Full Text of the Patient Protection and Affordable Care Act
H. R. 3590
One Hundred Eleventh Congress
of the
United States of America
A T T H E S E C O N D S E S S I O N
Begun and held at the City of Washington on Tuesday,
the fifth day of January, two thousand and ten
An Act
Entitled The Patient Protection and Affordable Care Act.
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the ‘‘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. H. R. 3590—2
‘‘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. H. R. 3590—3
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. H. R. 3590—4
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. H. R. 3590—5
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. H. R. 3590—6
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. H. R. 3590—7
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. H. R. 3590—8
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. H. R. 3590—9
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. H. R. 3590—10
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. H. R. 3590—11
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. H. R. 3590—12
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: H. R. 3590—13
‘‘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 H. R. 3590—14
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: H. R. 3590—15
‘‘(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 H. R. 3590—16
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. H. R. 3590—17
‘‘(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.— H. R. 3590—18
‘‘(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 H. R. 3590—19
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; H. R. 3590—20
‘‘(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. H. R. 3590—21
‘‘(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 H. R. 3590—22
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. H. R. 3590—23
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); H. R. 3590—24
(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 H. R. 3590—25
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, H. R. 3590—26
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 H. R. 3590—27
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). H. R. 3590—28
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.— H. R. 3590—29
(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: H. R. 3590—30
‘‘(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 H. R. 3590—31
‘‘(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 H. R. 3590—32
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. H. R. 3590—33
‘‘(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 H. R. 3590—34
‘‘(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 H. R. 3590—35
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; H. R. 3590—36
(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)— H. R. 3590—37
(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) H. R. 3590—38
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 H. R. 3590—39
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 H. R. 3590—40
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. H. R. 3590—41
‘‘(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— H. R. 3590—42
‘‘(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. H. R. 3590—43
‘‘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). H. R. 3590—44
(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; H. R. 3590—45
(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. H. R. 3590—46
(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 H. R. 3590—47
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— H. R. 3590—48
(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. H. R. 3590—49
(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. H. R. 3590—50
(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 H. R. 3590—51
(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 H. R. 3590—52
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 H. R. 3590—53
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 H. R. 3590—54
(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. H. R. 3590—55
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 H. R. 3590—56
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. H. R. 3590—57
(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). H. R. 3590—58
(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 H. R. 3590—59
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.— H. R. 3590—60
(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 H. R. 3590—61
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; H. R. 3590—62
(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 H. R. 3590—63
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. H. R. 3590—64
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 H. R. 3590—65
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: H. R. 3590—66
(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. H. R. 3590—67
(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. H. R. 3590—68
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. H. R. 3590—69
(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 H. R. 3590—70
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.— H. R. 3590—71
(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— H. R. 3590—72
(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 H. R. 3590—73
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.’’. H. R. 3590—74
(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 H. R. 3590—75
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 H. R. 3590—76
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. H. R. 3590—77
(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 H. R. 3590—78
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’’. H. R. 3590—79
(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. H. R. 3590—80
(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. R. 3590—81
(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 H. R. 3590—82
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. H. R. 3590—83
(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 H. R. 3590—84
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); H. R. 3590—85
(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). H. R. 3590—86
(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. H. R. 3590—87
(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 H. R. 3590—88
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) H. R. 3590—89
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; H. R. 3590—90
(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— H. R. 3590—91
(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.— H. R. 3590—92
(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. H. R. 3590—93
(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. H. R. 3590—94
(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 H. R. 3590—95
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 H. R. 3590—96
‘‘(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 H. R. 3590—97
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— H. R. 3590—98
‘‘(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 H. R. 3590—99
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— H. R. 3590—100
‘‘(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 H. R. 3590—101
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.’’. H. R. 3590—102
(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). H. R. 3590—103
(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 H. R. 3590—104
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 H. R. 3590—105
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 H. R. 3590—106
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. H. R. 3590—107
(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. H. R. 3590—108
(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 H. R. 3590—109
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 H. R. 3590—110
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 H. R. 3590—111
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— H. R. 3590—112
(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. H. R. 3590—113
(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— H. R. 3590—114
(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— H. R. 3590—115
(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; H. R. 3590—116
(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. H. R. 3590—117
(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. H. R. 3590—118
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— H. R. 3590—119
‘‘(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- H. R. 3590—120
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. H. R. 3590—121
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. H. R. 3590—122
‘‘(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— H. R. 3590—123
‘‘(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: H. R. 3590—124
‘‘(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). H. R. 3590—125
(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 H. R. 3590—126
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 H. R. 3590—127
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.— H. R. 3590—128
‘‘(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.— H. R. 3590—129
‘‘(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 H. R. 3590—130
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 H. R. 3590—131
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. H. R. 3590—132
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 H. R. 3590—133
(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: H. R. 3590—134
‘‘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. H. R. 3590—135
‘‘(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 H. R. 3590—136
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. H. R. 3590—137
‘‘(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.’’. H. R. 3590—138
(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, H. R. 3590—139
‘‘(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 H. R. 3590—140
(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). H. R. 3590—141
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. H. R. 3590—142
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. H. R. 3590—143
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. H. R. 3590—144
(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. §§ 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. H. R. 3590—145
‘‘(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. H. R. 3590—146
‘‘(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)— H. R. 3590—147
(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)— H. R. 3590—148
(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’’; H. R. 3590—149
(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’’; H. R. 3590—150
(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)— H. R. 3590—151
(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. H. R. 3590—152
(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. H. R. 3590—153
(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) H. R. 3590—154
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: H. R. 3590—155
‘‘For any fiscal year quarter occurring in the calendar year:
If the State is an expansion State, the applicable
percentage point increase
is:
If the State is not an expansion State, the applicable percentage 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. H. R. 3590—156
‘‘(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’’. H. R. 3590—157
(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 H. R. 3590—158
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),’’; H. R. 3590—159
(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 H. R. 3590—160
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, H. R. 3590—161
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 H. R. 3590—162
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 H. R. 3590—163
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. H. R. 3590—164
‘‘(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. H. R. 3590—165
(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’’; H. R. 3590—166
(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 H. R. 3590—167
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’’. H. R. 3590—168
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 H. R. 3590—169
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 H. R. 3590—170
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). H. R. 3590—171
(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 H. R. 3590—172
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). H. R. 3590—173
‘‘(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 H. R. 3590—174
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 H. R. 3590—175
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: H. R. 3590—176
‘‘(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 H. R. 3590—177
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. H. R. 3590—178
‘‘(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’’. H. R. 3590—179
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, H. R. 3590—180
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 H. R. 3590—181
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 H. R. 3590—182
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. H. R. 3590—183
‘‘(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 H. R. 3590—184
(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. H. R. 3590—185
‘‘(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), H. R. 3590—186
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’’. H. R. 3590—187
(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 H. R. 3590—188
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. H. R. 3590—189
‘‘(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 H. R. 3590—190
(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.’’. H. R. 3590—191
(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). H. R. 3590—192
(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: H. R. 3590—193
‘‘(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 H. R. 3590—194
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)’’; H. R. 3590—195
(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 H. R. 3590—196
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. H. R. 3590—197
‘‘(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. H. R. 3590—198
(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 H. R. 3590—199
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 H. R. 3590—200
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 H. R. 3590—201
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— H. R. 3590—202
‘‘(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 H. R. 3590—203
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 H. R. 3590—204
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 H. R. 3590—205
(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 H. R. 3590—206
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 H. R. 3590—207
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 H. R. 3590—208
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 H. R. 3590—209
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 H. R. 3590—210
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)— H. R. 3590—211
(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 H. R. 3590—212
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 H. R. 3590—213
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.’’. H. R. 3590—214
(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, H. R. 3590—215
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. H. R. 3590—216
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 H. R. 3590—217
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 H. R. 3590—218
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). H. R. 3590—219
‘‘(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— H. R. 3590—220
‘‘(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. H. R. 3590—221
‘‘(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 H. R. 3590—222
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. H. R. 3590—223
‘‘(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 H. R. 3590—224
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. H. R. 3590—225
‘‘(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.’’. H. R. 3590—226
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 H. R. 3590—227
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 H. R. 3590—228
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. H. R. 3590—229
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 H. R. 3590—230
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 H. R. 3590—231
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: H. R. 3590—232
‘‘(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 H. R. 3590—233
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)). H. R. 3590—234
‘‘(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 H. R. 3590—235
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; H. R. 3590—236
‘‘(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 H. R. 3590—237
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 H. R. 3590—238
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.— H. R. 3590—239
‘‘(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 H. R. 3590—240
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. H. R. 3590—241
‘‘(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— H. R. 3590—242
(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 H. R. 3590—243
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. H. R. 3590—244
(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. H. R. 3590—245
(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— H. R. 3590—246
(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. H. R. 3590—247
‘‘(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 H. R. 3590—248
(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 H. R. 3590—249
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 H. R. 3590—250
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. H. R. 3590—251
‘‘(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 H. R. 3590—252
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). H. R. 3590—253
‘‘(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 H. R. 3590—254
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, H. R. 3590—255
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 H. R. 3590—256
(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 H. R. 3590—257
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. H. R. 3590—258
‘‘(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 H. R. 3590—259
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 H. R. 3590—260
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 H. R. 3590—261
‘‘(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— H. R. 3590—262
‘‘(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. R. 3590—263
(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. H. R. 3590—264
‘‘(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 H. R. 3590—265
‘‘(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 H. R. 3590—266
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.— H. R. 3590—267
‘‘(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. H. R. 3590—268
‘‘(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 H. R. 3590—269
‘‘(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; H. R. 3590—270
‘‘(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 H. R. 3590—271
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. H. R. 3590—272
‘‘(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. H. R. 3590—273
‘‘(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. H. R. 3590—274
‘‘(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, H. R. 3590—275
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; H. R. 3590—276
‘‘(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; H. R. 3590—277
(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. H. R. 3590—278
‘‘(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 H. R. 3590—279
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 H. R. 3590—280
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); H. R. 3590—281
‘‘(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 H. R. 3590—282
‘‘(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 H. R. 3590—283
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 H. R. 3590—284
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.— H. R. 3590—285
‘‘(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.’’. H. R. 3590—286
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; H. R. 3590—287
‘‘(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 H. R. 3590—288
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 H. R. 3590—289
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 H. R. 3590—290
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 H. R. 3590—291
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. H. R. 3590—292
‘‘(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 H. R. 3590—293
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 H. R. 3590—294
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 H. R. 3590—295
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 H. R. 3590—296
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. H. R. 3590—297
(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.’’. H. R. 3590—298
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 H. R. 3590—299
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 H. R. 3590—300
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 H. R. 3590—301
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. H. R. 3590—302
(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’’. H. R. 3590—303
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’’. H. R. 3590—304
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 H. R. 3590—305
(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 H. R. 3590—306
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 H. R. 3590—307
(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— H. R. 3590—308
(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— H. R. 3590—309
(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 H. R. 3590—310
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)— H. R. 3590—311
(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 H. R. 3590—312
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— H. R. 3590—313
‘‘(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 H. R. 3590—314
(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.— H. R. 3590—315
‘‘(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.’’. H. R. 3590—316
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 H. R. 3590—317
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. H. R. 3590—318
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 H. R. 3590—319
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’’. H. R. 3590—320
(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; H. R. 3590—321
(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: H. R. 3590—322
‘‘(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 H. R. 3590—323
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 H. R. 3590—324
(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— H. R. 3590—325
‘‘(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 H. R. 3590—326
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 H. R. 3590—327
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 H. R. 3590—328
‘‘(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))— H. R. 3590—329
(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; H. R. 3590—330
‘‘(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 H. R. 3590—331
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 H. R. 3590—332
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.— H. R. 3590—333
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 H. R. 3590—334
‘‘(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— H. R. 3590—335
‘‘(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. H. R. 3590—336
‘‘(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 H. R. 3590—337
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).’’. H. R. 3590—338
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.’’. H. R. 3590—339
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) H. R. 3590—340
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 H. R. 3590—341
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. H. R. 3590—342
‘‘(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 H. R. 3590—343
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 H. R. 3590—344
‘‘(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 H. R. 3590—345
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, H. R. 3590—346
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). H. R. 3590—347
‘‘(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— H. R. 3590—348
‘‘(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— H. R. 3590—349
‘‘(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 H. R. 3590—350
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. H. R. 3590—351
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.’’. H. R. 3590—352
(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. H. R. 3590—353
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). H. R. 3590—354
‘‘(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- H. R. 3590—355
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, H. R. 3590—356
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 H. R. 3590—357
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 H. R. 3590—358
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. H. R. 3590—359
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 H. R. 3590—360
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— H. R. 3590—361
‘‘(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 H. R. 3590—362
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— H. R. 3590—363
‘‘(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. H. R. 3590—364
‘‘(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— H. R. 3590—365
‘‘(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— H. R. 3590—366
‘‘(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— H. R. 3590—367
‘‘(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— H. R. 3590—368
‘‘(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.’’. H. R. 3590—369
(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 H. R. 3590—370
(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— H. R. 3590—371
(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, H. R. 3590—372
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 H. R. 3590—373
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 H. R. 3590—374
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); H. R. 3590—375
‘‘(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 H. R. 3590—376
‘‘(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. H. R. 3590—377
‘‘(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. H. R. 3590—378
‘‘(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 H. R. 3590—379
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. H. R. 3590—380
‘‘(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 H. R. 3590—381
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 H. R. 3590—382
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 H. R. 3590—383
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. H. R. 3590—384
‘‘(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 H. R. 3590—385
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. H. R. 3590—386
‘‘(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 H. R. 3590—387
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. H. R. 3590—388
‘‘(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 H. R. 3590—389
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: H. R. 3590—390
‘‘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; H. R. 3590—391
‘‘(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 H. R. 3590—392
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; H. R. 3590—393
‘‘(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. H. R. 3590—394
‘‘(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; H. R. 3590—395
‘‘(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 H. R. 3590—396
(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 H. R. 3590—397
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. H. R. 3590—398
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; H. R. 3590—399
‘‘(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; H. R. 3590—400
‘‘(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. H. R. 3590—401
‘‘(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 H. R. 3590—402
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 H. R. 3590—403
‘‘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.’’. H. R. 3590—404
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. H. R. 3590—405
‘‘(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). H. R. 3590—406
‘‘(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 H. R. 3590—407
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— H. R. 3590—408
‘‘(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: H. R. 3590—409
‘‘(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.— H. R. 3590—410
‘‘(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)— H. R. 3590—411
‘‘(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 H. R. 3590—412
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 H. R. 3590—413
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.— H. R. 3590—414
(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.— H. R. 3590—415
‘‘(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— H. R. 3590—416
‘‘(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: H. R. 3590—417
‘‘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; H. R. 3590—418
‘‘(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 H. R. 3590—419
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’’. H. R. 3590—420
SEC. 3511. AUTHORIZATION OF APPROPRIATIONS.
Except where otherwise provided in this subtitle (or an amendment made by this subtitle), there is authorized to be appropriated
such sums as may be necessary to carry out this subtitle (and
such amendments made by this subtitle).
Subtitle G—Protecting and Improving
Guaranteed Medicare Benefits
SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE
BENEFITS.
(a) PROTECTING GUARANTEED MEDICARE BENEFITS.—Nothing
in the provisions of, or amendments made by, this Act shall result
in a reduction of guaranteed benefits under title XVIII of the
Social Security Act.
(b) ENSURING THAT MEDICARE SAVINGS BENEFIT THE MEDICARE
PROGRAM AND MEDICARE BENEFICIARIES.—Savings generated for
the Medicare program under title XVIII of the Social Security
Act under the provisions of, and amendments made by, this Act
shall extend the solvency of the Medicare trust funds, reduce Medicare premiums and other cost-sharing for beneficiaries, and improve
or expand guaranteed Medicare benefits and protect access to Medicare providers.
SEC. 3602. NO CUTS IN GUARANTEED BENEFITS.
Nothing in this Act shall result in the reduction or elimination
of any benefits guaranteed by law to participants in Medicare
Advantage plans.
TITLE IV—PREVENTION OF CHRONIC
DISEASE AND IMPROVING PUBLIC
HEALTH
Subtitle A—Modernizing Disease
Prevention and Public Health Systems
SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC
HEALTH COUNCIL.
(a) ESTABLISHMENT.—The President shall establish, within the
Department of Health and Human Services, a council to be known
as the ‘‘National Prevention, Health Promotion and Public Health
Council’’ (referred to in this section as the ‘‘Council’’).
(b) CHAIRPERSON.—The President shall appoint the Surgeon
General to serve as the chairperson of the Council.
(c) COMPOSITION.—The Council shall be composed of—
(1) the Secretary of Health and Human Services;
(2) the Secretary of Agriculture;
(3) the Secretary of Education;
(4) the Chairman of the Federal Trade Commission;
(5) the Secretary of Transportation;
(6) the Secretary of Labor;
(7) the Secretary of Homeland Security; H. R. 3590—421
(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 H. R. 3590—422
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 H. R. 3590—423
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 H. R. 3590—424
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. H. R. 3590—425
‘‘(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 H. R. 3590—426
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. H. R. 3590—427
(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 H. R. 3590—428
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 H. R. 3590—429
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 H. R. 3590—430
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, H. R. 3590—431
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, H. R. 3590—432
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 H. R. 3590—433
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 H. R. 3590—434
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. H. R. 3590—435
(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). H. R. 3590—436
‘‘(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. H. R. 3590—437
‘‘(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.— H. R. 3590—438
(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 H. R. 3590—439
(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. H. R. 3590—440
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: H. R. 3590—441
‘‘(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 H. R. 3590—442
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’’. H. R. 3590—443
(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. H. R. 3590—444
(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; H. R. 3590—445
(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. H. R. 3590—446
(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.— H. R. 3590—447
(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; H. R. 3590—448
(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; H. R. 3590—449
(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 H. R. 3590—450
(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. H. R. 3590—451
(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 H. R. 3590—452
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.).’’. H. R. 3590—453
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; H. R. 3590—454
‘‘(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; H. R. 3590—455
(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 H. R. 3590—456
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.— H. R. 3590—457
‘‘(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 H. R. 3590—458
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 H. R. 3590—459
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. H. R. 3590—460
‘‘(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 H. R. 3590—461
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. H. R. 3590—462
‘‘(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 H. R. 3590—463
‘‘(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: H. R. 3590—464
‘‘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: H. R. 3590—465
‘‘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 H. R. 3590—466
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’’). H. R. 3590—467
(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. H. R. 3590—468
‘‘(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. H. R. 3590—469
‘‘(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. H. R. 3590—470
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 H. R. 3590—471
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 H. R. 3590—472
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]. H. R. 3590—473
‘‘(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 H. R. 3590—474
‘‘(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 H. R. 3590—475
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 H. R. 3590—476
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); H. R. 3590—477
(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.— H. R. 3590—478
(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 H. R. 3590—479
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 H. R. 3590—480
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 H. R. 3590—481
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, H. R. 3590—482
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.— H. R. 3590—483
(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 H. R. 3590—484
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; H. R. 3590—485
(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 H. R. 3590—486
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). H. R. 3590—487
‘‘(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.’’. H. R. 3590—488
(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.’’. H. R. 3590—489
(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— H. R. 3590—490
‘‘(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). H. R. 3590—491
‘‘(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, H. R. 3590—492
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 H. R. 3590—493
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’’. H. R. 3590—494
(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. H. R. 3590—495
(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’’. H. R. 3590—496
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. H. R. 3590—497
‘‘(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 H. R. 3590—498
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; H. R. 3590—499
‘‘(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 H. R. 3590—500
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 H. R. 3590—501
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 H. R. 3590—502
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 H. R. 3590—503
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 H. R. 3590—504
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 H. R. 3590—505
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. H. R. 3590—506
‘‘(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, H. R. 3590—507
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’’. H. R. 3590—508
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 H. R. 3590—509
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 H. R. 3590—510
‘‘(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, H. R. 3590—511
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 H. R. 3590—512
(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. H. R. 3590—513
‘‘(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 H. R. 3590—514
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.— H. R. 3590—515
‘‘(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: H. R. 3590—516
‘‘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 H. R. 3590—517
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 H. R. 3590—518
‘‘(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: H. R. 3590—519
‘‘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 H. R. 3590—520
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 H. R. 3590—521
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 H. R. 3590—522
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 H. R. 3590—523
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. H. R. 3590—524
‘‘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 H. R. 3590—525
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.’’. H. R. 3590—526
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 H. R. 3590—527
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. H. R. 3590—528
‘‘(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; H. R. 3590—529
‘‘(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. H. R. 3590—530
‘‘(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 H. R. 3590—531
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 H. R. 3590—532
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— H. R. 3590—533
‘‘(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 H. R. 3590—534
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— H. R. 3590—535
‘‘(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 H. R. 3590—536
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 H. R. 3590—537
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.— H. R. 3590—538
‘‘(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). H. R. 3590—539
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: H. R. 3590—540
‘‘(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.’’. H. R. 3590—541
(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.’’. H. R. 3590—542
(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 H. R. 3590—543
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 H. R. 3590—544
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 H. R. 3590—545
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. H. R. 3590—546
‘‘(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). H. R. 3590—547
‘‘(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 H. R. 3590—548
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— H. R. 3590—549
‘‘(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 H. R. 3590—550
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. H. R. 3590—551
‘‘(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). H. R. 3590—552
‘‘(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 H. R. 3590—553
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 H. R. 3590—554
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. H. R. 3590—555
‘‘(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 H. R. 3590—556
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. H. R. 3590—557
(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 H. R. 3590—558
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: H. R. 3590—559
‘‘(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— H. R. 3590—560
(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. H. R. 3590—561
(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, H. R. 3590—562
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 H. R. 3590—563
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 H. R. 3590—564
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). H. R. 3590—565
(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. H. R. 3590—566
(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).’’; H. R. 3590—567
(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.— H. R. 3590—568
‘‘(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. H. R. 3590—569
‘‘(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 H. R. 3590—570
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 H. R. 3590—571
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). H. R. 3590—572
‘‘(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. H. R. 3590—573
‘‘(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.— H. R. 3590—574
‘‘(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, H. R. 3590—575
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 H. R. 3590—576
(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 H. R. 3590—577
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. H. R. 3590—578
‘‘(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).’’. H. R. 3590—579
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 H. R. 3590—580
‘‘(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 H. R. 3590—581
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 H. R. 3590—582
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 H. R. 3590—583
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; H. R. 3590—584
‘‘(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, H. R. 3590—585
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 H. R. 3590—586
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.— H. R. 3590—587
‘‘(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 H. R. 3590—588
‘‘(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: H. R. 3590—589
‘‘(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. H. R. 3590—590
‘‘(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 H. R. 3590—591
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 H. R. 3590—592
‘‘(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. H. R. 3590—593
(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 H. R. 3590—594
(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, H. R. 3590—595
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 H. R. 3590—596
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 H. R. 3590—597
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; H. R. 3590—598
‘‘(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 H. R. 3590—599
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. H. R. 3590—600
(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— H. R. 3590—601
‘‘(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)’’. H. R. 3590—602
(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 H. R. 3590—603
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.— H. R. 3590—604
(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 H. R. 3590—605
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 H. R. 3590—606
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.— H. R. 3590—607
(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: H. R. 3590—608
(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 H. R. 3590—609
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 H. R. 3590—610
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 H. R. 3590—611
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. H. R. 3590—612
‘‘(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, H. R. 3590—613
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 H. R. 3590—614
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 H. R. 3590—615
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 H. R. 3590—616
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. H. R. 3590—617
‘‘(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 H. R. 3590—618
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 H. R. 3590—619
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. H. R. 3590—620
‘‘(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.— H. R. 3590—621
‘‘(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 H. R. 3590—622
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— H. R. 3590—623
‘‘(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.’’. H. R. 3590—624
(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. H. R. 3590—625
‘‘(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 H. R. 3590—626
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— H. R. 3590—627
‘‘(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. H. R. 3590—628
‘‘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: H. R. 3590—629
‘‘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. H. R. 3590—630
‘‘(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 H. R. 3590—631
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. H. R. 3590—632
‘‘(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 H. R. 3590—633
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). H. R. 3590—634
‘‘(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 H. R. 3590—635
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 H. R. 3590—636
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, H. R. 3590—637
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)), H. R. 3590—638
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. H. R. 3590—639
‘‘(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 H. R. 3590—640
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; H. R. 3590—641
‘‘(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 H. R. 3590—642
(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— H. R. 3590—643
(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 H. R. 3590—644
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— H. R. 3590—645
(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: H. R. 3590—646
‘‘(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;’’; H. R. 3590—647
(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— H. R. 3590—648
‘‘(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 H. R. 3590—649
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.— H. R. 3590—650
(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 H. R. 3590—651
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 H. R. 3590—652
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— H. R. 3590—653
(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– H. R. 3590—654
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: H. R. 3590—655
(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.— H. R. 3590—656
(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’’. H. R. 3590—657
(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. H. R. 3590—658
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 H. R. 3590—659
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. H. R. 3590—660
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 H. R. 3590—661
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.’’. H. R. 3590—662
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: H. R. 3590—663
‘‘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: H. R. 3590—664
‘‘(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. H. R. 3590—665
‘‘(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. H. R. 3590—666
‘‘(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)). H. R. 3590—667
‘‘(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. H. R. 3590—668
‘‘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 H. R. 3590—669
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. H. R. 3590—670
‘‘(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; H. R. 3590—671
‘‘(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. H. R. 3590—672
‘‘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 H. R. 3590—673
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.— H. R. 3590—674
‘‘(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 H. R. 3590—675
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.— H. R. 3590—676
‘‘(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 H. R. 3590—677
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; H. R. 3590—678
‘‘(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 H. R. 3590—679
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— H. R. 3590—680
‘‘(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. H. R. 3590—681
(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; H. R. 3590—682
(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— H. R. 3590—683
‘‘(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. H. R. 3590—684
‘‘(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). H. R. 3590—685
(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. H. R. 3590—686
(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: H. R. 3590—687
‘‘(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 H. R. 3590—688
‘‘(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 H. R. 3590—689
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 H. R. 3590—690
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.— H. R. 3590—691
‘‘(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 H. R. 3590—692
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 H. R. 3590—693
‘‘(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 H. R. 3590—694
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.— H. R. 3590—695
‘‘(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 H. R. 3590—696
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: H. R. 3590—697
‘‘(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: H. R. 3590—698
‘‘(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: H. R. 3590—699
‘‘(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 H. R. 3590—700
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 H. R. 3590—701
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 H. R. 3590—702
(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; H. R. 3590—703
‘‘(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 H. R. 3590—704
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 H. R. 3590—705
‘‘(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: H. R. 3590—706
‘‘(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. H. R. 3590—707
‘‘(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 H. R. 3590—708
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) H. R. 3590—709
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: H. R. 3590—710
(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 H. R. 3590—711
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 FORH. R. 3590—712
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 H. R. 3590—713
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. H. R. 3590—714
‘‘(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; H. R. 3590—715
‘‘(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 H. R. 3590—716
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 H. R. 3590—717
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 H. R. 3590—718
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 H. R. 3590—719
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 H. R. 3590—720
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 H. R. 3590—721
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— H. R. 3590—722
‘‘(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— H. R. 3590—723
‘‘(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. H. R. 3590—724
‘‘(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 H. R. 3590—725
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. H. R. 3590—726
‘‘(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.— H. R. 3590—727
‘‘(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. H. R. 3590—728
‘‘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 H. R. 3590—729
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: H. R. 3590—730
‘‘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 H. R. 3590—731
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— H. R. 3590—732
‘‘(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 H. R. 3590—733
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. H. R. 3590—734
‘‘(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, H. R. 3590—735
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 H. R. 3590—736
‘‘(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 H. R. 3590—737
(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.— H. R. 3590—738
‘‘(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 H. R. 3590—739
‘‘(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 H. R. 3590—740
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.— H. R. 3590—741
(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 sales during the
calendar year that are:
The percentage of
such sales taken
into account is:
Not more than $5,000,000 ………………….. 0 percent
More than $5,000,000 but not more than
$125,000,000.
10 percent
More than $125,000,000 but not more
than $225,000,000.
40 percent
More than $225,000,000 but not more
than $400,000,000.
75 percent
More than $400,000,000 ……………………… 100 percent. H. R. 3590—742
(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. H. R. 3590—743
(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. H. R. 3590—744
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 H. R. 3590—745
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 device sales during the calendar year that are:
The percentage of
gross receipts taken
into account is:
Not more than $5,000,000 ………………….. 0 percent
More than $5,000,000 but not more than
$25,000,000.
50 percent
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. H. R. 3590—746
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 H. R. 3590—747
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 premiums written during the calendar year that
are:
The percentage of
net premiums written that are taken
into account is:
Not more than $25,000,000 ………………… 0 percent
More than $25,000,000 but not more
than $50,000,000.
50 percent
More than $50,000,000 ……………………….. 100 percent. H. R. 3590—748
(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 third party
administration agreement fees during the
calendar year that are:
The percentage of
third party administration agreement
fees that are taken
into account is:
Not more than $5,000,000 ………………….. 0 percent
More than $5,000,000 but not more than
$10,000,000.
50 percent
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. H. R. 3590—749
(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. H. R. 3590—750
(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— H. R. 3590—751
‘‘(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 H. R. 3590—752
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)) H. R. 3590—753
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’’. H. R. 3590—754
(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 H. R. 3590—755
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 H. R. 3590—756
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 H. R. 3590—757
‘‘(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 H. R. 3590—758
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. H. R. 3590—759
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, H. R. 3590—760
‘‘(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, H. R. 3590—761
‘‘(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 H. R. 3590—762
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 H. R. 3590—763
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. H. R. 3590—764
(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 H. R. 3590—765
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 H. R. 3590—766
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 H. R. 3590—767
‘‘(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 H. R. 3590—768
‘‘(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 H. R. 3590—769
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 H. R. 3590—770
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 H. R. 3590—771
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. H. R. 3590—772
‘‘(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 H. R. 3590—773
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.’’. H. R. 3590—774
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— H. R. 3590—775
‘‘(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 H. R. 3590—776
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. H. R. 3590—777
‘‘(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— H. R. 3590—778
‘‘(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.— H. R. 3590—779
‘‘(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— H. R. 3590—780
‘‘(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.— H. R. 3590—781
‘‘(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’).’’. H. R. 3590—782
(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 H. R. 3590—783
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 H. R. 3590—784
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 H. R. 3590—785
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; H. R. 3590—786
‘‘(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 H. R. 3590—787
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. H. R. 3590—788
‘‘(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’’. H. R. 3590—789
(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. H. R. 3590—790
‘‘(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 H. R. 3590—791
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.’’. H. R. 3590—792
(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 H. R. 3590—793
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, H. R. 3590—794
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 H. R. 3590—795
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.’’. H. R. 3590—796
(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) H. R. 3590—797
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 H. R. 3590—798
(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 H. R. 3590—799
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 H. R. 3590—800
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— H. R. 3590—801
‘‘(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’’. H. R. 3590—802
(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 H. R. 3590—803
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: H. R. 3590—804
‘‘(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.’’. H. R. 3590—805
(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— H. R. 3590—806
(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. H. R. 3590—807
(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. H. R. 3590—808
(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. H. R. 3590—809
(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 H. R. 3590—810
(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.’’. H. R. 3590—811
(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 H. R. 3590—812
(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 H. R. 3590—813
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. H. R. 3590—814
(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: H. R. 3590—815
(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— H. R. 3590—816
(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. H. R. 3590—817
(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.— H. R. 3590—818
(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 H. R. 3590—819
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 H. R. 3590—820
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.— H. R. 3590—821
‘‘(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 H. R. 3590—822
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 H. R. 3590—823
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 H. R. 3590—824
‘‘(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 H. R. 3590—825
(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 H. R. 3590—826
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 H. R. 3590—827
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. H. R. 3590—828
‘‘(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)’’; H. R. 3590—829
(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— H. R. 3590—830
‘‘(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: H. R. 3590—831
‘‘(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.’’; H. R. 3590—832
(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’’; H. R. 3590—833
(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 H. R. 3590—834
(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.— H. R. 3590—835
‘‘(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 H. R. 3590—836
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 H. R. 3590—837
‘‘(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. H. R. 3590—838
‘‘(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— H. R. 3590—839
‘‘(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. H. R. 3590—840
‘‘(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 H. R. 3590—841
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).’’. H. R. 3590—842
(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 H. R. 3590—843
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— H. R. 3590—844
(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 H. R. 3590—845
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)).’’. H. R. 3590—846
(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. H. R. 3590—847
‘‘(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. H. R. 3590—848
(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, H. R. 3590—849
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 H. R. 3590—850
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 H. R. 3590—851
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 H. R. 3590—852
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. H. R. 3590—853
‘‘(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 H. R. 3590—854
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 H. R. 3590—855
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.’’. H. R. 3590—856
(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— H. R. 3590—857
(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)— H. R. 3590—858
‘‘(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 H. R. 3590—859
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: H. R. 3590—860
(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 H. R. 3590—861
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. H. R. 3590—862
‘‘(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; H. R. 3590—863
‘‘(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. H. R. 3590—864
‘‘(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 H. R. 3590—865
‘‘(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. H. R. 3590—866
‘‘(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— H. R. 3590—867
‘‘(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 H. R. 3590—868
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 H. R. 3590—869
‘‘(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 H. R. 3590—870
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: H. R. 3590—871
‘‘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: H. R. 3590—872
‘‘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: H. R. 3590—873
‘‘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 H. R. 3590—874
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. H. R. 3590—875
‘‘(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: H. R. 3590—876
‘‘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]’’. H. R. 3590—877
(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; H. R. 3590—878
‘‘(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: H. R. 3590—879
‘‘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. H. R. 3590—880
‘‘(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 H. R. 3590—881
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: H. R. 3590—882
‘‘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. H. R. 3590—883
‘‘(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. H. R. 3590—884
‘‘(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 H. R. 3590—885
‘‘(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 H. R. 3590—886
(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. H. R. 3590—887
(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.’’. H. R. 3590—888
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— H. R. 3590—889
(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. H. R. 3590—890
(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 H. R. 3590—891
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; H. R. 3590—892
‘‘(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.— H. R. 3590—893
‘‘(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 H. R. 3590—894
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 H. R. 3590—895
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: H. R. 3590—896
‘‘(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; H. R. 3590—897
‘‘(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 H. R. 3590—898
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’’, H. R. 3590—899
(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 net premiums written during the calendar year that
are:
The percentage of
net premiums written that are taken
into account is:
Not more than $25,000,000 ………………… 0 percent
More than $25,000,000 but not more
than $50,000,000.
50 percent
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 H. R. 3590—900
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 H. R. 3590—901
‘‘(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. H. R. 3590—902
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: H. R. 3590—903
‘‘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— H. R. 3590—904
‘‘(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. H. R. 3590—905
(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. H. R. 3590—906
(d) EFFECTIVE DATE.—The amendments made by this section
shall apply to taxable years beginning after December 31, 2009.
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.
