Health Care Changes

Here are the health care changes released by Democrats on this Saturday, which will win the support of Sen. Ben Nelson (D-NE) and provide the decisive 60th vote in the Senate for approval.

You can also download the entire pdf file (383 pages) at http://bit.ly/5w4Vrp .

IN THE SENATE OF THE UNITED STATES--111th Cong., 1st Sess.

H. R. 3590
To amend the Internal Revenue Code of 1986 to modify
the first-time homebuyers credit in the case of members
of the Armed Forces and certain other Federal employees,
and for other purposes.

Referred to the Committee on ______ and
ordered to be printed
Ordered to lie on the table and to be printed

AMENDMENT intended to be proposed by
______ to the amendment (No. 2786)
proposed by Mr. REID

Viz:
1
On page 2074, strike lines 22 through 25, and insert
2
the following:
3
(f) EFFECTIVE DATE.--The amendments made by
4
subsections (a) through (d) of this section shall apply to
5
amounts paid or incurred after December 31, 2008, in
6
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 re

spect to plan years beginning prior to January 1,
2014, a group health plan and a health insurance
issuer offering group or individual health insurance
coverage may only establish a restricted annual limit
on the dollar value of benefits for any participant or
beneficiary with respect to the scope of benefits that
are essential health benefits under section 1302(b)
of the Patient Protection and Affordable Care Act,
as determined by the Secretary. In defining the term
'restricted annual limit' for purposes of the preceding
sentence, the Secretary shall ensure that access
to needed services is made available with a
minimal impact on premiums.
''(b) PER BENEFICIARY LIMITS.--Subsection (a)

shall not be construed to prevent a group health plan or
health insurance coverage from placing annual or lifetime
per beneficiary limits on specific covered benefits that are
not essential health benefits under section 1302(b) of the
Patient Protection and Affordable Care Act, to the extent
that such limits are otherwise permitted under Federal or
State law.''.

(b) Section 2715(a) of the Public Health Service Act,
as added by section 1001(5) of this Act, is amended by
striking ''and providing to enrollees'' and inserting ''and
providing to applicants, enrollees, and policyholders or certificate
holders''.
(c) Subpart II of part A of title XXVII of the Public
Health Service Act, as added by section 1001(5), is
amended by inserting after section 2715, the following:

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

''A group health plan and a health insurance issuer
offering group or individual health insurance coverage
shall comply with the provisions of section 1311(e)(3) of
the Patient Protection and Affordable Care Act, except
that a plan or coverage that is not offered through an Exchange
shall only be required to submit the information
required to the Secretary and the State insurance commissioner,
and make such information available to the public.''.

(d) Section 2716 of the Public Health Service Act,
as added by section 1001(5) of this Act, is amended to
read as follows:
''SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR

OF HIGHLY COMPENSATED INDIVIDUALS.

''(a) IN GENERAL.--A group health plan (other than
a self-insured plan) shall satisfy the requirements of section
105(h)(2) of the Internal Revenue Code of 1986 (relating
to prohibition on discrimination in favor of highly
compensated individuals).

''(b) RULES AND DEFINITIONS.--For purposes of
this section--
''(1) CERTAIN RULES TO APPLY.--Rules similar
to the rules contained in paragraphs (3), (4), and

(8) of section 105(h) of such Code shall apply.

''(2) HIGHLY COMPENSATED INDIVIDUAL.--The
term 'highly compensated individual' has the meaning
given such term by section 105(h)(5) of such
Code.''.

(e) Section 2717 of the Public Health Service Act,
as added by section 1001(5) of this Act, is amended--
(1) by redesignating subsections (c) and (d) as
subsections (d) and (e), respectively; and
(2) by inserting after subsection (b), the following:
''(c) PROTECTION OF SECOND AMENDMENT GUN
RIGHTS.--
''(1) WELLNESS AND PREVENTION PROGRAMS.--
A wellness and health promotion activity
implemented under subsection (a)(1)(D) may not require
the disclosure or collection of any information
relating to--
''(A) the presence or storage of a lawfully-
possessed firearm or ammunition in the residence
or on the property of an individual; or
''(B) the lawful use, possession, or storage
of a firearm or ammunition by an individual.
''(2) LIMITATION ON DATA COLLECTION.--None

of the authorities provided to the Secretary under
the Patient Protection and Affordable Care Act or

an amendment made by that Act shall be construed
to authorize or may be used for the collection of any
information relating to--

''(A) the lawful ownership or possession of

a firearm or ammunition;

''(B) the lawful use of a firearm or ammu

nition; or

''(C) the lawful storage of a firearm or am

munition.

''(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 RE

QUIREMENTS 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 Sec

retary a report concerning the ratio of the incurred loss
(or incurred claims) plus the loss adjustment expense (or
change in contract reserves) to earned premiums. Such report
shall include the percentage of total premium revenue,
after accounting for collections or receipts for risk
adjustment and risk corridors and payments of reinsurance,
that such coverage expends--

''(1) on reimbursement for clinical services provided
to enrollees under such coverage;
''(2) for activities that improve health care
quality; and

''(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding
Federal and State taxes and licensing or regulatory
fees.

The Secretary shall make reports received under this section
available to the public on the Internet website of the
Department of Health and Human Services.

''(b) ENSURING THAT CONSUMERS RECEIVE VALUE
FOR THEIR PREMIUM PAYMENTS.--
''(1) REQUIREMENT TO PROVIDE VALUE FOR
PREMIUM PAYMENTS.--

''(A) REQUIREMENT.--Beginning not later
than January 1, 2011, a health insurance
issuer offering group or individual health insur

ance coverage (including a grandfathered health
plan) shall, with respect to each plan year, provide
an annual rebate to each enrollee under
such coverage, on a pro rata basis, if the ratio
of the amount of premium revenue expended by
the issuer on costs described in paragraphs (1)
and (2) of subsection (a) to the total amount of
premium revenue (excluding Federal and State
taxes and licensing or regulatory fees and after
accounting for payments or receipts for risk adjustment,
risk corridors, and reinsurance under
sections 1341, 1342, and 1343 of the Patient
Protection and Affordable Care Act) for the
plan year (except as provided in subparagraph
(B)(ii)), is less than--

''(i) with respect to a health insurance
issuer offering coverage in the large group
market, 85 percent, or such higher percentage
as a State may by regulation determine;
or

''(ii) with respect to a health insurance
issuer offering coverage in the small
group market or in the individual market,
80 percent, or such higher percentage as a
State may by regulation determine, except

that the Secretary may adjust such percentage
with respect to a State if the Secretary
determines that the application of
such 80 percent may destabilize the individual
market in such State.
''(B) REBATE AMOUNT.--

''(i) CALCULATION OF AMOUNT.--The
total amount of an annual rebate required
under this paragraph shall be in an
amount equal to the product of--

''(I) the amount by which the

percentage described in clause (i) or

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

''(ii) CALCULATION BASED ON AVERAGE
RATIO.--Beginning on January 1,
2014, the determination made under subparagraph
(A) for the year involved shall
be based on the averages of the premiums
expended on the costs described in such
subparagraph and total premium revenue
for each of the previous 3 years for the
plan.

''(2) CONSIDERATION IN SETTING PERCENT-
AGES.--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 es

tablish uniform definitions of the activities reported under

subsection (a) and standardized methodologies for calcu

lating measures of such activities, including definitions of
which activities, and in what regard such activities, constitute
activities described in subsection (a)(2). Such
methodologies shall be designed to take into account the
special circumstances of smaller plans, different types of
plans, and newer plans.

''(d) ADJUSTMENTS.--The Secretary may adjust the
rates described in subsection (b) if the Secretary determines
appropriate on account of the volatility of the individual
market due to the establishment of State Exchanges.

''(e) STANDARD HOSPITAL CHARGES.--Each hospital
operating within the United States shall for each year establish
(and update) and make public (in accordance with
guidelines developed by the Secretary) a list of the hospital's
standard charges for items and services provided
by the hospital, including for diagnosis-related groups established
under section 1886(d)(4) of the Social Security
Act.''.

(g) Section 2719 of the Public Health Service Act,
as added by section 1001(4) of this Act, is amended to
read as follows:
''SEC. 2719. APPEALS PROCESS.

''(a) INTERNAL CLAIMS APPEALS.--

''(1) IN GENERAL.--A group health plan and a
health insurance issuer offering group or individual
health insurance coverage shall implement an effective
appeals process for appeals of coverage determinations
and claims, under which the plan or issuer
shall, at a minimum--

''(A) have in effect an internal claims appeal
process;

''(B) provide notice to enrollees, in a culturally
and linguistically appropriate manner, of
available internal and external appeals processes,
and the availability of any applicable office
of health insurance consumer assistance or
ombudsman established under section 2793 to
assist such enrollees with the appeals processes;
and

''(C) allow an enrollee to review their file,
to present evidence and testimony as part of the
appeals process, and to receive continued coverage
pending the outcome of the appeals process.
''(2) ESTABLISHED PROCESSES.--To comply

with paragraph (1)--
''(A) a group health plan and a health insurance
issuer offering group health coverage

shall provide an internal claims and appeals
process that initially incorporates the claims
and appeals procedures (including urgent
claims) set forth at section 2560.503-1 of title
29, Code of Federal Regulations, as published
on November 21, 2000 (65 Fed. Reg. 70256),
and shall update such process in accordance
with any standards established by the Secretary
of Labor for such plans and issuers; and

''(B) a health insurance issuer offering individual
health coverage, and any other issuer
not subject to subparagraph (A), shall provide
an internal claims and appeals process that initially
incorporates the claims and appeals procedures
set forth under applicable law (as in existence
on the date of enactment of this section),
and shall update such process in accordance
with any standards established by the Secretary
of Health and Human Services for such
issuers.

''(b) EXTERNAL REVIEW.--A group health plan and

a health insurance issuer offering group or individual

health insurance coverage--
''(1) shall comply with the applicable State external
review process for such plans and issuers

that, at a minimum, includes the consumer protections
set forth in the Uniform External Review
Model Act promulgated by the National Association
of Insurance Commissioners and is binding on such
plans; or

''(2) shall implement an effective external review
process that meets minimum standards established
by the Secretary through guidance and that is
similar to the process described under paragraph
(1)--

''(A) if the applicable State has not established
an external review process that meets the
requirements of paragraph (1); or

''(B) if the plan is a self-insured plan that
is not subject to State insurance regulation (including
a State law that establishes an external
review process described in paragraph (1)).

''(c) SECRETARY AUTHORITY.--The Secretary may
deem the external review process of a group health plan
or health insurance issuer, in operation as of the date of
enactment of this section, to be in compliance with the
applicable process established under subsection (b), as determined
appropriate by the Secretary.''.

(h) Subpart II of part A of title XVIII of the Public
Health Service Act, as added by section 1001(5) of this

Act, is amended by inserting after section 2719 the following:

''SEC. 2719A. PATIENT PROTECTIONS.

''(a) CHOICE OF HEALTH CARE PROFESSIONAL.--If
a group health plan, or a health insurance issuer offering
group or individual health insurance coverage, requires or
provides for designation by a participant, beneficiary, or
enrollee of a participating primary care provider, then the
plan or issuer shall permit each participant, beneficiary,
and enrollee to designate any participating primary care
provider who is available to accept such individual.

''(b) COVERAGE OF EMERGENCY SERVICES.--

''(1) IN GENERAL.--If a group health plan, or
a health insurance issuer offering group or individual
health insurance issuer, provides or covers
any benefits with respect to services in an emergency
department of a hospital, the plan or issuer shall
cover emergency services (as defined in paragraph
(2)(B))--

''(A) without the need for any prior authorization
determination;

''(B) whether the health care provider furnishing
such services is a participating provider
with respect to such services;

''(C) in a manner so that, if such services

are provided to a participant, beneficiary, or en

rollee--
''(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 So

cial Security Act) that is within the capability
of the emergency department of a
hospital, including ancillary services routinely
available to the emergency department
to evaluate such emergency medical
condition, and

''(ii) within the capabilities of the
staff and facilities available at the hospital,
such further medical examination and
treatment as are required under section
1867 of such Act to stabilize the patient.
''(C) STABILIZE.--The term 'to stabilize',

with respect to an emergency medical condition
(as defined in subparagraph (A)), has the
meaning give in section 1867(e)(3) of the Social
Security Act (42 U.S.C. 1395dd(e)(3)).

''(c) ACCESS TO PEDIATRIC CARE.--

''(1) PEDIATRIC CARE.--In the case of a person
who has a child who is a participant, beneficiary, or
enrollee under a group health plan, or health insurance
coverage offered by a health insurance issuer in
the group or individual market, if the plan or issuer
requires or provides for the designation of a participating
primary care provider for the child, the plan
or issuer shall permit such person to designate a

physician (allopathic or osteopathic) who specializes
in pediatrics as the child's primary care provider if
such provider participates in the network of the plan
or issuer.

''(2) CONSTRUCTION.--Nothing in paragraph

(1) shall be construed to waive any exclusions of coverage
under the terms and conditions of the plan or
health insurance coverage with respect to coverage
of pediatric care.
''(d) PATIENT ACCESS TO OBSTETRICAL AND GYNECOLOGICAL
CARE.--
''(1) GENERAL RIGHTS.--

''(A) DIRECT ACCESS.--A group health
plan, or health insurance issuer offering group
or individual health insurance coverage, described
in paragraph (2) may not require authorization
or referral by the plan, issuer, or
any person (including a primary care provider
described in paragraph (2)(B))) in the case of
a female participant, beneficiary, or enrollee
who seeks coverage for obstetrical or gynecological
care provided by a participating health
care professional who specializes in obstetrics or
gynecology. Such professional shall agree to
otherwise adhere to such plan's or issuer's poli

cies 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, de

scribed 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 partici

pant, beneficiary, or enrollee of a participating

primary care provider.

''(3) CONSTRUCTION.--Nothing in paragraph

(1) shall be construed to--
''(A) waive any exclusions of coverage
under the terms and conditions of the plan or
health insurance coverage with respect to coverage
of obstetrical or gynecological care; or

''(B) preclude the group health plan or
health insurance issuer involved from requiring
that the obstetrical or gynecological provider
notify the primary care health care professional
or the plan or issuer of treatment decisions.''.

(i) Section 2794 of the Public Health Service Act,
as added by section 1003 of this Act, is amended--
(1) in subsection (c)(1)--
(A) in subparagraph (A), by striking
''and'' at the end;
(B) in subparagraph (B), by striking the
period and inserting ''; and''; and
(C) by adding at the end the following:
''(C) in establishing centers (consistent
with subsection (d)) at academic or other nonprofit
institutions to collect medical reimburse

ment 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 es

tablished under subsection (c)(1)(C) shall adopt by-
laws that ensures that the center (and all members
of the governing board of the center) is independent
and free from all conflicts of interest. Such by-laws
shall ensure that the center is not controlled or influenced
by, and does not have any corporate relation
to, any individual or entity that may make or
receive payments for health care services based on
the center's analysis of health care costs.

''(3) RULE OF CONSTRUCTION.--Nothing in
this subsection shall be construed to permit a center
established under subsection (c)(1)(C) to compel
health insurance issuers to provide data to the center.''.

SEC. 10102. AMENDMENTS TO SUBTITLE B.

(a) Section 1102(a)(2)(B) of this Act is amended--

(1) in the matter preceding clause (i), by striking
''group health benefits plan'' and inserting
''group benefits plan providing health benefits''; and
(2) in clause (i)(I), by inserting ''or any agency
or instrumentality of any of the foregoing'' before
the closed parenthetical.
(b) Section 1103(a) of this Act is amended--
(1) in paragraph (1), by inserting '', or small
business in,'' after ''residents of any''; and
(2) by striking paragraph (2) and inserting the
following:
''(2) CONNECTING TO AFFORDABLE COV-
ERAGE.--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 So

cial Security Act.

''(D) A State health benefits high risk

pool, to the extent that such high risk pool is

offered in such State; and

''(E) Coverage under a high risk pool
under section 1101.

''(F) Coverage within the small group market
for small businesses and their employees,
including reinsurance for early retirees under
section 1102, tax credits available under section
45R of the Internal Revenue Code of 1986 (as
added by section 1421), and other information
specifically for small businesses regarding affordable
health care options.''.

SEC. 10103. AMENDMENTS TO SUBTITLE C.

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

(c) Subpart I of part A of title XXVII of the Public
Health Service Act, as added by section 1201(4) of this
Act, is amended by inserting after section 2708, the following:
''SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING

IN APPROVED CLINICAL TRIALS.

''(a) COVERAGE.--

''(1) IN GENERAL.--If a group health plan or
a health insurance issuer offering group or individual
health insurance coverage provides coverage
to a qualified individual, then such plan or issuer--

''(A) may not deny the individual participation
in the clinical trial referred to in subsection
(b)(2);

''(B) subject to subsection (c), may not
deny (or limit or impose additional conditions
on) the coverage of routine patient costs for
items and services furnished in connection with
participation in the trial; and

''(C) may not discriminate against the individual
on the basis of the individual's participation
in such trial.
''(2) ROUTINE PATIENT COSTS.--

''(A) INCLUSION.--For purposes of paragraph
(1)(B), subject to subparagraph (B), rou

tine 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 con

strued 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 pur

poses 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 estab

lishing that the individual's participation in
such trial would be appropriate based upon the
individual meeting the conditions described in
paragraph (1).

''(c) LIMITATIONS ON COVERAGE.--This section shall
not be construed to require a group health plan, or a
health insurance issuer offering group or individual health
insurance coverage, to provide benefits for routine patient
care services provided outside of the plan's (or coverage's)
health care provider network unless out-of-network benefits
are otherwise provided under the plan (or coverage).

''(d) APPROVED CLINICAL TRIAL DEFINED.--

''(1) IN GENERAL.--In this section, the term
'approved clinical trial' means a phase I, phase II,
phase III, or phase IV clinical trial that is conducted
in relation to the prevention, detection, or treatment
of cancer or other life-threatening disease or condition
and is described in any of the following subparagraphs:

''(A) FEDERALLY FUNDED TRIALS.--The
study or investigation is approved or funded
(which may include funding through in-kind
contributions) by one or more of the following:

''(i) The National Institutes of
Health.

''(ii) The Centers for Disease Control
and Prevention.
''(iii) The Agency for Health Care Research
and Quality.
''(iv) The Centers for Medicare &
Medicaid Services.

''(v) cooperative group or center of
any of the entities described in clauses (i)
through (iv) or the Department of Defense
or the Department of Veterans Affairs.

''(vi) A qualified non-governmental research
entity identified in the guidelines
issued by the National Institutes of Health
for center support grants.

''(vii) Any of the following if the conditions
described in paragraph (2) are met:
''(I) The Department of Veterans

Affairs.
''(II) The Department of Defense.
''(III) The Department of Energy.
''(B) The study or investigation is conducted
under an investigational new drug appli

cation reviewed by the Food and Drug Administration.

''(C) The study or investigation is a drug
trial that is exempt from having such an investigational
new drug application.
''(2) CONDITIONS FOR DEPARTMENTS.--The

conditions described in this paragraph, for a study
or investigation conducted by a Department, are
that the study or investigation has been reviewed
and approved through a system of peer review that
the Secretary determines--

''(A) to be comparable to the system of
peer review of studies and investigations used
by the National Institutes of Health, and

''(B) assures unbiased review of the highest
scientific standards by qualified individuals
who have no interest in the outcome of the review.

''(e) LIFE-THREATENING CONDITION DEFINED.--In
this section, the term 'life-threatening condition' means
any disease or condition from which the likelihood of death
is probable unless the course of the disease or condition
is interrupted.

''(f) CONSTRUCTION.--Nothing in this section shall
be construed to limit a plan's or issuer's coverage with
respect to clinical trials.

''(g) APPLICATION TO FEHBP.--Notwithstanding
any provision of chapter 89 of title 5, United States Code,
this section shall apply to health plans offered under the
program under such chapter.

''(h) PREEMPTION.--Notwithstanding any other provision
of this Act, nothing in this section shall preempt
State laws that require a clinical trials policy for State
regulated health insurance plans that is in addition to the
policy required under this section.''.

(d) Section 1251(a) of this Act is amended--
(1) in paragraph (2), by striking ''With'' and
inserting ''Except as provided in paragraph (3),
with''; and
(2) by adding at the end the following:
''(3) APPLICATION OF CERTAIN PROVISIONS.--
The provisions of sections 2715 and 2718 of the
Public Health Service Act (as added by subtitle A)
shall apply to grandfathered health plans for plan
years beginning on or after the date of enactment of
this Act.''.

(e) Section 1253 of this Act is amended insert before
the period the following: '', except that--

''(1) section 1251 shall take effect on the date
of enactment of this Act; and

''(2) the provisions of section 2704 of the Public
Health Service Act (as amended by section
1201), as they apply to enrollees who are under 19
years of age, shall become effective for plan years
beginning on or after the date that is 6 months after
the date of enactment of this Act.''.

(f) Subtitle C of title I of this Act is amended--
(1) by redesignating section 1253 as section
1255; and
(2) by inserting after section 1252, the following:
''SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS.

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

Secretary shall submit such reports to the appropriate
committees of Congress.

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

''(a) IN GENERAL.--The Secretary of Health and
Human Services shall conduct a study of the fully-insured
and self-insured group health plan markets to--

''(1) compare the characteristics of employers
(including industry, size, and other characteristics as
determined appropriate by the Secretary), health
plan benefits, financial solvency, capital reserve levels,
and the risks of becoming insolvent; and

''(2) determine the extent to which new insurance
market reforms are likely to cause adverse selection
in the large group market or to encourage
small and midsize employers to self-insure.
''(b) COLLECTION OF INFORMATION.--In conducting

the study under subsection (a), the Secretary, in coordination
with the Secretary of Labor, shall collect information
and analyze--

''(1) the extent to which self-insured group
health plans can offer less costly coverage and, if so,
whether lower costs are due to more efficient plan
administration and lower overhead or to the denial
of claims and the offering very limited benefit packages;

''(2) claim denial rates, plan benefit fluctuations
(to evaluate the extent that plans scale back
health benefits during economic downturns), and the
impact of the limited recourse options on consumers;
and

''(3) any potential conflict of interest as it relates
to the health care needs of self-insured enrollees
and self-insured employer's financial contribution
or profit margin, and the impact of such conflict on
administration of the health plan.
''(c) REPORT.--Not later than 1 year after the date

of enactment of this Act, the Secretary shall submit to
the appropriate committees of Congress a report concerning
the results of the study conducted under subsection
(a).''.

SEC. 10104. AMENDMENTS TO SUBTITLE D.

(a) Section 1301(a) of this Act is amended by striking
paragraph (2) and inserting the following:
''(2) INCLUSION OF CO-OP PLANS AND MULTI-
STATE QUALIFIED HEALTH PLANS.--Any reference
in this title to a qualified health plan shall be
deemed to include a qualified health plan offered
through the CO-OP program under section 1322,
and a multi-State plan under section 1334, unless
specifically provided for otherwise.

''(3) TREATMENT OF QUALIFIED DIRECT PRIMARY
CARE MEDICAL HOME PLANS.--The Secretary
of Health and Human Services shall permit a qualified
health plan to provide coverage through a qualified
direct primary care medical home plan that
meets criteria established by the Secretary, so long
as the qualified health plan meets all requirements
that are otherwise applicable and the services covered
by the medical home plan are coordinated with
the entity offering the qualified health plan.

''(4) VARIATION BASED ON RATING AREA.--A
qualified health plan, including a multi-State qualified
health plan, may as appropriate vary premiums
by rating area (as defined in section 2701(a)(2) of
the Public Health Service Act).''.

(b) Section 1302 of this Act is amended--
(1) in subsection (d)(2)(B), by striking ''may
issue'' and inserting ''shall issue''; and
(2) by adding at the end the following:
''(g) PAYMENTS TO FEDERALLY-QUALIFIED HEALTH
CENTERS.--If any item or service covered by a qualified
health plan is provided by a Federally-qualified health center
(as defined in section 1905(l)(2)(B) of the Social Security
Act (42 U.S.C. 1396d(l)(2)(B)) to an enrollee of the
plan, the offeror of the plan shall pay to the center for

the item or service an amount that is not less than the
amount of payment that would have been paid to the center
under section 1902(bb) of such Act (42 U.S.C.
1396a(bb)) for such item or service.''.

''(a) STATE OPT-OUT OF ABORTION COVERAGE.--

''(1) IN GENERAL.--A State may elect to prohibit
abortion coverage in qualified health plans offered
through an Exchange in such State if such
State enacts a law to provide for such prohibition.

''(2) TERMINATION OF OPT OUT.--A State may
repeal a law described in paragraph (1) and provide
for the offering of such services through the Exchange.
''(b) SPECIAL RULES RELATING TO COVERAGE OF

ABORTION SERVICES.--
''(1) VOLUNTARY CHOICE OF COVERAGE OF
ABORTION SERVICES.--

''(A) IN GENERAL.--Notwithstanding any
other provision of this title (or any amendment
made by this title)--

''(i) nothing in this title (or any
amendment made by this title), shall be

construed to require a qualified health plan
to provide coverage of services described in
subparagraph (B)(i) or (B)(ii) as part of
its essential health benefits for any plan
year; and

''(ii) subject to subsection (a), the
issuer of a qualified health plan shall determine
whether or not the plan provides
coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of such benefits
for the plan year.
''(B) ABORTION SERVICES.--

''(i) ABORTIONS FOR WHICH PUBLIC
FUNDING IS PROHIBITED.--The services
described in this clause are abortions for
which the expenditure of Federal funds appropriated
for the Department of Health
and Human Services is not permitted,
based on the law as in effect as of the date
that is 6 months before the beginning of
the plan year involved.

''(ii) ABORTIONS FOR WHICH PUBLIC
FUNDING IS ALLOWED.--The services described
in this clause are abortions for
which the expenditure of Federal funds ap

propriated for the Department of Health
and Human Services is permitted, based
on the law as in effect as of the date that
is 6 months before the beginning of the
plan year involved.

''(2) PROHIBITION ON THE USE OF FEDERAL
FUNDS.--

''(A) IN GENERAL.--If a qualified health
plan provides coverage of services described in
paragraph (1)(B)(i), the issuer of the plan shall
not use any amount attributable to any of the
following for purposes of paying for such services:

''(i) The credit under section 36B of
the Internal Revenue Code of 1986 (and
the amount (if any) of the advance payment
of the credit under section 1412 of
the Patient Protection and Affordable Care
Act).

''(ii) Any cost-sharing reduction under
section 1402 of thePatient Protection and
Affordable Care Act (and the amount (if
any) of the advance payment of the reduction
under section 1412 of the Patient
Protection and Affordable Care Act).

''(B) ESTABLISHMENT OF ALLOCATION AC-
COUNTS.--In the case of a plan to which subparagraph
(A) applies, the issuer of the plan
shall--

''(i) collect from each enrollee in the
plan (without regard to the enrollee's age,
sex, or family status) a separate payment
for each of the following:

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

''(II) an amount equal to the actuarial
value of the coverage of services
described in paragraph (1)(B)(i),
and
''(ii) shall deposit all such separate

payments into separate allocation accounts

as provided in subparagraph (C).
In the case of an enrollee whose premium for
coverage under the plan is paid through em

ployee payroll deposit, the separate payments
required under this subparagraph shall each be
paid by a separate deposit.

''(C) SEGREGATION OF FUNDS.--

''(i) IN GENERAL.--The issuer of a
plan to which subparagraph (A) applies
shall establish allocation accounts described
in clause (ii) for enrollees receiving
amounts described in subparagraph (A).

''(ii) ALLOCATION ACCOUNTS.--The
issuer of a plan to which subparagraph (A)
applies shall deposit--

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

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

''(D) ACTUARIAL VALUE.--

''(i) IN GENERAL.--The issuer of a
qualified health plan shall estimate the
basic per enrollee, per month cost, determined
on an average actuarial basis, for
including coverage under the qualified
health plan of the services described in
paragraph (1)(B)(i).

''(ii) CONSIDERATIONS.--In making
such estimate, the issuer--

''(I) may take into account the
impact on overall costs of the inclusion
of such coverage, but may not
take into account any cost reduction
estimated to result from such services,
including prenatal care, delivery, or
postnatal care;

''(II) shall estimate such costs as
if such coverage were included for the
entire population covered; and

''(III) may not estimate such a
cost at less than $1 per enrollee, per
month.

''(E) ENSURING COMPLIANCE WITH SEGREGATION
REQUIREMENTS.--

''(i) IN GENERAL.--Subject to clause
(ii), State health insurance commissioners
shall ensure that health plans comply with
the segregation requirements in this subsection
through the segregation of plan
funds in accordance with applicable provisions
of generally accepted accounting requirements,
circulars on funds management
of the Office of Management and
Budget, and guidance on accounting of the
Government Accountability Office.

''(ii) CLARIFICATION.--Nothing in
clause (i) shall prohibit the right of an individual
or health plan to appeal such action
in courts of competent jurisdiction.

''(3) RULES RELATING TO NOTICE.--

''(A) NOTICE.--A qualified health plan
that provides for coverage of the services described
in paragraph (1)(B)(i) shall provide a
notice to enrollees, only as part of the summary
of benefits and coverage explanation, at the
time of enrollment, of such coverage.

''(B) RULES RELATING TO PAYMENTS.--
The notice described in subparagraph (A), any
advertising used by the issuer with respect to

the plan, any information provided by the Exchange,
and any other information specified by
the Secretary shall provide information only
with respect to the total amount of the combined
payments for services described in paragraph
(1)(B)(i) and other services covered by
the plan.
''(4) NO DISCRIMINATION ON BASIS OF PROVI

SION OF ABORTION.--No qualified health plan offered
through an Exchange may discriminate against
any individual health care provider or health care facility
because of its unwillingness to provide, pay for,
provide coverage of, or refer for abortions
''(c) APPLICATION OF STATE AND FEDERAL LAWS

REGARDING ABORTION.--
''(1) NO PREEMPTION OF STATE LAWS REGARDING
ABORTION.--Nothing in this Act shall be construed
to preempt or otherwise have any effect on
State laws regarding the prohibition of (or requirement
of) coverage, funding, or procedural requirements
on abortions, including parental notification
or consent for the performance of an abortion on a
minor.
''(2) NO EFFECT ON FEDERAL LAWS REGARDING
ABORTION.--

''(A) IN GENERAL.--Nothing in this Act
shall be construed to have any effect on Federal
laws regarding--

''(i) conscience protection;
''(ii) willingness or refusal to provide
abortion; and

''(iii) discrimination on the basis of
the willingness or refusal to provide, pay
for, cover, or refer for abortion or to provide
or participate in training to provide
abortion.

''(3) NO EFFECT ON FEDERAL CIVIL RIGHTS
LAW.--Nothing in this subsection shall alter the
rights and obligations of employees and employers
under title VII of the Civil Rights Act of 1964.
''(d) APPLICATION OF EMERGENCY SERVICES

LAWS.--Nothing in this Act shall be construed to relieve
any health care provider from providing emergency services
as required by State or Federal law, including section
1867 of the Social Security Act (popularly known as
'EMTALA').''.

(d) Section 1304 of this Act is amended by adding
at the end the following:
''(e) EDUCATED HEALTH CARE CONSUMERS.--The
term 'educated health care consumer' means an individual

who is knowledgeable about the health care system, and
has background or experience in making informed decisions
regarding health, medical, and scientific matters.''.

(e) Section 1311(d) of this Act is amended--
(1) in paragraph (3)(B), by striking clause (ii)
and inserting the following:
''(ii) STATE MUST ASSUME COST.--A
State shall make payments--
''(I) to an individual enrolled in a
qualified health plan offered in such
State; or

''(II) on behalf of an individual
described in subclause (I) directly to
the qualified health plan in which
such individual is enrolled;

to defray the cost of any additional benefits
described in clause (i).''; and

(2) in paragraph (6)(A), by inserting ''educated''
before ''health care''.
(f) Section 1311(e) of this Act is amended--
(1) in paragraph (2), by striking ''may'' in the
second sentence and inserting ''shall''; and
(2) by adding at the end the following:
''(3) TRANSPARENCY IN COVERAGE.--

''(A) IN GENERAL.--The Exchange shall
require health plans seeking certification as
qualified health plans to submit to the Exchange,
the Secretary, the State insurance commissioner,
and make available to the public, accurate
and timely disclosure of the following information:

''(i) Claims payment policies and

practices.

''(ii) Periodic financial disclosures.

''(iii) Data on enrollment.

''(iv) Data on disenrollment.

''(v) Data on the number of claims

that are denied.

''(vi) Data on rating practices.

''(vii) Information on cost-sharing and

payments with respect to any out-of-net

work 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 lan

guage. The term 'plain language' means language
that the intended audience, including individuals
with limited English proficiency, can
readily understand and use because that language
is concise, well-organized, and follows
other best practices of plain language writing.
The Secretary and the Secretary of Labor shall
jointly develop and issue guidance on best practices
of plain language writing.

''(C) COST SHARING TRANSPARENCY.--The
Exchange shall require health plans seeking
certification as qualified health plans to permit
individuals to learn the amount of cost-sharing
(including deductibles, copayments, and coinsurance)
under the individual's plan or coverage
that the individual would be responsible for
paying with respect to the furnishing of a specific
item or service by a participating provider
in a timely manner upon the request of the individual.
At a minimum, such information shall
be made available to such individual through an
Internet website and such other means for individuals
without access to the Internet.

''(D) GROUP HEALTH PLANS.--The Secretary
of Labor shall update and harmonize the

Secretary's rules concerning the accurate and
timely disclosure to participants by group
health plans of plan disclosure, plan terms and
conditions, and periodic financial disclosure
with the standards established by the Secretary
under subparagraph (A).''.

(g) Section 1311(g)(1) of this Act is amended--
(1) in subparagraph (C), by striking ''; and''
and inserting a semicolon;
(2) in subparagraph (D), by striking the period
and inserting ''; and''; and
(3) by adding at the end the following:
''(E) the implementation of activities to reduce
health and health care disparities, including
through the use of language services, community
outreach, and cultural competency
trainings.''.

(h) Section 1311(i)(2)((B) of this Act is amended by
striking ''small business development centers'' and inserting
''resource partners of the Small Business Administration''.
(i) Section 1312 of this Act is amended--
(1) in subsection (a)(1), by inserting ''and for
which such individual is eligible'' before the period;
(2) in subsection (e)--

(A) in paragraph (1), by inserting ''and
employers'' after ''enroll individuals''; and
(B) by striking the flush sentence at the
end; and
(3) in subsection (f)(1)(A)(ii), by striking the
parenthetical.
(j)(1) Subparagraph (B) of section 1313(a)(6) of this
Act is hereby deemed null, void, and of no effect.

(2) Section 3730(e) of title 31, United States Code,
is amended by striking paragraph (4) and inserting the
following:
''(4)(A) The court shall dismiss an action or
claim under this section, unless opposed by the Government,
if substantially the same allegations or
transactions as alleged in the action or claim were
publicly disclosed--

''(i) in a Federal criminal, civil, or administrative
hearing in which the Government or its
agent is a party;

''(ii) in a congressional, Government Accountability
Office, or other Federal report,
hearing, audit, or investigation; or

''(iii) from the news media,

unless the action is brought by the Attorney General
or the person bringing the action is an original
source of the information.

''(B) For purposes of this paragraph, ''original
source'' means an individual who either (i) prior to
a public disclosure under subsection (e)(4)(a), has
voluntarily disclosed to the Government the information
on which allegations or transactions in a claim
are based, or (2) who has knowledge that is independent
of and materially adds to the publicly disclosed
allegations or transactions, and who has voluntarily
provided the information to the Government
before filing an action under this section.''.

(k) Section 1313(b) of this Act is amended--
(1) in paragraph (3), by striking ''and'' at the
end;
(2) by redesignating paragraph (4) as paragraph
(5); and
(3) by inserting after paragraph (3) the following:
''(4) a survey of the cost and affordability of
health care insurance provided under the Exchanges
for owners and employees of small business concerns
(as defined under section 3 of the Small Business
Act (15 U.S.C. 632)), including data on enrollees in

Exchanges and individuals purchasing health insurance
coverage outside of Exchanges; and''.

(l) Section 1322(b) of this Act is amended--
(1) by redesignating paragraph (3) as paragraph
(4); and
(2) by inserting after paragraph (2), the following:
''(3) REPAYMENT OF LOANS AND GRANTS.--
Not later than July 1, 2013, and prior to awarding
loans and grants under the CO-OP program, the
Secretary shall promulgate regulations with respect
to the repayment of such loans and grants in a manner
that is consistent with State solvency regulations
and other similar State laws that may apply. In promulgating
such regulations, the Secretary shall provide
that such loans shall be repaid within 5 years
and such grants shall be repaid within 15 years, taking
into consideration any appropriate State reserve
requirements, solvency regulations, and requisite
surplus note arrangements that must be constructed
in a State to provide for such repayment prior to
awarding such loans and grants.''.

(m) Part III of subtitle D of title I of this Act is
amended by striking section 1323.

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

''(a) OVERSIGHT BY THE OFFICE OF PERSONNEL
MANAGEMENT.--

''(1) IN GENERAL.--The Director of the Office
of Personnel Management (referred to in this section
as the 'Director') shall enter into contracts with

health insurance issuers (which may include a group
of health insurance issuers affiliated either by common
ownership and control or by the common use of
a nationally licensed service mark), without regard
to section 5 of title 41, United States Code, or other
statutes requiring competitive bidding, to offer at
least 2 multi-State qualified health plans through
each Exchange in each State. Such plans shall provide
individual, or in the case of small employers,
group coverage.

''(2) TERMS.--Each contract entered into
under paragraph (1) shall be for a uniform term of
at least 1 year, but may be made automatically renewable
from term to term in the absence of notice
of termination by either party. In entering into such
contracts, the Director shall ensure that health benefits
coverage is provided in accordance with the
types of coverage provided for under section
2701(a)(1)(A)(i) of the Public Health Service Act.

''(3) NON-PROFIT ENTITIES.--In entering into
contracts under paragraph (1), the Director shall
ensure that at least one contract is entered into with
a non-profit entity.

''(4) ADMINISTRATION.--The Director shall implement
this subsection in a manner similar to the

manner in which the Director implements the contracting
provisions with respect to carriers under the
Federal employees health benefit program under
chapter 89 of title 5, United States Code, including
(through negotiating with each multi-state plan)--

''(A) a medical loss ratio;

''(B) a profit margin;

''(C) the premiums to be charged; and

''(D) such other terms and conditions of

coverage as are in the interests of enrollees in

such plans.

''(5) AUTHORITY TO PROTECT CONSUMERS.--
The Director may prohibit the offering of any multi-
State health plan that does not meet the terms and
conditions defined by the Director with respect to
the elements described in subparagraphs (A)
through (D) of paragraph (4).

''(6) ASSURED AVAILABILITY OF VARIED COV-
ERAGE.--In entering into contracts under this subsection,
the Director shall ensure that with respect
to multi-State qualified health plans offered in an
Exchange, there is at least one such plan that does
not provide coverage of services described in section
1303(b)(1)(B)(i).

''(7) WITHDRAWAL.--Approval of a contract
under this subsection may be withdrawn by the Director
only after notice and opportunity for hearing
to the issuer concerned without regard to subchapter
II of chapter 5 and chapter 7 of title 5, United
States Code.
''(b) ELIGIBILITY.--A health insurance issuer shall

be eligible to enter into a contract under subsection (a)(1)

if such issuer--
''(1) agrees to offer a multi-State qualified
health plan that meets the requirements of subsection
(c) in each Exchange in each State;
''(2) is licensed in each State and is subject to
all requirements of State law not inconsistent with
this section, including the standards and requirements
that a State imposes that do not prevent the
application of a requirement of part A of title
XXVII of the Public Health Service Act or a requirement
of this title;
''(3) otherwise complies with the minimum
standards prescribed for carriers offering health benefits
plans under section 8902(e) of title 5, United
States Code, to the extent that such standards do
not conflict with a provision of this title; and

''(4) meets such other requirements as deter

mined 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 BENE

FITS.--Nothing in paragraph (1)(A) shall preclude a

State from requiring that benefits in addition to the

essential health benefits required under such para

graph be provided to enrollees of a multi-State quali

fied health plan offered in such State.
''(3) CREDITS.--
''(A) IN GENERAL.--An individual enrolled
in a multi-State qualified health plan under this
section shall be eligible for credits under section
36B of the Internal Revenue Code of 1986 and
cost sharing assistance under section 1402 in
the same manner as an individual who is enrolled
in a qualified health plan.
''(B) NO ADDITIONAL FEDERAL COST.--A
requirement by a State under paragraph (2)
that benefits in addition to the essential health
benefits required under paragraph (1)(A) be
provided to enrollees of a multi-State qualified
health plan shall not affect the amount of a
premium tax credit provided under section 36B
of the Internal Revenue Code of 1986 with respect
to such plan.

''(4) STATE MUST ASSUME COST.--A State
shall make payments--

''(A) to an individual enrolled in a multi-
State qualified health plan offered in such
State; or

''(B) on behalf of an individual described
in subparagraph (A) directly to the multi-State
qualified health plan in which such individual is
enrolled;

to defray the cost of any additional benefits described
in paragraph (2).

''(5) APPLICATION OF CERTAIN STATE RATING
REQUIREMENTS.--With respect to a multi-State
qualified health plan that is offered in a State with
age rating requirements that are lower than 3:1, the
State may require that Exchanges operating in such
State only permit the offering of such multi-State
qualified health plans if such plans comply with the
State's more protective age rating requirements.
''(d) PLANS DEEMED TO BE CERTIFIED.--A multi-

State qualified health plan that is offered under a contract

under subsection (a) shall be deemed to be certified by

an Exchange for purposes of section 1311(d)(4)(A).
''(e) PHASE-IN.--Notwithstanding paragraphs (1)

and (2) of subsection (b), the Director shall enter into a

contract with a health insurance issuer for the offering
of a multi-State qualified health plan under subsection (a)
if--

''(1) with respect to the first year for which the
issuer offers such plan, such issuer offers the plan
in at least 60 percent of the States;

''(2) with respect to the second such year, such
issuer offers the plan in at least 70 percent of the
States;

''(3) with respect to the third such year, such
issuer offers the plan in at least 85 percent of the
States; and

''(4) with respect to each subsequent year, such
issuer offers the plan in all States.
''(f) APPLICABILITY.--The requirements under chap

ter 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 EN-
TITIES.--The Director may establish such separate
units or offices within the Office of Personnel Management
as the Director determines to be appropriate
to ensure that the administration of multi-
State qualified health plans under this section does
not interfere with the effective administration of the
Federal Employees Health Benefit Program under
chapter 89 of title 5, United States Code.

''(4) EFFECTIVE OVERSIGHT.--The Director
may appoint such additional personnel as may be
necessary to enable the Director to carry out activities
under this section.

''(5) ASSURANCE OF SEPARATE PROGRAM.--In
carrying out this section, the Director shall ensure
that the program under this section is separate from

the Federal Employees Health Benefit Program
under chapter 89 of title 5, United States Code.
Premiums paid for coverage under a multi-State
qualified health plan under this section shall not be
considered to be Federal funds for any purposes.

''(6) FEHBP PLANS NOT REQUIRED TO PAR-
TICIPATE.--Nothing in this section shall require that
a carrier offering coverage under the Federal Employees
Health Benefit Program under chapter 89 of
title 5, United States Code, also offer a multi-State
qualified health plan under this section.
''(h) ADVISORY BOARD.--The Director shall establish

an advisory board to provide recommendations on the activities
described in this section. A significant percentage
of the members of such board shall be comprised of enrollees
in a multi-State qualified health plan, or representatives
of such enrollees.

''(i) AUTHORIZATION OF APPROPRIATIONS.--There is
authorized to be appropriated, such sums as may be necessary
to carry out this section.''.

(r) Section 1341 of this Act is amended--
(1) in the section heading, by striking ''AND
SMALL GROUP MARKETS'' and inserting ''MARKET'';

(2) in subsection (b)(2)(B), by striking ''paragraph
(1)(A)'' and inserting ''paragraph (1)(B)'';
and
(3) in subsection (c)(1)(A), by striking ''and
small group markets'' and inserting ''market''.
SEC. 10105. AMENDMENTS TO SUBTITLE E.

(a) Section 36B(b)(3)(A)(ii) of the Internal Revenue
Code of 1986, as added by section 1401(a) of this Act,
is amended by striking ''is in excess of'' and inserting
''equals or exceeds''.
(b) Section 36B(c)(1)(A) of the Internal Revenue
Code of 1986, as added by section 1401(a) of this Act,
is amended by inserting ''equals or'' before ''exceeds''.
(c) Section 36B(c)(2)(C)(iv) of the Internal Revenue
Code of 1986, as added by section 1401(a) of this Act,
is amended by striking ''subsection (b)(3)(A)(ii)'' and inserting
''subsection (b)(3)(A)(iii)''.
(d) Section 1401(d) of this Act is amended by adding
at the end the following:
''(3) Section 6211(b)(4)(A) of the Internal Revenue
Code of 1986 is amended by inserting '36B,'
after '36A,'.''.
(e)(1) Subparagraph (B) of section 45R(d)(3) of the

Internal Revenue Code of 1986, as added by section
1421(a) of this Act, is amended to read as follows:

''(B) DOLLAR AMOUNT.--For purposes of
paragraph (1)(B) and subsection (c)(2)--

''(i) 2010, 2011, 2012, AND 2013.--The
dollar amount in effect under this paragraph
for taxable years beginning in 2010,
2011, 2012, or 2013 is $25,000.

''(ii) SUBSEQUENT YEARS.--In the
case of a taxable year beginning in a calendar
year after 2013, the dollar amount
in effect under this paragraph shall be
equal to $25,000, multiplied by the cost-of-
living adjustment under section 1(f)(3) for
the calendar year, determined by substituting
'calendar year 2012' for 'calendar
year 1992' in subparagraph (B) thereof.''.

(2) Subsection (g) of section 45R of the Internal Revenue
Code of 1986, as added by section 1421(a) of this
Act, is amended by striking ''2011'' both places it appears
and inserting ''2010, 2011''.
(3) Section 280C(h) of the Internal Revenue Code of
1986, as added by section 1421(d)(1) of this Act, is
amended by striking ''2011'' and inserting ''2010, 2011''.
(4) Section 1421(f) of this Act is amended by striking
''2010'' both places it appears and inserting ''2009''.

(5) The amendments made by this subsection shall
take effect as if included in the enactment of section 1421
of this Act.
(f) Part I of subtitle E of title I of this Act is amended
by adding at the end of subpart B, the following:
''SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLI

CATION 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 de

scribed in this paragraph are the following:

''(A) The requirement regulates activity
that is commercial and economic in nature: economic
and financial decisions about how and
when health care is paid for, and when health
insurance is purchased. In the absence of the
requirement, some individuals would make an
economic and financial decision to forego health
insurance coverage and attempt to self-insure,
which increases financial risks to households
and medical providers.

''(B) Health insurance and health care
services are a significant part of the national
economy. National health spending is projected
to increase from $2,500,000,000,000, or 17.6
percent of the economy, in 2009 to
$4,700,000,000,000 in 2019. Private health insurance
spending is projected to be
$854,000,000,000 in 2009, and pays for medical
supplies, drugs, and equipment that are
shipped in interstate commerce. Since most
health insurance is sold by national or regional
health insurance companies, health insurance is
sold in interstate commerce and claims payments
flow through interstate commerce.

''(C) The requirement, together with the
other provisions of this Act, will add millions of
new consumers to the health insurance market,
increasing the supply of, and demand for,
health care services, and will increase the number
and share of Americans who are insured.

''(D) The requirement achieves near-universal
coverage by building upon and strengthening
the private employer-based health insurance
system, which covers 176,000,000 Americans
nationwide. In Massachusetts, a similar re

quirement has strengthened private employer-
based coverage: despite the economic downturn,
the number of workers offered employer-based
coverage has actually increased.

''(E) The economy loses up to
$207,000,000,000 a year because of the poorer
health and shorter lifespan of the uninsured. By
significantly reducing the number of the uninsured,
the requirement, together with the other
provisions of this Act, will significantly reduce
this economic cost.

''(F) The cost of providing uncompensated
care to the uninsured was $43,000,000,000 in
2008. To pay for this cost, health care providers
pass on the cost to private insurers,
which pass on the cost to families. This cost-
shifting increases family premiums by on average
over $1,000 a year. By significantly reducing
the number of the uninsured, the requirement,
together with the other provisions of this
Act, will lower health insurance premiums.

''(G) 62 percent of all personal bankruptcies
are caused in part by medical expenses.
By significantly increasing health insurance
coverage, the requirement, together with the

other provisions of this Act, will improve financial
security for families.

''(H) Under the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1001 et
seq.), the Public Health Service Act (42 U.S.C.
201 et seq.), and this Act, the Federal Government
has a significant role in regulating health
insurance. The requirement is an essential part
of this larger regulation of economic activity,
and the absence of the requirement would undercut
Federal regulation of the health insurance
market.

''(I) Under sections 2704 and 2705 of the
Public Health Service Act (as added by section
1201 of this Act), if there were no requirement,
many individuals would wait to purchase health
insurance until they needed care. By significantly
increasing health insurance coverage, the
requirement, together with the other provisions
of this Act, will minimize this adverse selection
and broaden the health insurance risk pool to
include healthy individuals, which will lower
health insurance premiums. The requirement is
essential to creating effective health insurance
markets in which improved health insurance

products that are guaranteed issue and do not
exclude coverage of pre-existing conditions can
be sold.

''(J) Administrative costs for private
health insurance, which were $90,000,000,000
in 2006, are 26 to 30 percent of premiums in
the current individual and small group markets.
By significantly increasing health insurance
coverage and the size of purchasing pools,
which will increase economies of scale, the requirement,
together with the other provisions of
this Act, will significantly reduce administrative
costs and lower health insurance premiums.
The requirement is essential to creating effective
health insurance markets that do not require
underwriting and eliminate its associated
administrative costs.''.

(b)(1) Section 5000A(b)(1) of the Internal Revenue

Code of 1986, as added by section 1501(b) of this Act,

is amended to read as follows:
''(1) IN GENERAL.--If a taxpayer who is an applicable
individual, or an applicable individual for
whom the taxpayer is liable under paragraph (3),
fails to meet the requirement of subsection (a) for
1 or more months, then, except as provided in sub

section (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 pur

poses of paragraph (1)(A), the monthly penalty
amount with respect to any taxpayer for any month
during which any failure described in subsection

(b)(1) occurred is an amount equal to 1/12 of the
greater of the following amounts:
''(A) FLAT DOLLAR AMOUNT.--An amount
equal to the lesser of--

''(i) the sum of the applicable dollar
amounts for all individuals with respect to
whom such failure occurred during such
month, or

''(ii) 300 percent of the applicable dollar
amount (determined without regard to
paragraph (3)(C)) for the calendar year
with or within which the taxable year ends.
''(B) PERCENTAGE OF INCOME.--An

amount equal to the following percentage of the
taxpayer's household income for the taxable
year:

''(i) 0.5 percent for taxable years beginning
in 2014.
''(ii) 1.0 percent for taxable years beginning
in 2015.
''(iii) 2.0 percent for taxable years beginning
after 2015.''.

(3) Section 5000A(c)(3) of the Internal Revenue
Code of 1986, as added by section 1501(b) of this Act,
is amended by striking ''$350'' and inserting ''$495''.

(c) Section 5000A(d)(2)(A) of the Internal Revenue
Code of 1986, as added by section 1501(b) of this Act,
is amended to read as follows:
''(A) RELIGIOUS CONSCIENCE EXEMP-
TION.--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 sub

paragraph (A) shall be made by reference to required
contribution of the employee.''.

(e) Section 4980H(b) of the Internal Revenue Code
of 1986, as added by section 1513(a) of this Act, is
amended to read as follows:
''(b) LARGE EMPLOYERS WITH WAITING PERIODS
EXCEEDING 60 DAYS.--

''(1) IN GENERAL.--In the case of any applicable
large employer which requires an extended waiting
period to enroll in any minimum essential coverage
under an employer-sponsored plan (as defined
in section 5000A(f)(2)), there is hereby imposed on
the employer an assessable payment of $600 for
each full-time employee of the employer to whom the
extended waiting period applies.

''(2) EXTENDED WAITING PERIOD.--The term

'extended waiting period' means any waiting period

(as defined in section 2701(b)(4) of the Public

Health Service Act) which exceeds 60 days.''.

(f)(1) Subparagraph (A) of section 4980H(d)(4) of

the Internal Revenue Code of 1986, as added by section
1513(a) of this Act, is amended by inserting '', with respect
to any month,'' after ''means''.

(2) Section 4980H(d)(2) of the Internal Revenue
Code of 1986, as added by section 1513(a) of this Act,
is amended by adding at the end the following:
''(D) APPLICATION TO CONSTRUCTION INDUSTRY
EMPLOYERS.--In the case of any employer
the substantial annual gross receipts of
which are attributable to the construction industry--

''(i) subparagraph (A) shall be applied
by substituting 'who employed an average
of at least 5 full-time employees on business
days during the preceding calendar
year and whose annual payroll expenses exceed
$250,000 for such preceding calendar
year' for 'who employed an average of at
least 50 full-time employees on business
days during the preceding calendar year',
and

''(ii) subparagraph (B) shall be applied
by substituting '5' for '50'.''.

(3) The amendment made by paragraph (2) shall
apply to months beginning after December 31, 2013.
(g) Section 6056(b) of the Internal Revenue Code of
1986, as added by section 1514(a) of the Act, is amended
by adding at the end the following new flush sentence:

''The Secretary shall have the authority to review the accuracy
of the information provided under this subsection,
including the applicable large employer's share under
paragraph (2)(C)(iv).''.

SEC. 10107. AMENDMENTS TO SUBTITLE G.

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

OF COVERAGE AND ENROLLMENT BY

HEALTH INSURANCE ISSUERS AND GROUP

HEALTH PLANS.

''(a) IN GENERAL.--The Comptroller General of the
United States (referred to in this section as the 'Comptroller
General') shall conduct a study of the incidence of
denials of coverage for medical services and denials of applications
to enroll in health insurance plans, as described
in subsection (b), by group health plans and health insurance
issuers.

''(b) DATA.--

''(1) IN GENERAL.--In conducting the study de

scribed in subsection (a), the Comptroller General

shall consider samples of data concerning the fol

lowing:
''(A)(i) denials of coverage for medical
services to a plan enrollees, by the types of
services for which such coverage was denied;
and
''(ii) the reasons such coverage was denied;
and
''(B)(i) incidents in which group health
plans and health insurance issuers deny the application
of an individual to enroll in a health
insurance plan offered by such group health
plan or issuer; and
''(ii) the reasons such applications are denied.
''(2) SCOPE OF DATA.--
''(A) FAVORABLY RESOLVED DISPUTES.--
The data that the Comptroller General considers
under paragraph (1) shall include data
concerning denials of coverage for medical services
and denials of applications for enrollment
in a plan by a group health plan or health insurance
issuer, where such group health plan or

health insurance issuer later approves such coverage
or application.

''(B) ALL HEALTH PLANS.--The study
under this section shall consider data from varied
group health plans and health insurance
plans offered by health insurance issuers, including
qualified health plans and health plans
that are not qualified health plans.

''(c) REPORT.--Not later than one year after the date
of enactment of this Act, the Comptroller General shall
submit to the Secretaries of Health and Human Services
and Labor a report describing the results of the study conducted
under this section.

''(d) PUBLICATION OF REPORT.--The Secretaries of
Health and Human Services and Labor shall make the
report described in subsection (c) available to the public
on an Internet website.

''SEC. 1563. SMALL BUSINESS PROCUREMENT.

''Part 19 of the Federal Acquisition Regulation, section
15 of the Small Business Act (15 U.S.C. 644), and
any other applicable laws or regulations establishing procurement
requirements relating to small business concerns
(as defined in section 3 of the Small Business Act (15

U.S.C. 632)) may not be waived with respect to any con

tract awarded under any program or other authority
under this Act or an amendment made by this Act.''.

SEC. 10108. FREE CHOICE VOUCHERS.

(a) IN GENERAL.--An offering employer shall provide
free choice vouchers to each qualified employee of
such employer.
(b) OFFERING EMPLOYER.--For purposes of this
section, the term ''offering employer'' means any employer
who--
(1) offers minimum essential coverage to its
employees consisting of coverage through an eligible
employer-sponsored plan; and
(2) pays any portion of the costs of such plan.
(c) QUALIFIED EMPLOYEE.--For purposes of this
section--
(1) IN GENERAL.--The term ''qualified employee''
means, with respect to any plan year of an
offering employer, any employee--
(A) whose required contribution (as determined
under section 5000A(e)(1)(B)) for minimum
essential coverage through an eligible employer-
sponsored plan--
(i) exceeds 8 percent of such employee's
household income for the taxable year

described in section 1412(b)(1)(B) which
ends with or within in the plan year; and

(ii) does not exceed 9.8 percent of
such employee's household income for such
taxable year;
(B) whose household income for such taxable
year is not greater than 400 percent of the
poverty line for a family of the size involved;
and
(C) who does not participate in a health
plan offered by the offering employer.
(2) INDEXING.--In the case of any calendar
year beginning after 2014, the Secretary shall adjust
the 8 percent under paragraph (1)(A)(i) and 9.8
percent under paragraph (1)(A)(ii) for the calendar
year to reflect the rate of premium growth between
the preceding calendar year and 2013 over the rate
of income growth for such period.
(d) FREE CHOICE VOUCHER.--
(1) AMOUNT.--
(A) IN GENERAL.--The amount of any free
choice voucher provided under subsection (a)
shall be equal to the monthly portion of the cost
of the eligible employer-sponsored plan which
would have been paid by the employer if the

employee were covered under the plan with respect
to which the employer pays the largest
portion of the cost of the plan. Such amount
shall be equal to the amount the employer
would pay for an employee with self-only coverage
unless such employee elects family coverage
(in which case such amount shall be the
amount the employer would pay for family coverage).

(B) DETERMINATION OF COST.--The cost
of any health plan shall be determined under
the rules similar to the rules of section 2204 of
the Public Health Service Act, except that such
amount shall be adjusted for age and category
of enrollment in accordance with regulations established
by the Secretary.
(2) USE OF VOUCHERS.--An Exchange shall
credit the amount of any free choice voucher provided
under subsection (a) to the monthly premium
of any qualified health plan in the Exchange in
which the qualified employee is enrolled and the offering
employer shall pay any amounts so credited to
the Exchange.
(3) PAYMENT OF EXCESS AMOUNTS.--If the
amount of the free choice voucher exceeds the

amount of the premium of the qualified health plan
in which the qualified employee is enrolled for such
month, such excess shall be paid to the employee.

(e) OTHER DEFINITIONS.--Any term used in this
section which is also used in section 5000A of the Internal
Revenue Code of 1986 shall have the meaning given such
term under such section 5000A.
(f) EXCLUSION FROM INCOME FOR EMPLOYEE.--
(1) IN GENERAL.--Part III of subchapter B of
chapter 1 of the Internal Revenue Code of 1986 is
amended by inserting after section 139C the following
new section:
''SEC. 139D. FREE CHOICE VOUCHERS.

''Gross income shall not include the amount of any
free choice voucher provided by an employer under section
10108 of the Patient Protection and Affordable Care Act
to the extent that the amount of such voucher does not
exceed the amount paid for a qualified health plan (as defined
in section 1301 of such Act) by the taxpayer.''.

(2) CLERICAL AMENDMENT.--The table of sections
for part III of subchapter B of chapter 1 of
such Code is amended by inserting after the item relating
to section 139C the following new item:
''Sec. 139D. Free choice vouchers.''.

(3) EFFECTIVE DATE.--The amendments made
by this subsection shall apply to vouchers provided
after December 31, 2013.
(g) DEDUCTION ALLOWED TO EMPLOYER.--
(1) IN GENERAL.--Section 162(a) of the Internal
Revenue Code of 1986 is amended by adding at
the end the following new sentence: ''For purposes
of paragraph (1), the amount of a free choice voucher
provided under section 10108 of the Patient Protection
and Affordable Care Act shall be treated as
an amount for compensation for personal services
actually rendered.''.
(2) EFFECTIVE DATE.--The amendments made
by this subsection shall apply to vouchers provided
after December 31, 2013.
(h) VOUCHER TAKEN INTO ACCOUNT IN DETERMINING
PREMIUM CREDIT.--
(1) IN GENERAL.--Subsection (c)(2) of section
36B of the Internal Revenue Code of 1986, as added
by section 1401, is amended by adding at the end
the following new subparagraph:
''(D) EXCEPTION FOR INDIVIDUAL RECEIVING
FREE CHOICE VOUCHERS.--The term 'coverage
month' shall not include any month in
which such individual has a free choice voucher

provided under section 10108 of the Patient
Protection and Affordable Care Act.''.

(2) EFFECTIVE DATE.--The amendment made
by this subsection shall apply to taxable years beginning
after December 31, 2013.
(i) COORDINATION WITH EMPLOYER RESPONSIBILITIES.--
(1) SHARED RESPONSIBILITY PENALTY.--
(A) IN GENERAL.--Subsection (c) of section
4980H of the Internal Revenue Code of
1986, as added by section 1513, is amended by
adding at the end the following new paragraph:
''(3) SPECIAL RULES FOR EMPLOYERS PROVIDING
FREE CHOICE VOUCHERS.--No assessable
payment shall be imposed under paragraph (1) for
any month with respect to any employee to whom
the employer provides a free choice voucher under
section 10108 of the Patient Protection and Affordable
Care Act for such month.''.

(B) EFFECTIVE DATE.--The amendment
made by this paragraph shall apply to months
beginning after December 31, 2013.
(2) NOTIFICATION REQUIREMENT.--Section
18B(a)(3) of the Fair Labor Standards Act of 1938,
as added by section 1512, is amended--

(A) by inserting ''and the employer does
not offer a free choice voucher'' after ''Exchange'';
and
(B) by striking ''will lose'' and inserting
''may lose''.
(j) EMPLOYER REPORTING.--
(1) IN GENERAL.--Subsection (a) of section
6056 of the Internal Revenue Code of 1986, as
added by section 1514, is amended by inserting
''and every offering employer'' before ''shall''.
(2) OFFERING EMPLOYERS.--Subsection (f) of
section 6056 of such Code, as added by section
1514, is amended to read as follows:
''(f) DEFINITIONS.--For purposes of this section--
''(1) OFFERING EMPLOYER.--

''(A) IN GENERAL.--The term 'offering
employer' means any offering employer (as defined
in section 10108(b) of the Patient Protection
and Affordable Care Act) if the required
contribution (within the meaning of section
5000A(e)(1)(B)(i)) of any employee exceeds 8
percent of the wages (as defined in section
3121(a)) paid to such employee by such employer.

''(B) INDEXING.--In the case of any calendar
year beginning after 2014, the 8 percent
under subparagraph (A) shall be adjusted for
the calendar year to reflect the rate of premium
growth between the preceding calendar year
and 2013 over the rate of income growth for
such period.
''(2) OTHER DEFINITIONS.--Any term used in

this section which is also used in section 4980H
shall have the meaning given such term by section
4980H.''.

(3) CONFORMING AMENDMENTS.--
(A) The heading of section 6056 of such
Code, as added by section 1514, is amended by
striking ''LARGE'' and inserting ''CERTAIN''.
(B) Section 6056(b)(2)(C) of such Code is
amended--
(i) by inserting ''in the case of an applicable
large employer,'' before ''the
length'' in clause (i);
(ii) by striking ''and'' at the end of
clause (iii);
(iii) by striking ''applicable large employer''
in clause (iv) and inserting ''employer'';

(iv) by inserting ''and'' at the end of
clause (iv); and
(v) by inserting at the end the following
new clause:
''(v) in the case of an offering employer,
the option for which the employer
pays the largest portion of the cost of the
plan and the portion of the cost paid by
the employer in each of the enrollment categories
under such option,''.

(C) Section 6056(d)(2) of such Code is
amended by inserting ''or offering employer''
after ''applicable large employer''.
(D) Section 6056(e) of such Code is
amended by inserting ''or offering employer''
after ''applicable large employer''.
(E) Section 6724(d)(1)(B)(xxv) of such
Code, as added by section 1514, is amended by
striking ''large'' and inserting ''certain''.
(F) Section 6724(d)(2)(HH) of such Code,
as added by section 1514, is amended by striking
''large'' and inserting ''certain''.
(G) The table of sections for subpart D of
part III of subchapter A of chapter 1 of such
Code, as amended by section 1514, is amended

by striking ''Large employers'' in the item relating
to section 6056 and inserting ''Certain
employers''.

(4) EFFECTIVE DATE.--The amendments made
by this subsection shall apply to periods beginning
after December 31, 2013.
SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL

AND ADMINISTRATIVE TRANSACTIONS.

(a) ADDITIONAL TRANSACTION STANDARDS AND OPERATING
RULES.--
(1) DEVELOPMENT OF ADDITIONAL TRANSACTION
STANDARDS AND OPERATING RULES.--Section
1173(a) of the Social Security Act (42 U.S.C.
1320d-2(a)), as amended by section 1104(b)(2), is
amended--
(A) in paragraph (1)(B), by inserting before
the period the following: '', and subject to
the requirements under paragraph (5)''; and
(B) by adding at the end the following new
paragraph:
''(5) CONSIDERATION OF STANDARDIZATION OF
ACTIVITIES AND ITEMS.--

''(A) IN GENERAL.--For purposes of carrying
out paragraph (1)(B), the Secretary shall
solicit, not later than January 1, 2012, and not

less than every 3 years thereafter, input from

entities described in subparagraph (B) on--
''(i) whether there could be greater
uniformity in financial and administrative
activities and items, as determined appropriate
by the Secretary; and
''(ii) whether such activities should be
considered financial and administrative
transactions (as described in paragraph
(1)(B)) for which the adoption of standards
and operating rules would improve
the operation of the health care system
and reduce administrative costs.
''(B) SOLICITATION OF INPUT.--For pur

poses 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 CONSIDER-
ATION.--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-9TOICD-10 CROSSWALK.--The Secretary
shall task the ICD-9-CM Coordination and
Maintenance Committee to convene a meeting, not
later than January 1, 2011, to receive input from
appropriate stakeholders (including health plans,
health care providers, and clinicians) regarding the
crosswalk between the Ninth and Tenth Revisions of
the International Classification of Diseases (ICD-9
and ICD-10, respectively) that is posted on the
website of the Centers for Medicare & Medicaid
Services, and make recommendations about appropriate
revisions to such crosswalk.
(2) REVISION OF CROSSWALK.--For purposes
of the crosswalk described in paragraph (1), the Secretary
shall make appropriate revisions and post any
such revised crosswalk on the website of the Centers
for Medicare & Medicaid Services.

(3) USE OF REVISED CROSSWALK.--For purposes
of paragraph (2), any revised crosswalk shall
be treated as a code set for which a standard has
been adopted by the Secretary for purposes of section
1173(c)(1)(B) of the Social Security Act (42
U.S.C. 1320d-2(c)(1)(B)).
(4) SUBSEQUENT CROSSWALKS.--For subsequent
revisions of the International Classification of
Diseases that are adopted by the Secretary as a
standard code set under section 1173(c) of the Social
Security Act (42 U.S.C. 1320d-2(c)), the Secretary
shall, after consultation with the appropriate
stakeholders, post on the website of the Centers for
Medicare & Medicaid Services a crosswalk between
the previous and subsequent version of the International
Classification of Diseases not later than the
date of implementation of such subsequent revision.
Subtitle B--Provisions Relating to
Title II

PART I--MEDICAID AND CHIP

SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT

AND TITLE II OF THIS ACT.

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

94
''(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 sub

paragraph (G), by striking ''and (XV)'' and inserting
''(XV)'', and by inserting ''and (XVI) if an individual is
described in subclause (IX) of subparagraph (A)(i) and
is also described in subclause (VIII) of that subparagraph,
the medical assistance shall be made available to the individual
through subclause (IX) instead of through sub-
clause (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 hos

pital services,'' after ''100 percent of the poverty
line, that''; and

(B) in paragraph (2)(A), by striking ''on
the date of enactment of the Patient Protection
and Affordable Care Act'' and inserting ''as of
December 1, 2009'';
(4) by inserting after subsection (y) the following:
''(z) EQUITABLE SUPPORT FOR CERTAIN STATES.--
''(1)(A) During the period that begins on January
1, 2014, and ends on September 30, 2019, notwithstanding
subsection (b), the Federal medical assistance
percentage otherwise determined under subsection
(b) with respect to a fiscal year occurring
during that period shall be increased by 2.2 percentage
points for any State described in subparagraph

(B) for amounts expended for medical assistance for
individuals who are not newly eligible (as defined in
subsection (y)(2)) individuals described in subclause
(VIII) of section 1902(a)(10)(A)(i).
''(B) For purposes of subparagraph (A), a
State described in this subparagraph is a State
that--

''(i) is an expansion State described in subsection
(y)(1)(B)(ii)(II);

''(ii) the Secretary determines will not receive
any payments under this title on the basis
of an increased Federal medical assistance percentage
under subsection (y) for expenditures
for medical assistance for newly eligible individuals
(as so defined); and

''(iii) has not been approved by the Secretary
to divert a portion of the DSH allotment
for a State to the costs of providing medical assistance
or other health benefits coverage under
a waiver that is in effect on July 2009.

''(2)(A) During the period that begins on January
1, 2014, and ends on December 31, 2016, notwithstanding
subsection (b), the Federal medical assistance percentage
otherwise determined under subsection (b) with respect to
all or any portion of a fiscal year occurring during that
period shall be increased by .5 percentage point for a State
described in subparagraph (B) for amounts expended for
medical assistance under the State plan under this title
or under a waiver of that plan during that period.

''(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that--
''(i) is described in clauses (i) and (ii) of paragraph
(1)(B); and

''(ii) is the State with the highest percentage of
its population insured during 2008, based on the
Current Population Survey.
''(3) Notwithstanding subsection (b) and paragraphs

(1) and (2) of this subsection, the Federal medical assistance
percentage otherwise determined under subsection
(b) with respect to all or any portion of a fiscal year that
begins on or after January 1, 2017, for the State of Nebraska,
with respect to amounts expended for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i), shall be determined as provided for
under subsection (y)(1)(A) (notwithstanding the period
provided for in such paragraph).
''(4) The increase in the Federal medical assistance
percentage for a State under paragraphs (1), (2), or (3)
shall apply only for purposes of this title and shall not
apply with respect to--

''(A) disproportionate share hospital payments

described in section 1923;

''(B) payments under title IV;

''(C) payments under title XXI; and

''(D) payments under this title that are based

on the enhanced FMAP described in section
2105(b).'';

(5) in subsection (aa), is amended by striking
''without regard to this subsection and subsection
(y)'' and inserting ''without regard to this subsection,
subsection (y), subsection (z), and section
10202 of the Patient Protection and Affordable Care
Act'' each place it appears;
(6) by adding after subsection (bb), the following:
''(cc) REQUIREMENT FOR CERTAIN STATES.--Notwithstanding
subsections (y), (z), and (aa), in the case of
a State that requires political subdivisions within the State
to contribute toward the non-Federal share of expenditures
required under the State plan under section
1902(a)(2), the State shall not be eligible for an increase
in its Federal medical assistance percentage under such
subsections if it requires that political subdivisions pay a
greater percentage of the non-Federal share of such expenditures,
or a greater percentage of the non-Federal
share of payments under section 1923, than the respective
percentages that would have been required by the State
under the State plan under this title, State law, or both,
as in effect on December 31, 2009, and without regard
to any such increase. Voluntary contributions by a political
subdivision to the non-Federal share of expenditures
under the State plan under this title or to the non-Federal

100

share of payments under section 1923, shall not be considered
to be required contributions for purposes of this subsection.
The treatment of voluntary contributions, and the
treatment of contributions required by a State under the
State plan under this title, or State law, as provided by
this subsection, shall also apply to the increases in the
Federal medical assistance percentage under section 5001
of the American Recovery and Reinvestment Act of
2009.''.

(d) Section 1108(g)(4)(B) of the Social Security Act
(42 U.S.C. 1308(g)(4)(B)), as added by section 2005(b),
is amended by striking ''income eligibility level in effect
for that population under title XIX or under a waiver''
and inserting ''the highest income eligibility level in effect
for parents under the commonwealth's or territory's State
plan under title XIX or under a waiver of the plan''.
(e)(1) Section 1923(f) of the Social Security Act (42

U.S.C. 1396r-4(f)), as amended by section 2551, is
amended--
(A) in paragraph (6)--
(i) by striking the paragraph heading and
inserting the following: ''ALLOTMENT ADJUSTMENTS'';
and
(ii) in subparagraph (B), by adding at the
end the following:

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''(iii) ALLOTMENT FOR 2D, 3RD, AND

4TH QUARTER OF FISCAL YEAR 2012, FIS

CAL 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 PAY-
MENTS.--The Secretary may not impose
a limitation on the total amount
of payments made to hospitals under
the QUEST section 1115 Demonstra

102

tion 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)--

103

(I) in clause (i), by striking sub-
clauses (I) and (II), and inserting the following:
''(I) if the State is a low DSH
State described in paragraph (5)(B)
and has spent not more than 99.90
percent of the DSH allotments for the
State on average for the period of fiscal
years 2004 through 2008, as of
September 30, 2009, the applicable
percentage is equal to 25 percent;

''(II) if the State is a low DSH
State described in paragraph (5)(B)
and has spent more than 99.90 percent
of the DSH allotments for the
State on average for the period of fiscal
years 2004 through 2008, as of
September 30, 2009, the applicable
percentage is equal to 17.5 percent;

''(III) if the State is not a low
DSH State described in paragraph
(5)(B) and has spent not more than

99.90 percent of the DSH allotments
for the State on average for the period
of fiscal years 2004 through

104

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 sub-
clauses (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

105

preceding fiscal year and 27.5 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 the
product of the percentage reduction in
uncovered individuals for the fiscal
year from the preceding fiscal year
and 55 percent; and

106

(III) in subparagraph (E), by striking
''35 percent'' and inserting ''50 percent'';
and
(IV) by adding at the end the following:
''(G) NONAPPLICATION.--The preceding
provisions of this paragraph shall not apply to
the DSH allotment determined for the State of
Hawaii for a fiscal year under paragraph (6).''.

(f) Section 2551 of this Act is amended by striking
subsection (b).
(g) Section 2105(d)(3)(B) of the Social Security Act
(42 U.S.C. 1397ee(d)(3)(B)), as added by section

107

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

108

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

109

the implementation of the demonstration project;
and

''(E) a process for the periodic evaluation by
the Secretary of the demonstration project.
''(3) The Secretary shall annually report to Congress

concerning actions taken by the Secretary with respect to
applications for demonstration projects under this section.''.

(j) Subtitle F of title III of this Act is amended by
adding at the end the following:
''SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF AC

TION.

''(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).

110

''(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 devel

opment).

''(I) Section 3014 (quality measurement).

''(J) Section 3021 (Establishment of Cen

ter 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

111

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 PRO-
GRAM.--Notwithstanding section 1905(b) of the Social Security
Act (42 U.S.C. 1396d(b)), in the case of a balancing
incentive payment State, as defined in subsection
(b), that meets the conditions described in subsection (c),
during the balancing incentive period, the Federal medical
assistance percentage determined for the State under section
1905(b) of such Act and, if applicable, increased
under subsection (z) or (aa) shall be increased by the applicable
percentage points determined under subsection
(d) with respect to eligible medical assistance expenditures
described in subsection (e).
(b) BALANCING INCENTIVE PAYMENT STATE.--A
balancing incentive payment State is a State--
(1) in which less than 50 percent of the total
expenditures for medical assistance under the State
Medicaid program for a fiscal year for long-term

112

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

113

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

114

and supports under the State Medicaid program
for fiscal year 2009 are for home and community-
based services, the target spending percentage
for the State to achieve by not later than
October 1, 2015, is that 25 percent of the total
expenditures for long-term services and supports
under the State Medicaid program are for
home and community-based services.

(B) In the case of any other balancing incentive
payment State, the target spending percentage
for the State to achieve by not later
than October 1, 2015, is that 50 percent of the
total expenditures for long-term services and
supports under the State Medicaid program are
for home and community-based services.
(3) MAINTENANCE OF ELIGIBILITY REQUIRE-
MENTS.--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.

115

(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.

116

(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:

117

(A) SERVICES DATA.--Services data from
providers of non-institutionally-based long-term
services and supports described in subsection
(f)(1)(B) on a per-beneficiary basis and in accordance
with such standardized coding procedures
as the State shall establish in consultation
with the Secretary.
(B) QUALITY DATA.--Quality data on a selected
set of core quality measures agreed upon
by the Secretary and the State that are linked
to population-specific outcomes measures and
accessible to providers.
(C) OUTCOMES MEASURES.--Outcomes
measures data on a selected set of core population-
specific outcomes measures agreed upon
by the Secretary and the State that are accessible
to providers and include--
(i) measures of beneficiary and family
caregiver experience with providers;
(ii) measures of beneficiary and family
caregiver satisfaction with services; and
(iii) measures for achieving desired
outcomes appropriate to a specific beneficiary,
including employment, participa

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tion 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:

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(1) LONG-TERM SERVICES AND SUPPORTS DE-
FINED.--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.

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(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-RE

LATED PROVISIONS.

(a) Section 1311(c)(1) of this Act is amended by
striking ''and'' at the end of subparagraph (G), by striking

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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

122

that subparagraph are hereby deemed null, void, and
of no effect.

(3) Section 2105(c)(10) of the Social Security
Act (42 U.S.C. 1397ee(c)(10)) is amended--
(A) in subparagraph (A), in the first sentence,
by inserting before the period the following:
''if the offering of such a subsidy is
cost-effective, as defined for purposes of paragraph
(3)(A)'';
(B) by striking subparagraph (M); and
(C) by redesignating subparagraph (N) as
subparagraph (M).
(4) Section 2105(c)(3)(A) of the Social Security
Act (42 U.S.C. 1397ee(c)(3)(A)) is amended--
(A) in the matter preceding clause (i), by
striking ''to'' and inserting ''to--''; and
(B) in clause (ii), by striking the period
and inserting a semicolon.
(c) Section 2105 of the Social Security Act (42
U.S.C. 1397ee), as amended by section 2101, is amended--
(1) in subsection (b), in the second sentence, by
striking ''2013'' and inserting ''2015''; and
(2) in subsection (d)(3)--
(A) in subparagraph (A)--

123

(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

124

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

125

(B) by striking paragraph (16) and inserting
the following:
''(16) for fiscal year 2013, $17,406,000,000;
''(17) for fiscal year 2014, $19,147,000,000;

and
''(18) for fiscal year 2015, for purposes of making
2 semi-annual allotments--

''(A) $2,850,000,000 for the period beginning
on October 1, 2014, and ending on March
31, 2015, and

''(B) $2,850,000,000 for the period beginning
on April 1, 2015, and ending on September
30, 2015.''.

(2)(A) Section 2104(m) of such Act (42 U.S.C.
1397dd(m)), as amended by section 2102(a)(1), is amended--

(i) in the subsection heading, by striking
''2013'' and inserting ''2015'';
(ii) in paragraph (2)--
(I) in the paragraph heading, by striking
''2012'' and inserting ''2014''; and
(II) by adding at the end the following:
''(B) FISCAL YEARS 2013 AND 2014.--Subject
to paragraphs (4) and (6), from the
amount made available under paragraphs (16)

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and (17) of subsection (a) for fiscal years 2013

and 2014, respectively, the Secretary shall com

pute a State allotment for each State (including

the District of Columbia and each common

wealth 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--

127

''(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

128

(bb) in clause (ii)(II), by striking

''subsection (a)(16)(B)'' and inserting

''subsection (a)(18)(B)'';

(iv) in paragraph (4), by striking ''2013''
and inserting ''2015'';
(v) in paragraph (6)--
(I) in subparagraph (A), by striking
''2013'' and inserting ''2015''; and
(II) in the flush language after and
below subparagraph (B)(ii), by striking ''or
fiscal year 2012'' and inserting '', fiscal
year 2012, or fiscal year 2014''; and
(vi) in paragraph (8)--
(I) in the paragraph heading, by striking
''2013'' and inserting ''2015''; and
(II) by striking ''2013'' and inserting
''2015''.
(B) Section 2104(n) of such Act (42 U.S.C.
1397dd(n)) is amended--
(i) in paragraph (2)--
(I) in subparagraph (A)(ii)--
(aa) by striking ''2012'' and inserting
''2014''; and
(bb) by striking ''2013'' and inserting
''2015'';

129

(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.--

130

''(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.

131

''(C) HARDSHIP EXCEPTION.--For purposes
of subparagraph (A)(ii), this subparagraph
applies to a child if the State determines,
on a case-by-case basis, that the annual aggregate
amount of premiums and cost-sharing imposed
for coverage of the family of the child
would exceed 5 percent of such family's income
for the year involved.''.

(E) Section 2113 of such Act (42 U.S.C. 1397mm)
is amended--
(i) in subsection (a)(1), by striking ''2013'' and
inserting ''2015''; and
(ii) in subsection (g), by striking
''$100,000,000 for the period of fiscal years 2009
through 2013'' and inserting ''$140,000,000 for the
period of fiscal years 2009 through 2015''.
(F) Section 108 of Public Law 111-3 is amended by
striking ''$11,706,000,000'' and all that follows through
the second sentence and inserting ''$15,361,000,000 to
accompany the allotment made for the period beginning
on October 1, 2014, and ending on March 31, 2015, under
section 2104(a)(18)(A) of the Social Security Act (42
U.S.C. 1397dd(a)(18)(A)), to remain available until expended.
Such amount shall be used to provide allotments
to States under paragraph (3) of section 2104(m) of the

132

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 EDU-
CATION.--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

133

part, a pregnant and parenting student services office.

(3) COMMUNITY SERVICE CENTER.--The term
''community service center'' means a non-profit organization
that provides social services to residents
of a specific geographical area via direct service or
by contract with a local governmental agency.
(4) HIGH SCHOOL.--The term ''high school''
means any public or private school that operates
grades 10 through 12, inclusive, grades 9 through
12, inclusive or grades 7 through 12, inclusive.
(5) INTERVENTION SERVICES.--The term
''intervention services'' means, with respect to domestic
violence, sexual violence, sexual assault, or
stalking, 24-hour telephone hotline services for police
protection and referral to shelters.
(6) SECRETARY.--The term ''Secretary'' means
the Secretary of Health and Human Services.
(7) STATE.--The term ''State'' includes the
District of Columbia, any commonwealth, possession,
or other territory of the United States, and any Indian
tribe or reservation.
(8) SUPPORTIVE SOCIAL SERVICES.--The term
''supportive social services'' means transitional and
permanent housing, vocational counseling, and indi

134

vidual 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.

135

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

136

funding provided. The non-Federal share may be in
cash or in-kind, fairly evaluated, including services,
facilities, supplies, or equipment.

(4) USE OF FUNDS FOR ASSISTING PREGNANT
AND PARENTING COLLEGE STUDENTS.--An eligible
institution of higher education that receives funding
under this subsection shall use such funds to establish,
maintain or operate pregnant and parenting
student services and may use such funding for the
following programs and activities:
(A) Conduct a needs assessment on campus
and within the local community--
(i) to assess pregnancy and parenting
resources, located on the campus or within
the local community, that are available to
meet the needs described in subparagraph
(B); and
(ii) to set goals for--
(I) improving such resources for
pregnant, parenting, and prospective
parenting students; and
(II) improving access to such resources.
(B) Annually assess the performance of
the eligible institution in meeting the following

137

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

138

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 edu

139

cation receives funds under this subsection,
the eligible institution shall prepare and
submit to the State, by the date determined
by the State, a report that--

(I) itemizes the pregnant and
parenting student services office's expenditures
for the fiscal year;
(II) contains a review and evaluation
of the performance of the office
in fulfilling the requirements of this
section, using the specific performance
criteria or standards established
under subparagraph (B)(i); and
(III) describes the achievement of
the office in meeting the needs listed
in paragraph (4)(B) of the students
served by the eligible institution, and
the frequency of use of the office by
such students.
(ii) PERFORMANCE CRITERIA.--Not
later than 180 days before the date the annual
report described in clause (i) is submitted,
the State--
(I) shall identify the specific performance
criteria or standards that

140

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.--

141

(1) IN GENERAL.--A State may use amounts
received under a grant under section 10212 to make
funding available tp its State Attorney General to
assist Statewide offices in providing--
(A) intervention services, accompaniment,
and supportive social services for eligible pregnant
women who are victims of domestic violence,
sexual violence, sexual assault, or stalking.
(B) technical assistance and training (as
described in subsection (c)) relating to violence
against eligible pregnant women to be made
available to the following:
(i) Federal, State, tribal, territorial,
and local governments, law enforcement
agencies, and courts.
(ii) Professionals working in legal, social
service, and health care settings.
(iii) Nonprofit organizations.
(iv) Faith-based organizations.
(2) ELIGIBILITY.--To be eligible for a grant
under paragraph (1), a State Attorney General shall
submit an application to the designated State agency
at such time, in such manner, and containing such
information, as specified by the State.

142

(3) TECHNICAL ASSISTANCE AND TRAINING DE-
SCRIBED.--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

143

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.

144

PART III--INDIAN HEALTH CARE IMPROVEMENT
SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.

(a) IN GENERAL.--Except as provided in subsection
(b), S. 1790 entitled ''A bill to amend the Indian Health
Care Improvement Act to revise and extend that Act, and
for other purposes.'', as reported by the Committee on Indian
Affairs of the Senate in December 2009, is enacted
into law.
(b) AMENDMENTS.--
(1) Section 119 of the Indian Health Care Improvement
Act (as amended by section 111 of the
bill referred to in subsection (a)) is amended--
(A) in subsection (d)--
(i) in paragraph (2), by striking ''In
establishing'' and inserting ''Subject to
paragraphs (3) and (4), in establishing'';
and
(ii) by adding at the end the following:
''(3) ELECTION OF INDIAN TRIBE OR TRIBAL
ORGANIZATION.--
''(A) IN GENERAL.--Subparagraph (B) of
paragraph (2) shall not apply in the case of an
election made by an Indian tribe or tribal organization
located in a State (other than Alaska)
in which the use of dental health aide therapist

145

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--

146

(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 PRO

GRAM FOR AMBULATORY SURGICAL CEN

TERS.

(a) IN GENERAL.--Section 3006 is amended by adding
at the end the following new subsection:
''(f) AMBULATORY SURGICAL CENTERS.--
''(1) IN GENERAL.--The Secretary shall develop
a plan to implement a value-based purchasing program
for payments under the Medicare program
under title XVIII of the Social Security Act for ambulatory
surgical centers (as described in section

147

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 fol

lowing 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.

148

''(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 QUAL

ITY 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''.

149

SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.

(a) DEVELOPMENT.--Section 931 of the Public
Health Service Act, as added by section 3013(a), is
amended by adding at the end the following new subsection:
''(f) DEVELOPMENT OF OUTCOME MEASURES.--

''(1) IN GENERAL.--The Secretary shall develop,
and periodically update (not less than every 3
years), provider-level outcome measures for hospitals
and physicians, as well as other providers as determined
appropriate by the Secretary.

''(2) CATEGORIES OF MEASURES.--The measures
developed under this subsection shall include, to
the extent determined appropriate by the Secretary--

''(A) outcome measurement for acute and
chronic diseases, including, to the extent feasible,
the 5 most prevalent and resource-intensive
acute and chronic medical conditions; and

''(B) outcome measurement for primary
and preventative care, including, to the extent
feasible, measurements that cover provision of
such care for distinct patient populations (such
as healthy children, chronically ill adults, or infirm
elderly individuals).

150

''(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 cur

151

rently 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.''.

152

SEC. 10304. SELECTION OF EFFICIENCY MEASURES.

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

SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.
Section 399II(a) of the Public Health Service Act,

as added by section 3015, is amended to read as follows:
''(a) IN GENERAL.--
''(1) ESTABLISHMENT OF STRATEGIC FRAME-
WORK.--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 inter

153

operability 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

154

inserting ''this subparagraph may include,
but are not limited to,''; and

(ii) by inserting after the first sentence
the following new sentence: ''The
Secretary shall focus on models expected to
reduce program costs under the applicable
title while preserving or enhancing the
quality of care received by individuals receiving
benefits under such title.'';
(B) in subparagraph (B), by adding at the
end the following new clauses:
''(xix) Utilizing, in particular in entities
located in medically underserved areas
and facilities of the Indian Health Service
(whether operated by such Service or by an
Indian tribe or tribal organization (as
those terms are defined in section 4 of the
Indian Health Care Improvement Act)),
telehealth services--

''(I) in treating behavioral health
issues (such as post-traumatic stress
disorder) and stroke; and

''(II) to improve the capacity of
non-medical providers and non-specialized
medical providers to provide

155

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-

156

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:

157

''(i) OPTION TO USE OTHER PAYMENT MODELS.--

''(1) IN GENERAL.--If the Secretary determines
appropriate, the Secretary may use any of the payment
models described in paragraph (2) or (3) for
making payments under the program rather than
the payment model described in subsection (d).

''(2) PARTIAL CAPITATION MODEL.--

''(A) IN GENERAL.--Subject to subparagraph
(B), a model described in this paragraph
is a partial capitation model in which an ACO
is at financial risk for some, but not all, of the
items and services covered under parts A and
B, such as at risk for some or all physicians'
services or all items and services under part B.
The Secretary may limit a partial capitation
model to ACOs that are highly integrated systems
of care and to ACOs capable of bearing
risk, as determined to be appropriate by the
Secretary.

''(B) NO ADDITIONAL PROGRAM EXPENDITURES.--
Payments to an ACO for items and
services under this title for beneficiaries for a
year under the partial capitation model shall be
established in a manner that does not result in
spending more for such ACO for such bene

158

ficiaries 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 EXPENDI-
TURES.--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

159

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

160

that such expansion would reduce program
spending under such title XVIII; and

''(iii) the Secretary determines that
such expansion would not deny or limit the
coverage or provision of benefits under this
title for individuals.''; and

(3) by striking subsection (g) and inserting the
following new subsection:
''(g) APPLICATION OF PILOT PROGRAM TO CONTINUING
CARE HOSPITALS.--
''(1) IN GENERAL.--In conducting the pilot program,
the Secretary shall apply the provisions of the
program so as to separately pilot test the continuing
care hospital model.
''(2) SPECIAL RULES.--In pilot testing the continuing
care hospital model under paragraph (1), the
following rules shall apply:
''(A) Such model shall be tested without
the limitation to the conditions selected under
subsection (a)(2)(B).

''(B) Notwithstanding subsection
(a)(2)(D), an episode of care shall be defined as
the full period that a patient stays in the continuing
care hospital plus the first 30 days following
discharge from such hospital.

161

''(3) CONTINUING CARE HOSPITAL DEFINED.--
In this subsection, the term 'continuing care hospital'
means an entity that has demonstrated the
ability to meet patient care and patient safety standards
and that provides under common management
the medical and rehabilitation services provided in
inpatient rehabilitation hospitals and units (as defined
in section 1886(d)(1)(B)(ii)), long term care
hospitals (as defined in section1886(d)(1)(B)(iv)(I)),
and skilled nursing facilities (as defined in section
1819(a)) that are located in a hospital described in
section 1886(d).''.

(b) TECHNICAL AMENDMENTS.--
(1) Section 3023 is amended by striking
''1886C'' and inserting ''1866C''.
(2) Title XVIII of the Social Security Act is
amended by redesignating section 1866D, as added
by section 3024, as section 1866E.
SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS RE

DUCTION 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 pay

162

ments (in addition to the payments described in paragraph
(2)(A)(ii)) for such a discharge to such hospital under
subsection (d) (or section 1814(b)(3), as the case may be)
in an amount equal to the product of''.

SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.

The provisions of, and the amendment made by, section
3101 are repealed
SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE

ADD-ONS.

(a) GROUND AMBULANCE.--Section 1834(l)(13)(A)
of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)),
as amended by section 3105(a), is further amended--
(1) in the matter preceding clause (i)--
(A) by striking ''2007, for'' and inserting
''2007, and for''; and
(B) by striking ''2010, and for such services
furnished on or after April 1, 2010, and
before January 1, 2011'' and inserting ''2011'';
and
(2) in each of clauses (i) and (ii)--
(A) by striking '', and on or after April 1,
2010, and before January 1, 2011'' each place
it appears; and

163

(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 MORATO

RIUM 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

164

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 DEMONSTRA

TION 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).

165

''(2) EXPANSION OF DEMONSTRATION
STATES.--Notwithstanding subsection (a)(2), during
the 5-year extension period, the Secretary shall expand
the number of States with low population densities
determined by the Secretary under such subsection
to 20. In determining which States to include
in such expansion, the Secretary shall use the same
criteria and data that the Secretary used to determine
the States under such subsection for purposes
of the initial 5-year period.

''(3) INCREASE IN MAXIMUM NUMBER OF HOSPITALS
PARTICIPATING IN THE DEMONSTRATION
PROGRAM.--Notwithstanding subsection (a)(4), during
the 5-year extension period, not more than 30
rural community hospitals may participate in the
demonstration program under this section.

''(4) HOSPITALS IN DEMONSTRATION PROGRAM
ON DATE OF ENACTMENT.--In the case of a rural
community hospital that is participating in the demonstration
program under this section as of the last
day of the initial 5-year period, the Secretary--

''(A) shall provide for the continued par

ticipation of such rural community hospital in

the demonstration program during the 5-year

extension period unless the rural community

166

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''.

167

SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PRO

VISION.

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 PROVI

SIONS.

(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.--

168

''(1) IN GENERAL.--The Secretary of Health
and Human Services (in this section referred to as
the 'Secretary') shall conduct a study on home
health agency costs involved with providing ongoing
access to care to low-income Medicare beneficiaries
or beneficiaries in medically underserved areas, and
in treating beneficiaries with varying levels of severity
of illness. In conducting the study, the Secretary
may analyze items such as the following:

''(A) Methods to potentially revise the
home health prospective payment system under
section 1895 of the Social Security Act (42

U.S.C. 1395fff) to account for costs related to
patient severity of illness or to improving beneficiary
access to care, such as--
''(i) payment adjustments for services
that may involve additional or fewer resources;

''(ii) changes to reflect resources involved
with providing home health services
to low-income Medicare beneficiaries or
Medicare beneficiaries residing in medically
underserved areas;

''(iii) ways outlier payments might be
revised to reflect costs of treating Medicare

169

beneficiaries with high levels of severity of
illness; and

''(iv) other issues determined appropriate
by the Secretary.
''(B) Operational issues involved with po

tential 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 con

sider 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;

170

''(C) the presence of severe or chronic diseases,
which might be measured by multiple,
discontinuous home health episodes;

''(D) poverty status, such as evidenced by
the receipt of Supplemental Security Income
under title XVI of the Social Security Act; and

''(E) other factors determined appropriate
by the Secretary.
''(3) REPORT.--Not later than March 1, 2014,

the Secretary shall submit to Congress a report on
the study conducted under paragraph (1), together
with recommendations for such legislation and administrative
action as the Secretary determines appropriate.

''(4) CONSULTATIONS.--In conducting the
study under paragraph (1), the Secretary shall consult
with appropriate stakeholders, such as groups
representing home health agencies and groups representing
Medicare beneficiaries.

''(5) MEDICARE DEMONSTRATION PROJECT
BASED ON THE RESULTS OF THE STUDY.--

''(A) IN GENERAL.--Subject to subparagraph
(D), taking into account the results of
the study conducted under paragraph (1), the
Secretary may, as determined appropriate, pro

171

vide 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 applica

ble for such services after such period.

172

''(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--

173

''(i) provide for an evaluation of the
project; and

''(ii) submit to Congress, by a date
specified by the Secretary, a report on the
project.
''(G) ADMINISTRATION.--Chapter 35 of

title 44, United States Code, shall not apply
with respect to this subsection.''.

SEC. 10316. MEDICARE DSH.

Section 1886(r)(2)(B) of the Social Security Act, as
added by section 3133, is amended--

(1) in clause (i)--
(A) in the matter preceding subclause (I),
by striking ''(divided by 100)'';
(B) in subclause (I), by striking ''2012''
and inserting ''2013'';
(C) in subclause (II), by striking the period
at the end and inserting a comma; and
(D) by adding at the end the following
flush matter:
''minus 1.5 percentage points.''.

(2) in clause (ii)--
(A) in the matter preceding subclause (I),
by striking ''(divided by 100)'';

174

(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), includ

175

ing (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 reclassi

fication, the Secretary shall include the average

hourly wage data of hospitals whose reclassi

fication was extended pursuant to the amend

ment made by paragraph (1) only if including

such data results in a higher applicable reclassi

fied wage index.

''(3) ADJUSTMENT FOR CERTAIN HOSPITALS IN

FISCAL YEAR 2010.--

176

''(A) IN GENERAL.--In the case of a subsection
(d) hospital (as defined in subsection
(d)(1)(B) of section 1886 of the Social Security
Act (42 U.S.C. 1395ww)) with respect to
which--

''(i) a reclassification of its wage
index for purposes of such section was extended
pursuant to the amendment made
by paragraph (1); and

''(ii) the wage index applicable for
such hospital for the period beginning on
October 1, 2009, and ending on March 31,
2010, was lower than for the period beginning
on April 1, 2010, and ending on September
30, 2010, by reason of the application
of paragraph (2)(B);

the Secretary shall pay such hospital an additional
payment that reflects the difference between
the wage index for such periods.

''(B) TIMEFRAME FOR PAYMENTS.--The
Secretary shall make payments required under
subparagraph by not later than December 31,
2010.''.

177

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)--

178

(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);

179

(3) by inserting after subclause (II) the following
new subclause:
''(II) for each of fiscal years
2012 and 2013, 0.1 percentage point;
and''; and

(4) in subclause (III), as redesignated by paragraph
(2), by striking ''2012'' and inserting ''2014''.
(d) HOME HEALTH AGENCIES.--Section
1895(b)(3)(B)(vi)(II) of such Act, as added by section
3401(e), is amended by striking ''and 2012'' and inserting
'', 2012, and 2013''.
(e) PSYCHIATRIC HOSPITALS.--Section
1886(s)(3)(A) of the Social Security Act, as added by section
3401(f), is amended--
(1) in clause (i), by striking ''and'' at the end;
(2) by redesignating clause (ii) as clause (iii);
(3) by inserting after clause (ii) the following
new clause:
''(ii) for each of the rate years beginning
in 2012 and 2013, 0.1 percentage
point; and''; and

(4) in clause (iii), as redesignated by paragraph
(2), by striking ''2012'' and inserting ''2014''.

180

(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 sub-
clause (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 ADDI

TIONAL IMPROVEMENTS TO, THE INDE

PENDENT MEDICARE ADVISORY BOARD.

(a) IN GENERAL.--Section 1899A of the Social Security
Act, as added by section 3403, is amended--

181

(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.'';

182

(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)--

183

(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

184

(ii) by inserting ''subsection
(c)(3)(A)(i) or'' after ''the Senate under'';
and
(B) in paragraph (2)(A), by inserting ''the
Board or'' after ''a proposal is submitted by'';
(3) in subsection (e)--
(A) in paragraph (1), by inserting ''the
Board or'' after ''a proposal submitted by''; and
(B) in paragraph (3)--
(i) by striking ''EXCEPTION.--The
Secretary shall not be required to implement
the recommendations contained in a
proposal submitted in a proposal year by''
and inserting ''EXCEPTIONS.--
''(A) IN GENERAL.--The Secretary shall
not implement the recommendations contained
in a proposal submitted in a proposal year by
the Board or'';

(ii) by redesignating subparagraphs
(A) and (B) as clauses (i) and (ii), respectively,
and indenting appropriately; and
(iii) by adding at the end the following
new subparagraph:
''(B) LIMITED ADDITIONAL EXCEPTION.--

185

''(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 EXCEP

TION 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

186

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

187

(5) by adding at the end the following new subsections:
''(n) ANNUAL PUBLIC REPORT.--
''(1) IN GENERAL.--Not later than July 1,
2014, and annually thereafter, the Board shall
produce a public report containing standardized information
on system-wide health care costs, patient
access to care, utilization, and quality-of-care that
allows for comparison by region, types of services,
types of providers, and both private payers and the
program under this title.

''(2) REQUIREMENTS.--Each report produced
pursuant to paragraph (1) shall include information
with respect to the following areas:

''(A) The quality and costs of care for the
population at the most local level determined
practical by the Board (with quality and costs
compared to national benchmarks and reflecting
rates of change, taking into account quality
measures described in section 1890(b)(7)(B)).

''(B) Beneficiary and consumer access to
care, patient and caregiver experience of care,
and the cost-sharing or out-of-pocket burden on
patients.

188

''(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;

189

''(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 recommenda

tions 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 sec

190

tion 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 HOS

PITALS.

(a) IN GENERAL.--Section 1886(s) of the Social Security
Act, as added by section 3401(f), is amended by
adding at the end the following new paragraph:
''(4) QUALITY REPORTING.--

''(A) REDUCTION IN UPDATE FOR FAILURE

TO REPORT.--

''(i) IN GENERAL.--Under the system
described in paragraph (1), for rate year
2014 and each subsequent rate year, in the
case of a psychiatric hospital or psychiatric
unit that does not submit data to the Secretary
in accordance with subparagraph

(C) with respect to such a rate year, any
annual update to a standard Federal rate
for discharges for the hospital during the
rate year, and after application of para

191

graph (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.--

192

''(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 SUB-

MITTED.--The Secretary shall establish proce

dures for making data submitted under sub

paragraph (C) available to the public. Such pro

193

cedures shall ensure that a psychiatric hospital
and a psychiatric unit has the opportunity to
review the data that is to be made public with
respect to the hospital or unit prior to such
data being made public. The Secretary shall report
quality measures that relate to services
furnished in inpatient settings in psychiatric
hospitals and psychiatric units on the Internet
website of the Centers for Medicare & Medicaid
Services.''.

(b) CONFORMING AMENDMENT.--Section
1890(b)(7)(B)(i)(I) of the Social Security Act, as added
by section 3014, is amended by inserting
''1886(s)(4)(D),'' after ''1886(o)(2),''.
SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EX

POSED TO ENVIRONMENTAL HEALTH HAZ

ARDS.

(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 EX

POSED TO ENVIRONMENTAL HEALTH HAZ

ARDS.

''(a) DEEMING OF INDIVIDUALS AS ELIGIBLE FOR
MEDICARE BENEFITS.--

194

''(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 In

dividual 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 INDI

VIDUALS RESIDING IN EMERGENCY DECLARATION

AREAS.--
''(1) PROGRAM; PURPOSE.--

195

''(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 para

graph 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

196

to an emergency declaration made as of June
17, 2009; or

''(B) is an environmental exposure affected
individual described in subsection (e)(3) who--
''(i) is deemed under subsection

(a)(2); and

''(ii) meets such other criteria or conditions
for participation in a pilot program
under paragraph (1)(B) as the Secretary
specifies.

''(3) FLEXIBLE BENEFITS AND SERVICES.--A
pilot program under this subsection may provide for
the furnishing of benefits, items, or services not otherwise
covered or authorized under this title, if the
Secretary determines that furnishing such benefits,
items, or services will further the purposes of such
pilot program (as described in paragraph (1)).

''(4) INNOVATIVE REIMBURSEMENT METH-
ODOLOGIES.--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 serv

197

ices are furnished pursuant to paragraph (3);

and

''(B) may develop and implement innova

tive 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

198

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 SECU-
RITY.--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.

199

''(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 ac

200

tions 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 pur

poses 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 stand

ards as the Secretary specifies,
except that this clause shall not apply to
pleural thickening or pleural plaques unless

201

there are symptoms or conditions requiring
medical treatment as a result of these diagnoses.

''(ii) Mesothelioma, or malignancies of
the lung, colon, rectum, larynx, stomach,
esophagus, pharynx, or ovary, as established
by--

''(I) pathologic examination of biopsy
tissue;
''(II) cytology from
bronchioalveolar lavage; or

''(III) such other diagnostic
standards as the Secretary specifies.
''(iii) Any other diagnosis which the

Secretary, in consultation with the Commissioner
of Social Security, determines is
an asbestos-related medical condition, as
established by such diagnostic standards as
the Secretary specifies.

''(3) OTHER INDIVIDUAL DESCRIBED.--An individual
described in this paragraph is any individual
who--

''(A) is not an individual described in paragraph
(2);

202

''(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:

203

''SEC. 2009. PROGRAM FOR EARLY DETECTION OF CERTAIN

MEDICAL CONDITIONS RELATED TO ENVI

RONMENTAL 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.

204

''(2) TYPES OF ELIGIBLE ENTITIES.--The entities
described in this paragraph are the following:
''(A) A hospital or community health cen

ter.
''(B) A Federally qualified health center.
''(C) A facility of the Indian Health Serv

ice.
''(D) A National Cancer Institute-designated
cancer center.
''(E) An agency of any State or local gov

ernment.
''(F) A nonprofit organization.
''(G) Any other entity the Secretary deter

mines appropriate.
''(c) DEFINITIONS.--In this section:
''(1) AT-RISK INDIVIDUAL.--The term 'at-risk
individual' means an individual who--

''(A)(i) as demonstrated in such manner as
the Secretary determines appropriate, has been
present for an aggregate total of 6 months in
the geographic area subject to an emergency
declaration specified under paragraph (2), during
a period ending--

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''(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 Sec

retary 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--

206

''(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.

207

''(4) HAZARDOUS SUBSTANCE; POLLUTANT;
CONTAMINANT.--The terms 'hazardous substance',
'pollutant', and 'contaminant' have the meanings
given those terms in section 101 of the Comprehensive
Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9601).

''(5) SUPERFUND SITE.--The term 'Superfund
site' means a site included on the National Priorities
List developed by the President in accordance with
section 105(a)(8)(B) of the Comprehensive Environmental
Response, Compensation, and Liability Act
of 1980 (42 U.S.C. 9605(a)(8)(B)).
''(d) HEALTH COVERAGE UNAFFECTED.--Nothing in

this section shall be construed to affect any coverage obligation
of a governmental or private health plan or program
relating to an at-risk individual.

''(e) FUNDING.--

''(1) IN GENERAL.--Out of any funds in the
Treasury not otherwise appropriated, there are appropriated
to the Secretary, to carry out the program
under this section--

''(A) $23,000,000 for the period of fiscal
years 2010 through 2014; and
''(B) $20,000,000 for each 5-fiscal year
period thereafter.

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''(2) AVAILABILITY.--Funds appropriated

under paragraph (1) shall remain available until ex

pended.

''(f) NONAPPLICATION.--

''(1) IN GENERAL.--Except as provided in para

graph (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:

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''(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 DE-
FINED.--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 DE-
FINED.--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).''.

210

(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 sub

211

section 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

212

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 PRO

SPECTIVE PAYMENT SYSTEM.

(a) TEMPORARY DELAY OF RUG-IV.--Notwithstanding
any other provision of law, the Secretary of
Health and Human Services shall not, prior to October
1, 2011, implement Version 4 of the Resource Utilization
Groups (in this subsection refereed to as ''RUG-IV'') published
in the Federal Register on August 11, 2009, entitled
''Prospective Payment System and Consolidated Billing
for Skilled Nursing Facilities for FY 2010; Minimum
Data Set, Version 3.0 for Skilled Nursing Facilities and
Medicaid Nursing Facilities'' (74 Fed. Reg. 40288). Be

213

ginning 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 PRO

GRAMS 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:

214

(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 pur

215

chasing program for such year than would otherwise be
expended for such provider type for such year if the pilot
program were not implemented, as estimated by the Secretary.

(e) EXPANSION OF PILOT PROGRAM.--The Secretary
may, at any point after January 1, 2018, expand the duration
and scope of a pilot program conducted under this
subsection, to the extent determined appropriate by the
Secretary, if--
(1) the Secretary determines that such expansion
is expected to--
(A) reduce spending under title XVIII of
the Social Security Act without reducing the
quality of care; or
(B) improve the quality of care and reduce
spending;
(2) the Chief Actuary of the Centers for Medicare
& Medicaid Services certifies that such expansion
would reduce program spending under such title
XVIII; and
(3) the Secretary determines that such expansion
would not deny or limit the coverage or provision
of benefits under such title XIII for Medicare
beneficiaries.

216

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 para

graph (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--

217

''(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

218

be in the form of a structural measure);

''(II) if requested by the Secretary,
on the survey of patient experience
with care (as described in subparagraph
(C)(ii)(II)); and

''(III) as the Secretary may require,
on the methods, measures, and
data used under the Maintenance of
Certification Program and the qualified
Maintenance of Certification Program
practice assessment.
''(C) DEFINITIONS.--For purposes of this

paragraph:
''(i) The term 'Maintenance of Certification
Program' means a continuous assessment
program, such as qualified American
Board of Medical Specialties Maintenance
of Certification program or an
equivalent program (as determined by the
Secretary), that advances quality and the
lifelong learning and self-assessment of
board certified specialty physicians by focusing
on the competencies of patient care,
medical knowledge, practice-based learning,

219

interpersonal and communication skills and

professionalism. Such a program shall in

clude 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).

220

''(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 Pro

221

gram and successful completion of a qualified Maintenance
of Certification Program practice assessment
into the composite of measures of quality of
care furnished pursuant to the physician fee schedule
payment modifier, as described in section
1848(p)(2) of the Social Security Act (42 U.S.C.
1395w-4(p)(2)).''.

(c) ELIMINATION OF MA REGIONAL PLAN STABILIZATION
FUND.--
(1) IN GENERAL.--Section 1858 of the Social
Security Act (42 U.S.C. 1395w-27a) is amended by
striking subsection (e).
(2) TRANSITION.--Any amount contained in the
MA Regional Plan Stabilization Fund as of the date
of the enactment of this Act shall be transferred to
the Federal Supplementary Medical Insurance Trust
Fund.
SEC. 10328. IMPROVEMENT IN PART D MEDICATION THER

APY 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

222

(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 pre

223

scriber 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 sub-
clause (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.

224

''(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 includ

225

ing 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 & MED

ICAID SERVICES TO SUPPORT IMPROVE

MENTS IN CARE DELIVERY.

(a) IN GENERAL.--The Secretary of Health and
Human Services (in this section referred to as the ''Sec

226

retary'') shall develop a plan (and detailed budget for the
resources needed to implement such plan) to modernize
the computer and data systems of the Centers for Medicare
& Medicaid Services (in this section referred to as
''CMS'').

(b) CONSIDERATIONS.--In developing the plan, the
Secretary shall consider how such modernized computer
system could--
(1) in accordance with the regulations promulgated
under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996, make
available data in a reliable and timely manner to
providers of services and suppliers to support their
efforts to better manage and coordinate care furnished
to beneficiaries of CMS programs; and
(2) support consistent evaluations of payment
and delivery system reforms under CMS programs.
(c) POSTING OF PLAN.--By not later than 9 months
after the date of the enactment of this Act, the Secretary
shall post on the website of the Centers for Medicare &
Medicaid Services the plan described in subsection (a).
SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFOR

MATION.

(a) IN GENERAL.--

227

(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;

228

(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,

229

as determined by the Secretary, to review his or her
individual results before they are made public;

(3) processes by the Secretary to assure that
the implementation of the plan and the data made
available on Physician Compare provide a robust
and accurate portrayal of a physician's performance;
(4) data that reflects the care provided to all
patients seen by physicians, under both the Medicare
program and, to the extent practicable, other payers,
to the extent such information would provide a more
accurate portrayal of physician performance;
(5) processes to ensure appropriate attribution
of care when multiple physicians and other providers
are involved in the care of a patient;
(6) processes to ensure timely statistical performance
feedback is provided to physicians concerning
the data reported under any program subject
to public reporting under this section; and
(7) implementation of computer and data systems
of the Centers for Medicare & Medicaid Services
that support valid, reliable, and accurate public
reporting activities authorized under this section.
(c) ENSURING PATIENT PRIVACY.--The Secretary
shall ensure that information on physician performance
and patient experience is not disclosed under this section

230

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

231

with recommendations for such legislation and administrative
action as the Secretary determines appropriate.

(g) EXPANSION.--At any time before the date on
which the report is submitted under subsection (f), the
Secretary may expand (including expansion to other providers
of services and suppliers under title XVIII of the
Social Security Act) the information made available on
such website.
(h) FINANCIAL INCENTIVES TO ENCOURAGE CONSUMERS
TO CHOOSE HIGH QUALITY PROVIDERS.--The
Secretary may establish a demonstration program, not
later than January 1, 2019, to provide financial incentives
to Medicare beneficiaries who are furnished services by
high quality physicians, as determined by the Secretary
based on factors in subparagraphs (A) through (G) of subsection
(a)(2). In no case may Medicare beneficiaries be
required to pay increased premiums or cost sharing or be
subject to a reduction in benefits under title XVIII of the
Social Security Act as a result of such demonstration program.
The Secretary shall ensure that any such demonstration
program does not disadvantage those beneficiaries
without reasonable access to high performing physicians
or create financial inequities under such title.
(i) DEFINITIONS.--In this section:

232

(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 PER

FORMANCE 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.

233

''(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

234

under this subsection at a fee equal to the cost
of making such data available. Any fee collected
pursuant to the preceding sentence shall be deposited
into the Federal Supplementary Medical
Insurance Trust Fund under section 1841.

''(B) SPECIFICATION OF USES AND METHODOLOGIES.--
A qualified entity requesting data
under this subsection shall--

''(i) submit to the Secretary a description
of the methodologies that such qualified
entity will use to evaluate the performance
of providers of services and suppliers
using such data;

''(ii)(I) except as provided in sub-
clause (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 pref

235

erences, 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 avail

able under this subsection shall--
''(i) include an understandable description
of the measures, which shall in

236

clude 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 de

scribed in paragraph (3) available to a qualified

entity unless the qualified entity agrees to re

lease the information on the evaluation of per

237

formance of providers of services and suppliers.
Such entity shall only use such data, and information
derived from such evaluation, for the reports
under subparagraph (C). Data released to
a qualified entity under this subsection shall
not be subject to discovery or admission as evidence
in judicial or administrative proceedings
without consent of the applicable provider of
services or supplier.''.

(b) EFFECTIVE DATE.--The amendment made by
subsection (a) shall take effect on January 1, 2012.
SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE

NETWORKS.

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

''Subpart XI--Community-Based Collaborative Care
Network Program
''SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE

NETWORK PROGRAM.

''(a) IN GENERAL.--The Secretary may award grants
to eligible entities to support community-based collaborative
care networks that meet the requirements of subsection
(b).

238

''(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 Sec

retary shall give priority to networks that include--
''(A) the capability to provide the broadest
range of services to low-income individuals;

239

''(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.

240

''(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

241

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

242

and ethnic minorities, and shall develop measures
to evaluate the effectiveness of activities
aimed at reducing health disparities and supporting
the local community. Such measures
shall evaluate community outreach activities,
language services, workforce cultural competence,
and other areas as determined by the
Secretary.''; and

(B) by striking subsection (h) and inserting
the following:
''(h) AUTHORIZATION OF APPROPRIATIONS.--For the
purpose of carrying out this section, there are authorized
to be appropriated such sums as may be necessary for
each of fiscal years 2011 through 2016.''.

(2) TRANSFER OF FUNCTIONS.--There are
transferred to the Office of Minority Health in the
office of the Secretary of Health and Human Services,
all duties, responsibilities, authorities, accountabilities,
functions, staff, funds, award mechanisms,
and other entities under the authority of the Office
of Minority Health of the Public Health Service as
in effect on the date before the date of enactment
of this Act, which shall continue in effect according
to the terms in effect on the date before such date
of enactment, until modified, terminated, super

243

seded, 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:

244

''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 Serv

245

ices) is deemed to be a reference to the Office of Minority

Health in the Office of the Secretary.
''(e) FUNDING.--
''(1) ALLOCATIONS.--Of the amounts appropriated
for a specified agency for a fiscal year, the
Secretary must designate an appropriate amount of
funds for the purpose of carrying out activities
under this section through the minority health office
of the agency. In reserving an amount under the
preceding sentence for a minority health office for a
fiscal year, the Secretary shall reduce, by substantially
the same percentage, the amount that otherwise
would be available for each of the programs of
the designated agency involved.
''(2) AVAILABILITY OF FUNDS FOR STAFF-
ING.--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.

246

(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--

247

(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:

248

''(h) INTERAGENCY COORDINATION.--The Director
of the Institute, as the primary Federal officials with responsibility
for coordinating all research and activities
conducted or supported by the National Institutes of
Health on minority health and health disparities, shall
plan, coordinate, review and evaluate research and other
activities conducted or supported by the Institutes and
Centers of the National Institutes of Health.''.

(3) TECHNICAL AND CONFORMING AMENDMENTS.--
(A) Section 401(b)(24) of the Public
Health Service Act (42 U.S.C. 281(b)(24)) is
amended by striking ''Center'' and inserting
''Institute''.
(B) Subsection (d)(1) of section 903 of the
Public Health Service Act (42 U.S.C. 299a-
1(d)(1)) is amended by striking ''section 485E''
and inserting ''section 464z-3''.
SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL

VALUE-BASED PURCHASING PROGRAM.

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

249

SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENE

FICIARY 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;

250

(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''.

251
(b) Section 4002(c) of this Act is amended--
(1) by striking ''research and health
screenings'' and inserting ''research, health
screenings, and initiatives''; and

(2) by striking ''for Preventive'' and inserting
''Regarding Preventive''.
(c) Section 4004(a)(4) of this Act is amended by
striking ''a Gateway'' and inserting ''an Exchange''.
SEC. 10402. AMENDMENTS TO SUBTITLE B.

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

252

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 COINSUR

ANCE FOR PREVENTIVE SERVICES.

Section 4104(b) of this Act is amended to read as
follows:

253

''(b) PAYMENT AND ELIMINATION OF COINSURANCE

IN ALL SETTINGS.--Section 1833(a)(1) of the Social Se

curity Act (42 U.S.C. 1395l(a)(1)), as amended by section

4103(c)(1), is amended--
''(1) in subparagraph (T), by inserting '(or 100
percent if such services are recommended with a
grade of A or B by the United States Preventive
Services Task Force for any indication or population
and are appropriate for the individual)' after '80
percent';
''(2) in subparagraph (W)--
''(A) in clause (i), by inserting '(if such
subparagraph were applied, by substituting
''100 percent'' for ''80 percent'')' after 'subparagraph
(D)'; and
''(B) in clause (ii), by striking '80 percent'
and inserting '100 percent';
''(3) by striking 'and' before '(X)'; and
''(4) by inserting before the semicolon at the
end the following: ', and (Y) with respect to preventive
services described in subparagraphs (A) and (B)
of section 1861(ddd)(3) that are appropriate for the
individual and, in the case of such services described
in subparagraph (A), are recommended with a grade
of A or B by the United States Preventive Services

254

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--

255

(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--

256

(A) promote the education and training of
physicians on the importance of birth and death
certificate data and how to properly complete
these documents, including the collection of
such data for diabetes and other chronic diseases;
(B) encourage State adoption of the latest
standard revisions of birth and death certificates;
and
(C) work with States to re-engineer their
vital statistics systems in order to provide cost-
effective, timely, and accurate vital systems
data.
(2) DEATH CERTIFICATE ADDITIONAL LAN-
GUAGE.--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

257

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.

258

(2) ELIGIBLE EMPLOYER.--The term ''eligible
employer'' means an employer (including a non-profit
employer) that--
(A) employs less than 100 employees who
work 25 hours or greater per week; and
(B) does not provide a workplace wellness
program as of the date of enactment of this
Act.
(c) COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS.--
(1) CRITERIA.--The Secretary shall develop
program criteria for comprehensive workplace
wellness programs under this section that are based
on and consistent with evidence-based research and
best practices, including research and practices as
provided in the Guide to Community Preventive
Services, the Guide to Clinical Preventive Services,
and the National Registry for Effective Programs.
(2) REQUIREMENTS.--A comprehensive workplace
wellness program shall be made available by an
eligible employer to all employees and include the
following components:
(A) Health awareness initiatives (including
health education, preventive screenings, and
health risk assessments).

259

(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.

260

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:

261

''SEC. 402C. CURES ACCELERATION NETWORK.

''(a) DEFINITIONS.--In this section:

''(1) BIOLOGICAL PRODUCT.--The term 'bio

logical product' has the meaning given such term in

section 351 of the Public Health Service Act.

''(2) DRUG; DEVICE.--The terms 'drug' and
'device' have the meanings given such terms in section
201 of the Federal Food, Drug, and Cosmetic
Act.

''(3) HIGH NEED CURE.--The term 'high need
cure' means a drug (as that term is defined by section
201(g)(1) of the Federal Food, Drug, and Cosmetic
Act, biological product (as that term is defined
by section 262(i)), or device (as that term is defined
by section 201(h) of the Federal Food, Drug, and
Cosmetic Act) that, in the determination of the Director
of NIH--

''(A) is a priority to diagnose, mitigate,
prevent, or treat harm from any disease or condition;
and

''(B) for which the incentives of the commercial
market are unlikely to result in its adequate
or timely development.
''(4) MEDICAL PRODUCT.--The term 'medical

product' means a drug, device, biological product, or

262

product that is a combination of drugs, devices, and
biological products.
''(b) ESTABLISHMENT OF THE CURES ACCELERA

TION 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;

263

''(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.--

264

''(1) ESTABLISHMENT.--There is established a

Cures Acceleration Network Review Board (referred

to in this section as the 'Board'), which shall advise

the Director of NIH on the conduct of the activities

of the Cures Acceleration Network.
''(2) MEMBERSHIP.--
''(A) IN GENERAL.--
''(i) APPOINTMENT.--The Board shall
be comprised of 24 members who are appointed
by the Secretary and who serve at
the pleasure of the Secretary.
''(ii) CHAIRPERSON AND VICE CHAIR-
PERSON.--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.

265

''(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;

266

''(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;

267

''(ii) a representative of the Office of
the Assistant Secretary of Defense for
Health Affairs, recommended by the Secretary
of Defense;

''(iii) a representative of the Office of
the Under Secretary for Health for the
Veterans Health Administration, recommended
by the Secretary of Veterans
Affairs;

''(iv) a representative of the National
Science Foundation, recommended by the
Chair of the National Science Board; and

''(v) a representative of the Food and
Drug Administration, recommended by the
Commissioner of Food and Drugs.
''(B) TERMS.--Each ex-officio member

shall serve a 3-year term on the Board, except
that the Chairperson may adjust the terms of
the initial ex-officio members in order to provide
for a staggered term of appointment for all
such members.
''(4) RESPONSIBILITIES OF THE BOARD AND

THE DIRECTOR OF NIH.--
''(A) RESPONSIBILITIES OF THE BOARD.--

268

''(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 im

269

plemented, such Director shall provide an expla

nation 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 CHAIR-
PERSON.--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.

270

''(6) COMPENSATION AND TRAVEL EXPENSES.--

''(A) COMPENSATION.--Members shall receive
compensation at a rate to be fixed by the
Chairperson but not to exceed a rate equal to
the daily equivalent of the annual rate of basic
pay prescribed for level IV of the Executive
Schedule under section 5315 of title 5, United
States Code, for each day (including travel
time) during which the member is engaged in
the performance of the duties of the Board. All
members of the Board who are officers or employees
of the Untied States shall serve without
compensation in addition to that received for
their services as officers or employees of the
United States.

''(B) TRAVEL EXPENSES.--Members of the
Board shall be allowed travel expenses, including
per diem in lieu of subsistence, at rates authorized
for persons employed intermittently by
the Federal Government under section 5703(b)
of title 5, United States Code, while away from
their homes or regular places of business in the
performance of services for the Board.

''(e) GRANT PROGRAM.--

271

''(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 assist

ance under paragraph (1), an entity shall--

272

''(A) be a public or private entity, which
may include a private or public research institution,
an institution of higher education, a medical
center, a biotechnology company, a pharmaceutical
company, a disease advocacy organization,
a patient advocacy organization, or an
academic research institution;

''(B) submit an application containing--

''(i) a detailed description of the
project for which the entity seeks such
grant or contract;

''(ii) a timetable for such project;
''(iii) an assurance that the entity will
submit--
''(I) interim reports describing
the entity's--
''(aa) progress in carrying
out the project; and

''(bb) compliance with all
provisions of this section and
conditions of receipt of such
grant or contract; and
''(II) a final report at the conclu

sion of the grant period, describing
the outcomes of the project; and

273

''(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 PART

NERSHIP 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

274

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 condi

tion for receiving an award under this sub

section, 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 Direc

tor 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.

275

''(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 FLEXI

BLE 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.

276

''(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.--

277

''(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 DE

PRESSION.

''(a) DEPRESSIVE DISORDER DEFINED.--In this section,
the term 'depressive disorder' means a mental or

278

brain disorder relating to depression, including major de

pression, bipolar disorder, and related mood disorders.
''(b) GRANT PROGRAM.--
''(1) IN GENERAL.--The Secretary, acting
through the Administrator, shall award grants on a
competitive basis to eligible entities to establish national
centers of excellence for depression (referred
to in this section as 'Centers'), which shall engage
in activities related to the treatment of depressive
disorders.
''(2) ALLOCATION OF AWARDS.--If the funds
authorized under subsection (f) are appropriated in
the amounts provided for under such subsection, the
Secretary shall allocate such amounts so that--
''(A) not later than 1 year after the date
of enactment of the ENHANCED Act of 2009,
not more than 20 Centers may be established;
and
''(B) not later than September 30, 2016,
not more than 30 Centers may be established.
''(3) GRANT PERIOD.--
''(A) IN GENERAL.--A grant awarded
under this section shall be for a period of 5
years.

279

''(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 de

scribed in subparagraph (A)(ii) shall include--
''(i) evidence that such entity--

280

''(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 pri

ority 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.

281

''(iii) A location in a geographic area
with disproportionate numbers of under-
served and at-risk populations in medically
underserved areas and health professional
shortage areas.

''(iv) Proposed innovative approaches
for outreach to initiate or expand services.

''(v) Use of the most up-to-date
science, practices, and interventions available.

''(vi) Demonstrated capacity to establish
cooperative and collaborative agreements
with community mental health centers
and other community entities to provide
mental health, social, and human services
to individuals with depressive disorders.

''(6) NATIONAL COORDINATING CENTER.--

''(A) IN GENERAL.--The Secretary, acting
through the Administrator, shall designate 1 recipient
of a grant under this section to be the
coordinating center of excellence for depression
(referred to in this section as the 'coordinating
center'). The Secretary shall select such coordinating
center on a competitive basis, based

282

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.

283

''(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

284

agenda and disseminate findings, and to provide
support in the implementation of evidence-
based practices;

''(C) provide training and technical assistance
to mental health professionals, and engage
in and disseminate translational research with a
focus on meeting the needs of individuals with
depressive disorders; and

''(D) educate policy makers, employers,
community leaders, and the public about depressive
disorders to reduce stigma and raise
awareness of treatments.
''(2) IMPROVED TREATMENT STANDARDS, CLIN

ICAL 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;

285

''(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 tele

health technology to better coordinate and man

age, 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

286

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 de

pressive disorders;

''(B) the health and social outcomes of in

dividuals with depressive disorders;

''(C) the effectiveness of interventions de

signed, tested, and evaluated;

''(D) other information, as the Secretary

may require.

''(3) SUBMISSION OF DATA TO THE ADMINIS-
TRATOR.--The coordinating center shall submit to
the Administrator the data and financial information
gathered under paragraph (2).

287

''(4) PUBLICATION USING DATA FROM THE

DATABASE.--A Center, or an individual affiliated

with a Center, may publish findings using the data

described in paragraph (2) only if such center sub

mits such data to the coordinating center, as re

quired under such paragraph.

''(e) ESTABLISHMENT OF STANDARDS; REPORT

CARDS AND RECOMMENDATIONS; THIRD PARTY RE

VIEW.--
''(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

288

of the network of centers of excellence as a
whole.
''(3) RECOMMENDATIONS.--Based upon the re

port 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.

289

''(2) ALLOCATION OF FUNDS AUTHORIZED.--Of
the amount appropriated under paragraph (1) for a
fiscal year, the Secretary shall determine the allocation
of each Center receiving a grant under this section,
but in no case may the allocation be more than
$5,000,000, except that the Secretary may allocate
not more than $10,000,000 to the coordinating center.''.

SEC. 10411. PROGRAMS RELATING TO CONGENITAL HEART

DISEASE.

(a) SHORT TITLE.--This subtitle may be cited as the
''Congenital Heart Futures Act''.
(b) PROGRAMS RELATING TO CONGENITAL HEART
DISEASE.--
(1) NATIONAL CONGENITAL HEART DISEASE
SURVEILLANCE SYSTEM.--Part P of title III of the
Public Health Service Act (42 U.S.C. 280g et seq.),
as amended by section 5405, is further amended by
adding at the end the following:
''SEC. 399V-2. NATIONAL CONGENITAL HEART DISEASE SUR

VEILLANCE SYSTEM.

''(a) IN GENERAL.--The Secretary, acting through

the Director of the Centers for Disease Control and Pre

vention, may--

290

''(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--

291

''(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 dis

ease;
''(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 Dis

ease 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.

292

''(f) ELIGIBILITY FOR GRANT.--To be eligible to receive
a grant under subsection (a)(2), an entity shall--

''(1) be a public or private nonprofit entity with
specialized experience in congenital heart disease;
and

''(2) submit to the Secretary an application at
such time, in such manner, and containing such information
as the Secretary may require.''.

(2) CONGENITAL HEART DISEASE RESEARCH.--
Subpart 2 of part C of title IV of the Public Health
Service Act (42 U.S.C. 285b et seq.) is amended by
adding at the end the following:
''SEC. 425. CONGENITAL HEART DISEASE.

''(a) IN GENERAL.--The Director of the Institute
may expand, intensify, and coordinate research and related
activities of the Institute with respect to congenital
heart disease, which may include congenital heart disease
research with respect to--

''(1) causation of congenital heart disease, including
genetic causes;

''(2) long-term outcomes in individuals with
congenital heart disease, including infants, children,
teenagers, adults, and elderly individuals;

''(3) diagnosis, treatment, and prevention;

293

''(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 MEM

ORY 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 organiza

294

tion 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 DIAG

NOSED WITH BREAST CANCER.

(a) SHORT TITLE.--This section may be cited as the
''Young Women's Breast Health Education and Awareness
Requires Learning Young Act of 2009'' or the
''EARLY Act''.
(b) AMENDMENT.--Title III of the Public Health
Service Act (42 U.S.C. 241 et seq.), as amended by this
Act, is further amended by adding at the end the following:
''PART V--PROGRAMS RELATING TO BREAST
HEALTH AND CANCER
''SEC. 399NN. YOUNG WOMEN'S BREAST HEALTH AWARE

NESS AND SUPPORT OF YOUNG WOMEN DIAG

NOSED WITH BREAST CANCER.

''(a) PUBLIC EDUCATION CAMPAIGN.--

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''(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 MES-

SAGES.--The campaign shall provide evidence-based,
age-appropriate messages and materials as developed
by the Centers for Disease Control and Prevention

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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

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advise the Secretary, and shall include organizations
and individuals with expertise in breast
cancer, disease prevention, early detection, diagnosis,
public health, social marketing, genetic
screening and counseling, treatment, rehabilitation,
palliative care, and survivorship in young
women.

''(b) HEALTH CARE PROFESSIONAL EDUCATION
CAMPAIGN.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention, and
in consultation with the Administrator of the Health Resources
and Services Administration, shall conduct an
education campaign among physicians and other health
care professionals to increase awareness--

''(1) of breast health, symptoms, and early diagnosis
and treatment of breast cancer in young
women, including specific risk factors such as family
history of cancer and women that may be at high
risk for breast cancer, such as Ashkenazi Jewish
population;

''(2) on how to provide counseling to young
women about their breast health, including knowledge
of their family cancer history and importance
of providing regular clinical breast examinations;

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''(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 Sec

retary, 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;

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''(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 diag

300

nosed with breast cancer and pre-neoplastic breast
diseases.

''(2) PRIORITY.--In making grants under paragraph
(1), the Secretary shall give priority to applicants
that deal specifically with young women diagnosed
with breast cancer and pre-neoplastic breast
disease.
''(e) NO DUPLICATION OF EFFORT.--In conducting

an education campaign or other program under subsections
(a), (b), (c), or (d), the Secretary shall avoid duplicating
other existing Federal breast cancer education
efforts.

''(f) MEASUREMENT; REPORTING.--The Secretary,
acting through the Director of the Centers for Disease
Control and Prevention, shall--

''(1) measure--

''(A) young women's awareness regarding
breast health, including knowledge of family
cancer history, specific risk factors and early
warning signs, and young women's proactive efforts
at early detection;

''(B) the number or percentage of young
women utilizing information regarding lifestyle
interventions that foster healthy behaviors;

301

''(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 SERV

ICE ACT, THE SOCIAL SECURITY ACT, AND

TITLE V OF THIS ACT.

(a) Section 5101 of this Act is amended--

302

(1) in subsection (c)(2)(B)(i)(II), by inserting
'', including representatives of small business and
self-employed individuals'' after ''employers'';
(2) in subsection (d)(4)(A)--
(A) by redesignating clause (iv) as clause
(v); and
(B) by inserting after clause (iii) the following:
''(iv) An analysis of, and recommendations
for, eliminating the barriers
to entering and staying in primary care,
including provider compensation.''; and

(3) in subsection (i)(2)(B), by inserting ''optometrists,
ophthalmologists,'' after ''occupational
therapists,''.
(b) Subtitle B of title V of this Act is amended by
adding at the end the following:
''SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IM

PROVE 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--

303

''(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 com

prised 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

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among officers at the Air Force performing medical

service functions.

''(5) The Secretary of Veterans Affairs shall ap

point 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.

305

''(g) TERMINATION.--The Task Force shall be terminated
on the date of submission of the report described
in subsection (f).''.

(c) Section 399V of the Public Health Service Act,
as added by section 5313, is amended--
(1) in subsection (b)(4), by striking ''identify,
educate, refer, and enroll'' and inserting ''identify
and refer''; and
(2) in subsection (k)(1), by striking '', as defined
by the Department of Labor as Standard Occupational
Classification [21-1094]''.
(d) Section 738(a)(3) of the Public Health Service
Act (42 U.S.C. 293b(a)(3)) is amended by inserting
''schools offering physician assistant education programs,''
after ''public health,''.
(e) Subtitle D of title V of this Act is amended by
adding at the end the following:
''SEC. 5316. DEMONSTRATION GRANTS FOR FAMILY NURSE

PRACTITIONER TRAINING PROGRAMS.

''(a) ESTABLISHMENT OF PROGRAM.--The Secretary
of Health and Human Services (referred to in this section
as the 'Secretary') shall establish a training demonstration
program for family nurse practitioners (referred to in this
section as the 'program') to employ and provide 1-year
training for nurse practitioners who have graduated from

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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--

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''(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, or

308

thopedics, geriatrics, and at least 3 other high-volume,
high-burden specialty areas;

''(4) provide sessions on high-volume, high-risk
health problems and have a record of training health
care professionals in the care of children, older
adults, and underserved populations; and

''(5) collaborate with other safety net providers,
schools, colleges, and universities that provide health
professions training.
''(f) ELIGIBILITY OF NURSE PRACTITIONERS.--

''(1) IN GENERAL.--To be eligible for acceptance
to a program funded through a grant awarded
under this section, an individual shall--

''(A) be licensed or eligible for licensure in
the State in which the program is located as an
advanced practice registered nurse or advanced
practice nurse and be eligible or board-certified
as a family nurse practitioner; and

''(B) demonstrate commitment to a career
as a primary care provider in a FQHC or in a
NMHC.
''(2) PREFERENCE.--In selecting awardees

under the program, each grant recipient shall give
preference to bilingual candidates that meet the requirements
described in paragraph (1).

309

''(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.''.

310

(f)(1) Section 399W of the Public Health Service Act,
as added by section 5405, is redesignated as section
399V-1.

(2) Section 399V-1 of the Public Health Service Act,
as so redesignated, is amended in subsection (b)(2)(A) by
striking ''and the departments of 1 or more health professions
schools in the State that train providers in primary
care'' and inserting ''and the departments that train providers
in primary care in 1 or more health professions
schools in the State''.
(3) Section 934 of the Public Health Service Act, as
added by section 3501, is amended by striking ''399W''
each place such term appears and inserting ''399V-1''.
(4) Section 935(b) of the Public Health Service Act,
as added by section 3503, is amended by striking ''399W''
and inserting ''399V-1''.
(g) Part P of title III of the Public Health Service
Act 42 U.S.C. 280g et seq.), as amended by section
10411, is amended by adding at the end the following:
''SEC. 399V-3. NATIONAL DIABETES PREVENTION PROGRAM.

''(a) IN GENERAL.--The Secretary, acting through
the Director of the Centers for Disease Control and Prevention,
shall establish a national diabetes prevention program
(referred to in this section as the 'program') tar

311

geted 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.''.

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(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 serv

313

ices furnished by Federally qualified health centers
and shall establish payment rates for specific
payment codes based on such appropriate
descriptions of services. Such system shall be
established to take into account the type, intensity,
and duration of services furnished by Federally
qualified health centers. Such system may
include adjustments, including geographic adjustments,
determined appropriate by the Secretary.

''(B) COLLECTION OF DATA AND EVALUA-
TION.--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

314

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

315

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 IMPLEMENTA-
TION.--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--

316

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

317

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 PER

CENTAGE OF MEDICALLY UNDERSERVED

POPULATIONS OR OTHER SPECIAL POPU

LATIONS.

''(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.

318

''(b) SOURCE OF FUNDS.--A grant program established
by a State under subsection (a) may not be established
within a department, agency, or other entity of such
State that administers the Medicaid program under title
XIX of the Social Security Act (42 U.S.C. 1396 et seq.),
and no Federal or State funds allocated to such Medicaid
program, the Medicare program under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.), or the
TRICARE program under chapter 55 of title 10, United
States Code, may be used to award grants or to pay administrative
costs associated with a grant program established
under subsection (a).''.

(l) Part C of title VII of the Public Health Service
Act (42 U.S.C. 293k et seq.) is amended--
(1) after the part heading, by inserting the following:
''Subpart I--Medical Training Generally'';

and

(2) by inserting at the end the following:
''Subpart II--Training in Underserved Communities
''SEC. 749B. RURAL PHYSICIAN TRAINING GRANTS.

''(a) IN GENERAL.--The Secretary, acting through
the Administrator of the Health Resources and Services
Administration, shall establish a grant program for the
purposes of assisting eligible entities in recruiting students

319

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 under-
served 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 grad

320

uates 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

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''(B) develop criteria for admission to the
Program that gives priority to students--

''(i) who have originated from or lived
for a period of 2 or more years in an underserved
rural community; and

''(ii) who express a commitment to
practice medicine in an underserved rural
community.

''(3) CURRICULA.--The Program shall require
students to enroll in didactic coursework and clinical
experience particularly applicable to medical practice
in underserved rural communities, including--

''(A) clinical rotations in underserved rural
communities, and in applicable specialties, or
other coursework or clinical experience deemed
appropriate by the Secretary; and

''(B) in addition to core school curricula,
additional coursework or training experiences
focused on medical issues prevalent in under-
served 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 under

322

served 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 receiv

ing 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.

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''(h) MAINTENANCE OF EFFORT.--With respect to
activities for which funds awarded under this section are
to be expended, the entity shall agree to maintain expenditures
of non-Federal amounts for such activities at a level
that is not less than the level of such expenditures maintained
by the entity for the fiscal year preceding the fiscal
year for which the entity receives a grant under this section.

''(i) AUTHORIZATION OF APPROPRIATIONS.--There
are authorized to be appropriated $4,000,000 for each of
the fiscal years 2010 through 2013.''.

(m)(1) Section 768 of the Public Health Service Act
(42 U.S.C. 295c) is amended to read as follows:
''SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH

TRAINING GRANT PROGRAM.

''(a) GRANTS.--The Secretary, acting through the
Administrator of the Health Resources and Services Administration
and in consultation with the Director of the
Centers for Disease Control and Prevention, shall award
grants to, or enter into contracts with, eligible entities to
provide training to graduate medical residents in preventive
medicine specialties.

''(b) ELIGIBILITY.--To be eligible for a grant or contract
under subsection (a), an entity shall be--

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''(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.

325

''(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)--

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(i) in subparagraphs (A)(ii) and (B), by
striking ''less than full time'' each place it appears
and inserting ''half time'';
(ii) in subparagraphs (C) and (F), by
striking ''less than full-time service'' each place
it appears and inserting ''half-time service'';
and
(iii) by amending subparagraphs (D) and
(E) to read as follows:
''(D) the entity and the Corps member agree in
writing that the Corps member will perform half-
time clinical practice;

''(E) the Corps member agrees in writing to
fulfill all of the service obligations under section
338C through half-time clinical practice and either--

''(i) double the period of obligated service

that would otherwise be required; or

''(ii) in the case of contracts entered into
under section 338B, accept a minimum service
obligation of 2 years with an award amount
equal to 50 percent of the amount that would
otherwise be payable for full-time service; and'';
and

327

(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 prac

tice, 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--

328

(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

329

the United States that contains a State's sole public academic
medical and dental school.

(b) REQUIREMENT.--Amount appropriated under
subsection (a) may only be made available by the Secretary
of Health and Human Services upon the receipt of
an application from the Governor of a State that certifies
that--
(1) the new health care facility is critical for
the provision of greater access to health care within
the State;
(2) such facility is essential for the continued
financial viability of the State's sole public medical
and dental school and its academic health center;
(3) the request for Federal support represents
not more than 40 percent of the total cost of the
proposed new facility; and
(4) the State has established a dedicated funding
mechanism to provide all remaining funds necessary
to complete the construction or renovation of
the proposed facility.
SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NA

TIONAL 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

330

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;

331

(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 AC

CESS 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 ''Sec

332

retary''), acting through the Health Resources and Services
Administration, shall establish a 3 year demonstration
project in up to 10 States to provide access to comprehensive
health care services to the uninsured at reduced fees.
The Secretary shall evaluate the feasibility of expanding
the project to additional States.

(b) ELIGIBILITY.--To be eligible to participate in the
demonstration project, an entity shall be a State-based,
nonprofit, public-private partnership that provides access
to comprehensive health care services to the uninsured at
reduced fees. Each State in which a participant selected
by the Secretary is located shall receive not more than
$2,000,000 to establish and carry out the project for the
3-year demonstration period.
(c) AUTHORIZATION.--There is authorized to be appropriated
such sums as may be necessary to carry out
this section.
Subtitle F--Provisions Relating to
Title VI

SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EX

CEPTION 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--

333

(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 OUT

COMES 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

334

(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.''.

335

SEC. 10603. STRIKING PROVISIONS RELATING TO INDI

VIDUAL 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

336

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

337

1861(aa)(5)) under the supervision of the physician,''
after ''must document that the physician''.

SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.

(a) FRAUD SENTENCING GUIDELINES.--
(1) DEFINITION.--In this subsection, the term
''Federal health care offense'' has the meaning given
that term in section 24 of title 18, United States
Code, as amended by this Act.
(2) REVIEW AND AMENDMENTS.--Pursuant to
the authority under section 994 of title 28, United
States Code, and in accordance with this subsection,
the United States Sentencing Commission shall--
(A) review the Federal Sentencing Guidelines
and policy statements applicable to persons
convicted of Federal health care offenses;
(B) amend the Federal Sentencing Guidelines
and policy statements applicable to persons
convicted of Federal health care offenses
involving Government health care programs to
provide that the aggregate dollar amount of
fraudulent bills submitted to the Government
health care program shall constitute prima facie
evidence of the amount of the intended loss by
the defendant; and

338

(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.

339

(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

340

the date of enactment of this Act, provide sentencing
enhancements;

(E) make any necessary conforming
changes to the Federal Sentencing Guidelines;
and
(F) ensure that the Federal Sentencing
Guidelines adequately meet the purposes of sentencing.
(b) INTENT REQUIREMENT FOR HEALTH CARE
FRAUD.--Section 1347 of title 18, United States Code,
is amended--
(1) by inserting ''(a)'' before ''Whoever knowingly'';
and
(2) by adding at the end the following:
''(b) With respect to violations of this section, a person
need not have actual knowledge of this section or specific
intent to commit a violation of this section.''.

(c) HEALTH CARE FRAUD OFFENSE.--Section 24(a)
of title 18, United States Code, is amended--
(1) in paragraph (1), by striking the semicolon
and inserting ''or section 1128B of the Social Security
Act (42 U.S.C. 1320a-7b); or''; and
(2) in paragraph (2)--
(A) by inserting ''1349,'' after ''1343,'';
and

341

(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:

342

''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.

343

''(2) ENFORCEMENT.--In the case of contumacy
or failure to obey a subpoena issued under this
section, the United States district court for the judicial
district in which the institution is located may
issue an order requiring compliance. Any failure to
obey the order of the court may be punished by the
court as a contempt that court.
''(c) PROTECTION OF SUBPOENAED RECORDS AND

INFORMATION.--Any document, record, material, file, re

port, 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

344

''(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 EVALU

ATE 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.--

345

''(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 LITIGA-

TION.--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;

346

''(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 compensa

tion would be paid for claims resolved under the pro

347

posed 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 partici

348

pate 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 DEMONSTRA

TION GRANTS.--In awarding grants under subsection
(a), the Secretary shall give preference to
States--

''(A) that have developed the proposed alternative
through substantive consultation with
relevant stakeholders, including patient advocates,
health care providers and health care organizations,
attorneys with expertise in representing
patients and health care providers,
medical malpractice insurers, and patient safety
experts;

''(B) that make proposals that are likely to
enhance patient safety by detecting, analyzing,
and helping to reduce medical errors and adverse
events; and

''(C) that make proposals that are likely to
improve access to liability insurance.
''(d) APPLICATION.--

''(1) IN GENERAL.--Each State desiring a
grant under subsection (a) shall submit to the Secretary
an application, at such time, in such manner,

349

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.

350

''(III) Attorneys with expertise in

representing patients and health care

providers.

''(IV) Medical malpractice insur

ers.

''(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

351

of such department or agency shall furnish the

requested information to the review panel.
''(e) REPORTS.--

''(1) BY STATE.--Each State receiving a grant
under subsection (a) shall submit to the Secretary
an annual report evaluating the effectiveness of activities
funded with grants awarded under such subsection.
Such report shall, at a minimum, include
the impact of the activities funded on patient safety
and on the availability and price of medical liability
insurance.

''(2) BY SECRETARY.--The Secretary shall submit
to Congress an annual compendium of the reports
submitted under paragraph (1) and an analysis
of the activities funded under subsection (a)
that examines any differences that result from such
activities in terms of the quality of care, number and
nature of medical errors, medical resources used,
length of time for dispute resolution, and the availability
and price of liability insurance.
''(f) TECHNICAL ASSISTANCE.--

''(1) IN GENERAL.--The Secretary shall provide
technical assistance to the States applying for or
awarded grants under subsection (a).

352

''(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

353

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

354

''(E) a comparison, with regard to the
measures described in paragraph (3), of--
''(i) States receiving grants under
subsection (a);

''(ii) States that enacted, prior to the
date of enactment of the Patient Protection
and Affordable Care Act, any cap on
non-economic damages; and

''(iii) States that have enacted, prior
to the date of enactment of the Patient
Protection and Affordable Care Act, a requirement
that the complainant obtain an
opinion regarding the merit of the claim,
although the substance of such opinion
may have no bearing on whether the complainant
may proceed with a case.

''(3) MEASURES.--The evaluations under para

graph (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);

355

''(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

356

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 sub

section (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 appli

357

cations meeting the criteria described in subsection (c).
In selecting States to receive such planning grants, the
Secretary shall give preference to those States in which
State law at the time of the application would not prohibit
the adoption of an alternative to current tort litigation.

''(j) DEFINITIONS.--In this section:

''(1) HEALTH CARE SERVICES.--The term
'health care services' means any services provided by
a health care provider, or by any individual working
under the supervision of a health care provider, that
relate to--

''(A) the diagnosis, prevention, or treatment
of any human disease or impairment; or

''(B) the assessment of the health of
human beings.
''(2) HEALTH CARE ORGANIZATION.--The term

'health care organization' means any individual or
entity which is obligated to provide, pay for, or administer
health benefits under any health plan.

''(3) HEALTH CARE PROVIDER.--The term
'health care provider' means any individual or entity--

''(A) licensed, registered, or certified under
Federal or State laws or regulations to provide
health care services; or

358

''(B) required to be so licensed, registered,

or certified but that is exempted by other stat

ute 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 COV

ERAGE 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

359

this Act and apply to any act or omission which occurs
on or after that date.

SEC. 10609. LABELING CHANGES.

Section 505(j) of the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 355(j)) is amended by adding at the
end the following:

''(10)(A) If the proposed labeling of a drug that is
the subject of an application under this subsection differs
from the listed drug due to a labeling revision described
under clause (i), the drug that is the subject of such application
shall, notwithstanding any other provision of this
Act, be eligible for approval and shall not be considered
misbranded under section 502 if--

''(i) the application is otherwise eligible for approval
under this subsection but for expiration of
patent, an exclusivity period, or of a delay in approval
described in paragraph (5)(B)(iii), and a revision
to the labeling of the listed drug has been approved
by the Secretary within 60 days of such expiration;

''(ii) the labeling revision described under clause

(i) does not include a change to the 'Warnings' section
of the labeling;
''(iii) the sponsor of the application under this
subsection agrees to submit revised labeling of the

360

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 sub

paragraph (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

361

(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''.

362

(c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction
Act of 2005, as added by section 8002(d) of this Act,
is amended by striking ''and coverage available'' and all
that follows through ''that program,''.
Subtitle H--Provisions Relating to
Title IX

SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST

EMPLOYER-SPONSORED HEALTH COVERAGE.

(a) LONGSHORE WORKERS TREATED AS EMPLOYEES
ENGAGED IN HIGH-RISK PROFESSIONS.--Paragraph (3)
of section 4980I(f) of the Internal Revenue Code of 1986,
as added by section 9001 of this Act, is amended by inserting
''individuals whose primary work is longshore work
(as defined in section 258(b) of the Immigration and Nationality
Act (8 U.S.C. 1288(b)), determined without regard
to paragraph (2) thereof),'' before ''and individuals
engaged in the construction, mining''.

(b) EXEMPTION FROM HIGH-COST INSURANCE TAX
INCLUDES CERTAIN ADDITIONAL EXCEPTED BENEFITS.--
Clause (i) of section 4980I(d)(1)(B) of the Internal
Revenue Code of 1986, as added by section 9001 of
this Act, is amended by striking ''section 9832(c)(1)(A)''
and inserting ''section 9832(c)(1) (other than subparagraph
(G) thereof)''.

363

(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 ARRANGE

MENTS 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

364

''(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--

365

(1) by striking ''2009'' in subsection (a)(1) and
inserting ''2010'',
(2) by inserting ''($3,000,000,000 after 2017)''
after ''$2,000,000,000'', and
(3) by striking ''2008'' in subsection (i) and inserting
''2009''.
(b) EFFECTIVE DATE.--The amendments made by
this section shall take effect as if included in the enactment
of section 9009.
SEC. 10905. MODIFICATION OF ANNUAL FEE ON HEALTH IN

SURANCE 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

366

1
''(B) the aggregate net premiums written

2
with respect to such health insurance of all cov

3
ered entities that are taken into account during

4
such preceding calendar year.

5
''(2) AMOUNTS TAKEN INTO ACCOUNT.--For

6
purposes of paragraph (1), the net premiums written

7
with respect to health insurance for any United

8
States health risk that are taken into account during

9
any calendar year with respect to any covered entity
10
shall be determined in accordance with the following
11
table:

The percentage of net

''With respect to a covered entity's net premiums writ-premiums written that

ten during the calendar year that are: are taken into account

is:

Not more than $25,000,000 .................................. 0 percent
More than $25,000,000 but not more than 50 percent
$50,000,000.
More than $50,000,000 ......................................... 100 percent.

12
''(3) SECRETARIAL DETERMINATION.--The Sec13
retary shall calculate the amount of each covered en14
tity's fee for any calendar year under paragraph (1).
15
In calculating such amount, the Secretary shall de16
termine such covered entity's net premiums written
17
with respect to any United States health risk on the
18
basis of reports submitted by the covered entity
19
under subsection (g) and through the use of any
20
other source of information available to the Sec21
retary.''.

367

1
(b) APPLICABLE AMOUNT.--Subsection (e) of section
2
9010 of this Act is amended to read as follows:
3
''(e) APPLICABLE AMOUNT.--For purposes of sub4
section (b)(1), the applicable amount shall be determined

5
in accordance with the following table:

''Calendar year

2011 .......................................................................
2012 .......................................................................
2013 .......................................................................
2014, 2015 and 2016 .............................................
2017 and thereafter ...............................................

Applicable
amount

$2,000,000,000
$4,000,000,000
$7,000,000,000
$9,000,000,000
$10,000,000,000.''.

6
(c) EXEMPTION FROM ANNUAL FEE ON HEALTH IN7
SURANCE FOR CERTAIN NONPROFIT ENTITIES.--Section
8
9010(c)(2) of this Act is amended by striking ''or'' at the
9
end of subparagraph (A), by striking the period at the
10
end of subparagraph (B) and inserting a comma, and by
11
adding at the end the following new subparagraphs:
12
''(C) any entity--
13
''(i)(I) which is incorporated as, is a
14
wholly owned subsidiary of, or is a wholly
15
owned affiliate of, a nonprofit corporation
16
under a State law, or
17
''(II) which is described in section
18
501(c)(4) of the Internal Revenue Code of
19
1986 and the activities of which consist of
20
providing commercial-type insurance (with21
in the meaning of section 501(m) of such
22
Code),

368

''(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)--

369

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

''(II) with respect to all such
markets for such entity for the calendar
year is not less than 92 percent,
or

''(E) any entity--
''(i) which is a mutual insurance company,

''(ii) which for the period reported on
the 2008 Accident and Health Policy Experience
Exhibit of the National Association
of Insurance Commissioners had--

''(I) a market share of the insured
population of a State of at least
40 but not more than 60 percent, and

''(II) with respect to all markets
described in subparagraph (D)(ii)(I),
a medical loss ratio of not less than
90 percent, and
''(iii) with respect to annual payment

dates in calendar years after 2011, for

370

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

371

''(C) any medicare supplemental health in

surance (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.''.

372

(4) Section 9010(g)(1) of this Act is amended
by striking ''and third party administration agreement
fees''.
(5) Section 9010(j) of this Act is amended--
(A) by striking ''2008'' and inserting
''2009'', and
(B) by striking '', and any third party administration
agreement fees received after such
date''.
(g) EFFECTIVE DATE.--The amendments made by
this section shall take effect as if included in the enactment
of section 9010.
SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL IN

SURANCE 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 re

373

1
ceived, and taxable years beginning, after December 31,
2
2012.
3
SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN
4
LIEU OF ELECTIVE COSMETIC MEDICAL PRO5
CEDURES.
6
(a) IN GENERAL.--The provisions of, and amend7
ments made by, section 9017 of this Act are hereby
8
deemed null, void, and of no effect.
9
(b) EXCISE TAX ON INDOOR TANNING SERVICES.--
10
Subtitle D of the Internal Revenue Code of 1986, as
11
amended by this Act, is amended by adding at the end
12
the following new chapter:
13
''CHAPTER 49--COSMETIC SERVICES

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

14
''SEC. 5000B. IMPOSITION OF TAX ON INDOOR TANNING
15
SERVICES.
16
''(a) IN GENERAL.--There is hereby imposed on any
17
indoor tanning service a tax equal to 10 percent of the
18
amount paid for such service (determined without regard
19
to this section), whether paid by insurance or otherwise.
20
''(b) INDOOR TANNING SERVICE.--For purposes of
21
this section--
22
''(1) IN GENERAL.--The term 'indoor tanning
23
service' means a service employing any electronic
24
product designed to incorporate 1 or more ultraviolet

374

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 SERV-
ICES.--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.''.

375

1
(c) CLERICAL AMENDMENT.--The table of chapter
2
for subtitle D of the Internal Revenue Code of 1986, as
3
amended by this Act, is amended by inserting after the
4
item relating to chapter 48 the following new item:

''CHAPTER 49--COSMETIC SERVICES''.

5
(d) EFFECTIVE DATE.--The amendments made by

6
this section shall apply to services performed on or after

7
July 1, 2010.

8
SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO

9
PARTICIPANTS IN STATE STUDENT LOAN RE10
PAYMENT PROGRAMS FOR CERTAIN HEALTH
11
PROFESSIONALS.
12
(a) IN GENERAL.--Paragraph (4) of section 108(f)
13
of the Internal Revenue Code of 1986 is amended to read
14
as follows:
15
''(4) PAYMENTS UNDER NATIONAL HEALTH
16
SERVICE CORPS LOAN REPAYMENT PROGRAM AND
17
CERTAIN STATE LOAN REPAYMENT PROGRAMS.--In
18
the case of an individual, gross income shall not in19
clude any amount received under section 338B(g) of
20
the Public Health Service Act, under a State pro21
gram described in section 338I of such Act, or under
22
any other State loan repayment or loan forgiveness
23
program that is intended to provide for the in24
creased availability of health care services in under

376

served 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 ADOP

TION 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

377

23 of such Code (relating to adjustments for inflation)
is amended to read as follows:
''(h) ADJUSTMENTS FOR INFLATION.--

''(1) DOLLAR LIMITATIONS.--In the case of a
taxable year beginning after December 31, 2010,
each of the dollar amounts in subsections (a)(3) and
(b)(1) shall be increased by an amount equal to--

''(A) such dollar amount, multiplied by

''(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar
year in which the taxable year begins, determined
by substituting 'calendar year 2009' for
'calendar year 1992' in subparagraph (B)
thereof.

If any amount as increased under the preceding sentence
is not a multiple of $10, such amount shall be
rounded to the nearest multiple of $10.

''(2) INCOME LIMITATION.--In the case of a
taxable year beginning after December 31, 2002, the
dollar amount in subsection (b)(2)(A)(i) shall be increased
by an amount equal to--

''(A) such dollar amount, multiplied by

''(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar
year in which the taxable year begins, deter

378

mined 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.--

379

''(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

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.

380

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 sub-
chapter A of chapter 1.
(2) CONFORMING AMENDMENTS.--
(A) Section 24(b)(3)(B) of such Code is
amended by striking ''23,''.
(B) Section 25(e)(1)(C) of such Code is
amended by striking ''23,'' both places it appears.
(C) Section 25A(i)(5)(B) of such Code is
amended by striking ''23, 25D,'' and inserting
''25D''.
(D) Section 25B(g)(2) of such Code is
amended by striking ''23,''.

381

(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,''.

382

1
(L) Section 1016(a)(26) is amended by
2
striking ''23(g)'' and inserting ''36C(g)''.
3
(M) Section 1400C(d) of such Code is
4
amended by striking ''23,''.
5
(N) Section 6211(b)(4)(A) of such Code is
6
amended by inserting ''36C,'' before ''53(e)''.
7
(O) The table of sections for subpart A of
8
part IV of subchapter A of chapter 1 of such
9
Code of 1986 is amended by striking the item
10
relating to section 23.
11
(P) Paragraph (2) of section 1324(b) of
12
title 31, United States Code, as amended by
13
this Act, is amended by inserting ''36C,'' after
14
''36B,''.
15
(Q) The table of sections for subpart C of
16
part IV of subchapter A of chapter 1 of the In17
ternal Revenue Code of 1986, as amended by
18
this Act, is amended by inserting after the item
19
relating to section 36B the following new item:

''Sec. 36C. Adoption expenses.''.
20
(c) APPLICATION AND EXTENSION OF EGTRRA
21
SUNSET.--Notwithstanding section 901 of the Economic
22
Growth and Tax Relief Reconciliation Act of 2001, such
23
section shall apply to the amendments made by this sec24
tion and the amendments made by section 202 of such

1
Act by substituting ''December 31, 2011'' for ''December
2
31, 2010'' in subsection (a)(1) thereof.
3
(d) EFFECTIVE DATE.--The amendments made by
4
this section shall apply to taxable years beginning after
5
December 31, 2009.

Here are the health care changes released by Democrats on this Saturday, which will win the support of Sen. Ben Nelson (D-NE) and provide the decisive 60th vote in the Senate for approval. You can also download the entire pdf file (383 pages) at http://bit.ly/5w4Vrp . - IN THE SENATE ...

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