subsection (f)(1)(B) under the State Medicaid
program that are more restrictive than the eligibility
standards, methodologies, or procedures in effect for such
purposes on December 31, 2010.
(4) Use of additional funds.--The State agrees to use the
additional Federal funds paid to the State as a result of this
section only for purposes of providing new or expanded
offerings of non-institutionally-based long-term services and
supports described in subsection (f)(1)(B) under the State
Medicaid program.
(5) Structural changes.--The State agrees to make, not
later than the end of the 6-month period that begins on the
date the State submits an application under this section, the
following changes:
(A) ``No wrong door--single entry point system''.--
Development of a statewide system to enable consumers
to access all long-term services and supports through
an agency, organization, coordinated network, or
portal, in accordance with such standards as the State
shall establish and that shall provide information
regarding the availability of such services, how to
apply for such services, referral services for services
and supports otherwise available in the community, and
determinations of financial and functional eligibility
for such services and supports, or assistance with
assessment processes for financial and functional
eligibility.
(B) Conflict-free case management services.--
Conflict-free case management services to develop a
service plan, arrange for services and supports,
support the beneficiary (and, if appropriate, the
beneficiary's caregivers) in directing the provision of
services and supports for the beneficiary, and conduct
ongoing monitoring to assure that services and supports
are delivered to meet the beneficiary's needs and
achieve intended outcomes.
(C) Core standardized assessment instruments.--
Development of core standardized assessment instruments
for determining eligibility for non-institutionally-
based long-term services and supports described in
subsection (f)(1)(B), which shall be used in a uniform
manner throughout the State, to determine a
beneficiary's needs for training, support services,
medical care, transportation, and other services, and
develop an individual service plan to address such
needs.
(6) Data collection.--The State agrees to collect from
providers of services and through such other means as the State
determines appropriate the following data:
(A) Services data.--Services data from providers of
non-institutionally-based long-term services and
supports described in subsection (f)(1)(B) on a per-
beneficiary basis and in accordance with such
standardized coding procedures as the State shall
establish in consultation with the Secretary.
(B) Quality data.--Quality data on a selected set
of core quality measures agreed upon by the Secretary
and the State that are linked to population-specific
outcomes measures and accessible to providers.
(C) Outcomes measures.--Outcomes measures data on a
selected set of core population-specific outcomes
measures agreed upon by the Secretary and the State
that are accessible to providers and include--
(i) measures of beneficiary and family
caregiver experience with providers;
(ii) measures of beneficiary and family
caregiver satisfaction with services; and
(iii) measures for achieving desired
outcomes appropriate to a specific beneficiary,
including employment, participation in
community life, health stability, and
prevention of loss in function.
(d) Applicable Percentage Points Increase in FMAP.--The applicable
percentage points increase is--
(1) in the case of a balancing incentive payment State
subject to the target spending percentage described in
subsection (c)(2)(A), 5 percentage points; and
(2) in the case of any other balancing incentive payment
State, 2 percentage points.
(e) Eligible Medical Assistance Expenditures.--
(1) In general.--Subject to paragraph (2), medical
assistance described in this subsection is medical assistance
for non-institutionally-based long-term services and supports
described in subsection (f)(1)(B) that is provided by a
balancing incentive payment State under its State Medicaid
program during the balancing incentive payment period.
(2) Limitation on payments.--In no case may the aggregate
amount of payments made by the Secretary to balancing incentive
payment States under this section during the balancing
incentive period exceed $3,000,000,000.
(f) Definitions.--In this section:
(1) Long-term services and supports defined.--The term
``long-term services and supports'' has the meaning given that
term by Secretary and may include any of the following (as
defined for purposes of State Medicaid programs):
(A) Institutionally-based long-term services and
supports.--Services provided in an institution,
including the following:
(i) Nursing facility services.
(ii) Services in an intermediate care
facility for the mentally retarded described in
subsection (a)(15) of section 1905 of such Act.
(B) Non-institutionally-based long-term services
and supports.--Services not provided in an institution,
including the following:
(i) Home and community-based services
provided under subsection (c), (d), or (i) of
section 1915 of such Act or under a waiver
under section 1115 of such Act.
(ii) Home health care services.
(iii) Personal care services.
(iv) Services described in subsection
(a)(26) of section 1905 of such Act (relating
to PACE program services).
(v) Self-directed personal assistance
services described in section 1915(j) of such
Act.
(2) Balancing incentive period.--The term ``balancing
incentive period'' means the period that begins on October 1,
2011, and ends on September 30, 2015.
(3) Poverty line.--The term ``poverty line'' has the
meaning given that term in section 2110(c)(5) of the Social
Security Act (42 U.S.C. 1397jj(c)(5)).
(4) State medicaid program.--The term ``State Medicaid
program'' means the State program for medical assistance
provided under a State plan under title XIX of the Social
Security Act and under any waiver approved with respect to such
State plan.
SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL YEAR 2015 AND
OTHER CHIP-RELATED PROVISIONS.
(a) Section 1311(c)(1) of this Act is amended by striking ``and''
at the end of subparagraph (G), by striking the period at the end of
subparagraph (H) and inserting ``; and'', and by adding at the end the
following:
``(I) report to the Secretary at least annually and
in such manner as the Secretary shall require,
pediatric quality reporting measures consistent with
the pediatric quality reporting measures established
under section 1139A of the Social Security Act.''.
(b) Effective as if included in the enactment of the Children's
Health Insurance Program Reauthorization Act of 2009 (Public Law 111-
3):
(1) Section 1906(e)(2) of the Social Security Act (42
U.S.C. 1396e(e)(2)) is amended by striking ``means'' and all
that follows through the period and inserting ``has the meaning
given that term in section 2105(c)(3)(A).''.
(2)(A) Section 1906A(a) of the Social Security Act (42
U.S.C. 1396e-1(a)), is amended by inserting before the period
the following: ``and the offering of such a subsidy is cost-
effective, as defined for purposes of section 2105(c)(3)(A)''.
(B) This Act shall be applied without regard to
subparagraph (A) of section 2003(a)(1) of this Act and that
subparagraph and the amendment made by that subparagraph are
hereby deemed null, void, and of no effect.
(3) Section 2105(c)(10) of the Social Security Act (42
U.S.C. 1397ee(c)(10)) is amended--
(A) in subparagraph (A), in the first sentence, by
inserting before the period the following: ``if the
offering of such a subsidy is cost-effective, as
defined for purposes of paragraph (3)(A)'';
(B) by striking subparagraph (M); and
(C) by redesignating subparagraph (N) as
subparagraph (M).
(4) Section 2105(c)(3)(A) of the Social Security Act (42
U.S.C. 1397ee(c)(3)(A)) is amended--
(A) in the matter preceding clause (i), by striking
``to'' and inserting ``to--''; and
(B) in clause (ii), by striking the period and
inserting a semicolon.
(c) Section 2105 of the Social Security Act (42 U.S.C. 1397ee), as
amended by section 2101, is amended--
(1) in subsection (b), in the second sentence, by striking
``2013'' and inserting ``2015''; and
(2) in subsection (d)(3)--
(A) in subparagraph (A)--
(i) in the first sentence, by inserting
``as a condition of receiving payments under
section 1903(a),'' after ``2019,'';
(ii) in clause (i), by striking ``or'' at
the end;
(iii) by redesignating clause (ii) as
clause (iii); and
(iv) by inserting after clause (i), the
following:
``(ii) after September 30, 2015, enrolling
children eligible to be targeted low-income
children under the State child health plan in a
qualified health plan that has been certified
by the Secretary under subparagraph (C); or'';
(B) in subparagraph (B), by striking ``provided
coverage'' and inserting ``screened for eligibility for
medical assistance under the State plan under title XIX
or a waiver of that plan and, if found eligible,
enrolled in such plan or a waiver. In the case of such
children who, as a result of such screening, are
determined to not be eligible for medical assistance
under the State plan or a waiver under title XIX, the
State shall establish procedures to ensure that the
children are enrolled in a qualified health plan that
has been certified by the Secretary under subparagraph
(C) and is offered''; and
(C) by adding at the end the following:
``(C) Certification of comparability of pediatric
coverage offered by qualified health plans.--With
respect to each State, the Secretary, not later than
April 1, 2015, shall review the benefits offered for
children and the cost-sharing imposed with respect to
such benefits by qualified health plans offered through
an Exchange established by the State under section 1311
of the Patient Protection and Affordable Care Act and
shall certify those plans that offer benefits for
children and impose cost-sharing with respect to such
benefits that the Secretary determines are at least
comparable to the benefits offered and cost-sharing
protections provided under the State child health
plan.''.
(d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is
amended--
(A) in paragraph (15), by striking ``and'' at the end; and
(B) by striking paragraph (16) and inserting the following:
``(16) for fiscal year 2013, $17,406,000,000;
``(17) for fiscal year 2014, $19,147,000,000; and
``(18) for fiscal year 2015, for purposes of making 2 semi-
annual allotments--
``(A) $2,850,000,000 for the period beginning on
October 1, 2014, and ending on March 31, 2015, and
``(B) $2,850,000,000 for the period beginning on
April 1, 2015, and ending on September 30, 2015.''.
(2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)), as
amended by section 2102(a)(1), is amended--
(i) in the subsection heading, by striking ``2013'' and
inserting ``2015'';
(ii) in paragraph (2)--
(I) in the paragraph heading, by striking ``2012''
and inserting ``2014''; and
(II) by adding at the end the following:
``(B) Fiscal years 2013 and 2014.--Subject to
paragraphs (4) and (6), from the amount made available
under paragraphs (16) and (17) of subsection (a) for
fiscal years 2013 and 2014, respectively, the Secretary
shall compute a State allotment for each State
(including the District of Columbia and each
commonwealth and territory) for each such fiscal year
as follows:
``(i) Rebasing in fiscal year 2013.--For
fiscal year 2013, the allotment of the State is
equal to the Federal payments to the State that
are attributable to (and countable towards) the
total amount of allotments available under this
section to the State in fiscal year 2012
(including payments made to the State under
subsection (n) for fiscal year 2012 as well as
amounts redistributed to the State in fiscal
year 2012), multiplied by the allotment
increase factor under paragraph (5) for fiscal
year 2013.
``(ii) Growth factor update for fiscal year
2014.--For fiscal year 2014, the allotment of
the State is equal to the sum of--
``(I) the amount of the State
allotment under clause (i) for fiscal
year 2013; and
``(II) the amount of any payments
made to the State under subsection (n)
for fiscal year 2013,
multiplied by the allotment increase factor
under paragraph (5) for fiscal year 2014.'';
(iii) in paragraph (3)--
(I) in the paragraph heading, by striking
``2013'' and inserting ``2015'';
(II) in subparagraphs (A) and (B), by
striking ``paragraph (16)'' each place it
appears and inserting ``paragraph (18)'';
(III) in subparagraph (C)--
(aa) by striking ``2012'' each
place it appears and inserting
``2014''; and
(bb) by striking ``2013'' and
inserting ``2015''; and
(IV) in subparagraph (D)--
(aa) in clause (i)(I), by striking
``subsection (a)(16)(A)'' and inserting
``subsection (a)(18)(A)''; and
(bb) in clause (ii)(II), by
striking ``subsection (a)(16)(B)'' and
inserting ``subsection (a)(18)(B)'';
(iv) in paragraph (4), by striking ``2013'' and
inserting ``2015'';
(v) in paragraph (6)--
(I) in subparagraph (A), by striking
``2013'' and inserting ``2015''; and
(II) in the flush language after and below
subparagraph (B)(ii), by striking ``or fiscal
year 2012'' and inserting ``, fiscal year 2012,
or fiscal year 2014''; and
(vi) in paragraph (8)--
(I) in the paragraph heading, by striking
``2013'' and inserting ``2015''; and
(II) by striking ``2013'' and inserting
``2015''.
(B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is amended--
(i) in paragraph (2)--
(I) in subparagraph (A)(ii)--
(aa) by striking ``2012'' and inserting
``2014''; and
(bb) by striking ``2013'' and inserting
``2015'';
(II) in subparagraph (B)--
(aa) by striking ``2012'' and inserting
``2014''; and
(bb) by striking ``2013'' and inserting
``2015''; and
(ii) in paragraph (3)(A), by striking ``or a semi-annual
allotment period for fiscal year 2013'' and inserting ``fiscal
year 2013, fiscal year 2014, or a semi-annual allotment period
for fiscal year 2015''.
(C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4)) is
amended--
(i) in the paragraph heading, by striking ``2013'' and
inserting ``2015''; and
(ii) in subparagraph (A), by striking ``2013'' and
inserting ``2015''.
(D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is amended--
(i) in paragraph (2)(B), by inserting ``except as provided
in paragraph (6),'' before ``a child''; and
(ii) by adding at the end the following new paragraph:
``(6) Exceptions to exclusion of children of employees of a
public agency in the state.--
``(A) In general.--A child shall not be considered
to be described in paragraph (2)(B) if--
``(i) the public agency that employs a
member of the child's family to which such
paragraph applies satisfies subparagraph (B);
or
``(ii) subparagraph (C) applies to such
child.
``(B) Maintenance of effort with respect to per
person agency contribution for family coverage.--For
purposes of subparagraph (A)(i), a public agency
satisfies this subparagraph if the amount of annual
agency expenditures made on behalf of each employee
enrolled in health coverage paid for by the agency that
includes dependent coverage for the most recent State
fiscal year is not less than the amount of such
expenditures made by the agency for the 1997 State
fiscal year, increased by the percentage increase in
the medical care expenditure category of the Consumer
Price Index for All-Urban Consumers (all items: U.S.
City Average) for such preceding fiscal year.
``(C) Hardship exception.--For purposes of
subparagraph (A)(ii), this subparagraph applies to a
child if the State determines, on a case-by-case basis,
that the annual aggregate amount of premiums and cost-
sharing imposed for coverage of the family of the child
would exceed 5 percent of such family's income for the
year involved.''.
(E) Section 2113 of such Act (42 U.S.C. 1397mm) is amended--
(i) in subsection (a)(1), by striking ``2013'' and
inserting ``2015''; and
(ii) in subsection (g), by striking ``$100,000,000 for the
period of fiscal years 2009 through 2013'' and inserting
``$140,000,000 for the period of fiscal years 2009 through
2015''.
(F) Section 108 of Public Law 111-3 is amended by striking
``$11,706,000,000'' and all that follows through the second sentence
and inserting ``$15,361,000,000 to accompany the allotment made for the
period beginning on October 1, 2014, and ending on March 31, 2015,
under section 2104(a)(18)(A) of the Social Security Act (42 U.S.C.
1397dd(a)(18)(A)), to remain available until expended. Such amount
shall be used to provide allotments to States under paragraph (3) of
section 2104(m) of the Social Security Act (42 U.S.C. 1397dd(m)) for
the first 6 months of fiscal year 2015 in the same manner as allotments
are provided under subsection (a)(18)(A) of such section 2104 and
subject to the same terms and conditions as apply to the allotments
provided from such subsection (a)(18)(A).''.
PART II--SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN
SEC. 10211. DEFINITIONS.
In this part:
(1) Accompaniment.--The term ``accompaniment'' means
assisting, representing, and accompanying a woman in seeking
judicial relief for child support, child custody, restraining
orders, and restitution for harm to persons and property, and
in filing criminal charges, and may include the payment of
court costs and reasonable attorney and witness fees associated
therewith.
(2) Eligible institution of higher education.--The term
``eligible institution of higher education'' means an
institution of higher education (as such term is defined in
section 101 of the Higher Education Act of 1965 (20 U.S.C.
1001)) that has established and operates, or agrees to
establish and operate upon the receipt of a grant under this
part, a pregnant and parenting student services office.
(3) Community service center.--The term ``community service
center'' means a non-profit organization that provides social
services to residents of a specific geographical area via
direct service or by contract with a local governmental agency.
(4) High school.--The term ``high school'' means any public
or private school that operates grades 10 through 12,
inclusive, grades 9 through 12, inclusive or grades 7 through
12, inclusive.
(5) Intervention services.--The term ``intervention
services'' means, with respect to domestic violence, sexual
violence, sexual assault, or stalking, 24-hour telephone
hotline services for police protection and referral to
shelters.
(6) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(7) State.--The term ``State'' includes the District of
Columbia, any commonwealth, possession, or other territory of
the United States, and any Indian tribe or reservation.
(8) Supportive social services.--The term ``supportive
social services'' means transitional and permanent housing,
vocational counseling, and individual and group counseling
aimed at preventing domestic violence, sexual violence, sexual
assault, or stalking.
(9) Violence.--The term ``violence'' means actual violence
and the risk or threat of violence.
SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE FUND.
(a) In General.--The Secretary, in collaboration and coordination
with the Secretary of Education (as appropriate), shall establish a
Pregnancy Assistance Fund to be administered by the Secretary, for the
purpose of awarding competitive grants to States to assist pregnant and
parenting teens and women.
(b) Use of Fund.--A State may apply for a grant under subsection
(a) to carry out any activities provided for in section 10213.
(c) Applications.--To be eligible to receive a grant under
subsection (a), a State shall submit to the Secretary an application at
such time, in such manner, and containing such information as the
Secretary may require, including a description of the purposes for
which the grant is being requested and the designation of a State
agency for receipt and administration of funding received under this
part.
SEC. 10213. PERMISSIBLE USES OF FUND.
(a) In General.--A State shall use amounts received under a grant
under section 10212 for the purposes described in this section to
assist pregnant and parenting teens and women.
(b) Institutions of Higher Education.--
(1) In general.--A State may use amounts received under a
grant under section 10212 to make funding available to eligible
institutions of higher education to enable the eligible
institutions to establish, maintain, or operate pregnant and
parenting student services. Such funding shall be used to
supplement, not supplant, existing funding for such services.
(2) Application.--An eligible institution of higher
education that desires to receive funding under this subsection
shall submit an application to the designated State agency at
such time, in such manner, and containing such information as
the State agency may require.
(3) Matching requirement.--An eligible institution of
higher education that receives funding under this subsection
shall contribute to the conduct of the pregnant and parenting
student services office supported by the funding an amount from
non-Federal funds equal to 25 percent of the amount of the
funding provided. The non-Federal share may be in cash or in-
kind, fairly evaluated, including services, facilities,
supplies, or equipment.
(4) Use of funds for assisting pregnant and parenting
college students.--An eligible institution of higher education
that receives funding under this subsection shall use such
funds to establish, maintain or operate pregnant and parenting
student services and may use such funding for the following
programs and activities:
(A) Conduct a needs assessment on campus and within
the local community--
(i) to assess pregnancy and parenting
resources, located on the campus or within the
local community, that are available to meet the
needs described in subparagraph (B); and
(ii) to set goals for--
(I) improving such resources for
pregnant, parenting, and prospective
parenting students; and
(II) improving access to such
resources.
(B) Annually assess the performance of the eligible
institution in meeting the following needs of students
enrolled in the eligible institution who are pregnant
or are parents:
(i) The inclusion of maternity coverage and
the availability of riders for additional
family members in student health care.
(ii) Family housing.
(iii) Child care.
(iv) Flexible or alternative academic
scheduling, such as telecommuting programs, to
enable pregnant or parenting students to
continue their education or stay in school.
(v) Education to improve parenting skills
for mothers and fathers and to strengthen
marriages.
(vi) Maternity and baby clothing, baby food
(including formula), baby furniture, and
similar items to assist parents and prospective
parents in meeting the material needs of their
children.
(vii) Post-partum counseling.
(C) Identify public and private service providers,
located on the campus of the eligible institution or
within the local community, that are qualified to meet
the needs described in subparagraph (B), and
establishes programs with qualified providers to meet
such needs.
(D) Assist pregnant and parenting students, fathers
or spouses in locating and obtaining services that meet
the needs described in subparagraph (B).
(E) If appropriate, provide referrals for prenatal
care and delivery, infant or foster care, or adoption,
to a student who requests such information. An office
shall make such referrals only to service providers
that serve the following types of individuals:
(i) Parents.
(ii) Prospective parents awaiting adoption.
(iii) Women who are pregnant and plan on
parenting or placing the child for adoption.
(iv) Parenting or prospective parenting
couples.
(5) Reporting.--
(A) Annual report by institutions.--
(i) In general.--For each fiscal year that
an eligible institution of higher education
receives funds under this subsection, the
eligible institution shall prepare and submit
to the State, by the date determined by the
State, a report that--
(I) itemizes the pregnant and
parenting student services office's
expenditures for the fiscal year;
(II) contains a review and
evaluation of the performance of the
office in fulfilling the requirements
of this section, using the specific
performance criteria or standards
established under subparagraph (B)(i);
and
(III) describes the achievement of
the office in meeting the needs listed
in paragraph (4)(B) of the students
served by the eligible institution, and
the frequency of use of the office by
such students.
(ii) Performance criteria.--Not later than
180 days before the date the annual report
described in clause (i) is submitted, the
State--
(I) shall identify the specific
performance criteria or standards that
shall be used to prepare the report;
and
(II) may establish the form or
format of the report.
(B) Report by state.--The State shall annually
prepare and submit a report on the findings under this
subsection, including the number of eligible
institutions of higher education that were awarded
funds and the number of students served by each
pregnant and parenting student services office
receiving funds under this section, to the Secretary.
(c) Support for Pregnant and Parenting Teens.--A State may use
amounts received under a grant under section 10212 to make funding
available to eligible high schools and community service centers to
establish, maintain or operate pregnant and parenting services in the
same general manner and in accordance with all conditions and
requirements described in subsection (b), except that paragraph (3) of
such subsection shall not apply for purposes of this subsection.
(d) Improving Services for Pregnant Women Who Are Victims of
Domestic Violence, Sexual Violence, Sexual Assault, and Stalking.--
(1) In general.--A State may use amounts received under a
grant under section 10212 to make funding available tp its
State Attorney General to assist Statewide offices in
providing--
(A) intervention services, accompaniment, and
supportive social services for eligible pregnant women
who are victims of domestic violence, sexual violence,
sexual assault, or stalking.
(B) technical assistance and training (as described
in subsection (c)) relating to violence against
eligible pregnant women to be made available to the
following:
(i) Federal, State, tribal, territorial,
and local governments, law enforcement
agencies, and courts.
(ii) Professionals working in legal, social
service, and health care settings.
(iii) Nonprofit organizations.
(iv) Faith-based organizations.
(2) Eligibility.--To be eligible for a grant under
paragraph (1), a State Attorney General shall submit an
application to the designated State agency at such time, in
such manner, and containing such information, as specified by
the State.
(3) Technical assistance and training described.--For
purposes of paragraph (1)(B), technical assistance and training
is--
(A) the identification of eligible pregnant women
experiencing domestic violence, sexual violence, sexual
assault, or stalking;
(B) the assessment of the immediate and short-term
safety of such a pregnant woman, the evaluation of the
impact of the violence or stalking on the pregnant
woman's health, and the assistance of the pregnant
woman in developing a plan aimed at preventing further
domestic violence, sexual violence, sexual assault, or
stalking, as appropriate;
(C) the maintenance of complete medical or forensic
records that include the documentation of any
examination, treatment given, and referrals made,
recording the location and nature of the pregnant
woman's injuries, and the establishment of mechanisms
to ensure the privacy and confidentiality of those
medical records; and
(D) the identification and referral of the pregnant
woman to appropriate public and private nonprofit
entities that provide intervention services,
accompaniment, and supportive social services.
(4) Eligible pregnant woman.--In this subsection, the term
``eligible pregnant woman'' means any woman who is pregnant on
the date on which such woman becomes a victim of domestic
violence, sexual violence, sexual assault, or stalking or who
was pregnant during the one-year period before such date.
(e) Public Awareness and Education.--A State may use amounts
received under a grant under section 10212 to make funding available to
increase public awareness and education concerning any services
available to pregnant and parenting teens and women under this part, or
any other resources available to pregnant and parenting women in
keeping with the intent and purposes of this part. The State shall be
responsible for setting guidelines or limits as to how much of funding
may be utilized for public awareness and education in any funding
award.
SEC. 10214. APPROPRIATIONS.
There is authorized to be appropriated, and there are appropriated,
$25,000,000 for each of fiscal years 2010 through 2019, to carry out
this part.
PART III--INDIAN HEALTH CARE IMPROVEMENT
SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.
(a) In General.--Except as provided in subsection (b), S. 1790
entitled ``A bill to amend the Indian Health Care Improvement Act to
revise and extend that Act, and for other purposes.'', as reported by
the Committee on Indian Affairs of the Senate in December 2009, is
enacted into law.
(b) Amendments.--
(1) Section 119 of the Indian Health Care Improvement Act
(as amended by section 111 of the bill referred to in
subsection (a)) is amended--
(A) in subsection (d)--
(i) in paragraph (2), by striking ``In
establishing'' and inserting ``Subject to
paragraphs (3) and (4), in establishing''; and
(ii) by adding at the end the following:
``(3) Election of indian tribe or tribal organization.--
``(A) In general.--Subparagraph (B) of paragraph
(2) shall not apply in the case of an election made by
an Indian tribe or tribal organization located in a
State (other than Alaska) in which the use of dental
health aide therapist services or midlevel dental
health provider services is authorized under State law
to supply such services in accordance with State law.
``(B) Action by secretary.--On an election by an
Indian tribe or tribal organization under subparagraph
(A), the Secretary, acting through the Service, shall
facilitate implementation of the services elected.
``(4) Vacancies.--The Secretary shall not fill any vacancy
for a certified dentist in a program operated by the Service
with a dental health aide therapist.''; and
(B) by adding at the end the following:
``(e) Effect of Section.--Nothing in this section shall restrict
the ability of the Service, an Indian tribe, or a tribal organization
to participate in any program or to provide any service authorized by
any other Federal law.''.
(2) The Indian Health Care Improvement Act (as amended by
section 134(b) of the bill referred to in subsection (a)) is
amended by striking section 125 (relating to treatment of
scholarships for certain purposes).
(3) Section 806 of the Indian Health Care Improvement Act
(25 U.S.C. 1676) is amended--
(A) by striking ``Any limitation'' and inserting
the following:
``(a) HHS Appropriations.--Any limitation''; and
(B) by adding at the end the following:
``(b) Limitations Pursuant to Other Federal Law.--Any limitation
pursuant to other Federal laws on the use of Federal funds appropriated
to the Service shall apply with respect to the performance or coverage
of abortions.''.
(4) The bill referred to in subsection (a) is amended by
striking section 201.
Subtitle C--Provisions Relating to Title III
SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR AMBULATORY
SURGICAL CENTERS.
(a) In General.--Section 3006 is amended by adding at the end the
following new subsection:
``(f) Ambulatory Surgical Centers.--
``(1) In general.--The Secretary shall develop a plan to
implement a value-based purchasing program for payments under
the Medicare program under title XVIII of the Social Security
Act for ambulatory surgical centers (as described in section
1833(i) of the Social Security Act (42 U.S.C. 1395l(i))).
``(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
``(A) The ongoing development, selection, and
modification process for measures (including under
section 1890 of the Social Security Act (42 U.S.C.
1395aaa) and section 1890A of such Act, as added by
section 3014), to the extent feasible and practicable,
of all dimensions of quality and efficiency in
ambulatory surgical centers.
``(B) The reporting, collection, and validation of
quality data.
``(C) The structure of value-based payment
adjustments, including the determination of thresholds
or improvements in quality that would substantiate a
payment adjustment, the size of such payments, and the
sources of funding for the value-based bonus payments.
``(D) Methods for the public disclosure of
information on the performance of ambulatory surgical
centers.
``(E) Any other issues determined appropriate by
the Secretary.
``(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
``(A) consult with relevant affected parties; and
``(B) consider experience with such demonstrations
that the Secretary determines are relevant to the
value-based purchasing program described in paragraph
(1).
``(4) Report to congress.--Not later than January 1, 2011,
the Secretary shall submit to Congress a report containing the
plan developed under paragraph (1).''.
(b) Technical.--Section 3006(a)(2)(A) is amended by striking
clauses (i) and (ii).
SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN
HEALTH CARE.
Section 399HH(a)(2)(B)(iii) of the Public Health Service Act, as
added by section 3011, is amended by inserting ``(taking into
consideration the limitations set forth in subsections (c) and (d) of
section 1182 of the Social Security Act)'' after ``information''.
SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.
(a) Development.--Section 931 of the Public Health Service Act, as
added by section 3013(a), is amended by adding at the end the following
new subsection:
``(f) Development of Outcome Measures.--
``(1) In general.--The Secretary shall develop, and
periodically update (not less than every 3 years), provider-
level outcome measures for hospitals and physicians, as well as
other providers as determined appropriate by the Secretary.
``(2) Categories of measures.--The measures developed under
this subsection shall include, to the extent determined
appropriate by the Secretary--
``(A) outcome measurement for acute and chronic
diseases, including, to the extent feasible, the 5 most
prevalent and resource-intensive acute and chronic
medical conditions; and
``(B) outcome measurement for primary and
preventative care, including, to the extent feasible,
measurements that cover provision of such care for
distinct patient populations (such as healthy children,
chronically ill adults, or infirm elderly individuals).
``(3) Goals.--In developing such measures, the Secretary
shall seek to--
``(A) address issues regarding risk adjustment,
accountability, and sample size;
``(B) include the full scope of services that
comprise a cycle of care; and
``(C) include multiple dimensions.
``(4) Timeframe.--
``(A) Acute and chronic diseases.--Not later than
24 months after the date of enactment of this Act, the
Secretary shall develop not less than 10 measures
described in paragraph (2)(A).
``(B) Primary and preventive care.--Not later than
36 months after the date of enactment of this Act, the
Secretary shall develop not less than 10 measures
described in paragraph (2)(B).''.
(b) Hospital-acquired Conditions.--Section 1890A of the Social
Security Act, as amended by section 3013(b), is amended by adding at
the end the following new subsection:
``(f) Hospital Acquired Conditions.--The Secretary shall, to the
extent practicable, publicly report on measures for hospital-acquired
conditions that are currently utilized by the Centers for Medicare &
Medicaid Services for the adjustment of the amount of payment to
hospitals based on rates of hospital-acquired infections.''.
(c) Clinical Practice Guidelines.--Section 304(b) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275) is amended by adding at the end the following new paragraph:
``(4) Identification.--
``(A) In general.--Following receipt of the report
submitted under paragraph (2), and not less than every
3 years thereafter, the Secretary shall contract with
the Institute to employ the results of the study
performed under paragraph (1) and the best methods
identified by the Institute for the purpose of
identifying existing and new clinical practice
guidelines that were developed using such best methods,
including guidelines listed in the National Guideline
Clearinghouse.
``(B) Consultation.--In carrying out the
identification process under subparagraph (A), the
Secretary shall allow for consultation with
professional societies, voluntary health care
organizations, and expert panels.''.
SEC. 10304. SELECTION OF EFFICIENCY MEASURES.
Sections 1890(b)(7) and 1890A of the Social Security Act, as added
by section 3014, are amended by striking ``quality'' each place it
appears and inserting ``quality and efficiency''.
SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.
Section 399II(a) of the Public Health Service Act, as added by
section 3015, is amended to read as follows:
``(a) In General.--
``(1) Establishment of strategic framework.--The Secretary
shall establish and implement an overall strategic framework to
carry out the public reporting of performance information, as
described in section 399JJ. Such strategic framework may
include methods and related timelines for implementing
nationally consistent data collection, data aggregation, and
analysis methods.
``(2) Collection and aggregation of data.--The Secretary
shall collect and aggregate consistent data on quality and
resource use measures from information systems used to support
health care delivery, and may award grants or contracts for
this purpose. The Secretary shall align such collection and
aggregation efforts with the requirements and assistance
regarding the expansion of health information technology
systems, the interoperability of such technology systems, and
related standards that are in effect on the date of enactment
of the Patient Protection and Affordable Care Act.
``(3) Scope.--The Secretary shall ensure that the data
collection, data aggregation, and analysis systems described in
paragraph (1) involve an increasingly broad range of patient
populations, providers, and geographic areas over time.''.
SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND MEDICAID
INNOVATION.
Section 1115A of the Social Security Act, as added by section 3021,
is amended--
(1) in subsection (a), by inserting at the end the
following new paragraph:
``(5) Testing within certain geographic areas.--For
purposes of testing payment and service delivery models under
this section, the Secretary may elect to limit testing of a
model to certain geographic areas.'';
(2) in subsection (b)(2)--
(A) in subparagraph (A)--
(i) in the second sentence, by striking
``the preceding sentence may include'' and
inserting ``this subparagraph may include, but
are not limited to,''; and
(ii) by inserting after the first sentence
the following new sentence: ``The Secretary
shall focus on models expected to reduce
program costs under the applicable title while
preserving or enhancing the quality of care
received by individuals receiving benefits
under such title.'';
(B) in subparagraph (B), by adding at the end the
following new clauses:
``(xix) Utilizing, in particular in
entities located in medically underserved areas
and facilities of the Indian Health Service
(whether operated by such Service or by an
Indian tribe or tribal organization (as those
terms are defined in section 4 of the Indian
Health Care Improvement Act)), telehealth
services--
``(I) in treating behavioral health
issues (such as post-traumatic stress
disorder) and stroke; and
``(II) to improve the capacity of
non-medical providers and non-
specialized medical providers to
provide health services for patients
with chronic complex conditions.
``(xx) Utilizing a diverse network of
providers of services and suppliers to improve
care coordination for applicable individuals
described in subsection (a)(4)(A)(i) with 2 or
more chronic conditions and a history of prior-
year hospitalization through interventions
developed under the Medicare Coordinated Care
Demonstration Project under section 4016 of the
Balanced Budget Act of 1997 (42 U.S.C. 1395b-1
note).''; and
(C) in subparagraph (C), by adding at the end the
following new clause:
``(viii) Whether the model demonstrates
effective linkage with other public sector or
private sector payers.'';
(3) in subsection (b)(4), by adding at the end the
following new subparagraph:
``(C) Measure selection.--To the extent feasible,
the Secretary shall select measures under this
paragraph that reflect national priorities for quality
improvement and patient-centered care consistent with
the measures described in 1890(b)(7)(B).''; and
(4) in subsection (c)--
(A) in paragraph (1)(B), by striking ``care and
reduce spending; and'' and inserting ``patient care
without increasing spending;'';
(B) in paragraph (2), by striking ``reduce program
spending under applicable titles.'' and inserting
``reduce (or would not result in any increase in) net
program spending under applicable titles; and''; and
(C) by adding at the end the following:
``(3) the Secretary determines that such expansion would
not deny or limit the coverage or provision of benefits under
the applicable title for applicable individuals.
In determining which models or demonstration projects to expand under
the preceding sentence, the Secretary shall focus on models and
demonstration projects that improve the quality of patient care and
reduce spending.''.
SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS PROGRAM.
Section 1899 of the Social Security Act, as added by section 3022,
is amended by adding at the end the following new subsections:
``(i) Option To Use Other Payment Models.--
``(1) In general.--If the Secretary determines appropriate,
the Secretary may use any of the payment models described in
paragraph (2) or (3) for making payments under the program
rather than the payment model described in subsection (d).
``(2) Partial capitation model.--
``(A) In general.--Subject to subparagraph (B), a
model described in this paragraph is a partial
capitation model in which an ACO is at financial risk
for some, but not all, of the items and services
covered under parts A and B, such as at risk for some
or all physicians' services or all items and services
under part B. The Secretary may limit a partial
capitation model to ACOs that are highly integrated
systems of care and to ACOs capable of bearing risk, as
determined to be appropriate by the Secretary.
``(B) No additional program expenditures.--Payments
to an ACO for items and services under this title for
beneficiaries for a year under the partial capitation
model shall be established in a manner that does not
result in spending more for such ACO for such
beneficiaries than would otherwise be expended for such
ACO for such beneficiaries for such year if the model
were not implemented, as estimated by the Secretary.
``(3) Other payment models.--
``(A) In general.--Subject to subparagraph (B), a
model described in this paragraph is any payment model
that the Secretary determines will improve the quality
and efficiency of items and services furnished under
this title.
``(B) No additional program expenditures.--
Subparagraph (B) of paragraph (2) shall apply to a
payment model under subparagraph (A) in a similar
manner as such subparagraph (B) applies to the payment
model under paragraph (2).
``(j) Involvement in Private Payer and Other Third Party
Arrangements.--The Secretary may give preference to ACOs who are
participating in similar arrangements with other payers.
``(k) Treatment of Physician Group Practice Demonstration.--During
the period beginning on the date of the enactment of this section and
ending on the date the program is established, the Secretary may enter
into an agreement with an ACO under the demonstration under section
1866A, subject to rebasing and other modifications deemed appropriate
by the Secretary.''.
SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.
(a) In General.--Section 1866D of the Social Security Act, as added
by section 3023, is amended--
(1) in paragraph (a)(2)(B), in the matter preceding clause
(i), by striking ``8 conditions'' and inserting ``10
conditions'';
(2) by striking subsection (c)(1)(B) and inserting the
following:
``(B) Expansion.--The Secretary may, at any point
after January 1, 2016, expand the duration and scope of
the pilot program, to the extent determined appropriate
by the Secretary, if--
``(i) the Secretary determines that such
expansion is expected to--
``(I) reduce spending under title
XVIII of the Social Security Act
without reducing the quality of care;
or
``(II) improve the quality of care
and reduce spending;
``(ii) the Chief Actuary of the Centers for
Medicare & Medicaid Services certifies that
such expansion would reduce program spending
under such title XVIII; and
``(iii) the Secretary determines that such
expansion would not deny or limit the coverage
or provision of benefits under this title for
individuals.''; and
(3) by striking subsection (g) and inserting the following
new subsection:
``(g) Application of Pilot Program to Continuing Care Hospitals.--
``(1) In general.--In conducting the pilot program, the
Secretary shall apply the provisions of the program so as to
separately pilot test the continuing care hospital model.
``(2) Special rules.--In pilot testing the continuing care
hospital model under paragraph (1), the following rules shall
apply:
``(A) Such model shall be tested without the
limitation to the conditions selected under subsection
(a)(2)(B).
``(B) Notwithstanding subsection (a)(2)(D), an
episode of care shall be defined as the full period
that a patient stays in the continuing care hospital
plus the first 30 days following discharge from such
hospital.
``(3) Continuing care hospital defined.--In this
subsection, the term `continuing care hospital' means an entity
that has demonstrated the ability to meet patient care and
patient safety standards and that provides under common
management the medical and rehabilitation services provided in
inpatient rehabilitation hospitals and units (as defined in
section 1886(d)(1)(B)(ii)), long term care hospitals (as
defined in section 1886(d)(1)(B)(iv)(I)), and skilled nursing
facilities (as defined in section 1819(a)) that are located in
a hospital described in section 1886(d).''.
(b) Technical Amendments.--
(1) Section 3023 is amended by striking ``1886C'' and
inserting ``1866C''.
(2) Title XVIII of the Social Security Act is amended by
redesignating section 1866D, as added by section 3024, as
section 1866E.
SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION PROGRAM.
Section 1886(q)(1) of the Social Security Act, as added by section
3025, in the matter preceding subparagraph (A), is amended by striking
``the Secretary shall reduce the payments'' and all that follows
through ``the product of'' and inserting ``the Secretary shall make
payments (in addition to the payments described in paragraph
(2)(A)(ii)) for such a discharge to such hospital under subsection (d)
(or section 1814(b)(3), as the case may be) in an amount equal to the
product of''.
SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.
The provisions of, and the amendment made by, section 3101 are
repealed.
SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)), as amended by section
3105(a), is further amended--
(1) in the matter preceding clause (i)--
(A) by striking ``2007, for'' and inserting ``2007,
and for''; and
(B) by striking ``2010, and for such services
furnished on or after April 1, 2010, and before January
1, 2011'' and inserting ``2011''; and
(2) in each of clauses (i) and (ii)--
(A) by striking ``, and on or after April 1, 2010,
and before January 1, 2011'' each place it appears; and
(B) by striking ``January 1, 2010'' and inserting
``January 1, 2011'' each place it appears.
(b) Air Ambulance.--Section 146(b)(1) of the Medicare Improvements
for Patients and Providers Act of 2008 (Public Law 110-275), as amended
by section 3105(b), is further amended by striking ``December 31, 2009,
and during the period beginning on April 1, 2010, and ending on January
1, 2011'' and inserting ``December 31, 2010''.
(c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(12)(A)), as amended by section
3105(c), is further amended by striking ``2010, and on or after April
1, 2010, and before January 1, 2011'' and inserting ``2011''.
SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL SERVICES
AND MORATORIUM ON THE ESTABLISHMENT OF CERTAIN HOSPITALS
AND FACILITIES.
(a) Certain Payment Rules.--Section 114(c) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as
amended by section 4302(a) of the American Recovery and Reinvestment
Act (Public Law 111-5) and section 3106(a) of this Act, is further
amended by striking ``4-year period'' each place it appears and
inserting ``5-year period''.
(b) Moratorium.--Section 114(d) of such Act (42 U.S.C. 1395ww
note), as amended by section 3106(b) of this Act, in the matter
preceding subparagraph (A), is amended by striking ``4-year period''
and inserting ``5-year period''.
SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL COMMUNITY HOSPITAL
DEMONSTRATION PROGRAM.
(a) In General.--Subsection (g) of section 410A of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173; 117 Stat. 2272), as added by section 3123(a) of this Act,
is amended to read as follows:
``(g) Five-Year Extension of Demonstration Program.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall conduct the demonstration
program under this section for an additional 5-year period (in
this section referred to as the `5-year extension period') that
begins on the date immediately following the last day of the
initial 5-year period under subsection (a)(5).
``(2) Expansion of demonstration states.--Notwithstanding
subsection (a)(2), during the 5-year extension period, the
Secretary shall expand the number of States with low population
densities determined by the Secretary under such subsection to
20. In determining which States to include in such expansion,
the Secretary shall use the same criteria and data that the
Secretary used to determine the States under such subsection
for purposes of the initial 5-year period.
``(3) Increase in maximum number of hospitals participating
in the demonstration program.--Notwithstanding subsection
(a)(4), during the 5-year extension period, not more than 30
rural community hospitals may participate in the demonstration
program under this section.
``(4) Hospitals in demonstration program on date of
enactment.--In the case of a rural community hospital that is
participating in the demonstration program under this section
as of the last day of the initial 5-year period, the
Secretary--
``(A) shall provide for the continued participation
of such rural community hospital in the demonstration
program during the 5-year extension period unless the
rural community hospital makes an election, in such
form and manner as the Secretary may specify, to
discontinue such participation; and
``(B) in calculating the amount of payment under
subsection (b) to the rural community hospital for
covered inpatient hospital services furnished by the
hospital during such 5-year extension period, shall
substitute, under paragraph (1)(A) of such subsection--
``(i) the reasonable costs of providing
such services for discharges occurring in the
first cost reporting period beginning on or
after the first day of the 5-year extension
period, for
``(ii) the reasonable costs of providing
such services for discharges occurring in the
first cost reporting period beginning on or
after the implementation of the demonstration
program.''.
(b) Conforming Amendments.--Subsection (a)(5) of section 410A of
the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (Public Law 108-173; 117 Stat. 2272), as amended by section
3123(b) of this Act, is amended by striking ``1-year extension'' and
inserting ``5-year extension''.
SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12), as amended by section 3125, is amended--
(1) in subparagraph (C)(i), by striking ``1,500
discharges'' and inserting ``1,600 discharges''; and
(2) in subparagraph (D), by striking ``1,500 discharges''
and inserting ``1,600 discharges''.
SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS.
(a) Rebasing.--Section 1895(b)(3)(A)(iii) of the Social Security
Act, as added by section 3131, is amended--
(1) in the clause heading, by striking ``2013'' and
inserting ``2014'';
(2) in subclause (I), by striking ``2013'' and inserting
``2014''; and
(3) in subclause (II), by striking ``2016'' and inserting
``2017''.
(b) Revision of Home Health Study and Report.--Section 3131(d) is
amended to read as follows:
``(d) Study and Report on the Development of Home Health Payment
Revisions in Order to Ensure Access to Care and Payment for Severity of
Illness.--
``(1) In general.--The Secretary of Health and Human
Services (in this section referred to as the `Secretary') shall
conduct a study on home health agency costs involved with
providing ongoing access to care to low-income Medicare
beneficiaries or beneficiaries in medically underserved areas,
and in treating beneficiaries with varying levels of severity
of illness. In conducting the study, the Secretary may analyze
items such as the following:
``(A) Methods to potentially revise the home health
prospective payment system under section 1895 of the
Social Security Act (42 U.S.C. 1395fff) to account for
costs related to patient severity of illness or to
improving beneficiary access to care, such as--
``(i) payment adjustments for services that
may involve additional or fewer resources;
``(ii) changes to reflect resources
involved with providing home health services to
low-income Medicare beneficiaries or Medicare
beneficiaries residing in medically underserved
areas;
``(iii) ways outlier payments might be
revised to reflect costs of treating Medicare
beneficiaries with high levels of severity of
illness; and
``(iv) other issues determined appropriate
by the Secretary.
``(B) Operational issues involved with potential
implementation of potential revisions to the home
health payment system, including impacts for both home
health agencies and administrative and systems issues
for the Centers for Medicare & Medicaid Services, and
any possible payment vulnerabilities associated with
implementing potential revisions.
``(C) Whether additional research might be needed.
``(D) Other items determined appropriate by the
Secretary.
``(2) Considerations.--In conducting the study under
paragraph (1), the Secretary may consider whether patient
severity of illness and access to care could be measured by
factors, such as--
``(A) population density and relative patient
access to care;
``(B) variations in service costs for providing
care to individuals who are dually eligible under the
Medicare and Medicaid programs;
``(C) the presence of severe or chronic diseases,
which might be measured by multiple, discontinuous home
health episodes;
``(D) poverty status, such as evidenced by the
receipt of Supplemental Security Income under title XVI
of the Social Security Act; and
``(E) other factors determined appropriate by the
Secretary.
``(3) Report.--Not later than March 1, 2014, the Secretary
shall submit to Congress a report on the study conducted under
paragraph (1), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
``(4) Consultations.--In conducting the study under
paragraph (1), the Secretary shall consult with appropriate
stakeholders, such as groups representing home health agencies
and groups representing Medicare beneficiaries.
``(5) Medicare demonstration project based on the results
of the study.--
``(A) In general.--Subject to subparagraph (D),
taking into account the results of the study conducted
under paragraph (1), the Secretary may, as determined
appropriate, provide for a demonstration project to
test whether making payment adjustments for home health
services under the Medicare program would substantially
improve access to care for patients with high severity
levels of illness or for low-income or underserved
Medicare beneficiaries.
``(B) Waiving budget neutrality.--The Secretary
shall not reduce the standard prospective payment
amount (or amounts) under section 1895 of the Social
Security Act (42 U.S.C. 1395fff) applicable to home
health services furnished during a period to offset any
increase in payments during such period resulting from
the application of the payment adjustments under
subparagraph (A).
``(C) No effect on subsequent periods.--A payment
adjustment resulting from the application of
subparagraph (A) for a period--
``(i) shall not apply to payments for home
health services under title XVIII after such
period; and
``(ii) shall not be taken into account in
calculating the payment amounts applicable for
such services after such period.
``(D) Duration.--If the Secretary determines it
appropriate to conduct the demonstration project under
this subsection, the Secretary shall conduct the
project for a four year period beginning not later than
January 1, 2015.
``(E) Funding.--The Secretary shall provide for the
transfer from the Federal Hospital Insurance Trust Fund
under section 1817 of the Social Security Act (42
U.S.C. 1395i) and the Federal Supplementary Medical
Insurance Trust Fund established under section 1841 of
such Act (42 U.S.C. 1395t), in such proportion as the
Secretary determines appropriate, of $500,000,000 for
the period of fiscal years 2015 through 2018. Such
funds shall be made available for the study described
in paragraph (1) and the design, implementation and
evaluation of the demonstration described in this
paragraph. Amounts available under this subparagraph
shall be available until expended.
``(F) Evaluation and report.--If the Secretary
determines it appropriate to conduct the demonstration
project under this subsection, the Secretary shall--
``(i) provide for an evaluation of the
project; and
``(ii) submit to Congress, by a date
specified by the Secretary, a report on the
project.
``(G) Administration.--Chapter 35 of title 44,
United States Code, shall not apply with respect to
this subsection.''.
SEC. 10316. MEDICARE DSH.
Section 1886(r)(2)(B) of the Social Security Act, as added by
section 3133, is amended--
(1) in clause (i)--
(A) in the matter preceding subclause (I), by
striking ``(divided by 100)'';
(B) in subclause (I), by striking ``2012'' and
inserting ``2013'';
(C) in subclause (II), by striking the period at
the end and inserting a comma; and
(D) by adding at the end the following flush
matter:
``minus 1.5 percentage points.''.
(2) in clause (ii)--
(A) in the matter preceding subclause (I), by
striking ``(divided by 100)'';
(B) in subclause (I), by striking ``2012'' and
inserting ``2013'';
(C) in subclause (II), by striking the period at
the end and inserting a comma; and
(D) by adding at the end the following flush
matter:
``and, for each of 2018 and 2019, minus 1.5
percentage points.''.
SEC. 10317. REVISIONS TO EXTENSION OF SECTION 508 HOSPITAL PROVISIONS.
Section 3137(a) is amended to read as follows:
``(a) Extension.--
``(1) In general.--Subsection (a) of section 106 of
division B of the Tax Relief and Health Care Act of 2006 (42
U.S.C. 1395 note), as amended by section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173)
and section 124 of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275), is amended by
striking `September 30, 2009' and inserting `September 30,
2010'.
``(2) Special rule for fiscal year 2010.--
``(A) In general.--Subject to subparagraph (B), for
purposes of implementation of the amendment made by
paragraph (1), including (notwithstanding paragraph (3)
of section 117(a) of the Medicare, Medicaid and SCHIP
Extension Act of 2007 (Public Law 110-173), as amended
by section 124(b) of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-
275)) for purposes of the implementation of paragraph
(2) of such section 117(a), during fiscal year 2010,
the Secretary of Health and Human Services (in this
subsection referred to as the `Secretary') shall use
the hospital wage index that was promulgated by the
Secretary in the Federal Register on August 27, 2009
(74 Fed. Reg. 43754), and any subsequent corrections.
``(B) Exception.--Beginning on April 1, 2010, in
determining the wage index applicable to hospitals that
qualify for wage index reclassification, the Secretary
shall include the average hourly wage data of hospitals
whose reclassification was extended pursuant to the
amendment made by paragraph (1) only if including such
data results in a higher applicable reclassified wage
index.
``(3) Adjustment for certain hospitals in fiscal year
2010.--
``(A) In general.--In the case of a subsection (d)
hospital (as defined in subsection (d)(1)(B) of section
1886 of the Social Security Act (42 U.S.C. 1395ww))
with respect to which--
``(i) a reclassification of its wage index
for purposes of such section was extended
pursuant to the amendment made by paragraph
(1); and
``(ii) the wage index applicable for such
hospital for the period beginning on October 1,
2009, and ending on March 31, 2010, was lower
than for the period beginning on April 1, 2010,
and ending on September 30, 2010, by reason of
the application of paragraph (2)(B);
the Secretary shall pay such hospital an additional
payment that reflects the difference between the wage
index for such periods.
``(B) Timeframe for payments.--The Secretary shall
make payments required under subparagraph by not later
than December 31, 2010.''.
SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER MEDICARE
ADVANTAGE.
Section 1853(p)(3)(A) of the Social Security Act, as added by
section 3201(h), is amended by inserting ``in 2009'' before the period
at the end.
SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS.
(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B)(xii) of the
Social Security Act, as added by section 3401(a), is amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of fiscal years 2012 and 2013, by 0.1
percentage point; and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
(b) Long-term Care Hospitals.--Section 1886(m)(4) of the Social
Security Act, as added by section 3401(c), is amended--
(1) in subparagraph (A)--
(A) in clause (i)--
(i) by striking ``each of rate years 2010
and 2011'' and inserting ``rate year 2010'';
and
(ii) by striking ``and'' at the end;
(B) by redesignating clause (ii) as clause (iv);
(C) by inserting after clause (i) the following new
clauses:
``(ii) for rate year 2011, 0.50 percentage
point;
``(iii) for each of the rate years
beginning in 2012 and 2013, 0.1 percentage
point; and''; and
(D) in clause (iv), as redesignated by subparagraph
(B), by striking ``2012'' and inserting ``2014''; and
(2) in subparagraph (B), by striking ``(A)(ii)'' and
inserting ``(A)(iv)''.
(c) Inpatient Rehabilitation Facilities.--Section 1886(j)(3)(D)(i)
of the Social Security Act, as added by section 3401(d), is amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of fiscal years
2012 and 2013, 0.1 percentage point;
and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
(d) Home Health Agencies.--Section 1895(b)(3)(B)(vi)(II) of such
Act, as added by section 3401(e), is amended by striking ``and 2012''
and inserting ``, 2012, and 2013''.
(e) Psychiatric Hospitals.--Section 1886(s)(3)(A) of the Social
Security Act, as added by section 3401(f), is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) by redesignating clause (ii) as clause (iii);
(3) by inserting after clause (ii) the following new
clause:
``(ii) for each of the rate years beginning
in 2012 and 2013, 0.1 percentage point; and'';
and
(4) in clause (iii), as redesignated by paragraph (2), by
striking ``2012'' and inserting ``2014''.
(f) Hospice Care.--Section 1814(i)(1)(C) of the Social Security Act
(42 U.S.C. 1395f(i)(1)(C)), as amended by section 3401(g), is amended--
(1) in clause (iv)(II), by striking ``0.5'' and inserting
``0.3''; and
(2) in clause (v), in the matter preceding subclause (I),
by striking ``0.5'' and inserting ``0.3''.
(g) Outpatient Hospitals.--Section 1833(t)(3)(G)(i) of the Social
Security Act, as added by section 3401(i), is amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of 2012 and 2013,
0.1 percentage point; and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL IMPROVEMENTS TO,
THE INDEPENDENT MEDICARE ADVISORY BOARD.
(a) In General.--Section 1899A of the Social Security Act, as added
by section 3403, is amended--
(1) in subsection (c)--
(A) in paragraph (1)(B), by adding at the end the
following new sentence: ``In any year (beginning with
2014) that the Board is not required to submit a
proposal under this section, the Board shall submit to
Congress an advisory report on matters related to the
Medicare program.'';
(B) in paragraph (2)(A)--
(i) in clause (iv), by inserting ``or the
full premium subsidy under section 1860D-
14(a)'' before the period at the end of the
last sentence; and
(ii) by adding at the end the following new
clause:
``(vii) If the Chief Actuary of the Centers
for Medicare & Medicaid Services has made a
determination described in subsection
(e)(3)(B)(i)(II) in the determination year, the
proposal shall be designed to help reduce the
growth rate described in paragraph (8) while
maintaining or enhancing beneficiary access to
quality care under this title.'';
(C) in paragraph (2)(B)--
(i) in clause (v), by striking ``and'' at
the end;
(ii) in clause (vi), by striking the period
at the end and inserting ``; and''; and
(iii) by adding at the end the following
new clause:
``(vii) take into account the data and
findings contained in the annual reports under
subsection (n) in order to develop proposals
that can most effectively promote the delivery
of efficient, high quality care to Medicare
beneficiaries.'';
(D) in paragraph (3)--
(i) in the heading, by striking
``Transmission of board proposal to president''
and inserting ``Submission of board proposal to
congress and the president'';
(ii) in subparagraph (A)(i), by striking
``transmit a proposal under this section to the
President'' and insert ``submit a proposal
under this section to Congress and the
President''; and
(iii) in subparagraph (A)(ii)--
(I) in subclause (I), by inserting
``or'' at the end;
(II) in subclause (II), by striking
``; or'' and inserting a period; and
(III) by striking subclause (III);
(E) in paragraph (4)--
(i) by striking ``the Board under paragraph
(3)(A)(i) or''; and
(ii) by striking ``immediately'' and
inserting ``within 2 days'';
(F) in paragraph (5)--
(i) by striking ``to but'' and inserting
``but''; and
(ii) by inserting ``Congress and'' after
``submit a proposal to''; and
(G) in paragraph (6)(B)(i), by striking ``per
unduplicated enrollee'' and inserting ``(calculated as
the sum of per capita spending under each of parts A,
B, and D)'';
(2) in subsection (d)--
(A) in paragraph (1)(A)--
(i) by inserting ``the Board or'' after ``a
proposal is submitted by''; and
(ii) by inserting ``subsection (c)(3)(A)(i)
or'' after ``the Senate under''; and
(B) in paragraph (2)(A), by inserting ``the Board
or'' after ``a proposal is submitted by'';
(3) in subsection (e)--
(A) in paragraph (1), by inserting ``the Board or''
after ``a proposal submitted by''; and
(B) in paragraph (3)--
(i) by striking ``Exception.--The Secretary
shall not be required to implement the
recommendations contained in a proposal
submitted in a proposal year by'' and inserting
``Exceptions.--
``(A) In general.--The Secretary shall not
implement the recommendations contained in a proposal
submitted in a proposal year by the Board or'';
(ii) by redesignating subparagraphs (A) and
(B) as clauses (i) and (ii), respectively, and
indenting appropriately; and
(iii) by adding at the end the following
new subparagraph:
``(B) Limited additional exception.--
``(i) In general.--Subject to clause (ii),
the Secretary shall not implement the
recommendations contained in a proposal
submitted by the Board or the President to
Congress pursuant to this section in a proposal
year (beginning with proposal year 2019) if--
``(I) the Board was required to
submit a proposal to Congress under
this section in the year preceding the
proposal year; and
``(II) the Chief Actuary of the
Centers for Medicare & Medicaid
Services makes a determination in the
determination year that the growth rate
described in subsection (c)(8) exceeds
the growth rate described in subsection
(c)(6)(A)(i).
``(ii) Limited additional exception may not
be applied in two consecutive years.--This
subparagraph shall not apply if the
recommendations contained in a proposal
submitted by the Board or the President to
Congress pursuant to this section in the year
preceding the proposal year were not required
to be implemented by reason of this
subparagraph.
``(iii) No affect on requirement to submit
proposals or for congressional consideration of
proposals.--Clause (i) and (ii) shall not
affect--
``(I) the requirement of the Board
or the President to submit a proposal
to Congress in a proposal year in
accordance with the provisions of this
section; or
``(II) Congressional consideration
of a legislative proposal (described in
subsection (c)(3)(B)(iv)) contained
such a proposal in accordance with
subsection (d).'';
(4) in subsection (f)(3)(B)--
(A) by striking ``or advisory reports to Congress''
and inserting ``, advisory reports, or advisory
recommendations''; and
(B) by inserting ``or produce the public report
under subsection (n)'' after ``this section''; and
(5) by adding at the end the following new subsections:
``(n) Annual Public Report.--
``(1) In general.--Not later than July 1, 2014, and
annually thereafter, the Board shall produce a public report
containing standardized information on system-wide health care
costs, patient access to care, utilization, and quality-of-care
that allows for comparison by region, types of services, types
of providers, and both private payers and the program under
this title.
``(2) Requirements.--Each report produced pursuant to
paragraph (1) shall include information with respect to the
following areas:
``(A) The quality and costs of care for the
population at the most local level determined practical
by the Board (with quality and costs compared to
national benchmarks and reflecting rates of change,
taking into account quality measures described in
section 1890(b)(7)(B)).
``(B) Beneficiary and consumer access to care,
patient and caregiver experience of care, and the cost-
sharing or out-of-pocket burden on patients.
``(C) Epidemiological shifts and demographic
changes.
``(D) The proliferation, effectiveness, and
utilization of health care technologies, including
variation in provider practice patterns and costs.
``(E) Any other areas that the Board determines
affect overall spending and quality of care in the
private sector.
``(o) Advisory Recommendations for Non-Federal Health Care
Programs.--
``(1) In general.--Not later than January 15, 2015, and at
least once every two years thereafter, the Board shall submit
to Congress and the President recommendations to slow the
growth in national health expenditures (excluding expenditures
under this title and in other Federal health care programs)
while preserving or enhancing quality of care, such as
recommendations--
``(A) that the Secretary or other Federal agencies
can implement administratively;
``(B) that may require legislation to be enacted by
Congress in order to be implemented;
``(C) that may require legislation to be enacted by
State or local governments in order to be implemented;
``(D) that private sector entities can voluntarily
implement; and
``(E) with respect to other areas determined
appropriate by the Board.
``(2) Coordination.--In making recommendations under
paragraph (1), the Board shall coordinate such recommendations
with recommendations contained in proposals and advisory
reports produced by the Board under subsection (c).
``(3) Available to public.--The Board shall make
recommendations submitted to Congress and the President under
this subsection available to the public.''.
(b) Name Change.--Any reference in the provisions of, or amendments
made by, section 3403 to the ``Independent Medicare Advisory Board''
shall be deemed to be a reference to the ``Independent Payment Advisory
Board''.
(c) Rule of Construction.--Nothing in the amendments made by this
section shall preclude the Independent Medicare Advisory Board, as
established under section 1899A of the Social Security Act (as added by
section 3403), from solely using data from public or private sources to
carry out the amendments made by subsection (a)(4).
SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS.
Section 3502(c)(2)(A) is amended by inserting ``or other primary
care providers'' after ``physicians''.
SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOSPITALS.
(a) In General.--Section 1886(s) of the Social Security Act, as
added by section 3401(f), is amended by adding at the end the following
new paragraph:
``(4) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--Under the system
described in paragraph (1), for rate year 2014
and each subsequent rate year, in the case of a
psychiatric hospital or psychiatric unit that
does not submit data to the Secretary in
accordance with subparagraph (C) with respect
to such a rate year, any annual update to a
standard Federal rate for discharges for the
hospital during the rate year, and after
application of paragraph (2), shall be reduced
by 2 percentage points.
``(ii) Special rule.--The application of
this subparagraph may result in such annual
update being less than 0.0 for a rate year, and
may result in payment rates under the system
described in paragraph (1) for a rate year
being less than such payment rates for the
preceding rate year.
``(B) Noncumulative application.--Any reduction
under subparagraph (A) shall apply only with respect to
the rate year involved and the Secretary shall not take
into account such reduction in computing the payment
amount under the system described in paragraph (1) for
a subsequent rate year.
``(C) Submission of quality data.--For rate year
2014 and each subsequent rate year, each psychiatric
hospital and psychiatric unit shall submit to the
Secretary data on quality measures specified under
subparagraph (D). Such data shall be submitted in a
form and manner, and at a time, specified by the
Secretary for purposes of this subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii),
any measure specified by the Secretary under
this subparagraph must have been endorsed by
the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a
specified area or medical topic determined
appropriate by the Secretary for which a
feasible and practical measure has not been
endorsed by the entity with a contract under
section 1890(a), the Secretary may specify a
measure that is not so endorsed as long as due
consideration is given to measures that have
been endorsed or adopted by a consensus
organization identified by the Secretary.
``(iii) Time frame.--Not later than October
1, 2012, the Secretary shall publish the
measures selected under this subparagraph that
will be applicable with respect to rate year
2014.
``(E) Public availability of data submitted.--The
Secretary shall establish procedures for making data
submitted under subparagraph (C) available to the
public. Such procedures shall ensure that a psychiatric
hospital and a psychiatric unit has the opportunity to
review the data that is to be made public with respect
to the hospital or unit prior to such data being made
public. The Secretary shall report quality measures
that relate to services furnished in inpatient settings
in psychiatric hospitals and psychiatric units on the
Internet website of the Centers for Medicare & Medicaid
Services.''.
(b) Conforming Amendment.--Section 1890(b)(7)(B)(i)(I) of the
Social Security Act, as added by section 3014, is amended by inserting
``1886(s)(4)(D),'' after ``1886(o)(2),''.
SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO ENVIRONMENTAL
HEALTH HAZARDS.
(a) In General.--Title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) is amended by inserting after section 1881 the following
new section:
``SEC. 1881A. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO
ENVIRONMENTAL HEALTH HAZARDS.
``(a) Deeming of Individuals as Eligible for Medicare Benefits.--
``(1) In general.--For purposes of eligibility for benefits
under this title, an individual determined under subsection (c)
to be an environmental exposure affected individual described
in subsection (e)(2) shall be deemed to meet the conditions
specified in section 226(a).
``(2) Discretionary deeming.--For purposes of eligibility
for benefits under this title, the Secretary may deem an
individual determined under subsection (c) to be an
environmental exposure affected individual described in
subsection (e)(3) to meet the conditions specified in section
226(a).
``(3) Effective date of coverage.--An Individual who is
deemed eligible for benefits under this title under paragraph
(1) or (2) shall be--
``(A) entitled to benefits under the program under
Part A as of the date of such deeming; and
``(B) eligible to enroll in the program under Part
B beginning with the month in which such deeming
occurs.
``(b) Pilot Program for Care of Certain Individuals Residing in
Emergency Declaration Areas.--
``(1) Program; purpose.--
``(A) Primary pilot program.--The Secretary shall
establish a pilot program in accordance with this
subsection to provide innovative approaches to
furnishing comprehensive, coordinated, and cost-
effective care under this title to individuals
described in paragraph (2)(A).
``(B) Optional pilot programs.--The Secretary may
establish a separate pilot program, in accordance with
this subsection, with respect to each geographic area
subject to an emergency declaration (other than the
declaration of June 17, 2009), in order to furnish such
comprehensive, coordinated and cost-effective care to
individuals described in subparagraph (2)(B) who reside
in each such area.
``(2) Individual described.--For purposes of paragraph (1),
an individual described in this paragraph is an individual who
enrolls in part B, submits to the Secretary an application to
participate in the applicable pilot program under this
subsection, and--
``(A) is an environmental exposure affected
individual described in subsection (e)(2) who resides
in or around the geographic area subject to an
emergency declaration made as of June 17, 2009; or
``(B) is an environmental exposure affected
individual described in subsection (e)(3) who--
``(i) is deemed under subsection (a)(2);
and
``(ii) meets such other criteria or
conditions for participation in a pilot program
under paragraph (1)(B) as the Secretary
specifies.
``(3) Flexible benefits and services.--A pilot program
under this subsection may provide for the furnishing of
benefits, items, or services not otherwise covered or
authorized under this title, if the Secretary determines that
furnishing such benefits, items, or services will further the
purposes of such pilot program (as described in paragraph (1)).
``(4) Innovative reimbursement methodologies.--For purposes
of the pilot program under this subsection, the Secretary--
``(A) shall develop and implement appropriate
methodologies to reimburse providers for furnishing
benefits, items, or services for which payment is not
otherwise covered or authorized under this title, if
such benefits, items, or services are furnished
pursuant to paragraph (3); and
``(B) may develop and implement innovative
approaches to reimbursing providers for any benefits,
items, or services furnished under this subsection.
``(5) Limitation.--Consistent with section 1862(b), no
payment shall be made under the pilot program under this
subsection with respect to benefits, items, or services
furnished to an environmental exposure affected individual (as
defined in subsection (e)) to the extent that such individual
is eligible to receive such benefits, items, or services
through any other public or private benefits plan or legal
agreement.
``(6) Waiver authority.--The Secretary may waive such
provisions of this title and title XI as are necessary to carry
out pilot programs under this subsection.
``(7) Funding.--For purposes of carrying out pilot programs
under this subsection, the Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance
Trust Fund under section 1841, in such proportion as the
Secretary determines appropriate, of such sums as the Secretary
determines necessary, to the Centers for Medicare & Medicaid
Services Program Management Account.
``(8) Waiver of budget neutrality.--The Secretary shall not
require that pilot programs under this subsection be budget
neutral with respect to expenditures under this title.
``(c) Determinations.--
``(1) By the commissioner of social security.--For purposes
of this section, the Commissioner of Social Security, in
consultation with the Secretary, and using the cost allocation
method prescribed in section 201(g), shall determine whether
individuals are environmental exposure affected individuals.
``(2) By the secretary.--The Secretary shall determine
eligibility for pilot programs under subsection (b).
``(d) Emergency Declaration Defined.--For purposes of this section,
the term `emergency declaration' means a declaration of a public health
emergency under section 104(a) of the Comprehensive Environmental
Response, Compensation, and Liability Act of 1980.
``(e) Environmental Exposure Affected Individual Defined.--
``(1) In general.--For purposes of this section, the term
`environmental exposure affected individual' means--
``(A) an individual described in paragraph (2); and
``(B) an individual described in paragraph (3).
``(2) Individual described.--
``(A) In general.--An individual described in this
paragraph is any individual who--
``(i) is diagnosed with 1 or more
conditions described in subparagraph (B);
``(ii) as demonstrated in such manner as
the Secretary determines appropriate, has been
present for an aggregate total of 6 months in
the geographic area subject to an emergency
declaration specified in subsection (b)(2)(A),
during a period ending--
``(I) not less than 10 years prior
to such diagnosis; and
``(II) prior to the implementation
of all the remedial and removal actions
specified in the Record of Decision for
Operating Unit 4 and the Record of
Decision for Operating Unit 7;
``(iii) files an application for benefits
under this title (or has an application filed
on behalf of the individual), including
pursuant to this section; and
``(iv) is determined under this section to
meet the criteria in this subparagraph.
``(B) Conditions described.--For purposes of
subparagraph (A), the following conditions are
described in this subparagraph:
``(i) Asbestosis, pleural thickening, or
pleural plaques as established by--
``(I) interpretation by a `B
Reader' qualified physician of a plain
chest x-ray or interpretation of a
computed tomographic radiograph of the
chest by a qualified physician, as
determined by the Secretary; or
``(II) such other diagnostic
standards as the Secretary specifies,
except that this clause shall not apply to
pleural thickening or pleural plaques unless
there are symptoms or conditions requiring
medical treatment as a result of these
diagnoses.
``(ii) Mesothelioma, or malignancies of the
lung, colon, rectum, larynx, stomach,
esophagus, pharynx, or ovary, as established
by--
``(I) pathologic examination of
biopsy tissue;
``(II) cytology from
bronchioalveolar lavage; or
``(III) such other diagnostic
standards as the Secretary specifies.
``(iii) Any other diagnosis which the
Secretary, in consultation with the
Commissioner of Social Security, determines is
an asbestos-related medical condition, as
established by such diagnostic standards as the
Secretary specifies.
``(3) Other individual described.--An individual described
in this paragraph is any individual who--
``(A) is not an individual described in paragraph
(2);
``(B) is diagnosed with a medical condition caused
by the exposure of the individual to a public health
hazard to which an emergency declaration applies, based
on such medical conditions, diagnostic standards, and
other criteria as the Secretary specifies;
``(C) as demonstrated in such manner as the
Secretary determines appropriate, has been present for
an aggregate total of 6 months in the geographic area
subject to the emergency declaration involved, during a
period determined appropriate by the Secretary;
``(D) files an application for benefits under this
title (or has an application filed on behalf of the
individual), including pursuant to this section; and
``(E) is determined under this section to meet the
criteria in this paragraph.''.
(b) Program for Early Detection of Certain Medical Conditions
Related to Environmental Health Hazards.--Title XX of the Social
Security Act (42 U.S.C. 1397 et seq.), as amended by section 5507, is
amended by adding at the end the following:
``SEC. 2009. PROGRAM FOR EARLY DETECTION OF CERTAIN MEDICAL CONDITIONS
RELATED TO ENVIRONMENTAL HEALTH HAZARDS.
``(a) Program Establishment.--The Secretary shall establish a
program in accordance with this section to make competitive grants to
eligible entities specified in subsection (b) for the purpose of--
``(1) screening at-risk individuals (as defined in
subsection (c)(1)) for environmental health conditions (as
defined in subsection (c)(3)); and
``(2) developing and disseminating public information and
education concerning--
``(A) the availability of screening under the
program under this section;
``(B) the detection, prevention, and treatment of
environmental health conditions; and
``(C) the availability of Medicare benefits for
certain individuals diagnosed with environmental health
conditions under section 1881A.
``(b) Eligible Entities.--
``(1) In general.--For purposes of this section, an
eligible entity is an entity described in paragraph (2) which
submits an application to the Secretary in such form and
manner, and containing such information and assurances, as the
Secretary determines appropriate.
``(2) Types of eligible entities.--The entities described
in this paragraph are the following:
``(A) A hospital or community health center.
``(B) A Federally qualified health center.
``(C) A facility of the Indian Health Service.
``(D) A National Cancer Institute-designated cancer
center.
``(E) An agency of any State or local government.
``(F) A nonprofit organization.
``(G) Any other entity the Secretary determines
appropriate.
``(c) Definitions.--In this section:
``(1) At-risk individual.--The term `at-risk individual'
means an individual who--
``(A)(i) as demonstrated in such manner as the
Secretary determines appropriate, has been present for
an aggregate total of 6 months in the geographic area
subject to an emergency declaration specified under
paragraph (2), during a period ending--
``(I) not less than 10 years prior to the
date of such individual's application under
subparagraph (B); and
``(II) prior to the implementation of all
the remedial and removal actions specified in
the Record of Decision for Operating Unit 4 and
the Record of Decision for Operating Unit 7; or
``(ii) meets such other criteria as the Secretary
determines appropriate considering the type of
environmental health condition at issue; and
``(B) has submitted an application (or has an
application submitted on the individual's behalf), to
an eligible entity receiving a grant under this
section, for screening under the program under this
section.
``(2) Emergency declaration.--The term `emergency
declaration' means a declaration of a public health emergency
under section 104(a) of the Comprehensive Environmental
Response, Compensation, and Liability Act of 1980.
``(3) Environmental health condition.--The term
`environmental health condition' means--
``(A) asbestosis, pleural thickening, or pleural
plaques, as established by--
``(i) interpretation by a `B Reader'
qualified physician of a plain chest x-ray or
interpretation of a computed tomographic
radiograph of the chest by a qualified
physician, as determined by the Secretary; or
``(ii) such other diagnostic standards as
the Secretary specifies;
``(B) mesothelioma, or malignancies of the lung,
colon, rectum, larynx, stomach, esophagus, pharynx, or
ovary, as established by--
``(i) pathologic examination of biopsy
tissue;
``(ii) cytology from bronchioalveolar
lavage; or
``(iii) such other diagnostic standards as
the Secretary specifies; and
``(C) any other medical condition which the
Secretary determines is caused by exposure to a
hazardous substance or pollutant or contaminant at a
Superfund site to which an emergency declaration
applies, based on such criteria and as established by
such diagnostic standards as the Secretary specifies.
``(4) Hazardous substance; pollutant; contaminant.--The
terms `hazardous substance', `pollutant', and `contaminant'
have the meanings given those terms in section 101 of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9601).
``(5) Superfund site.--The term `Superfund site' means a
site included on the National Priorities List developed by the
President in accordance with section 105(a)(8)(B) of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)).
``(d) Health Coverage Unaffected.--Nothing in this section shall be
construed to affect any coverage obligation of a governmental or
private health plan or program relating to an at-risk individual.
``(e) Funding.--
``(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary, to carry out the program under this section--
``(A) $23,000,000 for the period of fiscal years
2010 through 2014; and
``(B) $20,000,000 for each 5-fiscal year period
thereafter.
``(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until expended.
``(f) Nonapplication.--
``(1) In general.--Except as provided in paragraph (2), the
preceding sections of this title shall not apply to grants
awarded under this section.
``(2) Limitations on use of grants.--Section 2005(a) shall
apply to a grant awarded under this section to the same extent
and in the same manner as such section applies to payments to
States under this title, except that paragraph (4) of such
section shall not be construed to prohibit grantees from
conducting screening for environmental health conditions as
authorized under this section.''.
SEC. 10324. PROTECTIONS FOR FRONTIER STATES.
(a) Floor on Area Wage Index for Hospitals in Frontier States.--
(1) In general.--Section 1886(d)(3)(E) of the Social
Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended--
(A) in clause (i), by striking ``clause (ii)'' and
inserting ``clause (ii) or (iii)''; and
(B) by adding at the end the following new clause:
``(iii) Floor on area wage index for
hospitals in frontier states.--
``(I) In general.--Subject to
subclause (IV), for discharges
occurring on or after October 1, 2010,
the area wage index applicable under
this subparagraph to any hospital which
is located in a frontier State (as
defined in subclause (II)) may not be
less than 1.00.
``(II) Frontier state defined.--In
this clause, the term `frontier State'
means a State in which at least 50
percent of the counties in the State
are frontier counties.
``(III) Frontier county defined.--
In this clause, the term `frontier
county' means a county in which the
population per square mile is less than
6.
``(IV) Limitation.--This clause
shall not apply to any hospital located
in a State that receives a non-labor
related share adjustment under
paragraph (5)(H).''.
(2) Waiving budget neutrality.--Section 1886(d)(3)(E) of
the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended
by subsection (a), is amended in the third sentence by
inserting ``and the amendments made by section 10324(a)(1) of
the Patient Protection and Affordable Care Act'' after
``2003''.
(b) Floor on Area Wage Adjustment Factor for Hospital Outpatient
Department Services in Frontier States.--Section 1833(t) of the Social
Security Act (42 U.S.C. 1395l(t)), as amended by section 3138, is
amended--
(1) in paragraph (2)(D), by striking ``the Secretary'' and
inserting ``subject to paragraph (19), the Secretary''; and
(2) by adding at the end the following new paragraph:
``(19) Floor on area wage adjustment factor for hospital
outpatient department services in frontier states.--
``(A) In general.--Subject to subparagraph (B),
with respect to covered OPD services furnished on or
after January 1, 2011, the area wage adjustment factor
applicable under the payment system established under
this subsection to any hospital outpatient department
which is located in a frontier State (as defined in
section 1886(d)(3)(E)(iii)(II)) may not be less than
1.00. The preceding sentence shall not be applied in a
budget neutral manner.
``(B) Limitation.--This paragraph shall not apply
to any hospital outpatient department located in a
State that receives a non-labor related share
adjustment under section 1886(d)(5)(H).''.
(c) Floor for Practice Expense Index for Physicians' Services
Furnished in Frontier States.--Section 1848(e)(1) of the Social
Security Act (42 U.S.C. 1395w-4(e)(1)), as amended by section 3102, is
amended--
(1) in subparagraph (A), by striking ``and (H)'' and
inserting ``(H), and (I)''; and
(2) by adding at the end the following new subparagraph:
``(I) Floor for practice expense index for services
furnished in frontier states.--
``(i) In general.--Subject to clause (ii),
for purposes of payment for services furnished
in a frontier State (as defined in section
1886(d)(3)(E)(iii)(II)) on or after January 1,
2011, after calculating the practice expense
index in subparagraph (A)(i), the Secretary
shall increase any such index to 1.00 if such
index would otherwise be less that 1.00. The
preceding sentence shall not be applied in a
budget neutral manner.
``(ii) Limitation.--This subparagraph shall
not apply to services furnished in a State that
receives a non-labor related share adjustment
under section 1886(d)(5)(H).''.
SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE PAYMENT
SYSTEM.
(a) Temporary Delay of RUG-IV.--Notwithstanding any other provision
of law, the Secretary of Health and Human Services shall not, prior to
October 1, 2011, implement Version 4 of the Resource Utilization Groups
(in this subsection refereed to as ``RUG-IV'') published in the Federal
Register on August 11, 2009, entitled ``Prospective Payment System and
Consolidated Billing for Skilled Nursing Facilities for FY 2010;
Minimum Data Set, Version 3.0 for Skilled Nursing Facilities and
Medicaid Nursing Facilities'' (74 Fed. Reg. 40288). Beginning on
October 1, 2010, the Secretary of Health and Human Services shall
implement the change specific to therapy furnished on a concurrent
basis that is a component of RUG-IV and changes to the lookback period
to ensure that only those services furnished after admission to a
skilled nursing facility are used as factors in determining a case mix
classification under the skilled nursing facility prospective payment
system under section 1888(e) of the Social Security Act (42 U.S.C.
1395yy(e)).
(b) Construction.--Nothing in this section shall be interpreted as
delaying the implementation of Version 3.0 of the Minimum Data Sets
(MDS 3.0) beyond the planned implementation date of October 1, 2010.
SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR CERTAIN
MEDICARE PROVIDERS.
(a) In General.--Not later than January 1, 2016, the Secretary of
Health and Human Services (in this section referred to as the
``Secretary'') shall, for each provider described in subsection (b),
conduct a separate pilot program under title XVIII of the Social
Security Act to test the implementation of a value-based purchasing
program for payments under such title for the provider.
(b) Providers Described.--The providers described in this paragraph
are the following:
(1) Psychiatric hospitals (as described in clause (i) of
section 1886(d)(1)(B) of such Act (42 U.S.C. 1395ww(d)(1)(B)))
and psychiatric units (as described in the matter following
clause (v) of such section).
(2) Long-term care hospitals (as described in clause (iv)
of such section).
(3) Rehabilitation hospitals (as described in clause (ii)
of such section).
(4) PPS-exempt cancer hospitals (as described in clause (v)
of such section).
(5) Hospice programs (as defined in section 1861(dd)(2) of
such Act (42 U.S.C. 1395x(dd)(2))).
(c) Waiver Authority.--The Secretary may waive such requirements of
titles XI and XVIII of the Social Security Act as may be necessary
solely for purposes of carrying out the pilot programs under this
section.
(d) No Additional Program Expenditures.--Payments under this
section under the separate pilot program for value based purchasing (as
described in subsection (a)) for each provider type described in
paragraphs (1) through (5) of subsection (b) for applicable items and
services under title XVIII of the Social Security Act for a year shall
be established in a manner that does not result in spending more under
each such value based purchasing program for such year than would
otherwise be expended for such provider type for such year if the pilot
program were not implemented, as estimated by the Secretary.
(e) Expansion of Pilot Program.--The Secretary may, at any point
after January 1, 2018, expand the duration and scope of a pilot program
conducted under this subsection, to the extent determined appropriate
by the Secretary, if--
(1) the Secretary determines that such expansion is
expected to--
(A) reduce spending under title XVIII of the Social
Security Act without reducing the quality of care; or
(B) improve the quality of care and reduce
spending;
(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under such title XVIII; and
(3) the Secretary determines that such expansion would not
deny or limit the coverage or provision of benefits under such
title XIII for Medicare beneficiaries.
SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM.
(a) In General.--Section 1848(m) of the Social Security Act (42
U.S.C. 1395w-4(m)) is amended by adding at the end the following new
paragraph:
``(7) Additional incentive payment.--
``(A) In general.--For 2011 through 2014, if an
eligible professional meets the requirements described
in subparagraph (B), the applicable quality percent for
such year, as described in clauses (iii) and (iv) of
paragraph (1)(B), shall be increased by 0.5 percentage
points.
``(B) Requirements described.--In order to qualify
for the additional incentive payment described in
subparagraph (A), an eligible professional shall meet
the following requirements:
``(i) The eligible professional shall--
``(I) satisfactorily submit data on
quality measures for purposes of
paragraph (1) for a year; and
``(II) have such data submitted on
their behalf through a Maintenance of
Certification Program (as defined in
subparagraph (C)(i)) that meets--
``(aa) the criteria for a
registry (as described in
subsection (k)(4)); or
``(bb) an alternative form
and manner determined
appropriate by the Secretary.
``(ii) The eligible professional, more
frequently than is required to qualify for or
maintain board certification status--
``(I) participates in such a
Maintenance of Certification program
for a year; and
``(II) successfully completes a
qualified Maintenance of Certification
Program practice assessment (as defined
in subparagraph (C)(ii)) for such year.
``(iii) A Maintenance of Certification
program submits to the Secretary, on behalf of
the eligible professional, information--
``(I) in a form and manner
specified by the Secretary, that the
eligible professional has successfully
met the requirements of clause (ii)
(which may be in the form of a
structural measure);
``(II) if requested by the
Secretary, on the survey of patient
experience with care (as described in
subparagraph (C)(ii)(II)); and
``(III) as the Secretary may
require, on the methods, measures, and
data used under the Maintenance of
Certification Program and the qualified
Maintenance of Certification Program
practice assessment.
``(C) Definitions.--For purposes of this paragraph:
``(i) The term `Maintenance of
Certification Program' means a continuous
assessment program, such as qualified American
Board of Medical Specialties Maintenance of
Certification program or an equivalent program
(as determined by the Secretary), that advances
quality and the lifelong learning and self-
assessment of board certified specialty
physicians by focusing on the competencies of
patient care, medical knowledge, practice-based
learning, interpersonal and communication
skills and professionalism. Such a program
shall include the following:
``(I) The program requires the
physician to maintain a valid,
unrestricted medical license in the
United States.
``(II) The program requires a
physician to participate in educational
and self-assessment programs that
require an assessment of what was
learned.
``(III) The program requires a
physician to demonstrate, through a
formalized, secure examination, that
the physician has the fundamental
diagnostic skills, medical knowledge,
and clinical judgment to provide
quality care in their respective
specialty.
``(IV) The program requires
successful completion of a qualified
Maintenance of Certification Program
practice assessment as described in
clause (ii).
``(ii) The term `qualified Maintenance of
Certification Program practice assessment'
means an assessment of a physician's practice
that--
``(I) includes an initial
assessment of an eligible
professional's practice that is
designed to demonstrate the physician's
use of evidence-based medicine;
``(II) includes a survey of patient
experience with care; and
``(III) requires a physician to
implement a quality improvement
intervention to address a practice
weakness identified in the initial
assessment under subclause (I) and then
to remeasure to assess performance
improvement after such intervention.''.
(b) Authority.--Section 3002(c) of this Act is amended by adding at
the end the following new paragraph:
``(3) Authority.--For years after 2014, if the Secretary of
Health and Human Services determines it to be appropriate, the
Secretary may incorporate participation in a Maintenance of
Certification Program and successful completion of a qualified
Maintenance of Certification Program practice assessment into
the composite of measures of quality of care furnished pursuant
to the physician fee schedule payment modifier, as described in
section 1848(p)(2) of the Social Security Act (42 U.S.C. 1395w-
4(p)(2)).''.
(c) Elimination of MA Regional Plan Stabilization Fund.--
(1) In general.--Section 1858 of the Social Security Act
(42 U.S.C. 1395w-27a) is amended by striking subsection (e).
(2) Transition.--Any amount contained in the MA Regional
Plan Stabilization Fund as of the date of the enactment of this
Act shall be transferred to the Federal Supplementary Medical
Insurance Trust Fund.
SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY MANAGEMENT (MTM)
PROGRAMS.
(a) In General.--Section 1860D-4(c)(2) of the Social Security Act
(42 U.S.C. 1395w-104(c)(2)) is amended--
(1) by redesignating subparagraphs (C), (D), and (E) as
subparagraphs (E), (F), and (G), respectively; and
(2) by inserting after subparagraph (B) the following new
subparagraphs:
``(C) Required interventions.--For plan years
beginning on or after the date that is 2 years after
the date of the enactment of the Patient Protection and
Affordable Care Act, prescription drug plan sponsors
shall offer medication therapy management services to
targeted beneficiaries described in subparagraph
(A)(ii) that include, at a minimum, the following to
increase adherence to prescription medications or other
goals deemed necessary by the Secretary:
``(i) An annual comprehensive medication
review furnished person-to-person or using
telehealth technologies (as defined by the
Secretary) by a licensed pharmacist or other
qualified provider. The comprehensive
medication review--
``(I) shall include a review of the
individual's medications and may result
in the creation of a recommended
medication action plan or other actions
in consultation with the individual and
with input from the prescriber to the
extent necessary and practicable; and
``(II) shall include providing the
individual with a written or printed
summary of the results of the review.
The Secretary, in consultation with relevant
stakeholders, shall develop a standardized
format for the action plan under subclause (I)
and the summary under subclause (II).
``(ii) Follow-up interventions as warranted
based on the findings of the annual medication
review or the targeted medication enrollment
and which may be provided person-to-person or
using telehealth technologies (as defined by
the Secretary).
``(D) Assessment.--The prescription drug plan
sponsor shall have in place a process to assess, at
least on a quarterly basis, the medication use of
individuals who are at risk but not enrolled in the
medication therapy management program, including
individuals who have experienced a transition in care,
if the prescription drug plan sponsor has access to
that information.
``(E) Automatic enrollment with ability to opt-
out.--The prescription drug plan sponsor shall have in
place a process to--
``(i) subject to clause (ii), automatically
enroll targeted beneficiaries described in
subparagraph (A)(ii), including beneficiaries
identified under subparagraph (D), in the
medication therapy management program required
under this subsection; and
``(ii) permit such beneficiaries to opt-out
of enrollment in such program.''.
(b) Rule of Construction.--Nothing in this section shall limit the
authority of the Secretary of Health and Human Services to modify or
broaden requirements for a medication therapy management program under
part D of title XVIII of the Social Security Act or to study new models
for medication therapy management through the Center for Medicare and
Medicaid Innovation under section 1115A of such Act, as added by
section 3021.
SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN VALUE.
(a) Development.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), in consultation
with relevant stakeholders including health insurance issuers, health
care consumers, employers, health care providers, and other entities
determined appropriate by the Secretary, shall develop a methodology to
measure health plan value. Such methodology shall take into
consideration, where applicable--
(1) the overall cost to enrollees under the plan;
(2) the quality of the care provided for under the plan;
(3) the efficiency of the plan in providing care;
(4) the relative risk of the plan's enrollees as compared
to other plans;
(5) the actuarial value or other comparative measure of the
benefits covered under the plan; and
(6) other factors determined relevant by the Secretary.
(b) Report.--Not later than 18 months after the date of enactment
of this Act, the Secretary shall submit to Congress a report concerning
the methodology developed under subsection (a).
SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE CENTERS FOR
MEDICARE & MEDICAID SERVICES TO SUPPORT IMPROVEMENTS IN
CARE DELIVERY.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall develop a plan
(and detailed budget for the resources needed to implement such plan)
to modernize the computer and data systems of the Centers for Medicare
& Medicaid Services (in this section referred to as ``CMS'').
(b) Considerations.--In developing the plan, the Secretary shall
consider how such modernized computer system could--
(1) in accordance with the regulations promulgated under
section 264(c) of the Health Insurance Portability and
Accountability Act of 1996, make available data in a reliable
and timely manner to providers of services and suppliers to
support their efforts to better manage and coordinate care
furnished to beneficiaries of CMS programs; and
(2) support consistent evaluations of payment and delivery
system reforms under CMS programs.
(c) Posting of Plan.--By not later than 9 months after the date of
the enactment of this Act, the Secretary shall post on the website of
the Centers for Medicare & Medicaid Services the plan described in
subsection (a).
SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
(a) In General.--
(1) Development.--Not later than January 1, 2011, the
Secretary shall develop a Physician Compare Internet website
with information on physicians enrolled in the Medicare program
under section 1866(j) of the Social Security Act (42 U.S.C.
1395cc(j)) and other eligible professionals who participate in
the Physician Quality Reporting Initiative under section 1848
of such Act (42 U.S.C. 1395w-4).
(2) Plan.--Not later than January 1, 2013, and with respect
to reporting periods that begin no earlier than January 1,
2012, the Secretary shall also implement a plan for making
publicly available through Physician Compare, consistent with
subsection (c), information on physician performance that
provides comparable information for the public on quality and
patient experience measures with respect to physicians enrolled
in the Medicare program under such section 1866(j). To the
extent scientifically sound measures that are developed
consistent with the requirements of this section are available,
such information, to the extent practicable, shall include--
(A) measures collected under the Physician Quality
Reporting Initiative;
(B) an assessment of patient health outcomes and
the functional status of patients;
(C) an assessment of the continuity and
coordination of care and care transitions, including
episodes of care and risk-adjusted resource use;
(D) an assessment of efficiency;
(E) an assessment of patient experience and
patient, caregiver, and family engagement;
(F) an assessment of the safety, effectiveness, and
timeliness of care; and
(G) other information as determined appropriate by
the Secretary.
(b) Other Required Considerations.--In developing and implementing
the plan described in subsection (a)(2), the Secretary shall, to the
extent practicable, include--
(1) processes to assure that data made public, either by
the Centers for Medicare & Medicaid Services or by other
entities, is statistically valid and reliable, including risk
adjustment mechanisms used by the Secretary;
(2) processes by which a physician or other eligible
professional whose performance on measures is being publicly
reported has a reasonable opportunity, as determined by the
Secretary, to review his or her individual results before they
are made public;
(3) processes by the Secretary to assure that the
implementation of the plan and the data made available on
Physician Compare provide a robust and accurate portrayal of a
physician's performance;
(4) data that reflects the care provided to all patients
seen by physicians, under both the Medicare program and, to the
extent practicable, other payers, to the extent such
information would provide a more accurate portrayal of
physician performance;
(5) processes to ensure appropriate attribution of care
when multiple physicians and other providers are involved in
the care of a patient;
(6) processes to ensure timely statistical performance
feedback is provided to physicians concerning the data reported
under any program subject to public reporting under this
section; and
(7) implementation of computer and data systems of the
Centers for Medicare & Medicaid Services that support valid,
reliable, and accurate public reporting activities authorized
under this section.
(c) Ensuring Patient Privacy.--The Secretary shall ensure that
information on physician performance and patient experience is not
disclosed under this section in a manner that violates sections 552 or
552a of title 5, United States Code, with regard to the privacy of
individually identifiable health information.
(d) Feedback From Multi-stakeholder Groups.--The Secretary shall
take into consideration input provided by multi-stakeholder groups,
consistent with sections 1890(b)(7) and 1890A of the Social Security
Act, as added by section 3014 of this Act, in selecting quality
measures for use under this section.
(e) Consideration of Transition to Value-based Purchasing.--In
developing the plan under this subsection (a)(2), the Secretary shall,
as the Secretary determines appropriate, consider the plan to
transition to a value-based purchasing program for physicians and other
practitioners developed under section 131 of the Medicare Improvements
for Patients and Providers Act of 2008 (Public Law 110-275).
(f) Report to Congress.--Not later than January 1, 2015, the
Secretary shall submit to Congress a report on the Physician Compare
Internet website developed under subsection (a)(1). Such report shall
include information on the efforts of and plans made by the Secretary
to collect and publish data on physician quality and efficiency and on
patient experience of care in support of value-based purchasing and
consumer choice, together with recommendations for such legislation and
administrative action as the Secretary determines appropriate.
(g) Expansion.--At any time before the date on which the report is
submitted under subsection (f), the Secretary may expand (including
expansion to other providers of services and suppliers under title
XVIII of the Social Security Act) the information made available on
such website.
(h) Financial Incentives To Encourage Consumers To Choose High
Quality Providers.--The Secretary may establish a demonstration
program, not later than January 1, 2019, to provide financial
incentives to Medicare beneficiaries who are furnished services by high
quality physicians, as determined by the Secretary based on factors in
subparagraphs (A) through (G) of subsection (a)(2). In no case may
Medicare beneficiaries be required to pay increased premiums or cost
sharing or be subject to a reduction in benefits under title XVIII of
the Social Security Act as a result of such demonstration program. The
Secretary shall ensure that any such demonstration program does not
disadvantage those beneficiaries without reasonable access to high
performing physicians or create financial inequities under such title.
(i) Definitions.--In this section:
(1) Eligible professional.--The term ``eligible
professional'' has the meaning given that term for purposes of
the Physician Quality Reporting Initiative under section 1848
of the Social Security Act (42 U.S.C. 1395w-4).
(2) Physician.--The term ``physician'' has the meaning
given that term in section 1861(r) of such Act (42 U.S.C.
1395x(r)).
(3) Physician compare.--The term ``Physician Compare''
means the Internet website developed under subsection (a)(1).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE MEASUREMENT.
(a) In General.--Section 1874 of the Social Security Act (42 U.S.C.
1395kk) is amended by adding at the end the following new subsection:
``(e) Availability of Medicare Data.--
``(1) In general.--Subject to paragraph (4), the Secretary
shall make available to qualified entities (as defined in
paragraph (2)) data described in paragraph (3) for the
evaluation of the performance of providers of services and
suppliers.
``(2) Qualified entities.--For purposes of this subsection,
the term `qualified entity' means a public or private entity
that--
``(A) is qualified (as determined by the Secretary)
to use claims data to evaluate the performance of
providers of services and suppliers on measures of
quality, efficiency, effectiveness, and resource use;
and
``(B) agrees to meet the requirements described in
paragraph (4) and meets such other requirements as the
Secretary may specify, such as ensuring security of
data.
``(3) Data described.--The data described in this paragraph
are standardized extracts (as determined by the Secretary) of
claims data under parts A, B, and D for items and services
furnished under such parts for one or more specified geographic
areas and time periods requested by a qualified entity. The
Secretary shall take such actions as the Secretary deems
necessary to protect the identity of individuals entitled to or
enrolled for benefits under such parts.
``(4) Requirements.--
``(A) Fee.--Data described in paragraph (3) shall
be made available to a qualified entity under this
subsection at a fee equal to the cost of making such
data available. Any fee collected pursuant to the
preceding sentence shall be deposited into the Federal
Supplementary Medical Insurance Trust Fund under
section 1841.
``(B) Specification of uses and methodologies.--A
qualified entity requesting data under this subsection
shall--
``(i) submit to the Secretary a description
of the methodologies that such qualified entity
will use to evaluate the performance of
providers of services and suppliers using such
data;
``(ii)(I) except as provided in subclause
(II), if available, use standard measures, such
as measures endorsed by the entity with a
contract under section 1890(a) and measures
developed pursuant to section 931 of the Public
Health Service Act; or
``(II) use alternative measures if the
Secretary, in consultation with appropriate
stakeholders, determines that use of such
alternative measures would be more valid,
reliable, responsive to consumer preferences,
cost-effective, or relevant to dimensions of
quality and resource use not addressed by such
standard measures;
``(iii) include data made available under
this subsection with claims data from sources
other than claims data under this title in the
evaluation of performance of providers of
services and suppliers;
``(iv) only include information on the
evaluation of performance of providers and
suppliers in reports described in subparagraph
(C);
``(v) make available to providers of
services and suppliers, upon their request,
data made available under this subsection; and
``(vi) prior to their release, submit to
the Secretary the format of reports under
subparagraph (C).
``(C) Reports.--Any report by a qualified entity
evaluating the performance of providers of services and
suppliers using data made available under this
subsection shall--
``(i) include an understandable description
of the measures, which shall include quality
measures and the rationale for use of other
measures described in subparagraph (B)(ii)(II),
risk adjustment methods, physician attribution
methods, other applicable methods, data
specifications and limitations, and the
sponsors, so that consumers, providers of
services and suppliers, health plans,
researchers, and other stakeholders can assess
such reports;
``(ii) be made available confidentially, to
any provider of services or supplier to be
identified in such report, prior to the public
release of such report, and provide an
opportunity to appeal and correct errors;
``(iii) only include information on a
provider of services or supplier in an
aggregate form as determined appropriate by the
Secretary; and
``(iv) except as described in clause (ii),
be made available to the public.
``(D) Approval and limitation of uses.--The
Secretary shall not make data described in paragraph
(3) available to a qualified entity unless the
qualified entity agrees to release the information on
the evaluation of performance of providers of services
and suppliers. Such entity shall only use such data,
and information derived from such evaluation, for the
reports under subparagraph (C). Data released to a
qualified entity under this subsection shall not be
subject to discovery or admission as evidence in
judicial or administrative proceedings without consent
of the applicable provider of services or supplier.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on January 1, 2012.
SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.
Part D of title III of the Public Health Service Act (42 U.S.C.
254b et seq.) is amended by adding at the end the following new
subpart:
``Subpart XI--Community-Based Collaborative Care Network Program
``SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE NETWORK PROGRAM.
``(a) In General.--The Secretary may award grants to eligible
entities to support community-based collaborative care networks that
meet the requirements of subsection (b).
``(b) Community-based Collaborative Care Networks.--
``(1) Description.--A community-based collaborative care
network (referred to in this section as a `network') shall be a
consortium of health care providers with a joint governance
structure (including providers within a single entity) that
provides comprehensive coordinated and integrated health care
services (as defined by the Secretary) for low-income
populations.
``(2) Required inclusion.--A network shall include the
following providers (unless such provider does not exist within
the community, declines or refuses to participate, or places
unreasonable conditions on their participation):
``(A) A hospital that meets the criteria in section
1923(b)(1) of the Social Security Act; and
``(B) All Federally qualified health centers (as
defined in section 1861(aa) of the Social Security Act
located in the community.
``(3) Priority.--In awarding grants, the Secretary shall
give priority to networks that include--
``(A) the capability to provide the broadest range
of services to low-income individuals;
``(B) the broadest range of providers that
currently serve a high volume of low-income
individuals; and
``(C) a county or municipal department of health.
``(c) Application.--
``(1) Application.--A network described in subsection (b)
shall submit an application to the Secretary.
``(2) Renewal.--In subsequent years, based on the
performance of grantees, the Secretary may provide renewal
grants to prior year grant recipients.
``(d) Use of Funds.--
``(1) Use by grantees.--Grant funds may be used for the
following activities:
``(A) Assist low-income individuals to--
``(i) access and appropriately use health
services;
``(ii) enroll in health coverage programs;
and
``(iii) obtain a regular primary care
provider or a medical home.
``(B) Provide case management and care management.
``(C) Perform health outreach using neighborhood
health workers or through other means.
``(D) Provide transportation.
``(E) Expand capacity, including through
telehealth, after-hours services or urgent care.
``(F) Provide direct patient care services.
``(2) Grant funds to hrsa grantees.--The Secretary may
limit the percent of grant funding that may be spent on direct
care services provided by grantees of programs administered by
the Health Resources and Services Administration or impose
other requirements on such grantees deemed necessary.
``(e) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary
for each of fiscal years 2011 through 2015.''.
SEC. 10334. MINORITY HEALTH.
(a) Office of Minority Health.--
(1) In general.--Section 1707 of the Public Health Service
Act (42 U.S.C. 300u-6) is amended--
(A) in subsection (a), by striking ``within the
Office of Public Health and Science'' and all that
follows through the end and inserting ``. The Office of
Minority Health as existing on the date of enactment of
the Patient Protection and Affordable Care Act shall be
transferred to the Office of the Secretary in such
manner that there is established in the Office of the
Secretary, the Office of Minority Health, which shall
be headed by the Deputy Assistant Secretary for
Minority Health who shall report directly to the
Secretary, and shall retain and strengthen authorities
(as in existence on such date of enactment) for the
purpose of improving minority health and the quality of
health care minorities receive, and eliminating racial
and ethnic disparities. In carrying out this
subsection, the Secretary, acting through the Deputy
Assistant Secretary, shall award grants, contracts,
enter into memoranda of understanding, cooperative,
interagency, intra-agency and other agreements with
public and nonprofit private entities, agencies, as
well as Departmental and Cabinet agencies and
organizations, and with organizations that are
indigenous human resource providers in communities of
color to assure improved health status of racial and
ethnic minorities, and shall develop measures to
evaluate the effectiveness of activities aimed at
reducing health disparities and supporting the local
community. Such measures shall evaluate community
outreach activities, language services, workforce
cultural competence, and other areas as determined by
the Secretary.''; and
(B) by striking subsection (h) and inserting the
following:
``(h) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through 2016.''.
(2) Transfer of functions.--There are transferred to the
Office of Minority Health in the office of the Secretary of
Health and Human Services, all duties, responsibilities,
authorities, accountabilities, functions, staff, funds, award
mechanisms, and other entities under the authority of the
Office of Minority Health of the Public Health Service as in
effect on the date before the date of enactment of this Act,
which shall continue in effect according to the terms in effect
on the date before such date of enactment, until modified,
terminated, superseded, set aside, or revoked in accordance
with law by the President, the Secretary, a court of competent
jurisdiction, or by operation of law.
(3) Reports.--Not later than 1 year after the date of
enactment of this section, and biennially thereafter, the
Secretary of Health and Human Services shall prepare and submit
to the appropriate committees of Congress a report describing
the activities carried out under section 1707 of the Public
Health Service Act (as amended by this subsection) during the
period for which the report is being prepared. Not later than 1
year after the date of enactment of this section, and
biennially thereafter, the heads of each of the agencies of the
Department of Health and Human Services shall submit to the
Deputy Assistant Secretary for Minority Health a report
summarizing the minority health activities of each of the
respective agencies.
(b) Establishment of Individual Offices of Minority Health Within
the Department of Health and Human Services.--
(1) In general.--Title XVII of the Public Health Service
Act (42 U.S.C. 300u et seq.) is amended by inserting after
section 1707 the following section:
``SEC. 1707A. INDIVIDUAL OFFICES OF MINORITY HEALTH WITHIN THE
DEPARTMENT.
``(a) In General.--The head of each agency specified in subsection
(b)(1) shall establish within the agency an office to be known as the
Office of Minority Health. The head of each such Office shall be
appointed by the head of the agency within which the Office is
established, and shall report directly to the head of the agency. The
head of such agency shall carry out this section (as this section
relates to the agency) acting through such Director.
``(b) Specified Agencies.--The agencies referred to in subsection
(a) are the Centers for Disease Control and Prevention, the Health
Resources and Services Administration, the Substance Abuse and Mental
Health Services Administration, the Agency for Healthcare Research and
Quality, the Food and Drug Administration, and the Centers for Medicare
& Medicaid Services.
``(c) Director; Appointment.--Each Office of Minority Health
established in an agency listed in subsection (a) shall be headed by a
director, with documented experience and expertise in minority health
services research and health disparities elimination.
``(d) References.--Except as otherwise specified, any reference in
Federal law to an Office of Minority Health (in the Department of
Health and Human Services) is deemed to be a reference to the Office of
Minority Health in the Office of the Secretary.
``(e) Funding.--
``(1) Allocations.--Of the amounts appropriated for a
specified agency for a fiscal year, the Secretary must
designate an appropriate amount of funds for the purpose of
carrying out activities under this section through the minority
health office of the agency. In reserving an amount under the
preceding sentence for a minority health office for a fiscal
year, the Secretary shall reduce, by substantially the same
percentage, the amount that otherwise would be available for
each of the programs of the designated agency involved.
``(2) Availability of funds for staffing.--The purposes for
which amounts made available under paragraph may be expended by
a minority health office include the costs of employing staff
for such office.''.
(2) No new regulatory authority.--Nothing in this
subsection and the amendments made by this subsection may be
construed as establishing regulatory authority or modifying any
existing regulatory authority.
(3) Limitation on termination.--Notwithstanding any other
provision of law, a Federal office of minority health or
Federal appointive position with primary responsibility over
minority health issues that is in existence in an office of
agency of the Department of Health and Human Services on the
date of enactment of this section shall not be terminated,
reorganized, or have any of its power or duties transferred
unless such termination, reorganization, or transfer is
approved by an Act of Congress.
(c) Redesignation of National Center on Minority Health and Health
Disparities.--
(1) Redesignation.--Title IV of the Public Health Service
Act (42 U.S.C. 281 et seq.) is amended--
(A) by redesignating subpart 6 of part E as subpart
20;
(B) by transferring subpart 20, as so redesignated,
to part C of such title IV;
(C) by inserting subpart 20, as so redesignated,
after subpart 19 of such part C; and
(D) in subpart 20, as so redesignated--
(i) by redesignating sections 485E through
485H as sections 464z-3 through 464z-6,
respectively;
(ii) by striking ``National Center on
Minority Health and Health Disparities'' each
place such term appears and inserting
``National Institute on Minority Health and
Health Disparities''; and
(iii) by striking ``Center'' each place
such term appears and inserting ``Institute''.
(2) Purpose of institute; duties.--Section 464z-3 of the
Public Health Service Act, as so redesignated, is amended--
(A) in subsection (h)(1), by striking ``research
endowments at centers of excellence under section
736.'' and inserting the following: ``research
endowments--
``(1) at centers of excellence under section 736; and
``(2) at centers of excellence under section 464z-4.'';
(B) in subsection (h)(2)(A), by striking
``average'' and inserting ``median''; and
(C) by adding at the end the following:
``(h) Interagency Coordination.--The Director of the Institute, as
the primary Federal officials with responsibility for coordinating all
research and activities conducted or supported by the National
Institutes of Health on minority health and health disparities, shall
plan, coordinate, review and evaluate research and other activities
conducted or supported by the Institutes and Centers of the National
Institutes of Health.''.
(3) Technical and conforming amendments.--
(A) Section 401(b)(24) of the Public Health Service
Act (42 U.S.C. 281(b)(24)) is amended by striking
``Center'' and inserting ``Institute''.
(B) Subsection (d)(1) of section 903 of the Public
Health Service Act (42 U.S.C. 299a-1(d)(1)) is amended
by striking ``section 485E'' and inserting ``section
464z-3''.
SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED PURCHASING
PROGRAM.
Section 1886(o)(2)A) of the Social Security Act, as added by
section 3001, is amended, in the first sentence, by inserting ``, other
than measures of readmissions,'' after ``shall select measures''.
SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY ACCESS TO
HIGH-QUALITY DIALYSIS SERVICES.
(a) Study.--
(1) In general.--The Comptroller General of the United
States shall conduct a study on the impact on Medicare
beneficiary access to high-quality dialysis services of
including specified oral drugs that are furnished to such
beneficiaries for the treatment of end stage renal disease in
the bundled prospective payment system under section
1881(b)(14) of the Social Security Act (42 U.S.C.
1395rr(b)(14)) (pursuant to the proposed rule published by the
Secretary of Health and Human Services in the Federal Register
on September 29, 2009 (74 Fed. Reg. 49922 et seq.)). Such study
shall include an analysis of--
(A) the ability of providers of services and renal
dialysis facilities to furnish specified oral drugs or
arrange for the provision of such drugs;
(B) the ability of providers of services and renal
dialysis facilities to comply, if necessary, with
applicable State laws (such as State pharmacy licensure
requirements) in order to furnish specified oral drugs;
(C) whether appropriate quality measures exist to
safeguard care for Medicare beneficiaries being
furnished specified oral drugs by providers of services
and renal dialysis facilities; and
(D) other areas determined appropriate by the
Comptroller General.
(2) Specified oral drug defined.--For purposes of paragraph
(1), the term ``specified oral drug'' means a drug or
biological for which there is no injectable equivalent (or
other non-oral form of administration).
(b) Report.--Not later than 1 year after the date of the enactment
of this Act, the Comptroller General of the United States shall submit
to Congress a report containing the results of the study conducted
under subsection (a), together with recommendations for such
legislation and administrative action as the Comptroller General
determines appropriate.
Subtitle D--Provisions Relating to Title IV
SEC. 10401. AMENDMENTS TO SUBTITLE A.
(a) Section 4001(h)(4) and (5) of this Act is amended by striking
``2010'' each place such appears and inserting ``2020''.
(b) Section 4002(c) of this Act is amended--
(1) by striking ``research and health screenings'' and
inserting ``research, health screenings, and initiatives''; and
(2) by striking ``for Preventive'' and inserting
``Regarding Preventive''.
(c) Section 4004(a)(4) of this Act is amended by striking ``a
Gateway'' and inserting ``an Exchange''.
SEC. 10402. AMENDMENTS TO SUBTITLE B.
(a) Section 399Z-1(a)(1(A) of the Public Health Service Act, as
added by section 4101(b) of this Act, is amended by inserting ``and
vision'' after ``oral''.
(b) Section 1861(hhh)(4)(G) of the Social Security Act, as added by
section 4103(b), is amended to read as follows:
``(G) A beneficiary shall be eligible to receive
only an initial preventive physical examination (as
defined under subsection (ww)(1)) during the 12-month
period after the date that the beneficiary's coverage
begins under part B and shall be eligible to receive
personalized prevention plan services under this
subsection each year thereafter provided that the
beneficiary has not received either an initial
preventive physical examination or personalized
prevention plan services within the preceding 12-month
period.''.
SEC. 10403. AMENDMENTS TO SUBTITLE C.
Section 4201 of this Act is amended--
(1) in subsection (a), by adding before the period the
following: ``, with not less than 20 percent of such grants
being awarded to rural and frontier areas'';
(2) in subsection (c)(2)(B)(vii), by striking ``both urban
and rural areas'' and inserting ``urban, rural, and frontier
areas''; and
(3) in subsection (f), by striking ``each fiscal years''
and inserting ``each of fiscal year''.
SEC. 10404. AMENDMENTS TO SUBTITLE D.
Section 399MM(2) of the Public Health Service Act, as added by
section 4303 of this Act, is amended by striking ``by ensuring'' and
inserting ``and ensuring''.
SEC. 10405. AMENDMENTS TO SUBTITLE E.
Subtitle E of title IV of this Act is amended by striking section
4401.
SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR PREVENTIVE
SERVICES.
Section 4104(b) of this Act is amended to read as follows:
``(b) Payment and Elimination of Coinsurance in All Settings.--
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)),
as amended by section 4103(c)(1), is amended--
``(1) in subparagraph (T), by inserting `(or 100 percent if
such services are recommended with a grade of A or B by the
United States Preventive Services Task Force for any indication
or population and are appropriate for the individual)' after
`80 percent';
``(2) in subparagraph (W)--
``(A) in clause (i), by inserting `(if such
subparagraph were applied, by substituting ``100
percent'' for ``80 percent'')' after `subparagraph
(D)'; and
``(B) in clause (ii), by striking `80 percent' and
inserting `100 percent';
``(3) by striking `and' before `(X)'; and
``(4) by inserting before the semicolon at the end the
following: `, and (Y) with respect to preventive services
described in subparagraphs (A) and (B) of section 1861(ddd)(3)
that are appropriate for the individual and, in the case of
such services described in subparagraph (A), are recommended
with a grade of A or B by the United States Preventive Services
Task Force for any indication or population, the amount paid
shall be 100 percent of (i) except as provided in clause (ii),
the lesser of the actual charge for the services or the amount
determined under the fee schedule that applies to such services
under this part, and (ii) in the case of such services that are
covered OPD services (as defined in subsection (t)(1)(B)), the
amount determined under subsection (t)'.''.
SEC. 10407. BETTER DIABETES CARE.
(a) Short Title.--This section may be cited as the ``Catalyst to
Better Diabetes Care Act of 2009''.
(b) National Diabetes Report Card.--
(1) In general.--The Secretary, in collaboration with the
Director of the Centers for Disease Control and Prevention
(referred to in this section as the ``Director''), shall
prepare on a biennial basis a national diabetes report card
(referred to in this section as a ``Report Card'') and, to the
extent possible, for each State.
(2) Contents.--
(A) In general.--Each Report Card shall include
aggregate health outcomes related to individuals
diagnosed with diabetes and prediabetes including--
(i) preventative care practices and quality
of care;
(ii) risk factors; and
(iii) outcomes.
(B) Updated reports.--Each Report Card that is
prepared after the initial Report Card shall include
trend analysis for the Nation and, to the extent
possible, for each State, for the purpose of--
(i) tracking progress in meeting
established national goals and objectives for
improving diabetes care, costs, and prevalence
(including Healthy People 2010); and
(ii) informing policy and program
development.
(3) Availability.--The Secretary, in collaboration with the
Director, shall make each Report Card publicly available,
including by posting the Report Card on the Internet.
(c) Improvement of Vital Statistics Collection.--
(1) In general.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention and in
collaboration with appropriate agencies and States, shall--
(A) promote the education and training of
physicians on the importance of birth and death
certificate data and how to properly complete these
documents, including the collection of such data for
diabetes and other chronic diseases;
(B) encourage State adoption of the latest standard
revisions of birth and death certificates; and
(C) work with States to re-engineer their vital
statistics systems in order to provide cost-effective,
timely, and accurate vital systems data.
(2) Death certificate additional language.--In carrying out
this subsection, the Secretary may promote improvements to the
collection of diabetes mortality data, including the addition
of a question for the individual certifying the cause of death
regarding whether the deceased had diabetes.
(d) Study on Appropriate Level of Diabetes Medical Education.--
(1) In general.--The Secretary shall, in collaboration with
the Institute of Medicine and appropriate associations and
councils, conduct a study of the impact of diabetes on the
practice of medicine in the United States and the
appropriateness of the level of diabetes medical education that
should be required prior to licensure, board certification, and
board recertification.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit a report on
the study under paragraph (1) to the Committees on Ways and
Means and Energy and Commerce of the House of Representatives
and the Committees on Finance and Health, Education, Labor, and
Pensions of the Senate.
(e) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary.
SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE COMPREHENSIVE
WORKPLACE WELLNESS PROGRAMS.
(a) Establishment.--The Secretary shall award grants to eligible
employers to provide their employees with access to comprehensive
workplace wellness programs (as described under subsection (c)).
(b) Scope.--
(1) Duration.--The grant program established under this
section shall be conducted for a 5-year period.
(2) Eligible employer.--The term ``eligible employer''
means an employer (including a non-profit employer) that--
(A) employs less than 100 employees who work 25
hours or greater per week; and
(B) does not provide a workplace wellness program
as of the date of enactment of this Act.
(c) Comprehensive Workplace Wellness Programs.--
(1) Criteria.--The Secretary shall develop program criteria
for comprehensive workplace wellness programs under this
section that are based on and consistent with evidence-based
research and best practices, including research and practices
as provided in the Guide to Community Preventive Services, the
Guide to Clinical Preventive Services, and the National
Registry for Effective Programs.
(2) Requirements.--A comprehensive workplace wellness
program shall be made available by an eligible employer to all
employees and include the following components:
(A) Health awareness initiatives (including health
education, preventive screenings, and health risk
assessments).
(B) Efforts to maximize employee engagement
(including mechanisms to encourage employee
participation).
(C) Initiatives to change unhealthy behaviors and
lifestyle choices (including counseling, seminars,
online programs, and self-help materials).
(D) Supportive environment efforts (including
workplace policies to encourage healthy lifestyles,
healthy eating, increased physical activity, and
improved mental health).
(d) Application.--An eligible employer desiring to participate in
the grant program under this section shall submit an application to the
Secretary, in such manner and containing such information as the
Secretary may require, which shall include a proposal for a
comprehensive workplace wellness program that meet the criteria and
requirements described under subsection (c).
(e) Authorization of Appropriation.--For purposes of carrying out
the grant program under this section, there is authorized to be
appropriated $200,000,000 for the period of fiscal years 2011 through
2015. Amounts appropriated pursuant to this subsection shall remain
available until expended.
SEC. 10409. CURES ACCELERATION NETWORK.
(a) Short Title.--This section may be cited as the ``Cures
Acceleration Network Act of 2009''.
(b) Requirement for the Director of NIH To Establish a Cures
Acceleration Network.--Section 402(b) of the Public Health Service Act
(42 U.S.C. 282(b)) is amended--
(1) in paragraph (22), by striking ``and'' at the end;
(2) in paragraph (23), by striking the period and inserting
``; and''; and
(3) by inserting after paragraph (23), the following:
``(24) implement the Cures Acceleration Network described
in section 402C.''.
(c) Accepting Gifts To Support the Cures Acceleration Network.--
Section 499(c)(1) of the Public Health Service Act (42 U.S.C.
290b(c)(1)) is amended by adding at the end the following:
``(E) The Cures Acceleration Network described in
section 402C.''.
(d) Establishment of the Cures Acceleration Network.--Part A of
title IV of the Public Health Service Act is amended by inserting after
section 402B (42 U.S.C. 282b) the following:
``SEC. 402C. CURES ACCELERATION NETWORK.
``(a) Definitions.--In this section:
``(1) Biological product.--The term `biological product'
has the meaning given such term in section 351 of the Public
Health Service Act.
``(2) Drug; device.--The terms `drug' and `device' have the
meanings given such terms in section 201 of the Federal Food,
Drug, and Cosmetic Act.
``(3) High need cure.--The term `high need cure' means a
drug (as that term is defined by section 201(g)(1) of the
Federal Food, Drug, and Cosmetic Act, biological product (as
that term is defined by section 262(i)), or device (as that
term is defined by section 201(h) of the Federal Food, Drug,
and Cosmetic Act) that, in the determination of the Director of
NIH--
``(A) is a priority to diagnose, mitigate, prevent,
or treat harm from any disease or condition; and
``(B) for which the incentives of the commercial
market are unlikely to result in its adequate or timely
development.
``(4) Medical product.--The term `medical product' means a
drug, device, biological product, or product that is a
combination of drugs, devices, and biological products.
``(b) Establishment of the Cures Acceleration Network.--Subject to
the appropriation of funds as described in subsection (g), there is
established within the Office of the Director of NIH a program to be
known as the Cures Acceleration Network (referred to in this section as
`CAN'), which shall--
``(1) be under the direction of the Director of NIH, taking
into account the recommendations of a CAN Review Board
(referred to in this section as the `Board'), described in
subsection (d); and
``(2) award grants and contracts to eligible entities, as
described in subsection (e), to accelerate the development of
high need cures, including through the development of medical
products and behavioral therapies.
``(c) Functions.--The functions of the CAN are to--
``(1) conduct and support revolutionary advances in basic
research, translating scientific discoveries from bench to
bedside;
``(2) award grants and contracts to eligible entities to
accelerate the development of high need cures;
``(3) provide the resources necessary for government
agencies, independent investigators, research organizations,
biotechnology companies, academic research institutions, and
other entities to develop high need cures;
``(4) reduce the barriers between laboratory discoveries
and clinical trials for new therapies; and
``(5) facilitate review in the Food and Drug Administration
for the high need cures funded by the CAN, through activities
that may include--
``(A) the facilitation of regular and ongoing
communication with the Food and Drug Administration
regarding the status of activities conducted under this
section;
``(B) ensuring that such activities are coordinated
with the approval requirements of the Food and Drug
Administration, with the goal of expediting the
development and approval of countermeasures and
products; and
``(C) connecting interested persons with additional
technical assistance made available under section 565
of the Federal Food, Drug, and Cosmetic Act.
``(d) CAN Board.--
``(1) Establishment.--There is established a Cures
Acceleration Network Review Board (referred to in this section
as the `Board'), which shall advise the Director of NIH on the
conduct of the activities of the Cures Acceleration Network.
``(2) Membership.--
``(A) In general.--
``(i) Appointment.--The Board shall be
comprised of 24 members who are appointed by
the Secretary and who serve at the pleasure of
the Secretary.
``(ii) Chairperson and vice chairperson.--
The Secretary shall designate, from among the
24 members appointed under clause (i), one
Chairperson of the Board (referred to in this
section as the `Chairperson') and one Vice
Chairperson.
``(B) Terms.--
``(i) In general.--Each member shall be
appointed to serve a 4-year term, except that
any member appointed to fill a vacancy
occurring prior to the expiration of the term
for which the member's predecessor was
appointed shall be appointed for the remainder
of such term.
``(ii) Consecutive appointments; maximum
terms.--A member may be appointed to serve not
more than 3 terms on the Board, and may not
serve more than 2 such terms consecutively.
``(C) Qualifications.--
``(i) In general.--The Secretary shall
appoint individuals to the Board based solely
upon the individual's established record of
distinguished service in one of the areas of
expertise described in clause (ii). Each
individual appointed to the Board shall be of
distinguished achievement and have a broad
range of disciplinary interests.
``(ii) Expertise.--The Secretary shall
select individuals based upon the following
requirements:
``(I) For each of the fields of--
``(aa) basic research;
``(bb) medicine;
``(cc) biopharmaceuticals;
``(dd) discovery and
delivery of medical products;
``(ee) bioinformatics and
gene therapy;
``(ff) medical
instrumentation; and
``(gg) regulatory review
and approval of medical
products,
the Secretary shall select at least 1
individual who is eminent in such
fields.
``(II) At least 4 individuals shall
be recognized leaders in professional
venture capital or private equity
organizations and have demonstrated
experience in private equity investing.
``(III) At least 8 individuals
shall represent disease advocacy
organizations.
``(3) Ex-officio members.--
``(A) Appointment.--In addition to the 24 Board
members described in paragraph (2), the Secretary shall
appoint as ex-officio members of the Board--
``(i) a representative of the National
Institutes of Health, recommended by the
Secretary of the Department of Health and Human
Services;
``(ii) a representative of the Office of
the Assistant Secretary of Defense for Health
Affairs, recommended by the Secretary of
Defense;
``(iii) a representative of the Office of
the Under Secretary for Health for the Veterans
Health Administration, recommended by the
Secretary of Veterans Affairs;
``(iv) a representative of the National
Science Foundation, recommended by the Chair of
the National Science Board; and
``(v) a representative of the Food and Drug
Administration, recommended by the Commissioner
of Food and Drugs.
``(B) Terms.--Each ex-officio member shall serve a
3-year term on the Board, except that the Chairperson
may adjust the terms of the initial ex-officio members
in order to provide for a staggered term of appointment
for all such members.
``(4) Responsibilities of the board and the director of
nih.--
``(A) Responsibilities of the board.--
``(i) In general.--The Board shall advise,
and provide recommendations to, the Director of
NIH with respect to--
``(I) policies, programs, and
procedures for carrying out the duties
of the Director of NIH under this
section; and
``(II) significant barriers to
successful translation of basic science
into clinical application (including
issues under the purview of other
agencies and departments).
``(ii) Report.--In the case that the Board
identifies a significant barrier, as described
in clause (i)(II), the Board shall submit to
the Secretary a report regarding such barrier.
``(B) Responsibilities of the director of nih.--
With respect to each recommendation provided by the
Board under subparagraph (A)(i), the Director of NIH
shall respond in writing to the Board, indicating
whether such Director will implement such
recommendation. In the case that the Director of NIH
indicates a recommendation of the Board will not be
implemented, such Director shall provide an explanation
of the reasons for not implementing such
recommendation.
``(5) Meetings.--
``(A) In general.--The Board shall meet 4 times per
calendar year, at the call of the Chairperson.
``(B) Quorum; requirements; limitations.--
``(i) Quorum.--A quorum shall consist of a
total of 13 members of the Board, excluding ex-
officio members, with diverse representation as
described in clause (iii).
``(ii) Chairperson or vice chairperson.--
Each meeting of the Board shall be attended by
either the Chairperson or the Vice Chairperson.
``(iii) Diverse representation.--At each
meeting of the Board, there shall be not less
than one scientist, one representative of a
disease advocacy organization, and one
representative of a professional venture
capital or private equity organization.
``(6) Compensation and travel expenses.--
``(A) Compensation.--Members shall receive
compensation at a rate to be fixed by the Chairperson
but not to exceed a rate equal to the daily equivalent
of the annual rate of basic pay prescribed for level IV
of the Executive Schedule under section 5315 of title
5, United States Code, for each day (including travel
time) during which the member is engaged in the
performance of the duties of the Board. All members of
the Board who are officers or employees of the United
States shall serve without compensation in addition to
that received for their services as officers or
employees of the United States.
``(B) Travel expenses.--Members of the Board shall
be allowed travel expenses, including per diem in lieu
of subsistence, at rates authorized for persons
employed intermittently by the Federal Government under
section 5703(b) of title 5, United States Code, while
away from their homes or regular places of business in
the performance of services for the Board.
``(e) Grant Program.--
``(1) Supporting innovation.--To carry out the purposes
described in this section, the Director of NIH shall award
contracts, grants, or cooperative agreements to the entities
described in paragraph (2), to--
``(A) promote innovation in technologies supporting
the advanced research and development and production of
high need cures, including through the development of
medical products and behavioral therapies.
``(B) accelerate the development of high need
cures, including through the development of medical
products, behavioral therapies, and biomarkers that
demonstrate the safety or effectiveness of medical
products; or
``(C) help the award recipient establish protocols
that comply with Food and Drug Administration standards
and otherwise permit the recipient to meet regulatory
requirements at all stages of development,
manufacturing, review, approval, and safety
surveillance of a medical product.
``(2) Eligible entities.--To receive assistance under
paragraph (1), an entity shall--
``(A) be a public or private entity, which may
include a private or public research institution, an
institution of higher education, a medical center, a
biotechnology company, a pharmaceutical company, a
disease advocacy organization, a patient advocacy
organization, or an academic research institution;
``(B) submit an application containing--
``(i) a detailed description of the project
for which the entity seeks such grant or
contract;
``(ii) a timetable for such project;
``(iii) an assurance that the entity will
submit--
``(I) interim reports describing
the entity's--
``(aa) progress in carrying
out the project; and
``(bb) compliance with all
provisions of this section and
conditions of receipt of such
grant or contract; and
``(II) a final report at the
conclusion of the grant period,
describing the outcomes of the project;
and
``(iv) a description of the protocols the
entity will follow to comply with Food and Drug
Administration standards and regulatory
requirements at all stages of development,
manufacturing, review, approval, and safety
surveillance of a medical product; and
``(C) provide such additional information as the
Director of NIH may require.
``(3) Awards.--
``(A) The cures acceleration partnership awards.--
``(i) Initial award amount.--Each award
under this subparagraph shall be not more than
$15,000,000 per project for the first fiscal
year for which the project is funded, which
shall be payable in one payment.
``(ii) Funding in subsequent fiscal
years.--An eligible entity receiving an award
under clause (i) may apply for additional
funding for such project by submitting to the
Director of NIH the information required under
subparagraphs (B) and (C) of paragraph (2). The
Director may fund a project of such eligible
entity in an amount not to exceed $15,000,000
for a fiscal year subsequent to the initial
award under clause (i).
``(iii) Matching funds.--As a condition for
receiving an award under this subsection, an
eligible entity shall contribute to the project
non-Federal funds in the amount of $1 for every
$3 awarded under clauses (i) and (ii), except
that the Director of NIH may waive or modify
such matching requirement in any case where the
Director determines that the goals and
objectives of this section cannot adequately be
carried out unless such requirement is waived.
``(B) The cures acceleration grant awards.--
``(i) Initial award amount.--Each award
under this subparagraph shall be not more than
$15,000,000 per project for the first fiscal
year for which the project is funded, which
shall be payable in one payment.
``(ii) Funding in subsequent fiscal
years.--An eligible entity receiving an award
under clause (i) may apply for additional
funding for such project by submitting to the
Board the information required under
subparagraphs (B) and (C) of paragraph (2). The
Director of NIH may fund a project of such
eligible entity in an amount not to exceed
$15,000,000 for a fiscal year subsequent to the
initial award under clause (i).
``(C) The cures acceleration flexible research
awards.--If the Director of NIH determines that the
goals and objectives of this section cannot adequately
be carried out through a contract, grant, or
cooperative agreement, the Director of NIH shall have
flexible research authority to use other transactions
to fund projects in accordance with the terms and
conditions of this section. Awards made under such
flexible research authority for a fiscal year shall not
exceed 20 percent of the total funds appropriated under
subsection (g)(1) for such fiscal year.
``(4) Suspension of awards for defaults, noncompliance with
provisions and plans, and diversion of funds; repayment of
funds.--The Director of NIH may suspend the award to any entity
upon noncompliance by such entity with provisions and plans
under this section or diversion of funds.
``(5) Audits.--The Director of NIH may enter into
agreements with other entities to conduct periodic audits of
the projects funded by grants or contracts awarded under this
subsection.
``(6) Closeout procedures.--At the end of a grant or
contract period, a recipient shall follow the closeout
procedures under section 74.71 of title 45, Code of Federal
Regulations (or any successor regulation).
``(7) Review.--A determination by the Director of NIH as to
whether a drug, device, or biological product is a high need
cure (for purposes of subsection (a)(3)) shall not be subject
to judicial review.
``(f) Competitive Basis of Awards.--Any grant, cooperative
agreement, or contract awarded under this section shall be awarded on a
competitive basis.
``(g) Authorization of Appropriations.--
``(1) In general.--For purposes of carrying out this
section, there are authorized to be appropriated $500,000,000
for fiscal year 2010, and such sums as may be necessary for
subsequent fiscal years. Funds appropriated under this section
shall be available until expended.
``(2) Limitation on use of funds otherwise appropriated.--
No funds appropriated under this Act, other than funds
appropriated under paragraph (1), may be allocated to the Cures
Acceleration Network.''.
SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION.
(a) Short Title.--This section may be cited as the ``Establishing a
Network of Health-Advancing National Centers of Excellence for
Depression Act of 2009'' or the ``ENHANCED Act of 2009''.
(b) Centers of Excellence for Depression.--Subpart 3 of part B of
title V of the Public Health Service Act (42 U.S.C. 290bb et seq.) is
amended by inserting after section 520A the following:
``SEC. 520B. NATIONAL CENTERS OF EXCELLENCE FOR DEPRESSION.
``(a) Depressive Disorder Defined.--In this section, the term
`depressive disorder' means a mental or brain disorder relating to
depression, including major depression, bipolar disorder, and related
mood disorders.
``(b) Grant Program.--
``(1) In general.--The Secretary, acting through the
Administrator, shall award grants on a competitive basis to
eligible entities to establish national centers of excellence
for depression (referred to in this section as `Centers'),
which shall engage in activities related to the treatment of
depressive disorders.
``(2) Allocation of awards.--If the funds authorized under
subsection (f) are appropriated in the amounts provided for
under such subsection, the Secretary shall allocate such
amounts so that--
``(A) not later than 1 year after the date of
enactment of the ENHANCED Act of 2009, not more than 20
Centers may be established; and
``(B) not later than September 30, 2016, not more
than 30 Centers may be established.
``(3) Grant period.--
``(A) In general.--A grant awarded under this
section shall be for a period of 5 years.
``(B) Renewal.--A grant awarded under subparagraph
(A) may be renewed, on a competitive basis, for 1
additional 5-year period, at the discretion of the
Secretary. In determining whether to renew a grant, the
Secretary shall consider the report cards issued under
subsection (e)(2).
``(4) Use of funds.--Grant funds awarded under this
subsection shall be used for the establishment and ongoing
activities of the recipient of such funds.
``(5) Eligible entities.--
``(A) Requirements.--To be eligible to receive a
grant under this section, an entity shall--
``(i) be an institution of higher education
or a public or private nonprofit research
institution; and
``(ii) submit an application to the
Secretary at such time and in such manner as
the Secretary may require, as described in
subparagraph (B).
``(B) Application.--An application described in
subparagraph (A)(ii) shall include--
``(i) evidence that such entity--
``(I) provides, or is capable of
coordinating with other entities to
provide, comprehensive health services
with a focus on mental health services
and subspecialty expertise for
depressive disorders;
``(II) collaborates with other
mental health providers, as necessary,
to address co-occurring mental
illnesses;
``(III) is capable of training
health professionals about mental
health; and
``(ii) such other information, as the
Secretary may require.
``(C) Priorities.--In awarding grants under this
section, the Secretary shall give priority to eligible
entities that meet 1 or more of the following criteria:
``(i) Demonstrated capacity and expertise
to serve the targeted population.
``(ii) Existing infrastructure or expertise
to provide appropriate, evidence-based and
culturally and linguistically competent
services.
``(iii) A location in a geographic area
with disproportionate numbers of underserved
and at-risk populations in medically
underserved areas and health professional
shortage areas.
``(iv) Proposed innovative approaches for
outreach to initiate or expand services.
``(v) Use of the most up-to-date science,
practices, and interventions available.
``(vi) Demonstrated capacity to establish
cooperative and collaborative agreements with
community mental health centers and other
community entities to provide mental health,
social, and human services to individuals with
depressive disorders.
``(6) National coordinating center.--
``(A) In general.--The Secretary, acting through
the Administrator, shall designate 1 recipient of a
grant under this section to be the coordinating center
of excellence for depression (referred to in this
section as the `coordinating center'). The Secretary
shall select such coordinating center on a competitive
basis, based upon the demonstrated capacity of such
center to perform the duties described in subparagraph
(C).
``(B) Application.--A Center that has been awarded
a grant under paragraph (1) may apply for designation
as the coordinating center by submitting an application
to the Secretary at such time, in such manner, and
containing such information as the Secretary may
require.
``(C) Duties.--The coordinating center shall--
``(i) develop, administer, and coordinate
the network of Centers under this section;
``(ii) oversee and coordinate the national
database described in subsection (d);
``(iii) lead a strategy to disseminate the
findings and activities of the Centers through
such database; and
``(iv) serve as a liaison with the
Administration, the National Registry of
Evidence-based Programs and Practices of the
Administration, and any Federal interagency or
interagency forum on mental health.
``(7) Matching funds.--The Secretary may not award a grant
or contract under this section to an entity unless the entity
agrees that it will make available (directly or through
contributions from other public or private entities) non-
Federal contributions toward the activities to be carried out
under the grant or contract in an amount equal to $1 for each
$5 of Federal funds provided under the grant or contract. Such
non-Federal matching funds may be provided directly or through
donations from public or private entities and may be in cash or
in-kind, fairly evaluated, including plant, equipment, or
services.
``(c) Activities of the Centers.--Each Center shall carry out the
following activities:
``(1) General activities.--Each Center shall--
``(A) integrate basic, clinical, or health services
interdisciplinary research and practice in the
development, implementation, and dissemination of
evidence-based interventions;
``(B) involve a broad cross-section of
stakeholders, such as researchers, clinicians,
consumers, families of consumers, and voluntary health
organizations, to develop a research agenda and
disseminate findings, and to provide support in the
implementation of evidence-based practices;
``(C) provide training and technical assistance to
mental health professionals, and engage in and
disseminate translational research with a focus on
meeting the needs of individuals with depressive
disorders; and
``(D) educate policy makers, employers, community
leaders, and the public about depressive disorders to
reduce stigma and raise awareness of treatments.
``(2) Improved treatment standards, clinical guidelines,
diagnostic protocols, and care coordination practice.--Each
Center shall collaborate with other Centers in the network to--
``(A) develop and implement treatment standards,
clinical guidelines, and protocols that emphasize
primary prevention, early intervention, treatment for,
and recovery from, depressive disorders;
``(B) foster communication with other providers
attending to co-occurring physical health conditions
such as cardiovascular, diabetes, cancer, and substance
abuse disorders;
``(C) leverage available community resources,
develop and implement improved self-management
programs, and, when appropriate, involve family and
other providers of social support in the development
and implementation of care plans; and
``(D) use electronic health records and telehealth
technology to better coordinate and manage, and improve
access to, care, as determined by the coordinating
center.
``(3) Translational research through collaboration of
centers and community-based organizations.--Each Center shall--
``(A) demonstrate effective use of a public-private
partnership to foster collaborations among members of
the network and community-based organizations such as
community mental health centers and other social and
human services providers;
``(B) expand interdisciplinary, translational, and
patient-oriented research and treatment; and
``(C) coordinate with accredited academic programs
to provide ongoing opportunities for the professional
and continuing education of mental health providers.
``(d) National Database.--
``(1) In general.--The coordinating center shall establish
and maintain a national, publicly available database to improve
prevention programs, evidence-based interventions, and disease
management programs for depressive disorders, using data
collected from the Centers, as described in paragraph (2).
``(2) Data collection.--Each Center shall submit data
gathered at such center, as appropriate, to the coordinating
center regarding--
``(A) the prevalence and incidence of depressive
disorders;
``(B) the health and social outcomes of individuals
with depressive disorders;
``(C) the effectiveness of interventions designed,
tested, and evaluated;
``(D) other information, as the Secretary may
require.
``(3) Submission of data to the administrator.--The
coordinating center shall submit to the Administrator the data
and financial information gathered under paragraph (2).
``(4) Publication using data from the database.--A Center,
or an individual affiliated with a Center, may publish findings
using the data described in paragraph (2) only if such center
submits such data to the coordinating center, as required under
such paragraph.
``(e) Establishment of Standards; Report Cards and Recommendations;
Third Party Review.--
``(1) Establishment of standards.--The Secretary, acting
through the Administrator, shall establish performance
standards for--
``(A) each Center; and
``(B) the network of Centers as a whole.
``(2) Report cards.--The Secretary, acting through the
Administrator, shall--
``(A) for each Center, not later than 3 years after
the date on which such center of excellence is
established and annually thereafter, issue a report
card to the coordinating center to rate the performance
of such Center; and
``(B) not later than 3 years after the date on
which the first grant is awarded under subsection
(b)(1) and annually thereafter, issue a report card to
Congress to rate the performance of the network of
centers of excellence as a whole.
``(3) Recommendations.--Based upon the report cards
described in paragraph (2), the Secretary shall, not later than
September 30, 2015--
``(A) make recommendations to the Centers regarding
improvements such centers shall make; and
``(B) make recommendations to Congress for
expanding the Centers to serve individuals with other
types of mental disorders.
``(4) Third party review.--Not later than 3 years after the
date on which the first grant is awarded under subsection
(b)(1) and annually thereafter, the Secretary shall arrange for
an independent third party to conduct an evaluation of the
network of Centers to ensure that such centers are meeting the
goals of this section.
``(f) Authorization of Appropriations.--
``(1) In general.--To carry out this section, there are
authorized to be appropriated--
``(A) $100,000,000 for each of the fiscal years
2011 through 2015; and
``(B) $150,000,000 for each of the fiscal years
2016 through 2020.
``(2) Allocation of funds authorized.--Of the amount
appropriated under paragraph (1) for a fiscal year, the
Secretary shall determine the allocation of each Center
receiving a grant under this section, but in no case may the
allocation be more than $5,000,000, except that the Secretary
may allocate not more than $10,000,000 to the coordinating
center.''.
SEC. 10411. PROGRAMS RELATING TO CONGENITAL HEART DISEASE.
(a) Short Title.--This subtitle may be cited as the ``Congenital
Heart Futures Act''.
(b) Programs Relating to Congenital Heart Disease.--
(1) National congenital heart disease surveillance
system.--Part P of title III of the Public Health Service Act
(42 U.S.C. 280g et seq.), as amended by section 5405, is
further amended by adding at the end the following:
``SEC. 399V-2. NATIONAL CONGENITAL HEART DISEASE SURVEILLANCE SYSTEM.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, may--
``(1) enhance and expand infrastructure to track the
epidemiology of congenital heart disease and to organize such
information into a nationally-representative, population-based
surveillance system that compiles data concerning actual
occurrences of congenital heart disease, to be known as the
`National Congenital Heart Disease Surveillance System'; or
``(2) award a grant to one eligible entity to undertake the
activities described in paragraph (1).
``(b) Purpose.--The purpose of the Congenital Heart Disease
Surveillance System shall be to facilitate further research into the
types of health services patients use and to identify possible areas
for educational outreach and prevention in accordance with standard
practices of the Centers for Disease Control and Prevention.
``(c) Content.--The Congenital Heart Disease Surveillance System--
``(1) may include information concerning the incidence and
prevalence of congenital heart disease in the United States;
``(2) may be used to collect and store data on congenital
heart disease, including data concerning--
``(A) demographic factors associated with
congenital heart disease, such as age, race, ethnicity,
sex, and family history of individuals who are
diagnosed with the disease;
``(B) risk factors associated with the disease;
``(C) causation of the disease;
``(D) treatment approaches; and
``(E) outcome measures, such that analysis of the
outcome measures will allow derivation of evidence-
based best practices and guidelines for congenital
heart disease patients; and
``(3) may ensure the collection and analysis of
longitudinal data related to individuals of all ages with
congenital heart disease, including infants, young children,
adolescents, and adults of all ages.
``(d) Public Access.--The Congenital Heart Disease Surveillance
System shall be made available to the public, as appropriate, including
congenital heart disease researchers.
``(e) Patient Privacy.--The Secretary shall ensure that the
Congenital Heart Disease Surveillance System is maintained in a manner
that complies with the regulations promulgated under section 264 of the
Health Insurance Portability and Accountability Act of 1996.
``(f) Eligibility for Grant.--To be eligible to receive a grant
under subsection (a)(2), an entity shall--
``(1) be a public or private nonprofit entity with
specialized experience in congenital heart disease; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.''.
(2) Congenital heart disease research.--Subpart 2 of part C
of title IV of the Public Health Service Act (42 U.S.C. 285b et
seq.) is amended by adding at the end the following:
``SEC. 425. CONGENITAL HEART DISEASE.
``(a) In General.--The Director of the Institute may expand,
intensify, and coordinate research and related activities of the
Institute with respect to congenital heart disease, which may include
congenital heart disease research with respect to--
``(1) causation of congenital heart disease, including
genetic causes;
``(2) long-term outcomes in individuals with congenital
heart disease, including infants, children, teenagers, adults,
and elderly individuals;
``(3) diagnosis, treatment, and prevention;
``(4) studies using longitudinal data and retrospective
analysis to identify effective treatments and outcomes for
individuals with congenital heart disease; and
``(5) identifying barriers to life-long care for
individuals with congenital heart disease.
``(b) Coordination of Research Activities.--The Director of the
Institute may coordinate research efforts related to congenital heart
disease among multiple research institutions and may develop research
networks.
``(c) Minority and Medically Underserved Communities.--In carrying
out the activities described in this section, the Director of the
Institute shall consider the application of such research and other
activities to minority and medically underserved communities.''.
(c) Authorization of Appropriations.--There are authorized to be
appropriated to carry out the amendments made by this section such sums
as may be necessary for each of fiscal years 2011 through 2015.
SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM'S MEMORY ACT.
Section 312 of the Public Health Service Act (42 U.S.C. 244) is
amended--
(1) in subsection (c)(6), after ``clearinghouse'' insert
``, that shall be administered by an organization that has
substantial expertise in pediatric education, pediatric
medicine, and electrophysiology and sudden death,''; and
(2) in the first sentence of subsection (e), by striking
``fiscal year 2003'' and all that follows through ``2006'' and
inserting ``for each of fiscal years 2003 through 2014''.
SEC. 10413. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT OF YOUNG
WOMEN DIAGNOSED WITH BREAST CANCER.
(a) Short Title.--This section may be cited as the ``Young Women's
Breast Health Education and Awareness Requires Learning Young Act of
2009'' or the ``EARLY Act''.
(b) Amendment.--Title III of the Public Health Service Act (42
U.S.C. 241 et seq.), as amended by this Act, is further amended by
adding at the end the following:
``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER
``SEC. 399NN. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT OF
YOUNG WOMEN DIAGNOSED WITH BREAST CANCER.
``(a) Public Education Campaign.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall conduct a national evidence-based education campaign to
increase awareness of young women's knowledge regarding--
``(A) breast health in young women of all racial,
ethnic, and cultural backgrounds;
``(B) breast awareness and good breast health
habits;
``(C) the occurrence of breast cancer and the
general and specific risk factors in women who may be
at high risk for breast cancer based on familial,
racial, ethnic, and cultural backgrounds such as
Ashkenazi Jewish populations;
``(D) evidence-based information that would
encourage young women and their health care
professional to increase early detection of breast
cancers; and
``(E) the availability of health information and
other resources for young women diagnosed with breast
cancer.
``(2) Evidence-based, age appropriate messages.--The
campaign shall provide evidence-based, age-appropriate messages
and materials as developed by the Centers for Disease Control
and Prevention and the Advisory Committee established under
paragraph (4).
``(3) Media campaign.--In conducting the education campaign
under paragraph (1), the Secretary shall award grants to
entities to establish national multimedia campaigns oriented to
young women that may include advertising through television,
radio, print media, billboards, posters, all forms of existing
and especially emerging social networking media, other Internet
media, and any other medium determined appropriate by the
Secretary.
``(4) Advisory committee.--
``(A) Establishment.--Not later than 60 days after
the date of the enactment of this section, the
Secretary, acting through the Director of the Centers
for Disease Control and Prevention, shall establish an
advisory committee to assist in creating and conducting
the education campaigns under paragraph (1) and
subsection (b)(1).
``(B) Membership.--The Secretary, acting through
the Director of the Centers for Disease Control and
Prevention, shall appoint to the advisory committee
under subparagraph (A) such members as deemed necessary
to properly advise the Secretary, and shall include
organizations and individuals with expertise in breast
cancer, disease prevention, early detection, diagnosis,
public health, social marketing, genetic screening and
counseling, treatment, rehabilitation, palliative care,
and survivorship in young women.
``(b) Health Care Professional Education Campaign.--The Secretary,
acting through the Director of the Centers for Disease Control and
Prevention, and in consultation with the Administrator of the Health
Resources and Services Administration, shall conduct an education
campaign among physicians and other health care professionals to
increase awareness--
``(1) of breast health, symptoms, and early diagnosis and
treatment of breast cancer in young women, including specific
risk factors such as family history of cancer and women that
may be at high risk for breast cancer, such as Ashkenazi Jewish
population;
``(2) on how to provide counseling to young women about
their breast health, including knowledge of their family cancer
history and importance of providing regular clinical breast
examinations;
``(3) concerning the importance of discussing healthy
behaviors, and increasing awareness of services and programs
available to address overall health and wellness, and making
patient referrals to address tobacco cessation, good nutrition,
and physical activity;
``(4) on when to refer patients to a health care provider
with genetics expertise;
``(5) on how to provide counseling that addresses long-term
survivorship and health concerns of young women diagnosed with
breast cancer; and
``(6) on when to provide referrals to organizations and
institutions that provide credible health information and
substantive assistance and support to young women diagnosed
with breast cancer.
``(c) Prevention Research Activities.--The Secretary, acting
through--
``(1) the Director of the Centers for Disease Control and
Prevention, shall conduct prevention research on breast cancer
in younger women, including--
``(A) behavioral, survivorship studies, and other
research on the impact of breast cancer diagnosis on
young women;
``(B) formative research to assist with the
development of educational messages and information for
the public, targeted populations, and their families
about breast health, breast cancer, and healthy
lifestyles;
``(C) testing and evaluating existing and new
social marketing strategies targeted at young women;
and
``(D) surveys of health care providers and the
public regarding knowledge, attitudes, and practices
related to breast health and breast cancer prevention
and control in high-risk populations; and
``(2) the Director of the National Institutes of Health,
shall conduct research to develop and validate new screening
tests and methods for prevention and early detection of breast
cancer in young women.
``(d) Support for Young Women Diagnosed With Breast Cancer.--
``(1) In general.--The Secretary shall award grants to
organizations and institutions to provide health information
from credible sources and substantive assistance directed to
young women diagnosed with breast cancer and pre-neoplastic
breast diseases.
``(2) Priority.--In making grants under paragraph (1), the
Secretary shall give priority to applicants that deal
specifically with young women diagnosed with breast cancer and
pre-neoplastic breast disease.
``(e) No Duplication of Effort.--In conducting an education
campaign or other program under subsections (a), (b), (c), or (d), the
Secretary shall avoid duplicating other existing Federal breast cancer
education efforts.
``(f) Measurement; Reporting.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention, shall--
``(1) measure--
``(A) young women's awareness regarding breast
health, including knowledge of family cancer history,
specific risk factors and early warning signs, and
young women's proactive efforts at early detection;
``(B) the number or percentage of young women
utilizing information regarding lifestyle interventions
that foster healthy behaviors;
``(C) the number or percentage of young women
receiving regular clinical breast exams; and
``(D) the number or percentage of young women who
perform breast self exams, and the frequency of such
exams, before the implementation of this section;
``(2) not less than every 3 years, measure the impact of
such activities; and
``(3) submit reports to the Congress on the results of such
measurements.
``(g) Definition.--In this section, the term `young women' means
women 15 to 44 years of age.
``(h) Authorization of Appropriations.--To carry out subsections
(a), (b), (c)(1), and (d), there are authorized to be appropriated
$9,000,000 for each of the fiscal years 2010 through 2014.''.
Subtitle E--Provisions Relating to Title V
SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE SOCIAL
SECURITY ACT, AND TITLE V OF THIS ACT.
(a) Section 5101 of this Act is amended--
(1) in subsection (c)(2)(B)(i)(II), by inserting ``,
including representatives of small business and self-employed
individuals'' after ``employers'';
(2) in subsection (d)(4)(A)--
(A) by redesignating clause (iv) as clause (v); and
(B) by inserting after clause (iii) the following:
``(iv) An analysis of, and recommendations
for, eliminating the barriers to entering and
staying in primary care, including provider
compensation.''; and
(3) in subsection (i)(2)(B), by inserting ``optometrists,
ophthalmologists,'' after ``occupational therapists,''.
(b) Subtitle B of title V of this Act is amended by adding at the
end the following:
``SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE ACCESS TO
HEALTH CARE IN THE STATE OF ALASKA.
``(a) Establishment.--There is established a task force to be known
as the `Interagency Access to Health Care in Alaska Task Force'
(referred to in this section as the `Task Force').
``(b) Duties.--The Task Force shall--
``(1) assess access to health care for beneficiaries of
Federal health care systems in Alaska; and
``(2) develop a strategy for the Federal Government to
improve delivery of health care to Federal beneficiaries in the
State of Alaska.
``(c) Membership.--The Task Force shall be comprised of Federal
members who shall be appointed, not later than 45 days after the date
of enactment of this Act, as follows:
``(1) The Secretary of Health and Human Services shall
appoint one representative of each of the following:
``(A) The Department of Health and Human Services.
``(B) The Centers for Medicare and Medicaid
Services.
``(C) The Indian Health Service.
``(2) The Secretary of Defense shall appoint one
representative of the TRICARE Management Activity.
``(3) The Secretary of the Army shall appoint one
representative of the Army Medical Department.
``(4) The Secretary of the Air Force shall appoint one
representative of the Air Force, from among officers at the Air
Force performing medical service functions.
``(5) The Secretary of Veterans Affairs shall appoint one
representative of each of the following:
``(A) The Department of Veterans Affairs.
``(B) The Veterans Health Administration.
``(6) The Secretary of Homeland Security shall appoint one
representative of the United States Coast Guard.
``(d) Chairperson.--One chairperson of the Task Force shall be
appointed by the Secretary at the time of appointment of members under
subsection (c), selected from among the members appointed under
paragraph (1).
``(e) Meetings.--The Task Force shall meet at the call of the
chairperson.
``(f) Report.--Not later than 180 days after the date of enactment
of this Act, the Task Force shall submit to Congress a report detailing
the activities of the Task Force and containing the findings,
strategies, recommendations, policies, and initiatives developed
pursuant to the duty described in subsection (b)(2). In preparing such
report, the Task Force shall consider completed and ongoing efforts by
Federal agencies to improve access to health care in the State of
Alaska.
``(g) Termination.--The Task Force shall be terminated on the date
of submission of the report described in subsection (f).''.
(c) Section 399V of the Public Health Service Act, as added by
section 5313, is amended--
(1) in subsection (b)(4), by striking ``identify, educate,
refer, and enroll'' and inserting ``identify and refer''; and
(2) in subsection (k)(1), by striking ``, as defined by the
Department of Labor as Standard Occupational Classification
[21-1094]''.
(d) Section 738(a)(3) of the Public Health Service Act (42 U.S.C.
293b(a)(3)) is amended by inserting ``schools offering physician
assistant education programs,'' after ``public health,''.
(e) Subtitle D of title V of this Act is amended by adding at the
end the following:
``SEC. 5316. DEMONSTRATION GRANTS FOR FAMILY NURSE PRACTITIONER
TRAINING PROGRAMS.
``(a) Establishment of Program.--The Secretary of Health and Human
Services (referred to in this section as the `Secretary') shall
establish a training demonstration program for family nurse
practitioners (referred to in this section as the `program') to employ
and provide 1-year training for nurse practitioners who have graduated
from a nurse practitioner program for careers as primary care providers
in Federally qualified health centers (referred to in this section as
`FQHCs') and nurse-managed health clinics (referred to in this section
as `NMHCs').
``(b) Purpose.--The purpose of the program is to enable each grant
recipient to--
``(1) provide new nurse practitioners with clinical
training to enable them to serve as primary care providers in
FQHCs and NMHCs;
``(2) train new nurse practitioners to work under a model
of primary care that is consistent with the principles set
forth by the Institute of Medicine and the needs of vulnerable
populations; and
``(3) create a model of FQHC and NMHC training for nurse
practitioners that may be replicated nationwide.
``(c) Grants.--The Secretary shall award 3-year grants to eligible
entities that meet the requirements established by the Secretary, for
the purpose of operating the nurse practitioner primary care programs
described in subsection (a) in such entities.
``(d) Eligible Entities.--To be eligible to receive a grant under
this section, an entity shall--
``(1)(A) be a FQHC as defined in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)); or
``(B) be a nurse-managed health clinic, as defined in
section 330A-1 of the Public Health Service Act (as added by
section 5208 of this Act); and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(e) Priority in Awarding Grants.--In awarding grants under this
section, the Secretary shall give priority to eligible entities that--
``(1) demonstrate sufficient infrastructure in size, scope,
and capacity to undertake the requisite training of a minimum
of 3 nurse practitioners per year, and to provide to each
awardee 12 full months of full-time, paid employment and
benefits consistent with the benefits offered to other full-
time employees of such entity;
``(2) will assign not less than 1 staff nurse practitioner
or physician to each of 4 precepted clinics;
``(3) will provide to each awardee specialty rotations,
including specialty training in prenatal care and women's
health, adult and child psychiatry, orthopedics, geriatrics,
and at least 3 other high-volume, high-burden specialty areas;
``(4) provide sessions on high-volume, high-risk health
problems and have a record of training health care
professionals in the care of children, older adults, and
underserved populations; and
``(5) collaborate with other safety net providers, schools,
colleges, and universities that provide health professions
training.
``(f) Eligibility of Nurse Practitioners.--
``(1) In general.--To be eligible for acceptance to a
program funded through a grant awarded under this section, an
individual shall--
``(A) be licensed or eligible for licensure in the
State in which the program is located as an advanced
practice registered nurse or advanced practice nurse
and be eligible or board-certified as a family nurse
practitioner; and
``(B) demonstrate commitment to a career as a
primary care provider in a FQHC or in a NMHC.
``(2) Preference.--In selecting awardees under the program,
each grant recipient shall give preference to bilingual
candidates that meet the requirements described in paragraph
(1).
``(3) Deferral of certain service.--The starting date of
required service of individuals in the National Health Service
Corps Service program under title II of the Public Health
Service Act (42 U.S.C. 202 et seq.) who receive training under
this section shall be deferred until the date that is 22 days
after the date of completion of the program.
``(g) Grant Amount.--Each grant awarded under this section shall be
in an amount not to exceed $600,000 per year. A grant recipient may
carry over funds from 1 fiscal year to another without obtaining
approval from the Secretary.
``(h) Technical Assistance Grants.--The Secretary may award
technical assistance grants to 1 or more FQHCs or NMHCs that have
demonstrated expertise in establishing a nurse practitioner residency
training program. Such technical assistance grants shall be for the
purpose of providing technical assistance to other recipients of grants
under subsection (c).
``(i) Authorization of Appropriations.--To carry out this section,
there is authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2014.''.
(f)(1) Section 399W of the Public Health Service Act, as added by
section 5405, is redesignated as section 399V-1.
(2) Section 399V-1 of the Public Health Service Act, as so
redesignated, is amended in subsection (b)(2)(A) by striking ``and the
departments of 1 or more health professions schools in the State that
train providers in primary care'' and inserting ``and the departments
that train providers in primary care in 1 or more health professions
schools in the State''.
(3) Section 934 of the Public Health Service Act, as added by
section 3501, is amended by striking ``399W'' each place such term
appears and inserting ``399V-1''.
(4) Section 935(b) of the Public Health Service Act, as added by
section 3503, is amended by striking ``399W'' and inserting ``399V-1''.
(g) Part P of title III of the Public Health Service Act 42 U.S.C.
280g et seq.), as amended by section 10411, is amended by adding at the
end the following:
``SEC. 399V-3. NATIONAL DIABETES PREVENTION PROGRAM.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall establish a
national diabetes prevention program (referred to in this section as
the `program') targeted at adults at high risk for diabetes in order to
eliminate the preventable burden of diabetes.
``(b) Program Activities.--The program described in subsection (a)
shall include--
``(1) a grant program for community-based diabetes
prevention program model sites;
``(2) a program within the Centers for Disease Control and
Prevention to determine eligibility of entities to deliver
community-based diabetes prevention services;
``(3) a training and outreach program for lifestyle
intervention instructors; and
``(4) evaluation, monitoring and technical assistance, and
applied research carried out by the Centers for Disease Control
and Prevention.
``(c) Eligible Entities.--To be eligible for a grant under
subsection (b)(1), an entity shall be a State or local health
department, a tribal organization, a national network of community-
based non-profits focused on health and wellbeing, an academic
institution, or other entity, as the Secretary determines.
``(d) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2010 through 2014.''.
(h) The provisions of, and amendment made by, section 5501(c) of
this Act are repealed.
(i)(1) The provisions of, and amendments made by, section 5502 of
this Act are repealed.
(2)(A) Section 1861(aa)(3)(A) of the Social Security Act (42 U.S.C.
1395w(aa)(3)(A)) is amended to read as follows:
``(A) services of the type described in subparagraphs (A)
through (C) of paragraph (1) and preventive services (as
defined in section 1861(ddd)(3)); and''.
(B) The amendment made by subparagraph (A) shall apply to services
furnished on or after January 1, 2011.
(3)(A) Section 1834 of the Social Security Act (42 U.S.C. 1395m),
as amended by section 4105, is amended by adding at the end the
following new subsection:
``(o) Development and Implementation of Prospective Payment
System.--
``(1) Development.--
``(A) In general.--The Secretary shall develop a
prospective payment system for payment for Federally
qualified health center services furnished by Federally
qualified health centers under this title. Such system
shall include a process for appropriately describing
the services furnished by Federally qualified health
centers and shall establish payment rates for specific
payment codes based on such appropriate descriptions of
services. Such system shall be established to take into
account the type, intensity, and duration of services
furnished by Federally qualified health centers. Such
system may include adjustments, including geographic
adjustments, determined appropriate by the Secretary.
``(B) Collection of data and evaluation.--By not
later than January 1, 2011, the Secretary shall require
Federally qualified health centers to submit to the
Secretary such information as the Secretary may require
in order to develop and implement the prospective
payment system under this subsection, including the
reporting of services using HCPCS codes.
``(2) Implementation.--
``(A) In general.--Notwithstanding section
1833(a)(3)(A), the Secretary shall provide, for cost
reporting periods beginning on or after October 1,
2014, for payments of prospective payment rates for
Federally qualified health center services furnished by
Federally qualified health centers under this title in
accordance with the prospective payment system
developed by the Secretary under paragraph (1).
``(B) Payments.--
``(i) Initial payments.--The Secretary
shall implement such prospective payment system
so that the estimated aggregate amount of
prospective payment rates (determined prior to
the application of section 1833(a)(1)(Z)) under
this title for Federally qualified health
center services in the first year that such
system is implemented is equal to 100 percent
of the estimated amount of reasonable costs
(determined without the application of a per
visit payment limit or productivity screen and
prior to the application of section
1866(a)(2)(A)(ii)) that would have occurred for
such services under this title in such year if
the system had not been implemented.
``(ii) Payments in subsequent years.--
Payment rates in years after the year of
implementation of such system shall be the
payment rates in the previous year increased--
``(I) in the first year after
implementation of such system, by the
percentage increase in the MEI (as
defined in section 1842(i)(3)) for the
year involved; and
``(II) in subsequent years, by the
percentage increase in a market basket
of Federally qualified health center
goods and services as promulgated
through regulations, or if such an
index is not available, by the
percentage increase in the MEI (as
defined in section 1842(i)(3)) for the
year involved.
``(C) Preparation for pps implementation.--
Notwithstanding any other provision of law, the
Secretary may establish and implement by program
instruction or otherwise the payment codes to be used
under the prospective payment system under this
section.''.
(B) Section 1833(a)(1) of the Social Security Act (42 U.S.C.
1395l(a)(1)), as amended by section 4104, is amended--
(i) by striking ``and'' before ``(Y)''; and
(ii) by inserting before the semicolon at the end the
following: ``, and (Z) with respect to Federally qualified
health center services for which payment is made under section
1834(o), the amounts paid shall be 80 percent of the lesser of
the actual charge or the amount determined under such
section''.
(C) Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a))
is amended--
(i) in paragraph (3)(B)(i)--
(I) by inserting ``(I)'' after ``otherwise been
provided''; and
(II) by inserting ``, or (II) in the case of such
services furnished on or after the implementation date
of the prospective payment system under section
1834(o), under such section (calculated as if `100
percent' were substituted for `80 percent' in such
section) for such services if the individual had not
been so enrolled'' after ``been so enrolled''; and
(ii) by adding at the end the following flush sentence:
``Paragraph (3)(A) shall not apply to Federally qualified
health center services furnished on or after the implementation
date of the prospective payment system under section
1834(0).''.
(j) Section 5505 is amended by adding at the end the following new
subsection:
``(d) Application.--The amendments made by this section shall not
be applied in a manner that requires reopening of any settled cost
reports as to which there is not a jurisdictionally proper appeal
pending as of the date of the enactment of this Act on the issue of
payment for indirect costs of medical education under section
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or
for direct graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. 1395ww(h)).''.
(k) Subtitle G of title V of this Act is amended by adding at the
end the following:
``SEC. 5606. STATE GRANTS TO HEALTH CARE PROVIDERS WHO PROVIDE SERVICES
TO A HIGH PERCENTAGE OF MEDICALLY UNDERSERVED POPULATIONS
OR OTHER SPECIAL POPULATIONS.
``(a) In General.--A State may award grants to health care
providers who treat a high percentage, as determined by such State, of
medically underserved populations or other special populations in such
State.
``(b) Source of Funds.--A grant program established by a State
under subsection (a) may not be established within a department,
agency, or other entity of such State that administers the Medicaid
program under title XIX of the Social Security Act (42 U.S.C. 1396 et
seq.), and no Federal or State funds allocated to such Medicaid
program, the Medicare program under title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.), or the TRICARE program under chapter 55
of title 10, United States Code, may be used to award grants or to pay
administrative costs associated with a grant program established under
subsection (a).''.
(l) Part C of title VII of the Public Health Service Act (42 U.S.C.
293k et seq.) is amended--
(1) after the part heading, by inserting the following:
``Subpart I--Medical Training Generally'';
and
(2) by inserting at the end the following:
``Subpart II--Training in Underserved Communities
``SEC. 749B. RURAL PHYSICIAN TRAINING GRANTS.
``(a) In General.--The Secretary, acting through the Administrator
of the Health Resources and Services Administration, shall establish a
grant program for the purposes of assisting eligible entities in
recruiting students most likely to practice medicine in underserved
rural communities, providing rural-focused training and experience, and
increasing the number of recent allopathic and osteopathic medical
school graduates who practice in underserved rural communities.
``(b) Eligible Entities.--In order to be eligible to receive a
grant under this section, an entity shall--
``(1) be a school of allopathic or osteopathic medicine
accredited by a nationally recognized accrediting agency or
association approved by the Secretary for this purpose, or any
combination or consortium of such schools; and
``(2) submit an application to the Secretary that includes
a certification that such entity will use amounts provided to
the institution as described in subsection (d)(1).
``(c) Priority.--In awarding grant funds under this section, the
Secretary shall give priority to eligible entities that--
``(1) demonstrate a record of successfully training
students, as determined by the Secretary, who practice medicine
in underserved rural communities;
``(2) demonstrate that an existing academic program of the
eligible entity produces a high percentage, as determined by
the Secretary, of graduates from such program who practice
medicine in underserved rural communities;
``(3) demonstrate rural community institutional
partnerships, through such mechanisms as matching or
contributory funding, documented in-kind services for
implementation, or existence of training partners with
interprofessional expertise in community health center training
locations or other similar facilities; or
``(4) submit, as part of the application of the entity
under subsection (b), a plan for the long-term tracking of
where the graduates of such entity practice medicine.
``(d) Use of Funds.--
``(1) Establishment.--An eligible entity receiving a grant
under this section shall use the funds made available under
such grant to establish, improve, or expand a rural-focused
training program (referred to in this section as the `Program')
meeting the requirements described in this subsection and to
carry out such program.
``(2) Structure of program.--An eligible entity shall--
``(A) enroll no fewer than 10 students per class
year into the Program; and
``(B) develop criteria for admission to the Program
that gives priority to students--
``(i) who have originated from or lived for
a period of 2 or more years in an underserved
rural community; and
``(ii) who express a commitment to practice
medicine in an underserved rural community.
``(3) Curricula.--The Program shall require students to
enroll in didactic coursework and clinical experience
particularly applicable to medical practice in underserved
rural communities, including--
``(A) clinical rotations in underserved rural
communities, and in applicable specialties, or other
coursework or clinical experience deemed appropriate by
the Secretary; and
``(B) in addition to core school curricula,
additional coursework or training experiences focused
on medical issues prevalent in underserved rural
communities.
``(4) Residency placement assistance.--Where available, the
Program shall assist all students of the Program in obtaining
clinical training experiences in locations with postgraduate
programs offering residency training opportunities in
underserved rural communities, or in local residency training
programs that support and train physicians to practice in
underserved rural communities.
``(5) Program student cohort support.--The Program shall
provide and require all students of the Program to participate
in group activities designed to further develop, maintain, and
reinforce the original commitment of such students to practice
in an underserved rural community.
``(e) Annual Reporting.--An eligible entity receiving a grant under
this section shall submit an annual report to the Secretary on the
success of the Program, based on criteria the Secretary determines
appropriate, including the residency program selection of graduating
students who participated in the Program.
``(f) Regulations.--Not later than 60 days after the date of
enactment of this section, the Secretary shall by regulation define
`underserved rural community' for purposes of this section.
``(g) Supplement Not Supplant.--Any eligible entity receiving funds
under this section shall use such funds to supplement, not supplant,
any other Federal, State, and local funds that would otherwise be
expended by such entity to carry out the activities described in this
section.
``(h) Maintenance of Effort.--With respect to activities for which
funds awarded under this section are to be expended, the entity shall
agree to maintain expenditures of non-Federal amounts for such
activities at a level that is not less than the level of such
expenditures maintained by the entity for the fiscal year preceding the
fiscal year for which the entity receives a grant under this section.
``(i) Authorization of Appropriations.--There are authorized to be
appropriated $4,000,000 for each of the fiscal years 2010 through
2013.''.
(m)(1) Section 768 of the Public Health Service Act (42 U.S.C.
295c) is amended to read as follows:
``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT
PROGRAM.
``(a) Grants.--The Secretary, acting through the Administrator of
the Health Resources and Services Administration and in consultation
with the Director of the Centers for Disease Control and Prevention,
shall award grants to, or enter into contracts with, eligible entities
to provide training to graduate medical residents in preventive
medicine specialties.
``(b) Eligibility.--To be eligible for a grant or contract under
subsection (a), an entity shall be--
``(1) an accredited school of public health or school of
medicine or osteopathic medicine;
``(2) an accredited public or private nonprofit hospital;
``(3) a State, local, or tribal health department; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(c) Use of Funds.--Amounts received under a grant or contract
under this section shall be used to--
``(1) plan, develop (including the development of
curricula), operate, or participate in an accredited residency
or internship program in preventive medicine or public health;
``(2) defray the costs of practicum experiences, as
required in such a program; and
``(3) establish, maintain, or improve--
``(A) academic administrative units (including
departments, divisions, or other appropriate units) in
preventive medicine and public health; or
``(B) programs that improve clinical teaching in
preventive medicine and public health.
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
(2) Section 770(a) of the Public Health Service Act (42
U.S.C. 295e(a)) is amended to read as follows:
``(a) In General.--For the purpose of carrying out this subpart,
there is authorized to be appropriated $43,000,000 for fiscal year
2011, and such sums as may be necessary for each of the fiscal years
2012 through 2015.''.
(n)(1) Subsection (i) of section 331 of the Public Health Service
Act (42 U.S.C. 254d) of the Public Health Service Act is amended--
(A) in paragraph (1), by striking ``In carrying out subpart
III'' and all that follows through the period and inserting
``In carrying out subpart III, the Secretary may, in accordance
with this subsection, issue waivers to individuals who have
entered into a contract for obligated service under the
Scholarship Program or the Loan Repayment Program under which
the individuals are authorized to satisfy the requirement of
obligated service through providing clinical practice that is
half time.'';
(B) in paragraph (2)--
(i) in subparagraphs (A)(ii) and (B), by striking
``less than full time'' each place it appears and
inserting ``half time'';
(ii) in subparagraphs (C) and (F), by striking
``less than full-time service'' each place it appears
and inserting ``half-time service''; and
(iii) by amending subparagraphs (D) and (E) to read
as follows:
``(D) the entity and the Corps member agree in writing that
the Corps member will perform half-time clinical practice;
``(E) the Corps member agrees in writing to fulfill all of
the service obligations under section 338C through half-time
clinical practice and either--
``(i) double the period of obligated service that
would otherwise be required; or
``(ii) in the case of contracts entered into under
section 338B, accept a minimum service obligation of 2
years with an award amount equal to 50 percent of the
amount that would otherwise be payable for full-time
service; and''; and
(C) in paragraph (3), by striking ``In evaluating a
demonstration project described in paragraph (1)'' and
inserting ``In evaluating waivers issued under paragraph (1)''.
(2) Subsection (j) of section 331 of the Public Health Service Act
(42 U.S.C. 254d) is amended by adding at the end the following:
``(5) The terms `full time' and `full-time' mean a minimum
of 40 hours per week in a clinical practice, for a minimum of
45 weeks per year.
``(6) The terms `half time' and `half-time' mean a minimum
of 20 hours per week (not to exceed 39 hours per week) in a
clinical practice, for a minimum of 45 weeks per year.''.
(3) Section 337(b)(1) of the Public Health Service Act (42 U.S.C.
254j(b)(1)) is amended by striking ``Members may not be reappointed to
the Council.''.
(4) Section 338B(g)(2)(A) of the Public Health Service Act (42
U.S.C. 254l-1(g)(2)(A)) is amended by striking ``$35,000'' and
inserting ``$50,000, plus, beginning with fiscal year 2012, an amount
determined by the Secretary on an annual basis to reflect inflation,''.
(5) Subsection (a) of section 338C of the Public Health Service Act
(42 U.S.C. 254m), as amended by section 5508, is amended--
(A) by striking the second sentence and inserting the
following: ``The Secretary may treat teaching as clinical
practice for up to 20 percent of such period of obligated
service.''; and
(B) by adding at the end the following: ``Notwithstanding
the preceding sentence, with respect to a member of the Corps
participating in the teaching health centers graduate medical
education program under section 340H, for the purpose of
calculating time spent in full-time clinical practice under
this section, up to 50 percent of time spent teaching by such
member may be counted toward his or her service obligation.''.
SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE.
(a) Appropriation.--There are authorized to be appropriated, and
there are appropriated to the Department of Health and Human Services,
$100,000,000 for fiscal year 2010, to remain available for obligation
until September 30, 2011, to be used for debt service on, or direct
construction or renovation of, a health care facility that provides
research, inpatient tertiary care, or outpatient clinical services.
Such facility shall be affiliated with an academic health center at a
public research university in the United States that contains a State's
sole public academic medical and dental school.
(b) Requirement.--Amount appropriated under subsection (a) may only
be made available by the Secretary of Health and Human Services upon
the receipt of an application from the Governor of a State that
certifies that--
(1) the new health care facility is critical for the
provision of greater access to health care within the State;
(2) such facility is essential for the continued financial
viability of the State's sole public medical and dental school
and its academic health center;
(3) the request for Federal support represents not more
than 40 percent of the total cost of the proposed new facility;
and
(4) the State has established a dedicated funding mechanism
to provide all remaining funds necessary to complete the
construction or renovation of the proposed facility.
SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NATIONAL HEALTH SERVICE
CORPS FUND.
(a) Purpose.--It is the purpose of this section to establish a
Community Health Center Fund (referred to in this section as the ``CHC
Fund''), to be administered through the Office of the Secretary of the
Department of Health and Human Services to provide for expanded and
sustained national investment in community health centers under section
330 of the Public Health Service Act and the National Health Service
Corps.
(b) Funding.--There is authorized to be appropriated, and there is
appropriated, out of any monies in the Treasury not otherwise
appropriated, to the CHC Fund--
(1) to be transferred to the Secretary of Health and Human
Services to provide enhanced funding for the community health
center program under section 330 of the Public Health Service
Act--
(A) $700,000,000 for fiscal year 2011;
(B) $800,000,000 for fiscal year 2012;
(C) $1,000,000,000 for fiscal year 2013;
(D) $1,600,000,000 for fiscal year 2014; and
(E) $2,900,000,000 for fiscal year 2015; and
(2) to be transferred to the Secretary of Health and Human
Services to provide enhanced funding for the National Health
Service Corps--
(A) $290,000,000 for fiscal year 2011;
(B) $295,000,000 for fiscal year 2012;
(C) $300,000,000 for fiscal year 2013;
(D) $305,000,000 for fiscal year 2014; and
(E) $310,000,000 for fiscal year 2015.
(c) Construction.--There is authorized to be appropriated, and
there is appropriated, out of any monies in the Treasury not otherwise
appropriated, $1,500,000,000 to be available for fiscal years 2011
through 2015 to be used by the Secretary of Health and Human Services
for the construction and renovation of community health centers.
(d) Use of Fund.--The Secretary of Health and Human Services shall
transfer amounts in the CHC Fund to accounts within the Department of
Health and Human Services to increase funding, over the fiscal year
2008 level, for community health centers and the National Health
Service Corps.
(e) Availability.--Amounts appropriated under subsections (b) and
(c) shall remain available until expended.
SEC. 10504. DEMONSTRATION PROJECT TO PROVIDE ACCESS TO AFFORDABLE CARE.
(a) In General.--Not later than 6 months after the date of
enactment of this Act, the Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting through the
Health Resources and Services Administration, shall establish a 3 year
demonstration project in up to 10 States to provide access to
comprehensive health care services to the uninsured at reduced fees.
The Secretary shall evaluate the feasibility of expanding the project
to additional States.
(b) Eligibility.--To be eligible to participate in the
demonstration project, an entity shall be a State-based, nonprofit,
public-private partnership that provides access to comprehensive health
care services to the uninsured at reduced fees. Each State in which a
participant selected by the Secretary is located shall receive not more
than $2,000,000 to establish and carry out the project for the 3-year
demonstration period.
(c) Authorization.--There is authorized to be appropriated such
sums as may be necessary to carry out this section.
Subtitle F--Provisions Relating to Title VI
SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EXCEPTION TO THE
PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS.
(a) In General.--Section 1877(i) of the Social Security Act, as
added by section 6001(a), is amended--
(1) in paragraph (1)(A)(i), by striking ``February 1,
2010'' and inserting ``August 1, 2010''; and
(2) in paragraph (3)(A)--
(A) in clause (iii), by striking ``August 1, 2011''
and inserting ``February 1, 2012''; and
(B) in clause (iv), by striking ``July 1, 2011''
and inserting ``January 1, 2012''.
(b) Conforming Amendment.--Section 6001(b)(2) of this Act is
amended by striking ``November 1, 2011'' and inserting ``May 1, 2012''.
SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES RESEARCH.
Section 1181 of the Social Security Act (as added by section 6301)
is amended--
(1) in subsection (d)(2)(B)--
(A) in clause (ii)(IV)--
(i) by inserting ``, as described in
subparagraph (A)(ii),'' after ``original
research''; and
(ii) by inserting ``, as long as the
researcher enters into a data use agreement
with the Institute for use of the data from the
original research, as appropriate'' after
``publication''; and
(B) by amending clause (iv) to read as follows:
``(iv) Subsequent use of the data.--The
Institute shall not allow the subsequent use of
data from original research in work-for-hire
contracts with individuals, entities, or
instrumentalities that have a financial
interest in the results, unless approved under
a data use agreement with the Institute.'';
(2) in subsection (d)(8)(A)(iv), by striking ``not be
construed as mandates for'' and inserting ``do not include'';
and
(3) in subsection (f)(1)(C), by amending clause (ii) to
read as follows:
``(ii) 7 members representing physicians
and providers, including 4 members representing
physicians (at least 1 of whom is a surgeon), 1
nurse, 1 State-licensed integrative health care
practitioner, and 1 representative of a
hospital.''.
SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL PROVIDER
APPLICATION FEES.
(a) In General.--Section 1866(j)(2)(C) of the Social Security Act,
as added by section 6401(a), is amended--
(1) by striking clause (i);
(2) by redesignating clauses (ii) through (iv),
respectively, as clauses (i) through (iii); and
(3) in clause (i), as redesignated by paragraph (2), by
striking ``clause (iii)'' and inserting ``clause (ii)''.
(b) Technical Correction.--Section 6401(a)(2) of this Act is
amended to read as follows:
``(2) by redesignating paragraph (2) as paragraph (8);
and''.
SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405.
Paragraphs (1) and (2) of section 6405(b) are amended to read as
follows:
``(1) Part a.--Section 1814(a)(2) of the Social Security
Act (42 U.S.C. 1395(a)(2)) is amended in the matter preceding
subparagraph (A) by inserting `, or, in the case of services
described in subparagraph (C), a physician enrolled under
section 1866(j),' after `in collaboration with a physician,'.
``(2) Part b.--Section 1835(a)(2) of the Social Security
Act (42 U.S.C. 1395n(a)(2)) is amended in the matter preceding
subparagraph (A) by inserting `, or, in the case of services
described in subparagraph (A), a physician enrolled under
section 1866(j),' after `a physician'.''.
SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT FACE TO FACE
ENCOUNTER FOR HOME HEALTH SERVICES.
(a) Part A.--Section 1814(a)(2)(C) of the Social Security Act (42
U.S.C. 1395f(a)(2)(C)), as amended by section 6407(a)(1), is amended by
inserting ``, or a nurse practitioner or clinical nurse specialist (as
those terms are defined in section 1861(aa)(5)) who is working in
collaboration with the physician in accordance with State law, or a
certified nurse-midwife (as defined in section 1861(gg)) as authorized
by State law, or a physician assistant (as defined in section
1861(aa)(5)) under the supervision of the physician,'' after ``himself
or herself''.
(b) Part B.--Section 1835(a)(2)(A)(iv) of the Social Security Act,
as added by section 6407(a)(2), is amended by inserting ``, or a nurse
practitioner or clinical nurse specialist (as those terms are defined
in section 1861(aa)(5)) who is working in collaboration with the
physician in accordance with State law, or a certified nurse-midwife
(as defined in section 1861(gg)) as authorized by State law, or a
physician assistant (as defined in section 1861(aa)(5)) under the
supervision of the physician,'' after ``must document that the
physician''.
SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.
(a) Fraud Sentencing Guidelines.--
(1) Definition.--In this subsection, the term ``Federal
health care offense'' has the meaning given that term in
section 24 of title 18, United States Code, as amended by this
Act.
(2) Review and amendments.--Pursuant to the authority under
section 994 of title 28, United States Code, and in accordance
with this subsection, the United States Sentencing Commission
shall--
(A) review the Federal Sentencing Guidelines and
policy statements applicable to persons convicted of
Federal health care offenses;
(B) amend the Federal Sentencing Guidelines and
policy statements applicable to persons convicted of
Federal health care offenses involving Government
health care programs to provide that the aggregate
dollar amount of fraudulent bills submitted to the
Government health care program shall constitute prima
facie evidence of the amount of the intended loss by
the defendant; and
(C) amend the Federal Sentencing Guidelines to
provide--
(i) a 2-level increase in the offense level
for any defendant convicted of a Federal health
care offense relating to a Government health
care program which involves a loss of not less
than $1,000,000 and less than $7,000,000;
(ii) a 3-level increase in the offense
level for any defendant convicted of a Federal
health care offense relating to a Government
health care program which involves a loss of
not less than $7,000,000 and less than
$20,000,000;
(iii) a 4-level increase in the offense
level for any defendant convicted of a Federal
health care offense relating to a Government
health care program which involves a loss of
not less than $20,000,000; and
(iv) if appropriate, otherwise amend the
Federal Sentencing Guidelines and policy
statements applicable to persons convicted of
Federal health care offenses involving
Government health care programs.
(3) Requirements.--In carrying this subsection, the United
States Sentencing Commission shall--
(A) ensure that the Federal Sentencing Guidelines
and policy statements--
(i) reflect the serious harms associated
with health care fraud and the need for
aggressive and appropriate law enforcement
action to prevent such fraud; and
(ii) provide increased penalties for
persons convicted of health care fraud offenses
in appropriate circumstances;
(B) consult with individuals or groups representing
health care fraud victims, law enforcement officials,
the health care industry, and the Federal judiciary as
part of the review described in paragraph (2);
(C) ensure reasonable consistency with other
relevant directives and with other guidelines under the
Federal Sentencing Guidelines;
(D) account for any aggravating or mitigating
circumstances that might justify exceptions, including
circumstances for which the Federal Sentencing
Guidelines, as in effect on the date of enactment of
this Act, provide sentencing enhancements;
(E) make any necessary conforming changes to the
Federal Sentencing Guidelines; and
(F) ensure that the Federal Sentencing Guidelines
adequately meet the purposes of sentencing.
(b) Intent Requirement for Health Care Fraud.--Section 1347 of
title 18, United States Code, is amended--
(1) by inserting ``(a)'' before ``Whoever knowingly''; and
(2) by adding at the end the following:
``(b) With respect to violations of this section, a person need not
have actual knowledge of this section or specific intent to commit a
violation of this section.''.
(c) Health Care Fraud Offense.--Section 24(a) of title 18, United
States Code, is amended--
(1) in paragraph (1), by striking the semicolon and
inserting ``or section 1128B of the Social Security Act (42
U.S.C. 1320a-7b); or''; and
(2) in paragraph (2)--
(A) by inserting ``1349,'' after ``1343,''; and
(B) by inserting ``section 301 of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 331), or section 501
of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1131),'' after ``title,''.
(d) Subpoena Authority Relating to Health Care.--
(1) Subpoenas under the health insurance portability and
accountability act of 1996.--Section 1510(b) of title 18,
United States Code, is amended--
(A) in paragraph (1), by striking ``to the grand
jury''; and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking
``grand jury subpoena'' and inserting
``subpoena for records''; and
(ii) in the matter following subparagraph
(B), by striking ``to the grand jury''.
(2) Subpoenas under the civil rights of institutionalized
persons act.--The Civil Rights of Institutionalized Persons Act
(42 U.S.C. 1997 et seq.) is amended by inserting after section
3 the following:
``SEC. 3A. SUBPOENA AUTHORITY.
``(a) Authority.--The Attorney General, or at the direction of the
Attorney General, any officer or employee of the Department of Justice
may require by subpoena access to any institution that is the subject
of an investigation under this Act and to any document, record,
material, file, report, memorandum, policy, procedure, investigation,
video or audio recording, or quality assurance report relating to any
institution that is the subject of an investigation under this Act to
determine whether there are conditions which deprive persons residing
in or confined to the institution of any rights, privileges, or
immunities secured or protected by the Constitution or laws of the
United States.
``(b) Issuance and Enforcement of Subpoenas.--
``(1) Issuance.--Subpoenas issued under this section--
``(A) shall bear the signature of the Attorney
General or any officer or employee of the Department of
Justice as designated by the Attorney General; and
``(B) shall be served by any person or class of
persons designated by the Attorney General or a
designated officer or employee for that purpose.
``(2) Enforcement.--In the case of contumacy or failure to
obey a subpoena issued under this section, the United States
district court for the judicial district in which the
institution is located may issue an order requiring compliance.
Any failure to obey the order of the court may be punished by
the court as a contempt that court.
``(c) Protection of Subpoenaed Records and Information.--Any
document, record, material, file, report, memorandum, policy,
procedure, investigation, video or audio recording, or quality
assurance report or other information obtained under a subpoena issued
under this section--
``(1) may not be used for any purpose other than to protect
the rights, privileges, or immunities secured or protected by
the Constitution or laws of the United States of persons who
reside, have resided, or will reside in an institution;
``(2) may not be transmitted by or within the Department of
Justice for any purpose other than to protect the rights,
privileges, or immunities secured or protected by the
Constitution or laws of the United States of persons who
reside, have resided, or will reside in an institution; and
``(3) shall be redacted, obscured, or otherwise altered if
used in any publicly available manner so as to prevent the
disclosure of any personally identifiable information.''.
SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE ALTERNATIVES TO
CURRENT MEDICAL TORT LITIGATION.
Part P of title III of the Public Health Service Act (42 U.S.C.
280g et seq.), as amended by this Act, is further amended by adding at
the end the following:
``SEC. 399V-4. STATE DEMONSTRATION PROGRAMS TO EVALUATE ALTERNATIVES TO
CURRENT MEDICAL TORT LITIGATION.
``(a) In General.--The Secretary is authorized to award
demonstration grants to States for the development, implementation, and
evaluation of alternatives to current tort litigation for resolving
disputes over injuries allegedly caused by health care providers or
health care organizations. In awarding such grants, the Secretary shall
ensure the diversity of the alternatives so funded.
``(b) Duration.--The Secretary may award grants under subsection
(a) for a period not to exceed 5 years.
``(c) Conditions for Demonstration Grants.--
``(1) Requirements.--Each State desiring a grant under
subsection (a) shall develop an alternative to current tort
litigation that--
``(A) allows for the resolution of disputes over
injuries allegedly caused by health care providers or
health care organizations; and
``(B) promotes a reduction of health care errors by
encouraging the collection and analysis of patient
safety data related to disputes resolved under
subparagraph (A) by organizations that engage in
efforts to improve patient safety and the quality of
health care.
``(2) Alternative to current tort litigation.--Each State
desiring a grant under subsection (a) shall demonstrate how the
proposed alternative described in paragraph (1)(A)--
``(A) makes the medical liability system more
reliable by increasing the availability of prompt and
fair resolution of disputes;
``(B) encourages the efficient resolution of
disputes;
``(C) encourages the disclosure of health care
errors;
``(D) enhances patient safety by detecting,
analyzing, and helping to reduce medical errors and
adverse events;
``(E) improves access to liability insurance;
``(F) fully informs patients about the differences
in the alternative and current tort litigation;
``(G) provides patients the ability to opt out of
or voluntarily withdraw from participating in the
alternative at any time and to pursue other options,
including litigation, outside the alternative;
``(H) would not conflict with State law at the time
of the application in a way that would prohibit the
adoption of an alternative to current tort litigation;
and
``(I) would not limit or curtail a patient's
existing legal rights, ability to file a claim in or
access a State's legal system, or otherwise abrogate a
patient's ability to file a medical malpractice claim.
``(3) Sources of compensation.--Each State desiring a grant
under subsection (a) shall identify the sources from and
methods by which compensation would be paid for claims resolved
under the proposed alternative to current tort litigation,
which may include public or private funding sources, or a
combination of such sources. Funding methods shall to the
extent practicable provide financial incentives for activities
that improve patient safety.
``(4) Scope.--
``(A) In general.--Each State desiring a grant
under subsection (a) shall establish a scope of
jurisdiction (such as Statewide, designated geographic
region, a designated area of health care practice, or a
designated group of health care providers or health
care organizations) for the proposed alternative to
current tort litigation that is sufficient to evaluate
the effects of the alternative. No scope of
jurisdiction shall be established under this paragraph
that is based on a health care payer or patient
population.
``(B) Notification of patients.--A State shall
demonstrate how patients would be notified that they
are receiving health care services that fall within
such scope, and the process by which they may opt out
of or voluntarily withdraw from participating in the
alternative. The decision of the patient whether to
participate or continue participating in the
alternative process shall be made at any time and shall
not be limited in any way.
``(5) Preference in awarding demonstration grants.--In
awarding grants under subsection (a), the Secretary shall give
preference to States--
``(A) that have developed the proposed alternative
through substantive consultation with relevant
stakeholders, including patient advocates, health care
providers and health care organizations, attorneys with
expertise in representing patients and health care
providers, medical malpractice insurers, and patient
safety experts;
``(B) that make proposals that are likely to
enhance patient safety by detecting, analyzing, and
helping to reduce medical errors and adverse events;
and
``(C) that make proposals that are likely to
improve access to liability insurance.
``(d) Application.--
``(1) In general.--Each State desiring a grant under
subsection (a) shall submit to the Secretary an application, at
such time, in such manner, and containing such information as
the Secretary may require.
``(2) Review panel.--
``(A) In general.--In reviewing applications under
paragraph (1), the Secretary shall consult with a
review panel composed of relevant experts appointed by
the Comptroller General.
``(B) Composition.--
``(i) Nominations.--The Comptroller General
shall solicit nominations from the public for
individuals to serve on the review panel.
``(ii) Appointment.--The Comptroller
General shall appoint, at least 9 but not more
than 13, highly qualified and knowledgeable
individuals to serve on the review panel and
shall ensure that the following entities
receive fair representation on such panel:
``(I) Patient advocates.
``(II) Health care providers and
health care organizations.
``(III) Attorneys with expertise in
representing patients and health care
providers.
``(IV) Medical malpractice
insurers.
``(V) State officials.
``(VI) Patient safety experts.
``(C) Chairperson.--The Comptroller General, or an
individual within the Government Accountability Office
designated by the Comptroller General, shall be the
chairperson of the review panel.
``(D) Availability of information.--The Comptroller
General shall make available to the review panel such
information, personnel, and administrative services and
assistance as the review panel may reasonably require
to carry out its duties.
``(E) Information from agencies.--The review panel
may request directly from any department or agency of
the United States any information that such panel
considers necessary to carry out its duties. To the
extent consistent with applicable laws and regulations,
the head of such department or agency shall furnish the
requested information to the review panel.
``(e) Reports.--
``(1) By state.--Each State receiving a grant under
subsection (a) shall submit to the Secretary an annual report
evaluating the effectiveness of activities funded with grants
awarded under such subsection. Such report shall, at a minimum,
include the impact of the activities funded on patient safety
and on the availability and price of medical liability
insurance.
``(2) By secretary.--The Secretary shall submit to Congress
an annual compendium of the reports submitted under paragraph
(1) and an analysis of the activities funded under subsection
(a) that examines any differences that result from such
activities in terms of the quality of care, number and nature
of medical errors, medical resources used, length of time for
dispute resolution, and the availability and price of liability
insurance.
``(f) Technical Assistance.--
``(1) In general.--The Secretary shall provide technical
assistance to the States applying for or awarded grants under
subsection (a).
``(2) Requirements.--Technical assistance under paragraph
(1) shall include--
``(A) guidance on non-economic damages, including
the consideration of individual facts and circumstances
in determining appropriate payment, guidance on
identifying avoidable injuries, and guidance on
disclosure to patients of health care errors and
adverse events; and
``(B) the development, in consultation with States,
of common definitions, formats, and data collection
infrastructure for States receiving grants under this
section to use in reporting to facilitate aggregation
and analysis of data both within and between States.
``(3) Use of common definitions, formats, and data
collection infrastructure.--States not receiving grants under
this section may also use the common definitions, formats, and
data collection infrastructure developed under paragraph
(2)(B).
``(g) Evaluation.--
``(1) In general.--The Secretary, in consultation with the
review panel established under subsection (d)(2), shall enter
into a contract with an appropriate research organization to
conduct an overall evaluation of the effectiveness of grants
awarded under subsection (a) and to annually prepare and submit
a report to Congress. Such an evaluation shall begin not later
than 18 months following the date of implementation of the
first program funded by a grant under subsection (a).
``(2) Contents.--The evaluation under paragraph (1) shall
include--
``(A) an analysis of the effects of the grants
awarded under subsection (a) with regard to the
measures described in paragraph (3);
``(B) for each State, an analysis of the extent to
which the alternative developed under subsection (c)(1)
is effective in meeting the elements described in
subsection (c)(2);
``(C) a comparison among the States receiving
grants under subsection (a) of the effectiveness of the
various alternatives developed by such States under
subsection (c)(1);
``(D) a comparison, considering the measures
described in paragraph (3), of States receiving grants
approved under subsection (a) and similar States not
receiving such grants; and
``(E) a comparison, with regard to the measures
described in paragraph (3), of--
``(i) States receiving grants under
subsection (a);
``(ii) States that enacted, prior to the
date of enactment of the Patient Protection and
Affordable Care Act, any cap on non-economic
damages; and
``(iii) States that have enacted, prior to
the date of enactment of the Patient Protection
and Affordable Care Act, a requirement that the
complainant obtain an opinion regarding the
merit of the claim, although the substance of
such opinion may have no bearing on whether the
complainant may proceed with a case.
``(3) Measures.--The evaluations under paragraph (2) shall
analyze and make comparisons on the basis of--
``(A) the nature and number of disputes over
injuries allegedly caused by health care providers or
health care organizations;
``(B) the nature and number of claims in which tort
litigation was pursued despite the existence of an
alternative under subsection (a);
``(C) the disposition of disputes and claims,
including the length of time and estimated costs to all
parties;
``(D) the medical liability environment;
``(E) health care quality;
``(F) patient safety in terms of detecting,
analyzing, and helping to reduce medical errors and
adverse events;
``(G) patient and health care provider and
organization satisfaction with the alternative under
subsection (a) and with the medical liability
environment; and
``(H) impact on utilization of medical services,
appropriately adjusted for risk.
``(4) Funding.--The Secretary shall reserve 5 percent of
the amount appropriated in each fiscal year under subsection
(k) to carry out this subsection.
``(h) MedPAC and MACPAC Reports.--
``(1) MedPAC.--The Medicare Payment Advisory Commission
shall conduct an independent review of the alternatives to
current tort litigation that are implemented under grants under
subsection (a) to determine the impact of such alternatives on
the Medicare program under title XVIII of the Social Security
Act, and its beneficiaries.
``(2) MACPAC.--The Medicaid and CHIP Payment and Access
Commission shall conduct an independent review of the
alternatives to current tort litigation that are implemented
under grants under subsection (a) to determine the impact of
such alternatives on the Medicaid or CHIP programs under titles
XIX and XXI of the Social Security Act, and their
beneficiaries.
``(3) Reports.--Not later than December 31, 2016, the
Medicare Payment Advisory Commission and the Medicaid and CHIP
Payment and Access Commission shall each submit to Congress a
report that includes the findings and recommendations of each
respective Commission based on independent reviews conducted
under paragraphs (1) and (2), including an analysis of the
impact of the alternatives reviewed on the efficiency and
effectiveness of the respective programs.
``(i) Option To Provide for Initial Planning Grants.--Of the funds
appropriated pursuant to subsection (k), the Secretary may use a
portion not to exceed $500,000 per State to provide planning grants to
such States for the development of demonstration project applications
meeting the criteria described in subsection (c). In selecting States
to receive such planning grants, the Secretary shall give preference to
those States in which State law at the time of the application would
not prohibit the adoption of an alternative to current tort litigation.
``(j) Definitions.--In this section:
``(1) Health care services.--The term `health care
services' means any services provided by a health care
provider, or by any individual working under the supervision of
a health care provider, that relate to--
``(A) the diagnosis, prevention, or treatment of
any human disease or impairment; or
``(B) the assessment of the health of human beings.
``(2) Health care organization.--The term `health care
organization' means any individual or entity which is obligated
to provide, pay for, or administer health benefits under any
health plan.
``(3) Health care provider.--The term `health care
provider' means any individual or entity--
``(A) licensed, registered, or certified under
Federal or State laws or regulations to provide health
care services; or
``(B) required to be so licensed, registered, or
certified but that is exempted by other statute or
regulation.
``(k) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section, $50,000,000 for the 5-fiscal
year period beginning with fiscal year 2011.
``(l) Current State Efforts To Establish Alternative To Tort
Litigation.--Nothing in this section shall be construed to limit any
prior, current, or future efforts of any State to establish any
alternative to tort litigation.
``(m) Rule of Construction.--Nothing in this section shall be
construed as limiting states' authority over or responsibility for
their state justice systems.''.
SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE TO FREE CLINICS.
(a) In General.--Section 224(o)(1) of the Public Health Service Act
(42 U.S.C. 233(o)(1)) is amended by inserting after ``to an
individual'' the following: ``, or an officer, governing board member,
employee, or contractor of a free clinic shall in providing services
for the free clinic,''.
(b) Effective Date.--The amendment made by this section shall take
effect on the date of enactment of this Act and apply to any act or
omission which occurs on or after that date.
SEC. 10609. LABELING CHANGES.
Section 505(j) of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355(j)) is amended by adding at the end the following:
``(10)(A) If the proposed labeling of a drug that is the subject of
an application under this subsection differs from the listed drug due
to a labeling revision described under clause (i), the drug that is the
subject of such application shall, notwithstanding any other provision
of this Act, be eligible for approval and shall not be considered
misbranded under section 502 if--
``(i) the application is otherwise eligible for approval
under this subsection but for expiration of patent, an
exclusivity period, or of a delay in approval described in
paragraph (5)(B)(iii), and a revision to the labeling of the
listed drug has been approved by the Secretary within 60 days
of such expiration;
``(ii) the labeling revision described under clause (i)
does not include a change to the `Warnings' section of the
labeling;
``(iii) the sponsor of the application under this
subsection agrees to submit revised labeling of the drug that
is the subject of such application not later than 60 days after
the notification of any changes to such labeling required by
the Secretary; and
``(iv) such application otherwise meets the applicable
requirements for approval under this subsection.
``(B) If, after a labeling revision described in subparagraph
(A)(i), the Secretary determines that the continued presence in
interstate commerce of the labeling of the listed drug (as in effect
before the revision described in subparagraph (A)(i)) adversely impacts
the safe use of the drug, no application under this subsection shall be
eligible for approval with such labeling.''.
Subtitle G--Provisions Relating to Title VIII
SEC. 10801. PROVISIONS RELATING TO TITLE VIII.
(a) Title XXXII of the Public Health Service Act, as added by
section 8002(a)(1), is amended--
(1) in section 3203--
(A) in subsection (a)(1), by striking subparagraph
(E);
(B) in subsection (b)(1)(C)(i), by striking ``for
enrollment'' and inserting ``for reenrollment''; and
(C) in subsection (c)(1), by striking ``, as part
of their automatic enrollment in the CLASS program,'';
and
(2) in section 3204--
(A) in subsection (c)(2), by striking subparagraph
(A) and inserting the following:
``(A) receives wages or income on which there is
imposed a tax under section 3101(a) or 3201(a) of the
Internal Revenue Code of 1986; or'';
(B) in subsection (d), by striking ``subparagraph
(B) or (C) of subsection (c)(1)'' and inserting
``subparagraph (A) or (B) of subsection (c)(2)'';
(C) in subsection (e)(2)(A), by striking
``subparagraph (A)'' and inserting ``paragraph (1)'';
and
(D) in subsection (g)(1), by striking ``has elected
to waive enrollment'' and inserting ``has not
enrolled''.
(b) Section 8002 of this Act is amended in the heading for
subsection (d), by striking ``Information on Supplemental Coverage''
and inserting ``CLASS Program Information''.
(c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction Act of 2005,
as added by section 8002(d) of this Act, is amended by striking ``and
coverage available'' and all that follows through ``that program,''.
Subtitle H--Provisions Relating to Title IX
SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED
HEALTH COVERAGE.
(a) Longshore Workers Treated as Employees Engaged in High-risk
Professions.--Paragraph (3) of section 4980I(f) of the Internal Revenue
Code of 1986, as added by section 9001 of this Act, is amended by
inserting ``individuals whose primary work is longshore work (as
defined in section 258(b) of the Immigration and Nationality Act (8
U.S.C. 1288(b)), determined without regard to paragraph (2) thereof),''
before ``and individuals engaged in the construction, mining''.
(b) Exemption From High-cost Insurance Tax Includes Certain
Additional Excepted Benefits.--Clause (i) of section 4980I(d)(1)(B) of
the Internal Revenue Code of 1986, as added by section 9001 of this
Act, is amended by striking ``section 9832(c)(1)(A)'' and inserting
``section 9832(c)(1) (other than subparagraph (G) thereof)''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH FLEXIBLE
SPENDING ARRANGEMENTS UNDER CAFETERIA PLANS.
(a) In General.--Subsection (i) of section 125 of the Internal
Revenue Code of 1986, as added by section 9005 of this Act, is amended
to read as follows:
``(i) Limitation on Health Flexible Spending Arrangements.--
``(1) In general.--For purposes of this section, if a
benefit is provided under a cafeteria plan through employer
contributions to a health flexible spending arrangement, such
benefit shall not be treated as a qualified benefit unless the
cafeteria plan provides that an employee may not elect for any
taxable year to have salary reduction contributions in excess
of $2,500 made to such arrangement.
``(2) Adjustment for inflation.--In the case of any taxable
year beginning after December 31, 2011, the dollar amount in
paragraph (1) shall be increased by an amount equal to--
``(A) such amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year in which
such taxable year begins by substituting `calendar year
2010' for `calendar year 1992' in subparagraph (B)
thereof.
If any increase determined under this paragraph is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.''.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after December 31, 2010.
SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY CHARITABLE
HOSPITALS.
(a) In General.--Subparagraph (A) of section 501(r)(5) of the
Internal Revenue Code of 1986, as added by section 9007 of this Act, is
amended by striking ``the lowest amounts charged'' and inserting ``the
amounts generally billed''.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after the date of the enactment of this Act.
SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS
AND IMPORTERS.
(a) In General.--Section 9009 of this Act is amended--
(1) by striking ``2009'' in subsection (a)(1) and inserting
``2010'',
(2) by inserting ``($3,000,000,000 after 2017)'' after
``$2,000,000,000'', and
(3) by striking ``2008'' in subsection (i) and inserting
``2009''.
(b) Effective Date.--The amendments made by this section shall take
effect as if included in the enactment of section 9009.
SEC. 10905. MODIFICATION OF ANNUAL FEE ON HEALTH INSURANCE PROVIDERS.
(a) Determination of Fee Amount.--Subsection (b) of section 9010 of
this Act is amended to read as follows:
``(b) Determination of Fee Amount.--
``(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal to
an amount that bears the same ratio to the applicable amount
as--
``(A) the covered entity's net premiums written
with respect to health insurance for any United States
health risk that are taken into account during the
preceding calendar year, bears to
``(B) the aggregate net premiums written with
respect to such health insurance of all covered
entities that are taken into account during such
preceding calendar year.
``(2) Amounts taken into account.--For purposes of
paragraph (1), the net premiums written with respect to health
insurance for any United States health risk that are taken into
account during any calendar year with respect to any covered
entity shall be determined in accordance with the following
table:
``With respect to a covered entity's The percentage of net premiums
net premiums written during the written that are taken into
calendar year that are: account is:
Not more than $25,000,000............ 0 percent
More than $25,000,000 but not more 50 percent
than $50,000,000.
More than $50,000,000................ 100 percent.
``(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such amount,
the Secretary shall determine such covered entity's net
premiums written with respect to any United States health risk
on the basis of reports submitted by the covered entity under
subsection (g) and through the use of any other source of
information available to the Secretary.''.
(b) Applicable Amount.--Subsection (e) of section 9010 of this Act
is amended to read as follows:
``(e) Applicable Amount.--For purposes of subsection (b)(1), the
applicable amount shall be determined in accordance with the following
table:
``Calendar year Applicable amount
2011................................. $2,000,000,000
2012................................. $4,000,000,000
2013................................. $7,000,000,000
2014, 2015 and 2016.................. $9,000,000,000
2017 and thereafter.................. $10,000,000,000.''.
(c) Exemption From Annual Fee on Health Insurance for Certain
Nonprofit Entities.--Section 9010(c)(2) of this Act is amended by
striking ``or'' at the end of subparagraph (A), by striking the period
at the end of subparagraph (B) and inserting a comma, and by adding at
the end the following new subparagraphs:
``(C) any entity--
``(i)(I) which is incorporated as, is a
wholly owned subsidiary of, or is a wholly
owned affiliate of, a nonprofit corporation
under a State law, or
``(II) which is described in section
501(c)(4) of the Internal Revenue Code of 1986
and the activities of which consist of
providing commercial-type insurance (within the
meaning of section 501(m) of such Code),
``(ii) the premium rate increases of which
are regulated by a State authority,
``(iii) which, as of the date of the
enactment of this section, acts as the insurer
of last resort in the State and is subject to
State guarantee issue requirements, and
``(iv) for which the medical loss ratio
(determined in a manner consistent with the
determination of such ratio under section
2718(b)(1)(A) of the Public Health Service Act)
with respect to the individual insurance market
for such entity for the calendar year is not
less than 100 percent,
``(D) any entity--
``(i)(I) which is incorporated as a
nonprofit corporation under a State law, or
``(II) which is described in section
501(c)(4) of the Internal Revenue Code of 1986
and the activities of which consist of
providing commercial-type insurance (within the
meaning of section 501(m) of such Code), and
``(ii) for which the medical loss ratio (as
so determined)--
``(I) with respect to each of the
individual, small group, and large
group insurance markets for such entity
for the calendar year is not less than
90 percent, and
``(II) with respect to all such
markets for such entity for the
calendar year is not less than 92
percent, or
``(E) any entity--
``(i) which is a mutual insurance company,
``(ii) which for the period reported on the
2008 Accident and Health Policy Experience
Exhibit of the National Association of
Insurance Commissioners had--
``(I) a market share of the insured
population of a State of at least 40
but not more than 60 percent, and
``(II) with respect to all markets
described in subparagraph (D)(ii)(I), a
medical loss ratio of not less than 90
percent, and
``(iii) with respect to annual payment
dates in calendar years after 2011, for which
the medical loss ratio (determined in a manner
consistent with the determination of such ratio
under section 2718(b)(1)(A) of the Public
Health Service Act) with respect to all such
markets for such entity for the preceding
calendar year is not less than 89 percent
(except that with respect to such annual
payment date for 2012, the calculation under
2718(b)(1)(B)(ii) of such Act is determined by
reference to the previous year, and with
respect to such annual payment date for 2013,
such calculation is determined by reference to
the average for the previous 2 years).''.
(d) Certain Insurance Exempted From Fee.--Paragraph (3) of section
9010(h) of this Act is amended to read as follows:
``(3) Health insurance.--The term `health insurance' shall
not include--
``(A) any insurance coverage described in paragraph
(1)(A) or (3) of section 9832(c) of the Internal
Revenue Code of 1986,
``(B) any insurance for long-term care, or
``(C) any medicare supplemental health insurance
(as defined in section 1882(g)(1) of the Social
Security Act).''.
(e) Anti-avoidance Guidance.--Subsection (i) of section 9010 of
this Act is amended by inserting ``and shall prescribe such regulations
as are necessary or appropriate to prevent avoidance of the purposes of
this section, including inappropriate actions taken to qualify as an
exempt entity under subsection (c)(2)'' after ``section''.
(f) Conforming Amendments.--
(1) Section 9010(a)(1) of this Act is amended by striking
``2009'' and inserting ``2010''.
(2) Section 9010(c)(2)(B) of this Act is amended by
striking ``(except'' and all that follows through ``1323)''.
(3) Section 9010(c)(3) of this Act is amended by adding at
the end the following new sentence: ``If any entity described
in subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph
(2) is treated as a covered entity by reason of the application
of the preceding sentence, the net premiums written with
respect to health insurance for any United States health risk
of such entity shall not be taken into account for purposes of
this section.''.
(4) Section 9010(g)(1) of this Act is amended by striking
``and third party administration agreement fees''.
(5) Section 9010(j) of this Act is amended--
(A) by striking ``2008'' and inserting ``2009'',
and
(B) by striking ``, and any third party
administration agreement fees received after such
date''.
(g) Effective Date.--The amendments made by this section shall take
effect as if included in the enactment of section 9010.
SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-
INCOME TAXPAYERS.
(a) FICA.--Section 3101(b)(2) of the Internal Revenue Code of 1986,
as added by section 9015(a)(1) of this Act, is amended by striking
``0.5 percent'' and inserting ``0.9 percent''.
(b) SECA.--Section 1401(b)(2)(A) of the Internal Revenue Code of
1986, as added by section 9015(b)(1) of this Act, is amended by
striking ``0.5 percent'' and inserting ``0.9 percent''.
(c) Effective Date.--The amendments made by this section shall
apply with respect to remuneration received, and taxable years
beginning, after December 31, 2012.
SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF ELECTIVE
COSMETIC MEDICAL PROCEDURES.
(a) In General.--The provisions of, and amendments made by, section
9017 of this Act are hereby deemed null, void, and of no effect.
(b) Excise Tax on Indoor Tanning Services.--Subtitle D of the
Internal Revenue Code of 1986, as amended by this Act, is amended by
adding at the end the following new chapter:
``CHAPTER 49--COSMETIC SERVICES
``Sec. 5000B. Imposition of tax on indoor tanning services.
``SEC. 5000B. IMPOSITION OF TAX ON INDOOR TANNING SERVICES.
``(a) In General.--There is hereby imposed on any indoor tanning
service a tax equal to 10 percent of the amount paid for such service
(determined without regard to this section), whether paid by insurance
or otherwise.
``(b) Indoor Tanning Service.--For purposes of this section--
``(1) In general.--The term `indoor tanning service' means
a service employing any electronic product designed to
incorporate 1 or more ultraviolet lamps and intended for the
irradiation of an individual by ultraviolet radiation, with
wavelengths in air between 200 and 400 nanometers, to induce
skin tanning.
``(2) Exclusion of phototherapy services.--Such term does
not include any phototherapy service performed by a licensed
medical professional.
``(c) Payment of Tax.--
``(1) In general.--The tax imposed by this section shall be
paid by the individual on whom the service is performed.
``(2) Collection.--Every person receiving a payment for
services on which a tax is imposed under subsection (a) shall
collect the amount of the tax from the individual on whom the
service is performed and remit such tax quarterly to the
Secretary at such time and in such manner as provided by the
Secretary.
``(3) Secondary liability.--Where any tax imposed by
subsection (a) is not paid at the time payments for indoor
tanning services are made, then to the extent that such tax is
not collected, such tax shall be paid by the person who
performs the service.''.
(c) Clerical Amendment.--The table of chapter for subtitle D of the
Internal Revenue Code of 1986, as amended by this Act, is amended by
inserting after the item relating to chapter 48 the following new item:
``Chapter 49--Cosmetic Services''.
(d) Effective Date.--The amendments made by this section shall
apply to services performed on or after July 1, 2010.
SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS IN STATE
STUDENT LOAN REPAYMENT PROGRAMS FOR CERTAIN HEALTH
PROFESSIONALS.
(a) In General.--Paragraph (4) of section 108(f) of the Internal
Revenue Code of 1986 is amended to read as follows:
``(4) Payments under national health service corps loan
repayment program and certain state loan repayment programs.--
In the case of an individual, gross income shall not include
any amount received under section 338B(g) of the Public Health
Service Act, under a State program described in section 338I of
such Act, or under any other State loan repayment or loan
forgiveness program that is intended to provide for the
increased availability of health care services in underserved
or health professional shortage areas (as determined by such
State).''.
(b) Effective Date.--The amendment made by this section shall apply
to amounts received by an individual in taxable years beginning after
December 31, 2008.
SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION ASSISTANCE
PROGRAMS.
(a) Increase in Dollar Limitation.--
(1) Adoption credit.--
(A) In general.--Paragraph (1) of section 23(b) of
the Internal Revenue Code of 1986 (relating to dollar
limitation) is amended by striking ``$10,000'' and
inserting ``$13,170''.
(B) Child with special needs.--Paragraph (3) of
section 23(a) of such Code (relating to $10,000 credit
for adoption of child with special needs regardless of
expenses) is amended--
(i) in the text by striking ``$10,000'' and
inserting ``$13,170'', and
(ii) in the heading by striking ``$10,000''
and inserting ``$13,170''.
(C) Conforming amendment to inflation adjustment.--
Subsection (h) of section 23 of such Code (relating to
adjustments for inflation) is amended to read as
follows:
``(h) Adjustments for Inflation.--
``(1) Dollar limitations.--In the case of a taxable year
beginning after December 31, 2010, each of the dollar amounts
in subsections (a)(3) and (b)(1) shall be increased by an
amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year in which
the taxable year begins, determined by substituting
`calendar year 2009' for `calendar year 1992' in
subparagraph (B) thereof.
If any amount as increased under the preceding sentence is not
a multiple of $10, such amount shall be rounded to the nearest
multiple of $10.
``(2) Income limitation.--In the case of a taxable year
beginning after December 31, 2002, the dollar amount in
subsection (b)(2)(A)(i) shall be increased by an amount equal
to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year in which
the taxable year begins, determined by substituting
`calendar year 2001' for `calendar year 1992' in
subparagraph (B) thereof.
If any amount as increased under the preceding sentence is not
a multiple of $10, such amount shall be rounded to the nearest
multiple of $10.''.
(2) Adoption assistance programs.--
(A) In general.--Paragraph (1) of section 137(b) of
the Internal Revenue Code of 1986 (relating to dollar
limitation) is amended by striking ``$10,000'' and
inserting ``$13,170''.
(B) Child with special needs.--Paragraph (2) of
section 137(a) of such Code (relating to $10,000
exclusion for adoption of child with special needs
regardless of expenses) is amended--
(i) in the text by striking ``$10,000'' and
inserting ``$13,170'', and
(ii) in the heading by striking ``$10,000''
and inserting ``$13,170''.
(C) Conforming amendment to inflation adjustment.--
Subsection (f) of section 137 of such Code (relating to
adjustments for inflation) is amended to read as
follows:
``(f) Adjustments for Inflation.--
``(1) Dollar limitations.--In the case of a taxable year
beginning after December 31, 2010, each of the dollar amounts
in subsections (a)(2) and (b)(1) shall be increased by an
amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year in which
the taxable year begins, determined by substituting
`calendar year 2009' for `calendar year 1992' in
subparagraph (B) thereof.
If any amount as increased under the preceding sentence is not
a multiple of $10, such amount shall be rounded to the nearest
multiple of $10.
``(2) Income limitation.--In the case of a taxable year
beginning after December 31, 2002, the dollar amount in
subsection (b)(2)(A) shall be increased by an amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year in which
the taxable year begins, determined by substituting
`calendar year 2001' for `calendar year 1992' in
subparagraph thereof.
If any amount as increased under the preceding sentence is not
a multiple of $10, such amount shall be rounded to the nearest
multiple of $10.''.
(b) Credit Made Refundable.--
(1) Credit moved to subpart relating to refundable
credits.--The Internal Revenue Code of 1986 is amended--
(A) by redesignating section 23, as amended by
subsection (a), as section 36C, and
(B) by moving section 36C (as so redesignated) from
subpart A of part IV of subchapter A of chapter 1 to
the location immediately before section 37 in subpart C
of part IV of subchapter A of chapter 1.
(2) Conforming amendments.--
(A) Section 24(b)(3)(B) of such Code is amended by
striking ``23,''.
(B) Section 25(e)(1)(C) of such Code is amended by
striking ``23,'' both places it appears.
(C) Section 25A(i)(5)(B) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.
(D) Section 25B(g)(2) of such Code is amended by
striking ``23,''.
(E) Section 26(a)(1) of such Code is amended by
striking ``23,''.
(F) Section 30(c)(2)(B)(ii) of such Code is amended
by striking ``23, 25D,'' and inserting ``25D''.
(G) Section 30B(g)(2)(B)(ii) of such Code is
amended by striking ``23,''.
(H) Section 30D(c)(2)(B)(ii) of such Code is
amended by striking ``sections 23 and'' and inserting
``section''.
(I) Section 36C of such Code, as so redesignated,
is amended--
(i) by striking paragraph (4) of subsection
(b), and
(ii) by striking subsection (c).
(J) Section 137 of such Code is amended--
(i) by striking ``section 23(d)'' in
subsection (d) and inserting ``section
36C(d)'', and
(ii) by striking ``section 23'' in
subsection (e) and inserting ``section 36C''.
(K) Section 904(i) of such Code is amended by
striking ``23,''.
(L) Section 1016(a)(26) is amended by striking
``23(g)'' and inserting ``36C(g)''.
(M) Section 1400C(d) of such Code is amended by
striking ``23,''.
(N) Section 6211(b)(4)(A) of such Code is amended
by inserting ``36C,'' before ``53(e)''.
(O) The table of sections for subpart A of part IV
of subchapter A of chapter 1 of such Code of 1986 is
amended by striking the item relating to section 23.
(P) Paragraph (2) of section 1324(b) of title 31,
United States Code, as amended by this Act, is amended
by inserting ``36C,'' after ``36B,''.
(Q) The table of sections for subpart C of part IV
of subchapter A of chapter 1 of the Internal Revenue
Code of 1986, as amended by this Act, is amended by
inserting after the item relating to section 36B the
following new item:
``Sec. 36C. Adoption expenses.''.
(c) Application and Extension of EGTRRA Sunset.--Notwithstanding
section 901 of the Economic Growth and Tax Relief Reconciliation Act of
2001, such section shall apply to the amendments made by this section
and the amendments made by section 202 of such Act by substituting
``December 31, 2011'' for ``December 31, 2010'' in subsection (a)(1)
thereof.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2009.
Amend the title so as to read: ``An Act entitled The
Patient Protection and Affordable Care Act.''.
Attest:
Secretary.
111th CONGRESS
1st Session
H. R. 3590
_______________________________________________________________________
AMENDMENTS
_______________________________________________________________________
December 24, 2009
Ordered to be printed as passed
