[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3200 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 3200
To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 14, 2009
Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of
California, Mr. Stark, Mr. Pallone, and Mr. Andrews) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committees on Ways and Means,
Education and Labor, Oversight and Government Reform, and the Budget,
for a period to be subsequently determined by the Speaker, in each case
for consideration of such provisions as fall within the jurisdiction of
the committee concerned
_______________________________________________________________________
A BILL
To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES.
(a) Short Title.--This Act may be cited as the ``America's
Affordable Health Choices Act of 2009''.
(b) Table of Divisions, Titles, and Subtitles.--This Act is divided
into divisions, titles, and subtitles as follows:
DIVISION A--AFFORDABLE HEALTH CARE CHOICES
TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Subtitle D--Additional Consumer Protections
Subtitle E--Governance
Subtitle F--Relation to Other Requirements; Miscellaneous
Subtitle G--Early Investments
TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
Subtitle B--Public Health Insurance Option
Subtitle C--Individual Affordability Credits
TITLE III--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
Subtitle B--Employer Responsibility
TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Shared Responsibility
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
Subtitle C--Disclosures To Carry Out Health Insurance Exchange
Subsidies
Subtitle D--Other Revenue Provisions
DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS
TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions Related to Medicare Part A
Subtitle B--Provisions Related to Part B
Subtitle C--Provisions Related to Medicare Parts A and B
Subtitle D--Medicare Advantage Reforms
Subtitle E--Improvements to Medicare Part D
Subtitle F--Medicare Rural Access Protections
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
Subtitle B--Reducing Health Disparities
Subtitle C--Miscellaneous Improvements
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
Subtitle B--Nursing Home Transparency
Subtitle C--Quality Measurements
Subtitle D--Physician Payments Sunshine Provision
Subtitle E--Public Reporting on Health Care-Associated Infections
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse
Subtitle B--Enhanced Penalties for Fraud and Abuse
Subtitle C--Enhanced Program and Provider Protections
Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and
Abuse
TITLE VII--MEDICAID AND CHIP
Subtitle A--Medicaid and Health Reform
Subtitle B--Prevention
Subtitle C--Access
Subtitle D--Coverage
Subtitle E--Financing
Subtitle F--Waste, Fraud, and Abuse
Subtitle G--Puerto Rico and the Territories
Subtitle H--Miscellaneous
TITLE VIII--REVENUE-RELATED PROVISIONS
TITLE IX--MISCELLANEOUS PROVISIONS
DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
TITLE I--COMMUNITY HEALTH CENTERS
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
Subtitle B--Nursing Workforce
Subtitle C--Public Health Workforce
Subtitle D--Adapting Workforce to Evolving Health System Needs
TITLE III--PREVENTION AND WELLNESS
TITLE IV--QUALITY AND SURVEILLANCE
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals
Subtitle B--School-Based Health Clinics
Subtitle C--National Medical Device Registry
Subtitle D--Grants for Comprehensive Programs To Provide Education to
Nurses and Create a Pipeline to Nursing
Subtitle E--States Failing To Adhere to Certain Employment Obligations
DIVISION A--AFFORDABLE HEALTH CARE CHOICES
SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.
(a) Purpose.--
(1) In general.--The purpose of this division is to provide
affordable, quality health care for all Americans and reduce
the growth in health care spending.
(2) Building on current system.--This division achieves
this purpose by building on what works in today's health care
system, while repairing the aspects that are broken.
(3) Insurance reforms.--This division--
(A) enacts strong insurance market reforms;
(B) creates a new Health Insurance Exchange, with a
public health insurance option alongside private plans;
(C) includes sliding scale affordability credits;
and
(D) initiates shared responsibility among workers,
employers, and the government;
so that all Americans have coverage of essential health
benefits.
(4) Health delivery reform.--This division institutes
health delivery system reforms both to increase quality and to
reduce growth in health spending so that health care becomes
more affordable for businesses, families, and government.
(b) Table of Contents of Division.--The table of contents of this
division is as follows:
Sec. 100. Purpose; table of contents of division; general definitions.
TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
Sec. 101. Requirements reforming health insurance marketplace.
Sec. 102. Protecting the choice to keep current coverage.
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Sec. 111. Prohibiting pre-existing condition exclusions.
Sec. 112. Guaranteed issue and renewal for insured plans.
Sec. 113. Insurance rating rules.
Sec. 114. Nondiscrimination in benefits; parity in mental health and
substance abuse disorder benefits.
Sec. 115. Ensuring adequacy of provider networks.
Sec. 116. Ensuring value and lower premiums.
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Sec. 121. Coverage of essential benefits package.
Sec. 122. Essential benefits package defined.
Sec. 123. Health Benefits Advisory Committee.
Sec. 124. Process for adoption of recommendations; adoption of benefit
standards.
Subtitle D--Additional Consumer Protections
Sec. 131. Requiring fair marketing practices by health insurers.
Sec. 132. Requiring fair grievance and appeals mechanisms.
Sec. 133. Requiring information transparency and plan disclosure.
Sec. 134. Application to qualified health benefits plans not offered
through the Health Insurance Exchange.
Sec. 135. Timely payment of claims.
Sec. 136. Standardized rules for coordination and subrogation of
benefits.
Sec. 137. Application of administrative simplification.
Subtitle E--Governance
Sec. 141. Health Choices Administration; Health Choices Commissioner.
Sec. 142. Duties and authority of Commissioner.
Sec. 143. Consultation and coordination.
Sec. 144. Health Insurance Ombudsman.
Subtitle F--Relation to Other Requirements; Miscellaneous
Sec. 151. Relation to other requirements.
Sec. 152. Prohibiting discrimination in health care.
Sec. 153. Whistleblower protection.
Sec. 154. Construction regarding collective bargaining.
Sec. 155. Severability.
Subtitle G--Early Investments
Sec. 161. Ensuring value and lower premiums.
Sec. 162. Ending health insurance rescission abuse.
Sec. 163. Administrative simplification.
Sec. 164. Reinsurance program for retirees.
TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
Sec. 201. Establishment of Health Insurance Exchange; outline of
duties; definitions.
Sec. 202. Exchange-eligible individuals and employers.
Sec. 203. Benefits package levels.
Sec. 204. Contracts for the offering of Exchange-participating health
benefits plans.
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and
employers in Exchange-participating health
benefits plan.
Sec. 206. Other functions.
Sec. 207. Health Insurance Exchange Trust Fund.
Sec. 208. Optional operation of State-based health insurance exchanges.
Subtitle B--Public Health Insurance Option
Sec. 221. Establishment and administration of a public health insurance
option as an Exchange-qualified health
benefits plan.
Sec. 222. Premiums and financing.
Sec. 223. Payment rates for items and services.
Sec. 224. Modernized payment initiatives and delivery system reform.
Sec. 225. Provider participation.
Sec. 226. Application of fraud and abuse provisions.
Subtitle C--Individual Affordability Credits
Sec. 241. Availability through Health Insurance Exchange.
Sec. 242. Affordable credit eligible individual.
Sec. 243. Affordable premium credit.
Sec. 244. Affordability cost-sharing credit.
Sec. 245. Income determinations.
Sec. 246. No Federal payment for undocumented aliens.
TITLE III--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
Sec. 301. Individual responsibility.
Subtitle B--Employer Responsibility
Part 1--Health Coverage Participation Requirements
Sec. 311. Health coverage participation requirements.
Sec. 312. Employer responsibility to contribute towards employee and
dependent coverage.
Sec. 313. Employer contributions in lieu of coverage.
Sec. 314. Authority related to improper steering.
Part 2--Satisfaction of Health Coverage Participation Requirements
Sec. 321. Satisfaction of health coverage participation requirements
under the Employee Retirement Income
Security Act of 1974.
Sec. 322. Satisfaction of health coverage participation requirements
under the Internal Revenue Code of 1986.
Sec. 323. Satisfaction of health coverage participation requirements
under the Public Health Service Act.
Sec. 324. Additional rules relating to health coverage participation
requirements.
TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Shared Responsibility
Part 1--Individual Responsibility
Sec. 401. Tax on individuals without acceptable health care coverage.
Part 2--Employer Responsibility
Sec. 411. Election to satisfy health coverage participation
requirements.
Sec. 412. Responsibilities of nonelecting employers.
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
Sec. 421. Credit for small business employee health coverage expenses.
Subtitle C--Disclosures To Carry Out Health Insurance Exchange
Subsidies
Sec. 431. Disclosures to carry out health insurance exchange subsidies.
Subtitle D--Other Revenue Provisions
Part 1--General Provisions
Sec. 441. Surcharge on high income individuals.
Sec. 442. Delay in application of worldwide allocation of interest.
Part 2--Prevention of Tax Avoidance
Sec. 451. Limitation on treaty benefits for certain deductible
payments.
Sec. 452. Codification of economic substance doctrine.
Sec. 453. Penalties for underpayments.
(c) General Definitions.--Except as otherwise provided, in this
division:
(1) Acceptable coverage.--The term ``acceptable coverage''
has the meaning given such term in section 202(d)(2).
(2) Basic plan.--The term ``basic plan'' has the meaning
given such term in section 203(c).
(3) Commissioner.--The term ``Commissioner'' means the
Health Choices Commissioner established under section 141.
(4) Cost-sharing.--The term ``cost-sharing'' includes
deductibles, coinsurance, copayments, and similar charges but
does not include premiums or any network payment differential
for covered services or spending for non-covered services.
(5) Dependent.--The term ``dependent'' has the meaning
given such term by the Commissioner and includes a spouse.
(6) Employment-based health plan.--The term ``employment-
based health plan''--
(A) means a group health plan (as defined in
section 733(a)(1) of the Employee Retirement Income
Security Act of 1974); and
(B) includes such a plan that is the following:
(i) Federal, state, and tribal governmental
plans.--A governmental plan (as defined in
section 3(32) of the Employee Retirement Income
Security Act of 1974), including a health
benefits plan offered under chapter 89 of title
5, United States Code.
(ii) Church plans.--A church plan (as
defined in section 3(33) of the Employee
Retirement Income Security Act of 1974).
(7) Enhanced plan.--The term ``enhanced plan'' has the
meaning given such term in section 203(c).
(8) Essential benefits package.--The term ``essential
benefits package'' is defined in section 122(a).
(9) Family.--The term ``family'' means an individual and
includes the individual's dependents.
(10) Federal poverty level; fpl.--The terms ``Federal
poverty level'' and ``FPL'' have the meaning given the term
``poverty line'' in section 673(2) of the Community Services
Block Grant Act (42 U.S.C. 9902(2)), including any revision
required by such section.
(11) Health benefits plan.--The terms ``health benefits
plan'' means health insurance coverage and an employment-based
health plan and includes the public health insurance option.
(12) Health insurance coverage; health insurance issuer.--
The terms ``health insurance coverage'' and ``health insurance
issuer'' have the meanings given such terms in section 2791 of
the Public Health Service Act.
(13) Health insurance exchange.--The term ``Health
Insurance Exchange'' means the Health Insurance Exchange
established under section 201.
(14) Medicaid.--The term ``Medicaid'' means a State plan
under title XIX of the Social Security Act (whether or not the
plan is operating under a waiver under section 1115 of such
Act).
(15) Medicare.--The term ``Medicare'' means the health
insurance programs under title XVIII of the Social Security
Act.
(16) Plan sponsor.--The term ``plan sponsor'' has the
meaning given such term in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974.
(17) Plan year.--The term ``plan year'' means--
(A) with respect to an employment-based health
plan, a plan year as specified under such plan; or
(B) with respect to a health benefits plan other
than an employment-based health plan, a 12-month period
as specified by the Commissioner.
(18) Premium plan; premium-plus plan.--The terms ``premium
plan'' and ``premium-plus plan'' have the meanings given such
terms in section 203(c).
(19) QHBP offering entity.--The terms ``QHBP offering
entity'' means, with respect to a health benefits plan that
is--
(A) a group health plan (as defined, subject to
subsection (d), in section 733(a)(1) of the Employee
Retirement Income Security Act of 1974), the plan
sponsor in relation to such group health plan, except
that, in the case of a plan maintained jointly by 1 or
more employers and 1 or more employee organizations and
with respect to which an employer is the primary source
of financing, such term means such employer;
(B) health insurance coverage, the health insurance
issuer offering the coverage;
(C) the public health insurance option, the
Secretary of Health and Human Services;
(D) a non-Federal governmental plan (as defined in
section 2791(d) of the Public Health Service Act), the
State or political subdivision of a State (or agency or
instrumentality of such State or subdivision) which
establishes or maintains such plan; or
(E) a Federal governmental plan (as defined in
section 2791(d) of the Public Health Service Act), the
appropriate Federal official.
(20) Qualified health benefits plan.--The term ``qualified
health benefits plan'' means a health benefits plan that meets
the requirements for such a plan under title I and includes the
public health insurance option.
(21) Public health insurance option.--The term ``public
health insurance option'' means the public health insurance
option as provided under subtitle B of title II.
(22) Service area; premium rating area.--The terms
``service area'' and ``premium rating area'' mean with respect
to health insurance coverage--
(A) offered other than through the Health Insurance
Exchange, such an area as established by the QHBP
offering entity of such coverage in accordance with
applicable State law; and
(B) offered through the Health Insurance Exchange,
such an area as established by such entity in
accordance with applicable State law and applicable
rules of the Commissioner for Exchange-participating
health benefits plans.
(23) State.--The term ``State'' means the 50 States and the
District of Columbia.
(24) State medicaid agency.--The term ``State Medicaid
agency'' means, with respect to a Medicaid plan, the single
State agency responsible for administering such plan under
title XIX of the Social Security Act.
(25) Y1, y2, etc.--The terms ``Y1'' , ``Y2'', ``Y3'',
``Y4'', ``Y5'', and similar subsequently numbered terms, mean
2013 and subsequent years, respectively.
TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.
(a) Purpose.--The purpose of this title is to establish standards
to ensure that new health insurance coverage and employment-based
health plans that are offered meet standards guaranteeing access to
affordable coverage, essential benefits, and other consumer
protections.
(b) Requirements for Qualified Health Benefits Plans.--On or after
the first day of Y1, a health benefits plan shall not be a qualified
health benefits plan under this division unless the plan meets the
applicable requirements of the following subtitles for the type of plan
and plan year involved:
(1) Subtitle B (relating to affordable coverage).
(2) Subtitle C (relating to essential benefits).
(3) Subtitle D (relating to consumer protection).
(c) Terminology.--In this division:
(1) Enrollment in employment-based health plans.--An
individual shall be treated as being ``enrolled'' in an
employment-based health plan if the individual is a participant
or beneficiary (as such terms are defined in section 3(7) and
3(8), respectively, of the Employee Retirement Income Security
Act of 1974) in such plan.
(2) Individual and group health insurance coverage.--The
terms ``individual health insurance coverage'' and ``group
health insurance coverage'' mean health insurance coverage
offered in the individual market or large or small group
market, respectively, as defined in section 2791 of the Public
Health Service Act.
SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.
(a) Grandfathered Health Insurance Coverage Defined.--Subject to
the succeeding provisions of this section, for purposes of establishing
acceptable coverage under this division, the term ``grandfathered
health insurance coverage'' means individual health insurance coverage
that is offered and in force and effect before the first day of Y1 if
the following conditions are met:
(1) Limitation on new enrollment.--
(A) In general.--Except as provided in this
paragraph, the individual health insurance issuer
offering such coverage does not enroll any individual
in such coverage if the first effective date of
coverage is on or after the first day of Y1.
(B) Dependent coverage permitted.--Subparagraph (A)
shall not affect the subsequent enrollment of a
dependent of an individual who is covered as of such
first day.
(2) Limitation on changes in terms or conditions.--Subject
to paragraph (3) and except as required by law, the issuer does
not change any of its terms or conditions, including benefits
and cost-sharing, from those in effect as of the day before the
first day of Y1.
(3) Restrictions on premium increases.--The issuer cannot
vary the percentage increase in the premium for a risk group of
enrollees in specific grandfathered health insurance coverage
without changing the premium for all enrollees in the same risk
group at the same rate, as specified by the Commissioner.
(b) Grace Period for Current Employment-based Health Plans.--
(1) Grace period.--
(A) In general.--The Commissioner shall establish a
grace period whereby, for plan years beginning after
the end of the 5-year period beginning with Y1, an
employment-based health plan in operation as of the day
before the first day of Y1 must meet the same
requirements as apply to a qualified health benefits
plan under section 101, including the essential benefit
package requirement under section 121.
(B) Exception for limited benefits plans.--
Subparagraph (A) shall not apply to an employment-based
health plan in which the coverage consists only of one
or more of the following:
(i) Any coverage described in section
3001(a)(1)(B)(ii)(IV) of division B of the
American Recovery and Reinvestment Act of 2009
(Public Law 111-5).
(ii) Excepted benefits (as defined in
section 733(c) of the Employee Retirement
Income Security Act of 1974), including
coverage under a specified disease or illness
policy described in paragraph (3)(A) of such
section.
(iii) Such other limited benefits as the
Commissioner may specify.
In no case shall an employment-based health plan in
which the coverage consists only of one or more of the
coverage or benefits described in clauses (i) through
(iii) be treated as acceptable coverage under this
division
(2) Transitional treatment as acceptable coverage.--During
the grace period specified in paragraph (1)(A), an employment-
based health plan that is described in such paragraph shall be
treated as acceptable coverage under this division.
(c) Limitation on Individual Health Insurance Coverage.--
(1) In general.--Individual health insurance coverage that
is not grandfathered health insurance coverage under subsection
(a) may only be offered on or after the first day of Y1 as an
Exchange-participating health benefits plan.
(2) Separate, excepted coverage permitted.--Excepted
benefits (as defined in section 2791(c) of the Public Health
Service Act) are not included within the definition of health
insurance coverage. Nothing in paragraph (1) shall prevent the
offering, other than through the Health Insurance Exchange, of
excepted benefits so long as it is offered and priced
separately from health insurance coverage.
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.
A qualified health benefits plan may not impose any pre-existing
condition exclusion (as defined in section 2701(b)(1)(A) of the Public
Health Service Act) or otherwise impose any limit or condition on the
coverage under the plan with respect to an individual or dependent
based on any health status-related factors (as defined in section
2791(d)(9) of the Public Health Service Act) in relation to the
individual or dependent.
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.
The requirements of sections 2711 (other than subsections (c) and
(e)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and
subsection (e)) of the Public Health Service Act, relating to
guaranteed availability and renewability of health insurance coverage,
shall apply to individuals and employers in all individual and group
health insurance coverage, whether offered to individuals or employers
through the Health Insurance Exchange, through any employment-based
health plan, or otherwise, in the same manner as such sections apply to
employers and health insurance coverage offered in the small group
market, except that such section 2712(b)(1) shall apply only if, before
nonrenewal or discontinuation of coverage, the issuer has provided the
enrollee with notice of non-payment of premiums and there is a grace
period during which the enrollees has an opportunity to correct such
nonpayment. Rescissions of such coverage shall be prohibited except in
cases of fraud as defined in sections 2712(b)(2) of such Act.
SEC. 113. INSURANCE RATING RULES.
(a) In General.--The premium rate charged for an insured qualified
health benefits plan may not vary except as follows:
(1) Limited age variation permitted.--By age (within such
age categories as the Commissioner shall specify) so long as
the ratio of the highest such premium to the lowest such
premium does not exceed the ratio of 2 to 1.
(2) By area.--By premium rating area (as permitted by State
insurance regulators or, in the case of Exchange-participating
health benefits plans, as specified by the Commissioner in
consultation with such regulators).
(3) By family enrollment.--By family enrollment (such as
variations within categories and compositions of families) so
long as the ratio of the premium for family enrollment (or
enrollments) to the premium for individual enrollment is
uniform, as specified under State law and consistent with rules
of the Commissioner.
(b) Study and Reports.--
(1) Study.--The Commissioner, in coordination with the
Secretary of Health and Human Services and the Secretary of
Labor, shall conduct a study of the large group insured and
self-insured employer health care markets. Such study shall
examine the following:
(A) The types of employers by key characteristics,
including size, that purchase insured products versus
those that self-insure.
(B) The similarities and differences between
typical insured and self-insured health plans.
(C) The financial solvency and capital reserve
levels of employers that self-insure by employer size.
(D) The risk of self-insured employers not being
able to pay obligations or otherwise becoming
financially insolvent.
(E) The extent to which rating rules are likely to
cause adverse selection in the large group market or to
encourage small and mid size employers to self-insure
(2) Reports.--Not later than 18 months after the date of
the enactment of this Act, the Commissioner shall submit to
Congress and the applicable agencies a report on the study
conducted under paragraph (1). Such report shall include any
recommendations the Commissioner deems appropriate to ensure
that the law does not provide incentives for small and mid-size
employers to self-insure or create adverse selection in the
risk pools of large group insurers and self-insured employers.
Not later than 18 months after the first day of Y1, the
Commissioner shall submit to Congress and the applicable
agencies an updated report on such study, including updates on
such recommendations.
SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND
SUBSTANCE ABUSE DISORDER BENEFITS.
(a) Nondiscrimination in Benefits.--A qualified health benefits
plan shall comply with standards established by the Commissioner to
prohibit discrimination in health benefits or benefit structures for
qualifying health benefits plans, building from sections 702 of
Employee Retirement Income Security Act of 1974, 2702 of the Public
Health Service Act, and section 9802 of the Internal Revenue Code of
1986.
(b) Parity in Mental Health and Substance Abuse Disorder
Benefits.--To the extent such provisions are not superceded by or
inconsistent with subtitle C, the provisions of section 2705 (other
than subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public
Health Service Act shall apply to a qualified health benefits plan,
regardless of whether it is offered in the individual or group market,
in the same manner as such provisions apply to health insurance
coverage offered in the large group market.
SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.
(a) In General.--A qualified health benefits plan that uses a
provider network for items and services shall meet such standards
respecting provider networks as the Commissioner may establish to
assure the adequacy of such networks in ensuring enrollee access to
such items and services and transparency in the cost-sharing
differentials between in-network coverage and out-of-network coverage.
(b) Provider Network Defined.--In this division, the term
``provider network'' means the providers with respect to which covered
benefits, treatments, and services are available under a health
benefits plan.
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.
(a) In General.--A qualified health benefits plan shall meet a
medical loss ratio as defined by the Commissioner. For any plan year in
which the qualified health benefits plan does not meet such medical
loss ratio, QHBP offering entity shall provide in a manner specified by
the Commissioner for rebates to enrollees of payment sufficient to meet
such loss ratio.
(b) Building on Interim Rules.--In implementing subsection (a), the
Commissioner shall build on the definition and methodology developed by
the Secretary of Health and Human Services under the amendments made by
section 161 for determining how to calculate the medical loss ratio.
Such methodology shall be set at the highest level medical loss ratio
possible that is designed to ensure adequate participation by QHBP
offering entities, competition in the health insurance market in and
out of the Health Insurance Exchange, and value for consumers so that
their premiums are used for services.
Subtitle C--Standards Guaranteeing Access to Essential Benefits
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.
(a) In General.--A qualified health benefits plan shall provide
coverage that at least meets the benefit standards adopted under
section 124 for the essential benefits package described in section 122
for the plan year involved.
(b) Choice of Coverage.--
(1) Non-exchange-participating health benefits plans.--In
the case of a qualified health benefits plan that is not an
Exchange-participating health benefits plan, such plan may
offer such coverage in addition to the essential benefits
package as the QHBP offering entity may specify.
(2) Exchange-participating health benefits plans.--In the
case of an Exchange-participating health benefits plan, such
plan is required under section 203 to provide specified levels
of benefits and, in the case of a plan offering a premium-plus
level of benefits, provide additional benefits.
(3) Continuation of offering of separate excepted benefits
coverage.--Nothing in this division shall be construed as
affecting the offering of health benefits in the form of
excepted benefits (described in section 102(b)(1)(B)(ii)) if
such benefits are offered under a separate policy, contract, or
certificate of insurance.
(c) No Restrictions on Coverage Unrelated to Clinical
Appropriateness.--A qualified health benefits plan may not impose any
restriction (other than cost-sharing) unrelated to clinical
appropriateness on the coverage of the health care items and services.
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) In General.--In this division, the term ``essential benefits
package'' means health benefits coverage, consistent with standards
adopted under section 124 to ensure the provision of quality health
care and financial security, that--
(1) provides payment for the items and services described
in subsection (b) in accordance with generally accepted
standards of medical or other appropriate clinical or
professional practice;
(2) limits cost-sharing for such covered health care items
and services in accordance with such benefit standards,
consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the
coverage of covered health care items and services;
(4) complies with section 115(a) (relating to network
adequacy); and
(5) is equivalent, as certified by Office of the Actuary of
the Centers for Medicare & Medicaid Services, to the average
prevailing employer-sponsored coverage.
(b) Minimum Services To Be Covered.--The items and services
described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services,
including emergency department services.
(3) Professional services of physicians and other health
professionals.
(4) Such services, equipment, and supplies incident to the
services of a physician's or a health professional's delivery
of care in institutional settings, physician offices, patients'
homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services
recommended with a grade of A or B by the Task Force on
Clinical Preventive Services and those vaccines recommended for
use by the Director of the Centers for Disease Control and
Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision,
and hearing services, equipment, and supplies at least for
children under 21 years of age.
(c) Requirements Relating to Cost-sharing and Minimum Actuarial
Value.--
(1) No cost-sharing for preventive services.--There shall
be no cost-sharing under the essential benefits package for
preventive items and services (as specified under the benefit
standards), including well baby and well child care.
(2) Annual limitation.--
(A) Annual limitation.--The cost-sharing incurred
under the essential benefits package with respect to an
individual (or family) for a year does not exceed the
applicable level specified in subparagraph (B).
(B) Applicable level.--The applicable level
specified in this subparagraph for Y1 is $5,000 for an
individual and $10,000 for a family. Such levels shall
be increased (rounded to the nearest $100) for each
subsequent year by the annual percentage increase in
the Consumer Price Index (United States city average)
applicable to such year.
(C) Use of copayments.--In establishing cost-
sharing levels for basic, enhanced, and premium plans
under this subsection, the Secretary shall, to the
maximum extent possible, use only copayments and not
coinsurance.
(3) Minimum actuarial value.--
(A) In general.--The cost-sharing under the
essential benefits package shall be designed to provide
a level of coverage that is designed to provide
benefits that are actuarially equivalent to
approximately 70 percent of the full actuarial value of
the benefits provided under the reference benefits
package described in subparagraph (B).
(B) Reference benefits package described.--The
reference benefits package described in this
subparagraph is the essential benefits package if there
were no cost-sharing imposed.
SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.
(a) Establishment.--
(1) In general.--There is established a private-public
advisory committee which shall be a panel of medical and other
experts to be known as the Health Benefits Advisory Committee
to recommend covered benefits and essential, enhanced, and
premium plans.
(2) Chair.--The Surgeon General shall be a member and the
chair of the Health Benefits Advisory Committee.
(3) Membership.--The Health Benefits Advisory Committee
shall be composed of the following members, in addition to the
Surgeon General:
(A) 9 members who are not Federal employees or
officers and who are appointed by the President.
(B) 9 members who are not Federal employees or
officers and who are appointed by the Comptroller
General of the United States in a manner similar to the
manner in which the Comptroller General appoints
members to the Medicare Payment Advisory Commission
under section 1805(c) of the Social Security Act.
(C) Such even number of members (not to exceed 8)
who are Federal employees and officers, as the
President may appoint.
Such initial appointments shall be made not later than 60 days
after the date of the enactment of this Act.
(4) Terms.--Each member of the Health Benefits Advisory
Committee shall serve a 3-year term on the Committee, except
that the terms of the initial members shall be adjusted in
order to provide for a staggered term of appointment for all
such members.
(5) Participation.--The membership of the Health Benefits
Advisory Committee shall at least reflect providers, consumer
representatives, employers, labor, health insurance issuers,
experts in health care financing and delivery, experts in
racial and ethnic disparities, experts in care for those with
disabilities, representatives of relevant governmental
agencies. and at least one practicing physician or other health
professional and an expert on children's health and shall
represent a balance among various sectors of the health care
system so that no single sector unduly influences the
recommendations of such Committee.
(b) Duties.--
(1) Recommendations on benefit standards.--The Health
Benefits Advisory Committee shall recommend to the Secretary of
Health and Human Services (in this subtitle referred to as the
``Secretary'') benefit standards (as defined in paragraph (4)),
and periodic updates to such standards. In developing such
recommendations, the Committee shall take into account
innovation in health care and consider how such standards could
reduce health disparities.
(2) Deadline.--The Health Benefits Advisory Committee shall
recommend initial benefit standards to the Secretary not later
than 1 year after the date of the enactment of this Act.
(3) Public input.--The Health Benefits Advisory Committee
shall allow for public input as a part of developing
recommendations under this subsection.
(4) Benefit standards defined.--In this subtitle, the term
``benefit standards'' means standards respecting--
(A) the essential benefits package described in
section 122, including categories of covered
treatments, items and services within benefit classes,
and cost-sharing; and
(B) the cost-sharing levels for enhanced plans and
premium plans (as provided under section 203(c))
consistent with paragraph (5).
(5) Levels of cost-sharing for enhanced and premium
plans.--
(A) Enhanced plan.--The level of cost-sharing for
enhanced plans shall be designed so that such plans
have benefits that are actuarially equivalent to
approximately 85 percent of the actuarial value of the
benefits provided under the reference benefits package
described in section 122(c)(3)(B).
(B) Premium plan.--The level of cost-sharing for
premium plans shall be designed so that such plans have
benefits that are actuarially equivalent to
approximately 95 percent of the actuarial value of the
benefits provided under the reference benefits package
described in section 122(c)(3)(B).
(c) Operations.--
(1) Per diem pay.--Each member of the Health Benefits
Advisory Committee shall receive travel expenses, including per
diem in accordance with applicable provisions under subchapter
I of chapter 57 of title 5, United States Code, and shall
otherwise serve without additional pay.
(2) Members not treated as federal employees.--Members of
the Health Benefits Advisory Committee shall not be considered
employees of the Federal government solely by reason of any
service on the Committee.
(3) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.), other than section 14, shall apply to the
Health Benefits Advisory Committee.
(d) Publication.--The Secretary shall provide for publication in
the Federal Register and the posting on the Internet website of the
Department of Health and Human Services of all recommendations made by
the Health Benefits Advisory Committee under this section.
SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT
STANDARDS.
(a) Process for Adoption of Recommendations.--
(1) Review of recommended standards.--Not later than 45
days after the date of receipt of benefit standards recommended
under section 123 (including such standards as modified under
paragraph (2)(B)), the Secretary shall review such standards
and shall determine whether to propose adoption of such
standards as a package.
(2) Determination to adopt standards.--If the Secretary
determines--
(A) to propose adoption of benefit standards so
recommended as a package, the Secretary shall, by
regulation under section 553 of title 5, United States
Code, propose adoption such standards; or
(B) not to propose adoption of such standards as a
package, the Secretary shall notify the Health Benefits
Advisory Committee in writing of such determination and
the reasons for not proposing the adoption of such
recommendation and provide the Committee with a further
opportunity to modify its previous recommendations and
submit new recommendations to the Secretary on a timely
basis.
(3) Contingency.--If, because of the application of
paragraph (2)(B), the Secretary would otherwise be unable to
propose initial adoption of such recommended standards by the
deadline specified in subsection (b)(1), the Secretary shall,
by regulation under section 553 of title 5, United States Code,
propose adoption of initial benefit standards by such deadline.
(4) Publication.--The Secretary shall provide for
publication in the Federal Register of all determinations made
by the Secretary under this subsection.
(b) Adoption of Standards.--
(1) Initial standards.--Not later than 18 months after the
date of the enactment of this Act, the Secretary shall, through
the rulemaking process consistent with subsection (a), adopt an
initial set of benefit standards.
(2) Periodic updating standards.--Under subsection (a), the
Secretary shall provide for the periodic updating of the
benefit standards previously adopted under this section.
(3) Requirement.--The Secretary may not adopt any benefit
standards for an essential benefits package or for level of
cost-sharing that are inconsistent with the requirements for
such a package or level under sections 122 and 123(b)(5).
Subtitle D--Additional Consumer Protections
SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.
The Commissioner shall establish uniform marketing standards that
all insured QHBP offering entities shall meet.
SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.
(a) In General.--A QHBP offering entity shall provide for timely
grievance and appeals mechanisms that the Commissioner shall establish.
(b) Internal Claims and Appeals Process.--Under a qualified health
benefits plan the QHBP offering entity 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. 70246) and shall update such process in accordance
with any standards that the Commissioner may establish.
(c) External Review Process.--
(1) In general.--The Commissioner shall establish an
external review process (including procedures for expedited
reviews of urgent claims) that provides for an impartial,
independent, and de novo review of denied claims under this
division.
(2) Requiring fair grievance and appeals mechanisms.--A
determination made, with respect to a qualified health benefits
plan offered by a QHBP offering entity, under the external
review process established under this subsection shall be
binding on the plan and the entity.
(d) Construction.--Nothing in this section shall be construed as
affecting the availability of judicial review under State law for
adverse decisions under subsection (b) or (c), subject to section 151.
SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.
(a) Accurate and Timely Disclosure.--
(1) In general.--A qualified health benefits plan shall
comply with standards established by the Commissioner for the
accurate and timely disclosure of plan documents, plan terms
and conditions, claims payment policies and practices, periodic
financial disclosure, data on enrollment, data on
disenrollment, data on the number of claims denials, data on
rating practices, information on cost-sharing and payments with
respect to any out-of-network coverage, and other information
as determined appropriate by the Commissioner. The Commissioner
shall require that such disclosure be provided in plain
language.
(2) Plain language.--In this subsection, 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 clean, concise,
well-organized, and follows other best practices of plain
language writing.
(3) Guidance.--The Commissioner shall develop and issue
guidance on best practices of plain language writing.
(b) Contracting Reimbursement.--A qualified health benefits plan
shall comply with standards established by the Commissioner to ensure
transparency to each health care provider relating to reimbursement
arrangements between such plan and such provider.
(c) Advance Notice of Plan Changes.--A change in a qualified health
benefits plan shall not be made without such reasonable and timely
advance notice to enrollees of such change.
SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED
THROUGH THE HEALTH INSURANCE EXCHANGE.
The requirements of the previous provisions of this subtitle shall
apply to qualified health benefits plans that are not being offered
through the Health Insurance Exchange only to the extent specified by
the Commissioner.
SEC. 135. TIMELY PAYMENT OF CLAIMS.
A QHBP offering entity shall comply with the requirements of
section 1857(f) of the Social Security Act with respect to a qualified
health benefits plan it offers in the same manner an Medicare Advantage
organization is required to comply with such requirements with respect
to a Medicare Advantage plan it offers under part C of Medicare.
SEC. 136. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF
BENEFITS.
The Commissioner shall establish standards for the coordination and
subrogation of benefits and reimbursement of payments in cases
involving individuals and multiple plan coverage.
SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.
A QHBP offering entity is required to comply with standards for
electronic financial and administrative transactions under section
1173A of the Social Security Act, added by section 163(a).
Subtitle E--Governance
SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.
(a) In General.--There is hereby established, as an independent
agency in the executive branch of the Government, a Health Choices
Administration (in this division referred to as the
``Administration'').
(b) Commissioner.--
(1) In general.--The Administration shall be headed by a
Health Choices Commissioner (in this division referred to as
the ``Commissioner'') who shall be appointed by the President,
by and with the advice and consent of the Senate.
(2) Compensation; etc.--The provisions of paragraphs (2),
(5), and (7) of subsection (a) (relating to compensation,
terms, general powers, rulemaking, and delegation) of section
702 of the Social Security Act (42 U.S.C. 902) shall apply to
the Commissioner and the Administration in the same manner as
such provisions apply to the Commissioner of Social Security
and the Social Security Administration.
SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.
(a) Duties.--The Commissioner is responsible for carrying out the
following functions under this division:
(1) Qualified plan standards.--The establishment of
qualified health benefits plan standards under this title,
including the enforcement of such standards in coordination
with State insurance regulators and the Secretaries of Labor
and the Treasury.
(2) Health insurance exchange.--The establishment and
operation of a Health Insurance Exchange under subtitle A of
title II.
(3) Individual affordability credits.--The administration
of individual affordability credits under subtitle C of title
II, including determination of eligibility for such credits.
(4) Additional functions.--Such additional functions as may
be specified in this division.
(b) Promoting Accountability.--
(1) In general.--The Commissioner shall undertake
activities in accordance with this subtitle to promote
accountability of QHBP offering entities in meeting Federal
health insurance requirements, regardless of whether such
accountability is with respect to qualified health benefits
plans offered through the Health Insurance Exchange or outside
of such Exchange.
(2) Compliance examination and audits.--
(A) In general.--The commissioner shall, in
coordination with States, conduct audits of qualified
health benefits plan compliance with Federal
requirements. Such audits may include random compliance
audits and targeted audits in response to complaints or
other suspected non-compliance.
(B) Recoupment of costs in connection with
examination and audits.--The Commissioner is authorized
to recoup from qualified health benefits plans
reimbursement for the costs of such examinations and
audit of such QHBP offering entities.
(c) Data Collection.--The Commissioner shall collect data for
purposes of carrying out the Commissioner's duties, including for
purposes of promoting quality and value, protecting consumers, and
addressing disparities in health and health care and may share such
data with the Secretary of Health and Human Services.
(d) Sanctions Authority.--
(1) In general.--In the case that the Commissioner
determines that a QHBP offering entity violates a requirement
of this title, the Commissioner may, in coordination with State
insurance regulators and the Secretary of Labor, provide, in
addition to any other remedies authorized by law, for any of
the remedies described in paragraph (2).
(2) Remedies.--The remedies described in this paragraph,
with respect to a qualified health benefits plan offered by a
QHBP offering entity, are--
(A) civil money penalties of not more than the
amount that would be applicable under similar
circumstances for similar violations under section
1857(g) of the Social Security Act;
(B) suspension of enrollment of individuals under
such plan after the date the Commissioner notifies the
entity of a determination under paragraph (1) and until
the Commissioner is satisfied that the basis for such
determination has been corrected and is not likely to
recur;
(C) in the case of an Exchange-participating health
benefits plan, suspension of payment to the entity
under the Health Insurance Exchange for individuals
enrolled in such plan after the date the Commissioner
notifies the entity of a determination under paragraph
(1) and until the Secretary is satisfied that the basis
for such determination has been corrected and is not
likely to recur; or
(D) working with State insurance regulators to
terminate plans for repeated failure by the offering
entity to meet the requirements of this title.
(e) Standard Definitions of Insurance and Medical Terms.--The
Commissioner shall provide for the development of standards for the
definitions of terms used in health insurance coverage, including
insurance-related terms.
(f) Efficiency in Administration.--The Commissioner shall issue
regulations for the effective and efficient administration of the
Health Insurance Exchange and affordability credits under subtitle C,
including, with respect to the determination of eligibility for
affordability credits, the use of personnel who are employed in
accordance with the requirements of title 5, United States Code, to
carry out the duties of the Commissioner or, in the case of sections
208 and 241(b)(2), the use of State personnel who are employed in
accordance with standards prescribed by the Office of Personnel
Management pursuant to section 208 of the Intergovernmental Personnel
Act of 1970 (42 U.S.C. 4728).
SEC. 143. CONSULTATION AND COORDINATION.
(a) Consultation.--In carrying out the Commissioner's duties under
this division, the Commissioner, as appropriate, shall consult with at
least with the following:
(1) The National Association of Insurance Commissioners,
State attorneys general, and State insurance regulators,
including concerning the standards for insured qualified health
benefits plans under this title and enforcement of such
standards.
(2) Appropriate State agencies, specifically concerning the
administration of individual affordability credits under
subtitle C of title II and the offering of Exchange-
participating health benefits plans, to Medicaid eligible
individuals under subtitle A of such title.
(3) Other appropriate Federal agencies.
(4) Indian tribes and tribal organizations.
(5) The National Association of Insurance Commissioners for
purposes of using model guidelines established by such
association for purposes of subtitles B and D.
(b) Coordination.--
(1) In general.--In carrying out the functions of the
Commissioner, including with respect to the enforcement of the
provisions of this division, the Commissioner shall work in
coordination with existing Federal and State entities to the
maximum extent feasible consistent with this division and in a
manner that prevents conflicts of interest in duties and
ensures effective enforcement.
(2) Uniform standards.--The Commissioner, in coordination
with such entities, shall seek to achieve uniform standards
that adequately protect consumers in a manner that does not
unreasonably affect employers and insurers.
SEC. 144. HEALTH INSURANCE OMBUDSMAN.
(a) In General.--The Commissioner shall appoint within the Health
Choices Administration a Qualified Health Benefits Plan Ombudsman who
shall have expertise and experience in the fields of health care and
education of (and assistance to) individuals.
(b) Duties.--The Qualified Health Benefits Plan Ombudsman shall, in
a linguistically appropriate manner--
(1) receive complaints, grievances, and requests for
information submitted by individuals;
(2) provide assistance with respect to complaints,
grievances, and requests referred to in paragraph (1),
including--
(A) helping individuals determine the relevant
information needed to seek an appeal of a decision or
determination;
(B) assistance to such individuals with any
problems arising from disenrollment from such a plan;
(C) assistance to such individuals in choosing a
qualified health benefits plan in which to enroll; and
(D) assistance to such individuals in presenting
information under subtitle C (relating to affordability
credits); and
(3) submit annual reports to Congress and the Commissioner
that describe the activities of the Ombudsman and that include
such recommendations for improvement in the administration of
this division as the Ombudsman determines appropriate. The
Ombudsman shall not serve as an advocate for any increases in
payments or new coverage of services, but may identify issues
and problems in payment or coverage policies.
Subtitle F--Relation to Other Requirements; Miscellaneous
SEC. 151. RELATION TO OTHER REQUIREMENTS.
(a) Coverage Not Offered Through Exchange.--
(1) In general.--In the case of health insurance coverage
not offered through the Health Insurance Exchange (whether or
not offered in connection with an employment-based health
plan), and in the case of employment-based health plans, the
requirements of this title do not supercede any requirements
applicable under titles XXII and XXVII of the Public Health
Service Act, parts 6 and 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974, or State law,
except insofar as such requirements prevent the application of
a requirement of this division, as determined by the
Commissioner.
(2) Construction.--Nothing in paragraph (1) shall be
construed as affecting the application of section 514 of the
Employee Retirement Income Security Act of 1974.
(b) Coverage Offered Through Exchange.--
(1) In general.--In the case of health insurance coverage
offered through the Health Insurance Exchange--
(A) the requirements of this title do not supercede
any requirements (including requirements relating to
genetic information nondiscrimination and mental
health) applicable under title XXVII of the Public
Health Service Act or under State law, except insofar
as such requirements prevent the application of a
requirement of this division, as determined by the
Commissioner; and
(B) individual rights and remedies under State laws
shall apply.
(2) Construction.--In the case of coverage described in
paragraph (1), nothing in such paragraph shall be construed as
preventing the application of rights and remedies under State
laws with respect to any requirement referred to in paragraph
(1)(A).
SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.
(a) In General.--Except as otherwise explicitly permitted by this
Act and by subsequent regulations consistent with this Act, all health
care and related services (including insurance coverage and public
health activities) covered by this Act shall be provided without regard
to personal characteristics extraneous to the provision of high quality
health care or related services.
(b) Implementation.--To implement the requirement set forth in
subsection (a), the Secretary of Health and Human Services shall, not
later than 18 months after the date of the enactment of this Act,
promulgate such regulations as are necessary or appropriate to insure
that all health care and related services (including insurance coverage
and public health activities) covered by this Act are provided (whether
directly or through contractual, licensing, or other arrangements)
without regard to personal characteristics extraneous to the provision
of high quality health care or related services.
SEC. 153. WHISTLEBLOWER PROTECTION.
(a) Retaliation Prohibited.--No employer may discharge any employee
or otherwise discriminate against any employee with respect to his
compensation, terms, conditions, or other privileges of employment
because the employee (or any person acting pursuant to a request of the
employee)--
(1) provided, caused to be provided, or is about to provide
or cause to be provided to the employer, the Federal
Government, or the attorney general of a State information
relating to any violation of, or any act or omission the
employee reasonably believes to be a violation of any provision
of this Act or any order, rule, or regulation promulgated under
this Act;
(2) testified or is about to testify in a proceeding
concerning such violation;
(3) assisted or participated or is about to assist or
participate in such a proceeding; or
(4) objected to, or refused to participate in, any
activity, policy, practice, or assigned task that the employee
(or other such person) reasonably believed to be in violation
of any provision of this Act or any order, rule, or regulation
promulgated under this Act.
(b) Enforcement Action.--An employee covered by this section who
alleges discrimination by an employer in violation of subsection (a)
may bring an action governed by the rules, procedures, legal burdens of
proof, and remedies set forth in section 40(b) of the Consumer Product
Safety Act (15 U.S.C. 2087(b)).
(c) Employer Defined.--As used in this section, the term
``employer'' means any person (including one or more individuals,
partnerships, associations, corporations, trusts, professional
membership organization including a certification, disciplinary, or
other professional body, unincorporated organizations, nongovernmental
organizations, or trustees) engaged in profit or nonprofit business or
industry whose activities are governed by this Act, and any agent,
contractor, subcontractor, grantee, or consultant of such person.
(d) Rule of Construction.--The rule of construction set forth in
section 20109(h) of title 49, United States Code, shall also apply to
this section.
SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.
Nothing in this division shall be construed to alter of supercede
any statutory or other obligation to engage in collective bargaining
over the terms and conditions of employment related to health care.
SEC. 155. SEVERABILITY.
If any provision of this Act, or any application of such provision
to any person or circumstance, is held to be unconstitutional, the
remainder of the provisions of this Act and the application of the
provision to any other person or circumstance shall not be affected.
Subtitle G--Early Investments
SEC. 161. ENSURING VALUE AND LOWER PREMIUMS.
(a) Group Health Insurance Coverage.--Title XXVII of the Public
Health Service Act is amended by inserting after section 2713 the
following new section:
``SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.
``(a) In General.--Each health insurance issuer that offers health
insurance coverage in the small or large group market shall provide
that for any plan year in which the coverage has a medical loss ratio
below a level specified by the Secretary, the issuer shall provide in a
manner specified by the Secretary for rebates to enrollees of payment
sufficient to meet such loss ratio. Such methodology shall be set at
the highest level medical loss ratio possible that is designed to
ensure adequate participation by issuers, competition in the health
insurance market, and value for consumers so that their premiums are
used for services.
``(b) Uniform Definitions.--The Secretary shall establish a uniform
definition of medical loss ratio and methodology for determining how to
calculate the medical loss ratio. Such methodology shall be designed to
take into account the special circumstances of smaller plans, different
types of plans, and newer plans.''.
(b) Individual Health Insurance Coverage.--Such title is further
amended by inserting after section 2753 the following new section:
``SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.
``The provisions of section 2714 shall apply to health insurance
coverage offered in the individual market in the same manner as such
provisions apply to health insurance coverage offered in the small or
large group market.''.
(c) Immediate Implementation.--The amendments made by this section
shall apply in the group and individual market for plan years beginning
on or after January 1, 2011.
SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE.
(a) Clarification Regarding Application of Guaranteed Renewability
of Individual Health Insurance Coverage.--Section 2742 of the Public
Health Service Act (42 U.S.C. 300gg-42) is amended--
(1) in its heading, by inserting ``and continuation in
force, including prohibition of rescission,'' after
``guaranteed renewability''; and
(2) in subsection (a), by inserting ``, including without
rescission,'' after ``continue in force''.
(b) Secretarial Guidance Regarding Rescissions.--Section 2742 of
such Act (42 U.S.C. 300gg-42) is amended by adding at the end the
following:
``(f) Rescission.--A health insurance issuer may rescind health
insurance coverage only upon clear and convincing evidence of fraud
described in subsection (b)(2). The Secretary, no later than July 1,
2010, shall issue guidance implementing this requirement, including
procedures for independent, external third party review.''.
(c) Opportunity for Independent, External Third Party Review in
Certain Cases.--Subpart 1 of part B of title XXVII of such Act (42
U.S.C. 300gg-41 et seq.) is amended by adding at the end the following:
``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW
IN CASES OF RESCISSION.
``(a) Notice and Review Right.--If a health insurance issuer
determines to rescind health insurance coverage for an individual in
the individual market, before such rescission may take effect the
issuer shall provide the individual with notice of such proposed
rescission and an opportunity for a review of such determination by an
independent, external third party under procedures specified by the
Secretary under section 2742(f).
``(b) Independent Determination.--If the individual requests such
review by an independent, external third party of a rescission of
health insurance coverage, the coverage shall remain in effect until
such third party determines that the coverage may be rescinded under
the guidance issued by the Secretary under section 2742(f).''.
(d) Effective Date.--The amendments made by this section shall
apply on and after October 1, 2010, with respect to health insurance
coverage issued before, on, or after such date.
SEC. 163. ADMINISTRATIVE SIMPLIFICATION.
(a) Standardizing Electronic Administrative Transactions.--
(1) In general.--Part C of title XI of the Social Security
Act (42 U.S.C. 1320d et seq.) is amended by inserting after
section 1173 the following new section:
``SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.
``(a) Standards for Financial and Administrative Transactions.--
``(1) In general.--The Secretary shall adopt and regularly
update standards consistent with the goals described in
paragraph (2).
``(2) Goals for financial and administrative
transactions.--The goals for standards under paragraph (1) are
that such standards shall--
``(A) be unique with no conflicting or redundant
standards;
``(B) be authoritative, permitting no additions or
constraints for electronic transactions, including
companion guides;
``(C) be comprehensive, efficient and robust,
requiring minimal augmentation by paper transactions or
clarification by further communications;
``(D) enable the real-time (or near real-time)
determination of an individual's financial
responsibility at the point of service and, to the
extent possible, prior to service, including whether
the individual is eligible for a specific service with
a specific physician at a specific facility, which may
include utilization of a machine-readable health plan
beneficiary identification card;
``(E) enable, where feasible, near real-time
adjudication of claims;
``(F) provide for timely acknowledgment, response,
and status reporting applicable to any electronic
transaction deemed appropriate by the Secretary;
``(G) describe all data elements (such as reason
and remark codes) in unambiguous terms, not permit
optional fields, require that data elements be either
required or conditioned upon set values in other
fields, and prohibit additional conditions; and
``(H) harmonize all common data elements across
administrative and clinical transaction standards.
``(3) Time for adoption.--Not later than 2 years after the
date of implementation of the X12 Version 5010 transaction
standards implemented under this part, the Secretary shall
adopt standards under this section.
``(4) Requirements for specific standards.--The standards
under this section shall be developed, adopted and enforced so
as to--
``(A) clarify, refine, complete, and expand, as
needed, the standards required under section 1173;
``(B) require paper versions of standardized
transactions to comply with the same standards as to
data content such that a fully compliant, equivalent
electronic transaction can be populated from the data
from a paper version;
``(C) enable electronic funds transfers, in order
to allow automated reconciliation with the related
health care payment and remittance advice;
``(D) require timely and transparent claim and
denial management processes, including tracking,
adjudication, and appeal processing;
``(E) require the use of a standard electronic
transaction with which health care providers may
quickly and efficiently enroll with a health plan to
conduct the other electronic transactions provided for
in this part; and
``(F) provide for other requirements relating to
administrative simplification as identified by the
Secretary, in consultation with stakeholders.
``(5) Building on existing standards.--In developing the
standards under this section, the Secretary shall build upon
existing and planned standards.
``(6) Implementation and enforcement.--Not later than 6
months after the date of the enactment of this section, the
Secretary shall submit to the appropriate committees of
Congress a plan for the implementation and enforcement, by not
later than 5 years after such date of enactment, of the
standards under this section. Such plan shall include--
``(A) a process and timeframe with milestones for
developing the complete set of standards;
``(B) an expedited upgrade program for continually
developing and approving additions and modifications to
the standards as often as annually to improve their
quality and extend their functionality to meet evolving
requirements in health care;
``(C) programs to provide incentives for, and ease
the burden of, implementation for certain health care
providers, with special consideration given to such
providers serving rural or underserved areas and ensure
coordination with standards, implementation
specifications, and certification criteria being
adopted under the HITECH Act;
``(D) programs to provide incentives for, and ease
the burden of, health care providers who volunteer to
participate in the process of setting standards for
electronic transactions;
``(E) an estimate of total funds needed to ensure
timely completion of the implementation plan; and
``(F) an enforcement process that includes timely
investigation of complaints, random audits to ensure
compliance, civil monetary and programmatic penalties
for non-compliance consistent with existing laws and
regulations, and a fair and reasonable appeals process
building off of enforcement provisions under this part.
``(b) Limitations on Use of Data.--Nothing in this section shall be
construed to permit the use of information collected under this section
in a manner that would adversely affect any individual.
``(c) Protection of Data.--The Secretary shall ensure (through the
promulgation of regulations or otherwise) that all data collected
pursuant to subsection (a) are--
``(1) used and disclosed in a manner that meets the HIPAA
privacy and security law (as defined in section 3009(a)(2) of
the Public Health Service Act), including any privacy or
security standard adopted under section 3004 of such Act; and
``(2) protected from all inappropriate internal use by any
entity that collects, stores, or receives the data, including
use of such data in determinations of eligibility (or continued
eligibility) in health plans, and from other inappropriate
uses, as defined by the Secretary.''.
(2) Definitions.--Section 1171 of such Act (42 U.S.C.
1320d) is amended--
(A) in paragraph (7), by striking ``with reference
to'' and all that follows and inserting ``with
reference to a transaction or data element of health
information in section 1173 means implementation
specifications, certification criteria, operating
rules, messaging formats, codes, and code sets adopted
or established by the Secretary for the electronic
exchange and use of information''; and
(B) by adding at the end the following new
paragraph:
``(9) Operating rules.--The term `operating rules' means
business rules for using and processing transactions. Operating
rules should address the following:
``(A) Requirements for data content using available
and established national standards.
``(B) Infrastructure requirements that establish
best practices for streamlining data flow to yield
timely execution of transactions.
``(C) Policies defining the transaction related
rights and responsibilities for entities that are
transmitting or receiving data.''.
(3) Conforming amendment.--Section 1179(a) of such Act (42
U.S.C. 1320d-8(a)) is amended, in the matter before paragraph
(1)--
(A) by inserting ``on behalf of an individual''
after ``1978)''; and
(B) by inserting ``on behalf of an individual''
after ``for a financial institution.''
(b) Standards for Claims Attachments and Coordination of Benefits
.--
(1) Standard for health claims attachments.--Not later than
1 year after the date of the enactment of this Act, the
Secretary of Health and Human Services shall promulgate a final
rule to establish a standard for health claims attachment
transaction described in section 1173(a)(2)(B) of the Social
Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and coordination of
benefits.
(2) Revision in processing payment transactions by
financial institutions.--
(A) In general.--Section 1179 of the Social
Security Act (42 U.S.C. 1320d-8) is amended, in the
matter before paragraph (1)--
(i) by striking ``or is engaged'' and
inserting ``and is engaged''; and
(ii) by inserting ``(other than as a
business associate for a covered entity)''
after ``for a financial institution''.
(B) Effective date.--The amendments made by
paragraph (1) shall apply to transactions occurring on
or after such date (not later than 6 months after the
date of the enactment of this Act) as the Secretary of
Health and Human Services shall specify.
SEC. 164. REINSURANCE PROGRAM FOR RETIREES.
(a) Establishment.--
(1) In general.--Not later than 90 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services shall establish a temporary reinsurance program (in
this section referred to as the ``reinsurance program'') to
provide reimbursement to assist participating employment-based
plans with the cost of providing health benefits to retirees
and to eligible spouses, surviving spouses and dependents of
such retirees.
(2) Definitions.--For purposes of this section:
(A) The term ``eligible employment-based plan''
means a group health benefits plan that--
(i) is maintained by one or more employers,
former employers or employee associations, or a
voluntary employees' beneficiary association,
or a committee or board of individuals
appointed to administer such plan, and
(ii) provides health benefits to retirees.
(B) The term ``health benefits'' means medical,
surgical, hospital, prescription drug, and such other
benefits as shall be determined by the Secretary,
whether self-funded or delivered through the purchase
of insurance or otherwise.
(C) The term ``participating employment-based
plan'' means an eligible employment-based plan that is
participating in the reinsurance program.
(D) The term ``retiree'' means, with respect to a
participating employment-benefit plan, an individual
who--
(i) is 55 years of age or older;
(ii) is not eligible for coverage under
title XVIII of the Social Security Act; and
(iii) is not an active employee of an
employer maintaining the plan or of any
employer that makes or has made substantial
contributions to fund such plan.
(E) The term ``Secretary'' means Secretary of
Health and Human Services.
(b) Participation.--To be eligible to participate in the
reinsurance program, an eligible employment-based plan shall submit to
the Secretary an application for participation in the program, at such
time, in such manner, and containing such information as the Secretary
shall require.
(c) Payment.--
(1) Submission of claims.--
(A) In general.--Under the reinsurance program, a
participating employment-based plan shall submit claims
for reimbursement to the Secretary which shall contain
documentation of the actual costs of the items and
services for which each claim is being submitted.
(B) Basis for claims.--Each claim submitted under
subparagraph (A) shall be based on the actual amount
expended by the participating employment-based plan
involved within the plan year for the appropriate
employment based health benefits provided to a retiree
or to the spouse, surviving spouse, or dependent of a
retiree. In determining the amount of any claim for
purposes of this subsection, the participating
employment-based plan shall take into account any
negotiated price concessions (such as discounts, direct
or indirect subsidies, rebates, and direct or indirect
remunerations) obtained by such plan with respect to
such health benefits. For purposes of calculating the
amount of any claim, the costs paid by the retiree or
by the spouse, surviving spouse, or dependent of the
retiree in the form of deductibles, co-payments, and
co-insurance shall be included along with the amounts
paid by the participating employment-based plan.
(2) Program payments and limit.--If the Secretary
determines that a participating employment-based plan has
submitted a valid claim under paragraph (1), the Secretary
shall reimburse such plan for 80 percent of that portion of the
costs attributable to such claim that exceeds $15,000, but is
less than $90,000. Such amounts shall be adjusted each year
based on the percentage increase in the medical care component
of the Consumer Price Index (rounded to the nearest multiple of
$1,000) for the year involved.
(3) Use of payments.--Amounts paid to a participating
employment-based plan under this subsection shall be used to
lower the costs borne directly by the participants and
beneficiaries for health benefits provided under such plan in
the form of premiums, co-payments, deductibles, co-insurance,
or other out-of-pocket costs. Such payments shall not be used
to reduce the costs of an employer maintaining the
participating employment-based plan. The Secretary shall
develop a mechanism to monitor the appropriate use of such
payments by such plans.
(4) Appeals and program protections.--The Secretary shall
establish--
(A) an appeals process to permit participating
employment-based plans to appeal a determination of the
Secretary with respect to claims submitted under this
section; and
(B) procedures to protect against fraud, waste, and
abuse under the program.
(5) Audits.--The Secretary shall conduct annual audits of
claims data submitted by participating employment-based plans
under this section to ensure that they are in compliance with
the requirements of this section.
(d) Retiree Reserve Trust Fund.--
(1) Establishment.--
(A) In general.--There is established in the
Treasury of the United States a trust fund to be known
as the ``Retiree Reserve Trust Fund'' (referred to in
this section as the ``Trust Fund''), that shall consist
of such amounts as may be appropriated or credited to
the Trust Fund as provided for in this subsection to
enable the Secretary to carry out the reinsurance
program. Such amounts shall remain available until
expended.
(B) Funding.--There are hereby appropriated to the
Trust Fund, out of any moneys in the Treasury not
otherwise appropriated, an amount requested by the
Secretary as necessary to carry out this section,
except that the total of all such amounts requested
shall not exceed $10,000,000,000.
(C) Appropriations from the trust fund.--
(i) In general.--Amounts in the Trust Fund
are appropriated to provide funding to carry
out the reinsurance program and shall be used
to carry out such program.
(ii) Budgetary implications.--Amounts
appropriated under clause (i), and outlays
flowing from such appropriations, shall not be
taken into account for purposes of any budget
enforcement procedures including allocations
under section 302(a) and (b) of the Balanced
Budget and Emergency Deficit Control Act and
budget resolutions for fiscal years during
which appropriations are made from the Trust
Fund.
(iii) Limitation to available funds.--The
Secretary has the authority to stop taking
applications for participation in the program
or take such other steps in reducing
expenditures under the reinsurance program in
order to ensure that expenditures under the
reinsurance program do not exceed the funds
available under this subsection.
TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF
DUTIES; DEFINITIONS.
(a) Establishment.--There is established within the Health Choices
Administration and under the direction of the Commissioner a Health
Insurance Exchange in order to facilitate access of individuals and
employers, through a transparent process, to a variety of choices of
affordable, quality health insurance coverage, including a public
health insurance option.
(b) Outline of Duties of Commissioner.--In accordance with this
subtitle and in coordination with appropriate Federal and State
officials as provided under section 143(b), the Commissioner shall--
(1) under section 204 establish standards for, accept bids
from, and negotiate and enter into contracts with, QHBP
offering entities for the offering of health benefits plans
through the Health Insurance Exchange, with different levels of
benefits required under section 203, and including with respect
to oversight and enforcement;
(2) under section 205 facilitate outreach and enrollment in
such plans of Exchange-eligible individuals and employers
described in section 202; and
(3) conduct such activities related to the Health Insurance
Exchange as required, including establishment of a risk pooling
mechanism under section 206 and consumer protections under
subtitle D of title I.
(c) Exchange-participating Health Benefits Plan Defined.--In this
division, the term ``Exchange-participating health benefits plan''
means a qualified health benefits plan that is offered through the
Health Insurance Exchange.
SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.
(a) Access to Coverage.--In accordance with this section, all
individuals are eligible to obtain coverage through enrollment in an
Exchange-participating health benefits plan offered through the Health
Insurance Exchange unless such individuals are enrolled in another
qualified health benefits plan or other acceptable coverage.
(b) Definitions.--In this division:
(1) Exchange-eligible individual.--The term ``Exchange-
eligible individual'' means an individual who is eligible under
this section to be enrolled through the Health Insurance
Exchange in an Exchange-participating health benefits plan and,
with respect to family coverage, includes dependents of such
individual.
(2) Exchange-eligible employer.--The term ``Exchange-
eligible employer'' means an employer that is eligible under
this section to enroll through the Health Insurance Exchange
employees of the employer (and their dependents) in Exchange-
eligible health benefits plans.
(3) Employment-related definitions.--The terms
``employer'', ``employee'', ``full-time employee'', and ``part-
time employee'' have the meanings given such terms by the
Commissioner for purposes of this division.
(c) Transition.--Individuals and employers shall only be eligible
to enroll or participate in the Health Insurance Exchange in accordance
with the following transition schedule:
(1) First year.--In Y1 (as defined in section 100(c))--
(A) individuals described in subsection (d)(1),
including individuals described in paragraphs (3) and
(4) of subsection (d); and
(B) smallest employers described in subsection
(e)(1).
(2) Second year.--In Y2--
(A) individuals and employers described in
paragraph (1); and
(B) smaller employers described in subsection
(e)(2).
(3) Third and subsequent years.--In Y3 and subsequent
years--
(A) individuals and employers described in
paragraph (2); and
(B) larger employers as permitted by the
Commissioner under subsection (e)(3).
(d) Individuals.--
(1) Individual described.--Subject to the succeeding
provisions of this subsection, an individual described in this
paragraph is an individual who--
(A) is not enrolled in coverage described in
subparagraphs (C) through (F) of paragraph (2); and
(B) is not enrolled in coverage as a full-time
employee (or as a dependent of such an employee) under
a group health plan if the coverage and an employer
contribution under the plan meet the requirements of
section 312.
For purposes of subparagraph (B), in the case of an individual
who is self-employed, who has at least 1 employee, and who
meets the requirements of section 312, such individual shall be
deemed a full-time employee described in such subparagraph.
(2) Acceptable coverage.--For purposes of this division,
the term ``acceptable coverage'' means any of the following:
(A) Qualified health benefits plan coverage.--
Coverage under a qualified health benefits plan.
(B) Grandfathered health insurance coverage;
coverage under current group health plan.--Coverage
under a grandfathered health insurance coverage (as
defined in subsection (a) of section 102) or under a
current group health plan (described in subsection (b)
of such section).
(C) Medicare.--Coverage under part A of title XVIII
of the Social Security Act.
(D) Medicaid.--Coverage for medical assistance
under title XIX of the Social Security Act, excluding
such coverage that is only available because of the
application of subsection (u), (z), or (aa) of section
1902 of such Act.
(E) Members of the armed forces and dependents
(including tricare).--Coverage under chapter 55 of
title 10, United States Code, including similar
coverage furnished under section 1781 of title 38 of
such Code.
(F) VA.--Coverage under the veteran's health care
program under chapter 17 of title 38, United States
Code, but only if the coverage for the individual
involved is determined by the Commissioner in
coordination with the Secretary of Treasury to be not
less than a level specified by the Commissioner and
Secretary of Veteran's Affairs, in coordination with
the Secretary of Treasury, based on the individual's
priority for services as provided under section 1705(a)
of such title.
(G) Other coverage.--Such other health benefits
coverage, such as a State health benefits risk pool, as
the Commissioner, in coordination with the Secretary of
the Treasury, recognizes for purposes of this
paragraph.
The Commissioner shall make determinations under this paragraph
in coordination with the Secretary of the Treasury.
(3) Treatment of certain non-traditional medicaid eligible
individuals.--An individual who is a non-traditional Medicaid
eligible individual (as defined in section 205(e)(4)(C)) in a
State may be an Exchange-eligible individual if the individual
was enrolled in a qualified health benefits plan, grandfathered
health insurance coverage, or current group health plan during
the 6 months before the individual became a non-traditional
Medicaid eligible individual. During the period in which such
an individual has chosen to enroll in an Exchange-participating
health benefits plan, the individual is not also eligible for
medical assistance under Medicaid.
(4) Continuing eligibility permitted.--
(A) In general.--Except as provided in subparagraph
(B), once an individual qualifies as an Exchange-
eligible individual under this subsection (including as
an employee or dependent of an employee of an Exchange-
eligible employer) and enrolls under an Exchange-
participating health benefits plan through the Health
Insurance Exchange, the individual shall continue to be
treated as an Exchange-eligible individual until the
individual is no longer enrolled with an Exchange-
participating health benefits plan.
(B) Exceptions.--
(i) In general.--Subparagraph (A) shall not
apply to an individual once the individual
becomes eligible for coverage--
(I) under part A of the Medicare
program;
(II) under the Medicaid program as
a Medicaid eligible individual, except
as permitted under paragraph (3) or
clause (ii); or
(III) in such other circumstances
as the Commissioner may provide.
(ii) Transition period.--In the case
described in clause (i)(II), the Commissioner
shall permit the individual to continue
treatment under subparagraph (A) until such
limited time as the Commissioner determines it
is administratively feasible, consistent with
minimizing disruption in the individual's
access to health care.
(e) Employers.--
(1) Smallest employer.--Subject to paragraph (4), smallest
employers described in this paragraph are employers with 10 or
fewer employees.
(2) Smaller employers.--Subject to paragraph (4), smaller
employers described in this paragraph are employers that are
not smallest employers described in paragraph (1) and have 20
or fewer employees.
(3) Larger employers.--
(A) In general.--Beginning with Y3, the
Commissioner may permit employers not described in
paragraph (1) or (2) to be Exchange-eligible employers.
(B) Phase-in.--In applying subparagraph (A), the
Commissioner may phase-in the application of such
subparagraph based on the number of full-time employees
of an employer and such other considerations as the
Commissioner deems appropriate.
(4) Continuing eligibility.--Once an employer is permitted
to be an Exchange-eligible employer under this subsection and
enrolls employees through the Health Insurance Exchange, the
employer shall continue to be treated as an Exchange-eligible
employer for each subsequent plan year regardless of the number
of employees involved unless and until the employer meets the
requirement of section 311(a) through paragraph (1) of such
section by offering a group health plan and not through
offering Exchange-participating health benefits plan.
(5) Employer participation and contributions.--
(A) Satisfaction of employer responsibility.--For
any year in which an employer is an Exchange-eligible
employer, such employer may meet the requirements of
section 312 with respect to employees of such employer
by offering such employees the option of enrolling with
Exchange-participating health benefits plans through
the Health Insurance Exchange consistent with the
provisions of subtitle B of title III.
(B) Employee choice.--Any employee offered
Exchange-participating health benefits plans by the
employer of such employee under subparagraph (A) may
choose coverage under any such plan. That choice
includes, with respect to family coverage, coverage of
the dependents of such employee.
(6) Affiliated groups.--Any employer which is part of a
group of employers who are treated as a single employer under
subsection (b), (c), (m), or (o) of section 414 of the Internal
Revenue Code of 1986 shall be treated, for purposes of this
subtitle, as a single employer.
(7) Other counting rules.--The Commissioner shall establish
rules relating to how employees are counted for purposes of
carrying out this subsection.
(f) Special Situation Authority.--The Commissioner shall have the
authority to establish such rules as may be necessary to deal with
special situations with regard to uninsured individuals and employers
participating as Exchange-eligible individuals and employers, such as
transition periods for individuals and employers who gain, or lose,
Exchange-eligible participation status, and to establish grace periods
for premium payment.
(g) Surveys of Individuals and Employers.--The Commissioner shall
provide for periodic surveys of Exchange-eligible individuals and
employers concerning satisfaction of such individuals and employers
with the Health Insurance Exchange and Exchange-participating health
benefits plans.
(h) Exchange Access Study.--
(1) In general.--The Commissioner shall conduct a study of
access to the Health Insurance Exchange for individuals and for
employers, including individuals and employers who are not
eligible and enrolled in Exchange-participating health benefits
plans. The goal of the study is to determine if there are
significant groups and types of individuals and employers who
are not Exchange eligible individuals or employers, but who
would have improved benefits and affordability if made eligible
for coverage in the Exchange.
(2) Items included in study.--Such study also shall
examine--
(A) the terms, conditions, and affordability of
group health coverage offered by employers and QHBP
offering entities outside of the Exchange compared to
Exchange-participating health benefits plans; and
(B) the affordability-test standard for access of
certain employed individuals to coverage in the Health
Insurance Exchange.
(3) Report.--Not later than January 1 of Y3, in Y6, and
thereafter, the Commissioner shall submit to Congress on the
study conducted under this subsection and shall include in such
report recommendations regarding changes in standards for
Exchange eligibility for for individuals and employers.
SEC. 203. BENEFITS PACKAGE LEVELS.
(a) In General.--The Commissioner shall specify the benefits to be
made available under Exchange-participating health benefits plans
during each plan year, consistent with subtitle C of title I and this
section.
(b) Limitation on Health Benefits Plans Offered by Offering
Entities.--The Commissioner may not enter into a contract with a QHBP
offering entity under section 204(c) for the offering of an Exchange-
participating health benefits plan in a service area unless the
following requirements are met:
(1) Required offering of basic plan.--The entity offers
only one basic plan for such service area.
(2) Optional offering of enhanced plan.--If and only if the
entity offers a basic plan for such service area, the entity
may offer one enhanced plan for such area.
(3) Optional offering of premium plan.--If and only if the
entity offers an enhanced plan for such service area, the
entity may offer one premium plan for such area.
(4) Optional offering of premium-plus plans.--If and only
if the entity offers a premium plan for such service area, the
entity may offer one or more premium-plus plans for such area.
All such plans may be offered under a single contract with the
Commissioner.
(c) Specification of Benefit Levels for Plans.--
(1) In general.--The Commissioner shall establish the
following standards consistent with this subsection and title
I:
(A) Basic, enhanced, and premium plans.--Standards
for 3 levels of Exchange-participating health benefits
plans: basic, enhanced, and premium (in this division
referred to as a ``basic plan'', ``enhanced plan'', and
``premium plan'', respectively).
(B) Premium-plus plan benefits.--Standards for
additional benefits that may be offered, consistent
with this subsection and subtitle C of title I, under a
premium plan (such a plan with additional benefits
referred to in this division as a ``premium-plus
plan'').
(2) Basic plan.--
(A) In general.--A basic plan shall offer the
essential benefits package required under title I for a
qualified health benefits plan.
(B) Tiered cost-sharing for affordable credit
eligible individuals.--In the case of an affordable
credit eligible individual (as defined in section
242(a)(1)) enrolled in an Exchange-participating health
benefits plan, the benefits under a basic plan are
modified to provide for the reduced cost-sharing for
the income tier applicable to the individual under
section 244(c).
(3) Enhanced plan.--A enhanced plan shall offer, in
addition to the level of benefits under the basic plan, a lower
level of cost-sharing as provided under title I consistent with
section 123(b)(5)(A).
(4) Premium plan.--A premium plan shall offer, in addition
to the level of benefits under the basic plan, a lower level of
cost-sharing as provided under title I consistent with section
123(b)(5)(B).
(5) Premium-plus plan.--A premium-plus plan is a premium
plan that also provides additional benefits, such as adult oral
health and vision care, approved by the Commissioner. The
portion of the premium that is attributable to such additional
benefits shall be separately specified.
(6) Range of permissible variation in cost-sharing.--The
Commissioner shall establish a permissible range of variation
of cost-sharing for each basic, enhanced, and premium plan,
except with respect to any benefit for which there is no cost-
sharing permitted under the essential benefits package. Such
variation shall permit a variation of not more than plus (or
minus) 10 percent in cost-sharing with respect to each benefit
category specified under section 122.
(d) Treatment of State Benefit Mandates.--Insofar as a State
requires a health insurance issuer offering health insurance coverage
to include benefits beyond the essential benefits package, such
requirement shall continue to apply to an Exchange-participating health
benefits plan, if the State has entered into an arrangement
satisfactory to the Commissioner to reimburse the Commissioner for the
amount of any net increase in affordability premium credits under
subtitle C as a result of an increase in premium in basic plans as a
result of application of such requirement.
SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH
BENEFITS PLANS.
(a) Contracting Duties.--In carrying out section 201(b)(1) and
consistent with this subtitle:
(1) Offering entity and plan standards.--The Commissioner
shall--
(A) establish standards necessary to implement the
requirements of this title and title I for--
(i) QHBP offering entities for the offering
of an Exchange-participating health benefits
plan; and
(ii) for Exchange-participating health
benefits plans; and
(B) certify QHBP offering entities and qualified
health benefits plans as meeting such standards and
requirements of this title and title I for purposes of
this subtitle.
(2) Soliciting and negotiating bids; contracts.--The
Commissioner shall--
(A) solicit bids from QHBP offering entities for
the offering of Exchange-participating health benefits
plans;
(B) based upon a review of such bids, negotiate
with such entities for the offering of such plans; and
(C) enter into contracts with such entities for the
offering of such plans through the Health Insurance
Exchange under terms (consistent with this title)
negotiated between the Commissioner and such entities.
(3) FAR not applicable.--The provisions of the Federal
Acquisition Regulation shall not apply to contracts between the
Commissioner and QHBP offering entities for the offering of
Exchange-participating health benefits plans under this title.
(b) Standards for QHBP Offering Entities To Offer Exchange-
Participating Health Benefits Plans.--The standards established under
subsection (a)(1)(A) shall require that, in order for a QHBP offering
entity to offer an Exchange-participating health benefits plan, the
entity must meet the following requirements:
(1) Licensed.--The entity shall be licensed to offer health
insurance coverage under State law for each State in which it
is offering such coverage.
(2) Data reporting.--The entity shall provide for the
reporting of such information as the Commissioner may specify,
including information necessary to administer the risk pooling
mechanism described in section 206(b) and information to
address disparities in health and health care.
(3) Implementing affordability credits.--The entity shall
provide for implementation of the affordability credits
provided for enrollees under subtitle C, including the
reduction in cost-sharing under section 244(c).
(4) Enrollment.--The entity shall accept all enrollments
under this subtitle, subject to such exceptions (such as
capacity limitations) in accordance with the requirements under
title I for a qualified health benefits plan. The entity shall
notify the Commissioner if the entity projects or anticipates
reaching such a capacity limitation that would result in a
limitation in enrollment.
(5) Risk pooling participation.--The entity shall
participate in such risk pooling mechanism as the Commissioner
establishes under section 206(b).
(6) Essential community providers.--With respect to the
basic plan offered by the entity, the entity shall contract for
outpatient services with covered entities (as defined in
section 340B(a)(4) of the Public Health Service Act, as in
effect as of July 1, 2009). The Commissioner shall specify the
extent to which and manner in which the previous sentence shall
apply in the case of a basic plan with respect to which the
Commissioner determines provides substantially all benefits
through a health maintenance organization, as defined in
section 2791(b)(3) of the Public Health Service Act.
(7) Culturally and linguistically appropriate services and
communications.--The entity shall provide for culturally and
linguistically appropriate communication and health services.
(8) Additional requirements.--The entity shall comply with
other applicable requirements of this title, as specified by
the Commissioner, which shall include standards regarding
billing and collection practices for premiums and related grace
periods and which may include standards to ensure that the
entity does not use coercive practices to force providers not
to contract with other entities offering coverage through the
Health Insurance Exchange.
(c) Contracts.--
(1) Bid application.--To be eligible to enter into a
contract under this section, a QHBP offering entity shall
submit to the Commissioner a bid at such time, in such manner,
and containing such information as the Commissioner may
require.
(2) Term.--Each contract with a QHBP offering entity under
this section shall be for a term of not less than one year, but
may be made automatically renewable from term to term in the
absence of notice of termination by either party.
(3) Enforcement of network adequacy.--In the case of a
health benefits plan of a QHBP offering entity that uses a
provider network, the contract under this section with the
entity shall provide that if--
(A) the Commissioner determines that such provider
network does not meet such standards as the
Commissioner shall establish under section 115; and
(B) an individual enrolled in such plan receives an
item or service from a provider that is not within such
network;
then any cost-sharing for such item or service shall be equal
to the amount of such cost-sharing that would be imposed if
such item or service was furnished by a provider within such
network.
(4) Oversight and enforcement responsibilities.--The
Commissioner shall establish processes, in coordination with
State insurance regulators, to oversee, monitor, and enforce
applicable requirements of this title with respect to QHBP
offering entities offering Exchange-participating health
benefits plans and such plans, including the marketing of such
plans. Such processes shall include the following:
(A) Grievance and complaint mechanisms.--The
Commissioner shall establish, in coordination with
State insurance regulators, a process under which
Exchange-eligible individuals and employers may file
complaints concerning violations of such standards.
(B) Enforcement.--In carrying out authorities under
this division relating to the Health Insurance
Exchange, the Commissioner may impose one or more of
the intermediate sanctions described in section 142(c).
(C) Termination.--
(i) In general.--The Commissioner may
terminate a contract with a QHBP offering
entity under this section for the offering of
an Exchange-participating health benefits plan
if such entity fails to comply with the
applicable requirements of this title. Any
determination by the Commissioner to terminate
a contract shall be made in accordance with
formal investigation and compliance procedures
established by the Commissioner under which--
(I) the Commissioner provides the
entity with the reasonable opportunity
to develop and implement a corrective
action plan to correct the deficiencies
that were the basis of the
Commissioner's determination; and
(II) the Commissioner provides the
entity with reasonable notice and
opportunity for hearing (including the
right to appeal an initial decision)
before terminating the contract.
(ii) Exception for imminent and serious
risk to health.--Clause (i) shall not apply if
the Commissioner determines that a delay in
termination, resulting from compliance with the
procedures specified in such clause prior to
termination, would pose an imminent and serious
risk to the health of individuals enrolled
under the qualified health benefits plan of the
QHBP offering entity.
(D) Construction.--Nothing in this subsection shall
be construed as preventing the application of other
sanctions under subtitle E of title I with respect to
an entity for a violation of such a requirement.
SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND
EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN.
(a) In General.--
(1) Outreach.--The Commissioner shall conduct outreach
activities consistent with subsection (c), including through
use of appropriate entities as described in paragraph (4) of
such subsection, to inform and educate individuals and
employers about the Health Insurance Exchange and Exchange-
participating health benefits plan options. Such outreach shall
include outreach specific to vulnerable populations, such as
children, individuals with disabilities, individuals with
mental illness, and individuals with other cognitive
impairments.
(2) Eligibility.--The Commissioner shall make timely
determinations of whether individuals and employers are
Exchange-eligible individuals and employers (as defined in
section 202).
(3) Enrollment.--The Commissioner shall establish and carry
out an enrollment process for Exchange-eligible individuals and
employers, including at community locations, in accordance with
subsection (b).
(b) Enrollment Process.--
(1) In general.--The Commissioner shall establish a process
consistent with this title for enrollments in Exchange-
participating health benefits plans. Such process shall provide
for enrollment through means such as the mail, by telephone,
electronically, and in person.
(2) Enrollment periods.--
(A) Open enrollment period.--The Commissioner shall
establish an annual open enrollment period during which
an Exchange-eligible individual or employer may elect
to enroll in an Exchange-participating health benefits
plan for the following plan year and an enrollment
period for affordability credits under subtitle C. Such
periods shall be during September through November of
each year, or such other time that would maximize
timeliness of income verification for purposes of such
subtitle. The open enrollment period shall not be less
than 30 days.
(B) Special enrollment.--The Commissioner shall
also provide for special enrollment periods to take
into account special circumstances of individuals and
employers, such as an individual who--
(i) loses acceptable coverage;
(ii) experiences a change in marital or
other dependent status;
(iii) moves outside the service area of the
Exchange-participating health benefits plan in
which the individual is enrolled; or
(iv) experiences a significant change in
income.
(C) Enrollment information.--The Commissioner shall
provide for the broad dissemination of information to
prospective enrollees on the enrollment process,
including before each open enrollment period. In
carrying out the previous sentence, the Commissioner
may work with other appropriate entities to facilitate
such provision of information.
(3) Automatic enrollment for non-medicaid eligible
individuals.--
(A) In general.--The Commissioner shall provide for
a process under which individuals who are Exchange-
eligible individuals described in subparagraph (B) are
automatically enrolled under an appropriate Exchange-
participating health benefits plan. Such process may
involve a random assignment or some other form of
assignment that takes into account the health care
providers used by the individual involved or such other
relevant factors as the Commissioner may specify.
(B) Subsidized individuals described.--An
individual described in this subparagraph is an
Exchange-eligible individual who is either of the
following:
(i) Affordability credit eligible
individuals.--The individual--
(I) has applied for, and been
determined eligible for, affordability
credits under subtitle C;
(II) has not opted out from
receiving such affordability credit;
and
(III) does not otherwise enroll in
another Exchange-participating health
benefits plan.
(ii) Individuals enrolled in a terminated
plan.--The individual is enrolled in an
Exchange-participating health benefits plan
that is terminated (during or at the end of a
plan year) and who does not otherwise enroll in
another Exchange-participating health benefits
plan.
(4) Direct payment of premiums to plans.--Under the
enrollment process, individuals enrolled in an Exchange-
partcipating health benefits plan shall pay such plans
directly, and not through the Commissioner or the Health
Insurance Exchange.
(c) Coverage Information and Assistance.--
(1) Coverage information.--The Commissioner shall provide
for the broad dissemination of information on Exchange-
participating health benefits plans offered under this title.
Such information shall be provided in a comparative manner, and
shall include information on benefits, premiums, cost-sharing,
quality, provider networks, and consumer satisfaction.
(2) Consumer assistance with choice.--To provide assistance
to Exchange-eligible individuals and employers, the
Commissioner shall--
(A) provide for the operation of a toll-free
telephone hotline to respond to requests for assistance
and maintain an Internet website through which
individuals may obtain information on coverage under
Exchange-participating health benefits plans and file
complaints;
(B) develop and disseminate information to
Exchange-eligible enrollees on their rights and
responsibilities;
(C) assist Exchange-eligible individuals in
selecting Exchange-participating health benefits plans
and obtaining benefits through such plans; and
(D) ensure that the Internet website described in
subparagraph (A) and the information described in
subparagraph (B) is developed using plain language (as
defined in section 133(a)(2)).
(3) Use of other entities.--In carrying out this
subsection, the Commissioner may work with other appropriate
entities to facilitate the dissemination of information under
this subsection and to provide assistance as described in
paragraph (2).
(d) Special Duties Related to Medicaid and CHIP.--
(1) Coverage for certain newborns.--
(A) In general.--In the case of a child born in the
United States who at the time of birth is not otherwise
covered under acceptable coverage, for the period of
time beginning on the date of birth and ending on the
date the child otherwise is covered under acceptable
coverage (or, if earlier, the end of the month in which
the 60-day period, beginning on the date of birth,
ends), the child shall be deemed--
(i) to be a non-traditional Medicaid
eligible individual (as defined in subsection
(e)(5)) for purposes of this division and
Medicaid; and
(ii) to have elected to enroll in Medicaid
through the application of paragraph (3).
(B) Extended treatment as traditional medicaid
eligible individual.--In the case of a child described
in subparagraph (A) who at the end of the period
referred to in such subparagraph is not otherwise
covered under acceptable coverage, the child shall be
deemed (until such time as the child obtains such
coverage or the State otherwise makes a determination
of the child's eligibility for medical assistance under
its Medicaid plan pursuant to section 1943(c)(1) of the
Social Security Act) to be a traditional Medicaid
eligible individual described in section 1902(l)(1)(B)
of such Act.
(2) CHIP transition.--A child who, as of the day before the
first day of Y1, is eligible for child health assistance under
title XXI of the Social Security Act (including a child
receiving coverage under an arrangement described in section
2101(a)(2) of such Act) is deemed as of such first day to be an
Exchange-eligible individual unless the individual is a
traditional Medicaid eligible individual as of such day.
(3) Automatic enrollment of medicaid eligible individuals
into medicaid.--The Commissioner shall provide for a process
under which an individual who is described in section 202(d)(3)
and has not elected to enroll in an Exchange-participating
health benefits plan is automatically enrolled under Medicaid.
(4) Notifications.--The Commissioner shall notify each
State in Y1 and for purposes of section 1902(gg)(1) of the
Social Security Act (as added by section 1703(a)) whether the
Health Insurance Exchange can support enrollment of children
described in paragraph (2) in such State in such year.
(e) Medicaid Coverage for Medicaid Eligible Individuals.--
(1) In general.--
(A) Choice for limited exchange-eligible
individuals.--As part of the enrollment process under
subsection (b), the Commissioner shall provide the
option, in the case of an Exchange-eligible individual
described in section 202(d)(3), for the individual to
elect to enroll under Medicaid instead of under an
Exchange-participating health benefits plan. Such an
individual may change such election during an
enrollment period under subsection (b)(2).
(B) Medicaid enrollment obligation.--An Exchange
eligible individual may apply, in the manner described
in section 241(b)(1), for a determination of whether
the individual is a Medicaid-eligible individual. If
the individual is determined to be so eligible, the
Commissioner, through the Medicaid memorandum of
understanding, shall provide for the enrollment of the
individual under the State Medicaid plan in accordance
with the Medicaid memorandum of understanding under
paragraph (4). In the case of such an enrollment, the
State shall provide for the same periodic
redetermination of eligibility under Medicaid as would
otherwise apply if the individual had directly applied
for medical assistance to the State Medicaid agency.
(2) Non-traditional medicaid eligible individuals.--In the
case of a non-traditional Medicaid eligible individual
described in section 202(d)(3) who elects to enroll under
Medicaid under paragraph (1)(A), the Commissioner shall provide
for the enrollment of the individual under the State Medicaid
plan in accordance with the Medicaid memorandum of
understanding under paragraph (4).
(3) Coordinated enrollment with state through memorandum of
understanding.--The Commissioner, in consultation with the
Secretary of Health and Human Services, shall enter into a
memorandum of understanding with each State (each in this
division referred to as a ``Medicaid memorandum of
understanding'') with respect to coordinating enrollment of
individuals in Exchange-participating health benefits plans and
under the State's Medicaid program consistent with this section
and to otherwise coordinate the implementation of the
provisions of this division with respect to the Medicaid
program. Such memorandum shall permit the exchange of
information consistent with the limitations described in
section 1902(a)(7) of the Social Security Act. Nothing in this
section shall be construed as permitting such memorandum to
modify or vitiate any requirement of a State Medicaid plan.
(4) Medicaid eligible individuals.--For purposes of this
division:
(A) Medicaid eligible individual.--The term
``Medicaid eligible individual'' means an individual
who is eligible for medical assistance under Medicaid.
(B) Traditional medicaid eligible individual.--The
term ``traditional Medicaid eligible individual'' means
a Medicaid eligible individual other than an individual
who is--
(i) a Medicaid eligible individual by
reason of the application of subclause (VIII)
of section 1902(a)(10)(A)(i) of the Social
Security Act; or
(ii) a childless adult not described in
section 1902(a)(10) (A) or (C) of such Act (as
in effect as of the day before the date of the
enactment of this Act).
(C) Non-traditional medicaid eligible individual.--
The term ``non-traditional Medicaid eligible
individual'' means a Medicaid eligible individual who
is not a traditional Medicaid eligible individual.
(f) Effective Culturally and Linguistically Appropriate
Communication.--In carrying out this section, the Commissioner shall
establish effective methods for communicating in plain language and a
culturally and linguistically appropriate manner.
SEC. 206. OTHER FUNCTIONS.
(a) Coordination of Affordability Credits.--The Commissioner shall
coordinate the distribution of affordability premium and cost-sharing
credits under subtitle C to QHBP offering entities offering Exchange-
participating health benefits plans.
(b) Coordination of Risk Pooling.--The Commissioner shall establish
a mechanism whereby there is an adjustment made of the premium amounts
payable among QHBP offering entities offering Exchange-participating
health benefits plans of premiums collected for such plans that takes
into account (in a manner specified by the Commissioner) the
differences in the risk characteristics of individuals and employers
enrolled under the different Exchange-participating health benefits
plans offered by such entities so as to minimize the impact of adverse
selection of enrollees among the plans offered by such entities.
(c) Special Inspector General for the Health Insurance Exchange.--
(1) Establishment; appointment.--There is hereby
established the Office of the Special Inspector General for the
Health Insurance Exchange, to be headed by a Special Inspector
General for the Health Insurance Exchange (in this subsection
referred to as the ``Special Inspector General'') to be
appointed by the President, by and with the advice and consent
of the Senate. The nomination of an individual as Special
Inspector General shall be made as soon as practicable after
the establishment of the program under this subtitle.
(2) Duties.--The Special Inspector General shall--
(A) conduct, supervise, and coordinate audits,
evaluations and investigations of the Health Insurance
Exchange to protect the integrity of the Health
Insurance Exchange, as well as the health and welfare
of participants in the Exchange;
(B) report both to the Commissioner and to the
Congress regarding program and management problems and
recommendations to correct them;
(C) have other duties (described in paragraphs (2)
and (3) of section 121 of division A of Public Law 110-
343) in relation to the duties described in the
previous subparagraphs; and
(D) have the authorities provided in section 6 of
the Inspector General Act of 1978 in carrying out
duties under this paragraph.
(3) Application of other special inspector general
provisions.--The provisions of subsections (b) (other than
paragraphs (1) and (3)), (d) (other than paragraph (1)), and
(e) of section 121 of division A of the Emergency Economic
Stabilization Act of 2009 (Public Law 110-343) shall apply to
the Special Inspector General under this subsection in the same
manner as such provisions apply to the Special Inspector
General under such section.
(4) Reports.--Not later than one year after the
confirmation of the Special Inspector General, and annually
thereafter, the Special Inspector General shall submit to the
appropriate committees of Congress a report summarizing the
activities of the Special Inspector General during the one year
period ending on the date such report is submitted.
(5) Termination.--The Office of the Special Inspector
General shall terminate five years after the date of the
enactment of this Act.
SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.
(a) Establishment of Health Insurance Exchange Trust Fund.--There
is created within the Treasury of the United States a trust fund to be
known as the ``Health Insurance Exchange Trust Fund'' (in this section
referred to as the ``Trust Fund''), consisting of such amounts as may
be appropriated or credited to the Trust Fund under this section or any
other provision of law.
(b) Payments From Trust Fund.--The Commissioner shall pay from time
to time from the Trust Fund such amounts as the Commissioner determines
are necessary to make payments to operate the Health Insurance
Exchange, including payments under subtitle C (relating to
affordability credits).
(c) Transfers to Trust Fund.--
(1) Dedicated payments.--There is hereby appropriated to
the Trust Fund amounts equivalent to the following:
(A) Taxes on individuals not obtaining acceptable
coverage.--The amounts received in the Treasury under
section 59B of the Internal Revenue Code of 1986
(relating to requirement of health insurance coverage
for individuals).
(B) Employment taxes on employers not providing
acceptable coverage.--The amounts received in the
Treasury under section 3111(c) of the Internal Revenue
Code of 1986 (relating to employers electing to not
provide health benefits).
(C) Excise tax on failures to meet certain health
coverage requirements.--The amounts received in the
Treasury under section 4980H(b) (relating to excise tax
with respect to failure to meet health coverage
participation requirements).
(2) Appropriations to cover government contributions.--
There are hereby appropriated, out of any moneys in the
Treasury not otherwise appropriated, to the Trust Fund, an
amount equivalent to the amount of payments made from the Trust
Fund under subsection (b) plus such amounts as are necessary
reduced by the amounts deposited under paragraph (1).
(d) Application of Certain Rules.--Rules similar to the rules of
subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall
apply with respect to the Trust Fund.
SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.
(a) In General.--If--
(1) a State (or group of States, subject to the approval of
the Commissioner) applies to the Commissioner for approval of a
State-based Health Insurance Exchange to operate in the State
(or group of States); and
(2) the Commissioner approves such State-based Health
Insurance Exchange,
then, subject to subsections (c) and (d), the State-based Health
Insurance Exchange shall operate, instead of the Health Insurance
Exchange, with respect to such State (or group of States). The
Commissioner shall approve a State-based Health Insurance Exchange if
it meets the requirements for approval under subsection (b).
(b) Requirements for Approval.--The Commissioner may not approve a
State-based Health Insurance Exchange under this section unless the
following requirements are met:
(1) The State-based Health Insurance Exchange must
demonstrate the capacity to and provide assurances satisfactory
to the Commissioner that the State-based Health Insurance
Exchange will carry out the functions specified for the Health
Insurance Exchange in the State (or States) involved,
including--
(A) negotiating and contracting with QHBP offering
entities for the offering of Exchange-participating
health benefits plan, which satisfy the standards and
requirements of this title and title I;
(B) enrolling Exchange-eligible individuals and
employers in such State in such plans;
(C) the establishment of sufficient local offices
to meet the needs of Exchange-eligible individuals and
employers;
(D) administering affordability credits under
subtitle B using the same methodologies (and at least
the same income verification methods) as would
otherwise apply under such subtitle and at a cost to
the Federal Government which does exceed the cost to
the Federal Government if this section did not apply;
and
(E) enforcement activities consistent with federal
requirements.
(2) There is no more than one Health Insurance Exchange
operating with respect to any one State.
(3) The State provides assurances satisfactory to the
Commissioner that approval of such an Exchange will not result
in any net increase in expenditures to the Federal Government.
(4) The State provides for reporting of such information as
the Commissioner determines and assurances satisfactory to the
Commissioner that it will vigorously enforce violations of
applicable requirements.
(5) Such other requirements as the Commissioner may
specify.
(c) Ceasing Operation.--
(1) In general.--A State-based Health Insurance Exchange
may, at the option of each State involved, and only after
providing timely and reasonable notice to the Commissioner,
cease operation as such an Exchange, in which case the Health
Insurance Exchange shall operate, instead of such State-based
Health Insurance Exchange, with respect to such State (or
States).
(2) Termination; health insurance exchange resumption of
functions.--The Commissioner may terminate the approval (for
some or all functions) of a State-based Health Insurance
Exchange under this section if the Commissioner determines that
such Exchange no longer meets the requirements of subsection
(b) or is no longer capable of carrying out such functions in
accordance with the requirements of this subtitle. In lieu of
terminating such approval, the Commissioner may temporarily
assume some or all functions of the State-based Health
Insurance Exchange until such time as the Commissioner
determines the State-based Health Insurance Exchange meets such
requirements of subsection (b) and is capable of carrying out
such functions in accordance with the requirements of this
subtitle.
(3) Effectiveness.--The ceasing or termination of a State-
based Health Insurance Exchange under this subsection shall be
effective in such time and manner as the Commissioner shall
specify.
(d) Retention of Authority.--
(1) Authority retained.--Enforcement authorities of the
Commissioner shall be retained by the Commissioner.
(2) Discretion to retain additional authority.--The
Commissioner may specify functions of the Health Insurance
Exchange that--
(A) may not be performed by a State-based Health
Insurance Exchange under this section; or
(B) may be performed by the Commissioner and by
such a State-based Health Insurance Exchange.
(e) References.--In the case of a State-based Health Insurance
Exchange, except as the Commissioner may otherwise specify under
subsection (d), any references in this subtitle to the Health Insurance
Exchange or to the Commissioner in the area in which the State-based
Health Insurance Exchange operates shall be deemed a reference to the
State-based Health Insurance Exchange and the head of such Exchange,
respectively.
(f) Funding.--In the case of a State-based Health Insurance
Exchange, there shall be assistance provided for the operation of such
Exchange in the form of a matching grant with a State share of
expenditures required.
Subtitle B--Public Health Insurance Option
SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH INSURANCE
OPTION AS AN EXCHANGE-QUALIFIED HEALTH BENEFITS PLAN.
(a) Establishment.--For years beginning with Y1, the Secretary of
Health and Human Services (in this subtitle referred to as the
``Secretary'') shall provide for the offering of an Exchange-
participating health benefits plan (in this division referred to as the
``public health insurance option'') that ensures choice, competition,
and stability of affordable, high quality coverage throughout the
United States in accordance with this subtitle. In designing the
option, the Secretary's primary responsibility is to create a low-cost
plan without comprimising quality or access to care.
(b) Offering as an Exchange-participating Health Benefits Plan.--
(1) Exclusive to the exchange.--The public health insurance
option shall only be made available through the Health
Insurance Exchange.
(2) Ensuring a level playing field.--Consistent with this
subtitle, the public health insurance option shall comply with
requirements that are applicable under this title to an
Exchange-participating health benefits plan, including
requirements related to benefits, benefit levels, provider
networks, notices, consumer protections, and cost sharing.
(3) Provision of benefit levels.--The public health
insurance option--
(A) shall offer basic, enhanced, and premium plans;
and
(B) may offer premium-plus plans.
(c) Administrative Contracting.--The Secretary may enter into
contracts for the purpose of performing administrative functions
(including functions described in subsection (a)(4) of section 1874A of
the Social Security Act) with respect to the public health insurance
option in the same manner as the Secretary may enter into contracts
under subsection (a)(1) of such section. The Secretary has the same
authority with respect to the public health insurance option as the
Secretary has under subsections (a)(1) and (b) of section 1874A of the
Social Security Act with respect to title XVIII of such Act. Contracts
under this subsection shall not involve the transfer of insurance risk
to such entity.
(d) Ombudsman.--The Secretary shall establish an office of the
ombudsman for the public health insurance option which shall have
duties with respect to the public health insurance option similar to
the duties of the Medicare Beneficiary Ombudsman under section
1808(c)(2) of the Social Security Act.
(e) Data Collection.--The Secretary shall collect such data as may
be required to establish premiums and payment rates for the public
health insurance option and for other purposes under this subtitle,
including to improve quality and to reduce racial, ethnic, and other
disparities in health and health care.
(f) Treatment of Public Health Insurance Option.--With respect to
the public health insurance option, the Secretary shall be treated as a
QHBP offering entity offering an Exchange-participating health benefits
plan.
(g) Access to Federal Courts.--The provisions of Medicare (and
related provisions of title II of the Social Security Act) relating to
access of Medicare beneficiaries to Federal courts for the enforcement
of rights under Medicare, including with respect to amounts in
controversy, shall apply to the public health insurance option and
individuals enrolled under such option under this title in the same
manner as such provisions apply to Medicare and Medicare beneficiaries.
SEC. 222. PREMIUMS AND FINANCING.
(a) Establishment of Premiums.--
(1) In general.--The Secretary shall establish
geographically-adjusted premium rates for the public health
insurance option in a manner--
(A) that complies with the premium rules
established by the Commissioner under section 113 for
Exchange-participating health benefit plans; and
(B) at a level sufficient to fully finance the
costs of--
(i) health benefits provided by the public
health insurance option; and
(ii) administrative costs related to
operating the public health insurance option.
(2) Contingency margin.--In establishing premium rates
under paragraph (1), the Secretary shall include an appropriate
amount for a contingency margin.
(b) Account.--
(1) Establishment.--There is established in the Treasury of
the United States an Account for the receipts and disbursements
attributable to the operation of the public health insurance
option, including the start-up funding under paragraph (2).
Section 1854(g) of the Social Security Act shall apply to
receipts described in the previous sentence in the same manner
as such section applies to payments or premiums described in
such section.
(2) Start-up funding.--
(A) In general.--In order to provide for the
establishment of the public health insurance option
there is hereby appropriated to the Secretary, out of
any funds in the Treasury not otherwise appropriated,
$2,000,000,000. In order to provide for initial claims
reserves before the collection of premiums, there is
hereby appropriated to the Secretary, out of any funds
in the Treasury not otherwise appropriated, such sums
as necessary to cover 90 days worth of claims reserves
based on projected enrollment.
(B) Amortization of start-up funding.--The
Secretary shall provide for the repayment of the
startup funding provided under subparagraph (A) to the
Treasury in an amortized manner over the 10-year period
beginning with Y1.
(C) Limitation on funding.--Nothing in this section
shall be construed as authorizing any additional
appropriations to the Account, other than such amounts
as are otherwise provided with respect to other
Exchange-participating health benefits plans.
SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.
(a) Rates Established by Secretary.--
(1) In general.--The Secretary shall establish payment
rates for the public health insurance option for services and
health care providers consistent with this section and may
change such payment rates in accordance with section 224.
(2) Initial payment rules.--
(A) In general.--Except as provided in subparagraph
(B) and subsection (b)(1), during Y1, Y2, and Y3, the
Secretary shall base the payment rates under this
section for services and providers described in
paragraph (1) on the payment rates for similar services
and providers under parts A and B of Medicare.
(B) Exceptions.--
(i) Practitioners' services.--Payment rates
for practitioners' services otherwise
established under the fee schedule under
section 1848 of the Social Security Act shall
be applied without regard to the provisions
under subsection (f) of such section and the
update under subsection (d)(4) under such
section for a year as applied under this
paragraph shall be not less than 1 percent.
(ii) Adjustments.--The Secretary may
determine the extent to which Medicare
adjustments applicable to base payment rates
under parts A and B of Medicare shall apply
under this subtitle.
(3) For new services.--The Secretary shall modify payment
rates described in paragraph (2) in order to accommodate
payments for services, such as well-child visits, that are not
otherwise covered under Medicare.
(4) Prescription drugs.--Payment rates under this section
for prescription drugs that are not paid for under part A or
part B of Medicare shall be at rates negotiated by the
Secretary.
(b) Incentives for Participating Providers.--
(1) Initial incentive period.--
(A) In general.--The Secretary shall provide, in
the case of services described in subparagraph (B)
furnished during Y1, Y2, and Y3, for payment rates that
are 5 percent greater than the rates established under
subsection (a).
(B) Services described.--The services described in
this subparagraph are items and professional services,
under the public health insurance option by a physician
or other health care practitioner who participates in
both Medicare and the public health insurance option.
(C) Special rules.--A pediatrician and any other
health care practitioner who is a type of practitioner
that does not typically participate in Medicare (as
determined by the Secretary) shall also be eligible for
the increased payment rates under subparagraph (A).
(2) Subsequent periods.--Beginning with Y4 and for
subsequent years, the Secretary shall continue to use an
administrative process to set such rates in order to promote
payment accuracy, to ensure adequate beneficiary access to
providers, and to promote affordablility and the efficient
delivery of medical care consistent with section 221(a). Such
rates shall not be set at levels expected to increase overall
medical costs under the option beyond what would be expected if
the process under subsection (a)(2) and paragraph (1) of this
subsection were continued.
(3) Establishment of a provider network.--Health care
providers participating under Medicare are participating
providers in the public health insurance option unless they opt
out in a process established by the Secretary.
(c) Administrative Process for Setting Rates.--Chapter 5 of title
5, United States Code shall apply to the process for the initial
establishment of payment rates under this section but not to the
specific methodology for establishing such rates or the calculation of
such rates.
(d) Construction.--Nothing in this subtitle shall be construed as
limiting the Secretary's authority to correct for payments that are
excessive or deficient, taking into account the provisions of section
221(a) and the amounts paid for similar health care providers and
services under other Exchange-participating health benefits plans.
(e) Construction.--Nothing in this subtitle shall be construed as
affecting the authority of the Secretary to establish payment rates,
including payments to provide for the more efficient delivery of
services, such as the initiatives provided for under section 224.
(f) Limitations on Review.--There shall be no administrative or
judicial review of a payment rate or methodology established under this
section or under section 224.
SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.
(a) In General.--For plan years beginning with Y1, the Secretary
may utilize innovative payment mechanisms and policies to determine
payments for items and services under the public health insurance
option. The payment mechanisms and policies under this section may
include patient-centered medical home and other care management
payments, accountable care organizations, value-based purchasing,
bundling of services, differential payment rates, performance or
utilization based payments, partial capitation, and direct contracting
with providers.
(b) Requirements for Innovative Payments.--The Secretary shall
design and implement the payment mechanisms and policies under this
section in a manner that--
(1) seeks to--
(A) improve health outcomes;
(B) reduce health disparities (including racial,
ethnic, and other disparities);
(C) provide efficent and affordable care;
(D) address geographic variation in the provision
of health services; or
(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-centered,
quality, and efficient.
(c) Encouraging the Use of High Value Services.--To the extent
allowed by the benefit standards applied to all Exchange-participating
health benefits plans, the public health insurance option may modify
cost sharing and payment rates to encourage the use of services that
promote health and value.
(d) Non-uniformity Permitted.--Nothing in this subtitle shall
prevent the Secretary from varying payments based on different payment
structure models (such as accountable care organizations and medical
homes) under the public health insurance option for different
geographic areas.
SEC. 225. PROVIDER PARTICIPATION.
(a) In General.--The Secretary shall establish conditions of
participation for health care providers under the public health
insurance option.
(b) Licensure or Certification.--The Secretary shall not allow a
health care provider to participate in the public health insurance
option unless such provider is appropriately licensed or certified
under State law.
(c) Payment Terms for Providers.--
(1) Physicians.--The Secretary shall provide for the annual
participation of physicians under the public health insurance
option, for which payment may be made for services furnished
during the year, in one of 2 classes:
(A) Preferred physicians.--Those physicians who
agree to accept the payment rate established under
section 223 (without regard to cost-sharing) as the
payment in full.
(B) Participating, non-preferred physicians.--Those
physicians who agree not to impose charges (in relation
to the payment rate described in section 223 for such
physicians) that exceed the ratio permitted under
section 1848(g)(2)(C) of the Social Security Act.
(2) Other providers.--The Secretary shall provide for the
participation (on an annual or other basis specified by the
Secretary) of health care providers (other than physicians)
under the public health insurance option under which payment
shall only be available if the provider agrees to accept the
payment rate established under section 223 (without regard to
cost-sharing) as the payment in full.
(d) Exclusion of Certain Providers.--The Secretary shall exclude
from participation under the public health insurance option a health
care provider that is excluded from participation in a Federal health
care program (as defined in section 1128B(f) of the Social Security
Act).
SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVISIONS.
Provisions of law (other than criminal law provisions) identified
by the Secretary by regulation, in consultation with the Inspector
General of the Department of Health and Human Services, that impose
sanctions with respect to waste, fraud, and abuse under Medicare, such
as the False Claims Act (31 U.S.C. 3729 et seq.), shall also apply to
the public health insurance option.
Subtitle C--Individual Affordability Credits
SEC. 241. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.
(a) In General.--Subject to the succeeding provisions of this
subtitle, in the case of an affordable credit eligible individual
enrolled in an Exchange-participating health benefits plan--
(1) the individual shall be eligible for, in accordance
with this subtitle, affordability credits consisting of--
(A) an affordability premium credit under section
243 to be applied against the premium for the Exchange-
participating health benefits plan in which the
individual is enrolled; and
(B) an affordability cost-sharing credit under
section 244 to be applied as a reduction of the cost-
sharing otherwise applicable to such plan; and
(2) the Commissioner shall pay the QHBP offering entity
that offers such plan from the Health Insurance Exchange Trust
Fund the aggregate amount of affordability credits for all
affordable credit eligible individuals enrolled in such plan.
(b) Application.--
(1) In general.--An Exchange eligible individual may apply
to the Commissioner through the Health Insurance Exchange or
through another entity under an arrangement made with the
Commissioner, in a form and manner specified by the
Commissioner. The Commissioner through the Health Insurance
Exchange or through another public entity under an arrangement
made with the Commissioner shall make a determination as to
eligibility of an individual for affordability credits under
this subtitle. The Commissioner shall establish a process
whereby, on the basis of information otherwise available,
individuals may be deemed to be affordable credit eligible
individuals. In carrying this subtitle, the Commissioner shall
establish effective methods that ensure that individuals with
limited English proficiency are able to apply for affordability
credits.
(2) Use of state medicaid agencies.--If the Commissioner
determines that a State Medicaid agency has the capacity to
make a determination of eligibility for affordability credits
under this subtitle and under the same standards as used by the
Commissioner, under the Medicaid memorandum of understanding
(as defined in section 205(c)(4))--
(A) the State Medicaid agency is authorized to
conduct such determinations for any Exchange-eligible
individual who requests such a determination; and
(B) the Commissioner shall reimburse the State
Medicaid agency for the costs of conducting such
determinations.
(3) Medicaid screen and enroll obligation.--In the case of
an application made under paragraph (1), there shall be a
determination of whether the individual is a Medicaid-eligible
individual. If the individual is determined to be so eligible,
the Commissioner, through the Medicaid memorandum of
understanding, shall provide for the enrollment of the
individual under the State Medicaid plan in accordance with the
Medicaid memorandum of understanding. In the case of such an
enrollment, the State shall provide for the same periodic
redetermination of eligibility under Medicaid as would
otherwise apply if the individual had directly applied for
medical assistance to the State Medicaid agency.
(c) Use of Affordability Credits.--
(1) In general.--In Y1 and Y2 an affordable credit eligible
individual may use an affordability credit only with respect to
a basic plan.
(2) Flexibility in plan enrollment authorized.--Beginning
with Y3, the Commissioner shall establish a process to allow an
affordability credit to be used for enrollees in enhanced or
premium plans. In the case of an affordable credit eligible
individual who enrolls in an enhanced or premium plan, the
individual shall be responsible for any difference between the
premium for such plan and the affordable credit amount
otherwise applicable if the individual had enrolled in a basic
plan.
(d) Access to Data.--In carrying out this subtitle, the
Commissioner shall request from the Secretary of the Treasury
consistent with section 6103 of the Internal Revenue Code of 1986 such
information as may be required to carry out this subtitle.
(e) No Cash Rebates.--In no case shall an affordable credit
eligible individual receive any cash payment as a result of the
application of this subtitle.
SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.
(a) Definition.--
(1) In general.--For purposes of this division, the term
``affordable credit eligible individual'' means, subject to
subsection (b), an individual who is lawfully present in a
State in the United States (other than as a nonimmigrant
described in a subparagraph (excluding subparagraphs (K), (T),
(U), and (V)) of section 101(a)(15) of the Immigration and
Nationality Act)--
(A) who is enrolled under an Exchange-participating
health benefits plan and is not enrolled under such
plan as an employee (or dependent of an employee)
through an employer qualified health benefits plan that
meets the requirements of section 312;
(B) with family income below 400 percent of the
Federal poverty level for a family of the size
involved; and
(C) who is not a Medicaid eligible individual,
other than an individual described in section 202(d)(3)
or an individual during a transition period under
section 202(d)(4)(B)(ii).
(2) Treatment of family.--Except as the Commissioner may
otherwise provide, members of the same family who are
affordable credit eligible individuals shall be treated as a
single affordable credit individual eligible for the applicable
credit for such a family under this subtitle.
(b) Limitations on Employee and Dependent Disqualification.--
(1) In general.--Subject to paragraph (2), the term
``affordable credit eligible individual'' does not include a
full-time employee of an employer if the employer offers the
employee coverage (for the employee and dependents) as a full-
time employee under a group health plan if the coverage and
employer contribution under the plan meet the requirements of
section 312.
(2) Exceptions.--
(A) For certain family circumstances.--The
Commissioner shall establish such exceptions and
special rules in the case described in paragraph (1) as
may be appropriate in the case of a divorced or
separated individual or such a dependent of an employee
who would otherwise be an affordable credit eligible
individual.
(B) For unaffordable employer coverage.--Beginning
in Y2, in the case of full-time employees for which the
cost of the employee premium for coverage under a group
health plan would exceed 11 percent of current family
income (determined by the Commissioner on the basis of
verifiable documentation and without regard to section
245), paragraph (1) shall not apply.
(c) Income Defined.--
(1) In general.--In this title, the term ``income'' means
modified adjusted gross income (as defined in section 59B of
the Internal Revenue Code of 1986).
(2) Study of income disregards.--The Commissioner shall
conduct a study that examines the application of income
disregards for purposes of this subtitle. Not later than the
first day of Y2, the Commissioner shall submit to Congress a
report on such study and shall include such recommendations as
the Commissioner determines appropriate.
(d) Clarification of Treatment of Affordability Credits.--
Affordabilty credits under this subtitle shall not be treated, for
purposes of title IV of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, to be a benefit provided under
section 403 of such title.
SEC. 243. AFFORDABLE PREMIUM CREDIT.
(a) In General.--The affordability premium credit under this
section for an affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan is in an amount equal to
the amount (if any) by which the premium for the plan (or, if less, the
reference premium amount specified in subsection (c)), exceeds the
affordable premium amount specified in subsection (b) for the
individual.
(b) Affordable Premium Amount.--
(1) In general.--The affordable premium amount specified in
this subsection for an individual for monthly premium in a plan
year shall be equal to \1/12\ of the product of--
(A) the premium percentage limit specified in
paragraph (2) for the individual based upon the
individual's family income for the plan year; and
(B) the individual's family income for such plan
year.
(2) Premium percentage limits based on table.--The
Commissioner shall establish premium percentage limits so that
for individuals whose family income is within an income tier
specified in the table in subsection (d) such percentage limits
shall increase, on a sliding scale in a linear manner, from the
initial premium percentage to the final premium percentage
specified in such table for such income tier.
(c) Reference Premium Amount.--The reference premium amount
specified in this subsection for a plan year for an individual in a
premium rating area is equal to the average premium for the 3 basic
plans in the area for the plan year with the lowest premium levels. In
computing such amount the Commissioner may exclude plans with extremely
limited enrollments.
(d) Table of Premium Percentage Limits and Actuarial Value
Percentages Based on Income Tier.--
(1) In general.--For purposes of this subtitle, the table
specified in this subsection is as follows:
In the case of family income
(expressed as a percent of FPL) The initial premium The final premium The actuarial value
within the following income tier: percentage is-- percentage is-- percentage is--
133% through 150% 1.5% 3% 97%
150% through 200% 3% 5% 93%
200% through 250% 5% 7% 85%
250% through 300% 7% 9% 78%
300% through 350% 9% 10% 72%
350% through 400% 10% 11% 70%
(2) Special rules.--For purposes of applying the table
under paragraph (1)--
(A) For lowest level of income.--In the case of an
individual with income that does not exceed 133 percent
of FPL, the individual shall be considered to have
income that is 133 percent of FPL.
(B) Application of higher actuarial value
percentage at tier transition points.--If two actuarial
value percentages may be determined with respect to an
individual, the actuarial value percentage shall be the
higher of such percentages.
SEC. 244. AFFORDABILITY COST-SHARING CREDIT.
(a) In General.--The affordability cost-sharing credit under this
section for an affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan is in the form of the cost-
sharing reduction described in subsection (b) provided under this
section for the income tier in which the individual is classified based
on the individual's family income.
(b) Cost-sharing Reductions.--The Commissioner shall specify a
reduction in cost-sharing amounts and the annual limitation on cost-
sharing specified in section 122(c)(2)(B) under a basic plan for each
income tier specified in the table under section 243(d), with respect
to a year, in a manner so that, as estimated by the Commissioner, the
actuarial value of the coverage with such reduced cost-sharing amounts
(and the reduced annual cost-sharing limit) is equal to the actuarial
value percentage (specified in the table under section 243(d) for the
income tier involved) of the full actuarial value if there were no
cost-sharing imposed under the plan.
(c) Determination and Payment of Cost-sharing Affordability
Credit.--In the case of an affordable credit eligible individual in a
tier enrolled in an Exchange-participating health benefits plan offered
by a QHBP offering entity, the Commissioner shall provide for payment
to the offering entity of an amount equivalent to the increased
actuarial value of the benefits under the plan provided under section
203(c)(2)(B) resulting from the reduction in cost-sharing described in
subsection (b).
SEC. 245. INCOME DETERMINATIONS.
(a) In General.--In applying this subtitle for an affordability
credit for an individual for a plan year, the individual's income shall
be the income (as defined in section 242(c)) for the individual for the
most recent taxable year (as determined in accordance with rules of the
Commissioner). The Federal poverty level applied shall be such level in
effect as of the date of the application.
(b) Program Integrity; Income Verification Procedures.--
(1) Program integrity.--The Commissioner shall take such
steps as may be appropriate to ensure the accuracy of
determinations and redeterminations under this subtitle.
(2) Income verification.--
(A) In general.--Upon an initial application of an
individual for an affordability credit under this
subtitle (or in applying section 242(b)) or upon an
application for a change in the affordability credit
based upon a significant change in family income
described in subparagraph (A)--
(i) the Commissioner shall request from the
Secretary of the Treasury the disclosure to the
Commissioner of such information as may be
permitted to verify the information contained
in such application; and
(ii) the Commissioner shall use the
information so disclosed to verify such
information.
(B) Alternative procedures.--The Commissioner shall
establish procedures for the verification of income for
purposes of this subtitle if no income tax return is
available for the most recent completed tax year.
(c) Special Rules.--
(1) Changes in income as a percent of fpl.--In the case
that an individual's income (expressed as a percentage of the
Federal poverty level for a family of the size involved) for a
plan year is expected (in a manner specified by the
Commissioner) to be significantly different from the income (as
so expressed) used under subsection (a), the Commissioner shall
establish rules requiring an individual to report, consistent
with the mechanism established under paragraph (2), significant
changes in such income (including a significant change in
family composition) to the Commissioner and requiring the
substitution of such income for the income otherwise
applicable.
(2) Reporting of significant changes in income.--The
Commissioner shall establish rules under which an individual
determined to be an affordable credit eligible individual would
be required to inform the Commissioner when there is a
significant change in the family income of the individual
(expressed as a percentage of the FPL for a family of the size
involved) and of the information regarding such change. Such
mechanism shall provide for guidelines that specify the
circumstances that qualify as a significant change, the
verifiable information required to document such a change, and
the process for submission of such information. If the
Commissioner receives new information from an individual
regarding the family income of the individual, the Commissioner
shall provide for a redetermination of the individual's
eligibility to be an affordable credit eligible individual.
(3) Transition for chip.--In the case of a child described
in section 202(d)(2), the Commissioner shall establish rules
under which the family income of the child is deemed to be no
greater than the family income of the child as most recently
determined before Y1 by the State under title XXI of the Social
Security Act.
(4) Study of geographic variation in application of fpl.--
The Commissioner shall examine the feasibility and implication
of adjusting the application of the Federal poverty level under
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 Commissioner determines that an
adjustment is feasible, the study should include a methodology
to make such an adjustment. Not later than the first day of Y2,
the Commissioner shall submit to Congress a report on such
study and shall include such recommendations as the
Commissioner determines appropriate.
(d) Penalties for Misrepresentation.--In the case of an individual
intentionally misrepresents family income or the individual fails
(without regard to intent) to disclose to the Commissioner a
significant change in family income under subsection (c) in a manner
that results in the individual becoming an affordable credit eligible
individual when the individual is not or in the amount of the
affordability credit exceeding the correct amount--
(1) the individual is liable for repayment of the amount of
the improper affordability credit; and
(2) in the case of such an intentional misrepresentation or
other egregious circumstances specified by the Commissioner,
the Commissioner may impose an additional penalty.
SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.
Nothing in this subtitle shall allow Federal payments for
affordability credits on behalf of individuals who are not lawfully
present in the United States.
TITLE III--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
SEC. 301. INDIVIDUAL RESPONSIBILITY.
For an individual's responsibility to obtain acceptable coverage,
see section 59B of the Internal Revenue Code of 1986 (as added by
section 401 of this Act).
Subtitle B--Employer Responsibility
PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS
SEC. 311. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
An employer meets the requirements of this section if such employer
does all of the following:
(1) Offer of coverage.--The employer offers each employee
individual and family coverage under a qualified health
benefits plan (or under a current employment-based health plan
(within the meaning of section 102(b))) in accordance with
section 312.
(2) Contribution towards coverage.--If an employee accepts
such offer of coverage, the employer makes timely contributions
towards such coverage in accordance with section 312.
(3) Contribution in lieu of coverage.--Beginning with Y2,
if an employee declines such offer but otherwise obtains
coverage in an Exchange-participating health benefits plan
(other than by reason of being covered by family coverage as a
spouse or dependent of the primary insured), the employer shall
make a timely contribution to the Health Insurance Exchange
with respect to each such employee in accordance with section
313.
SEC. 312. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND
DEPENDENT COVERAGE.
(a) In General.--An employer meets the requirements of this section
with respect to an employee if the following requirements are met:
(1) Offering of coverage.--The employer offers the coverage
described in section 311(1) either through an Exchange-
participating health benefits plan or other than through such a
plan.
(2) Employer required contribution.--The employer timely
pays to the issuer of such coverage an amount not less than the
employer required contribution specified in subsection (b) for
such coverage.
(3) Provision of information.--The employer provides the
Health Choices Commissioner, the Secretary of Labor, the
Secretary of Health and Human Services, and the Secretary of
the Treasury, as applicable, with such information as the
Commissioner may require to ascertain compliance with the
requirements of this section.
(4) Autoenrollment of employees.--The employer provides for
autoenrollment of the employee in accordance with subsection
(c).
(b) Reduction of Employee Premiums Through Minimum Employer
Contribution.--
(1) Full-time employees.--The minimum employer contribution
described in this subsection for coverage of a full-time
employee (and, if any, the employee's spouse and qualifying
children (as defined in section 152(c) of the Internal Revenue
Code of 1986) under a qualified health benefits plan (or
current employment-based health plan) is equal to--
(A) in case of individual coverage, not less than
72.5 percent of the applicable premium (as defined in
section 4980B(f)(4) of such Code, subject to paragraph
(2)) of the lowest cost plan offered by the employer
that is a qualified health benefits plan (or is such
current employment-based health plan); and
(B) in the case of family coverage which includes
coverage of such spouse and children, not less 65
percent of such applicable premium of such lowest cost
plan.
(2) Applicable premium for exchange coverage.--In this
subtitle, the amount of the applicable premium of the lowest
cost plan with respect to coverage of an employee under an
Exchange-participating health benefits plan is the reference
premium amount under section 243(c) for individual coverage
(or, if elected, family coverage) for the premium rating area
in which the individual or family resides.
(3) Minimum employer contribution for employees other than
full-time employees.--In the case of coverage for an employee
who is not a full-time employee, the amount of the minimum
employer contribution under this subsection shall be a
proportion (as determined in accordance with rules of the
Health Choices Commissioner, the Secretary of Labor, the
Secretary of Health and Human Services, and the Secretary of
the Treasury, as applicable) of the minimum employer
contribution under this subsection with respect to a full-time
employee that reflects the proportion of--
(A) the average weekly hours of employment of the
employee by the employer, to
(B) the minimum weekly hours specified by the
Commissioner for an employee to be a full-time
employee.
(4) Salary reductions not treated as employer
contributions.--For purposes of this section, any contribution
on behalf of an employee with respect to which there is a
corresponding reduction in the compensation of the employee
shall not be treated as an amount paid by the employer.
(c) Automatic Enrollment for Employer Sponsored Health Benefits.--
(1) In general.--The requirement of this subsection with
respect to an employer and an employee is that the employer
automatically enroll suchs employee into the employment-based
health benefits plan for individual coverage under the plan
option with the lowest applicable employee premium.
(2) Opt-out.--In no case may an employer automatically
enroll an employee in a plan under paragraph (1) if such
employee makes an affirmative election to opt out of such plan
or to elect coverage under an employment-based health benefits
plan offered by such employer. An employer shall provide an
employee with a 30-day period to make such an affirmative
election before the employer may automatically enroll the
employee in such a plan.
(3) Notice requirements.--
(A) In general.--Each employer described in
paragraph (1) who automatically enrolls an employee
into a plan as described in such paragraph shall
provide the employees, within a reasonable period
before the beginning of each plan year (or, in the case
of new employees, within a reasonable period before the
end of the enrollment period for such a new employee),
written notice of the employees' rights and obligations
relating to the automatic enrollment requirement under
such paragraph. Such notice must be comprehensive and
understood by the average employee to whom the
automatic enrollment requirement applies.
(B) Inclusion of specific information.--The written
notice under subparagraph (A) must explain an
employee's right to opt out of being automatically
enrolled in a plan and in the case that more than one
level of benefits or employee premium level is offered
by the employer involved, the notice must explain which
level of benefits and employee premium level the
employee will be automatically enrolled in the absence
of an affirmative election by the employee.
SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.
(a) In General.--A contribution is made in accordance with this
section with respect to an employee if such contribution is equal to an
amount equal to 8 percent of the average wages paid by the employer
during the period of enrollment (determined by taking into account all
employees of the employer and in such manner as the Commissioner
provides, including rules providing for the appropriate aggregation of
related employers). Any such contribution--
(1) shall be paid to the Health Choices Commissioner for
deposit into the Health Insurance Exchange Trust Fund, and
(2) shall not be applied against the premium of the
employee under the Exchange-participating health benefits plan
in which the employee is enrolled.
(b) Special Rules for Small Employers.--
(1) In general.--In the case of any employer who is a small
employer for any calendar year, subsection (a) shall be applied
by substituting the applicable percentage determined in
accordance with the following table for ``8 percent'':
If the annual payroll of such employer The applicable percentage is:
for the preceding calendar year:
Does not exceed $250,000............. 0 percent
Exceeds $250,000, but does not exceed 2 percent
$300,000.
Exceeds $300,000, but does not exceed 4 percent
$350,000.
Exceeds $350,000, but does not exceed 6 percent
$400,000.
(2) Small employer.--For purposes of this subsection, the
term ``small employer'' means any employer for any calendar
year if the annual payroll of such employer for the preceding
calendar year does not exceed $400,000.
(3) Annual payroll.--For purposes of this paragraph, the
term ``annual payroll'' means, with respect to any employer for
any calendar year, the aggregate wages paid by the employer
during such calendar year.
(4) Aggregation rules.--Related employers and predecessors
shall be treated as a single employer for purposes of this
subsection.
SEC. 314. AUTHORITY RELATED TO IMPROPER STEERING.
The Health Choices Commissioner (in coordination with the Secretary
of Labor, the Secretary of Health and Human Services, and the Secretary
of the Treasury) shall have authority to set standards for determining
whether employers or insurers are undertaking any actions to affect the
risk pool within the Health Insurance Exchange by inducing individuals
to decline coverage under a qualified health benefits plan (or current
employment-based health plan (within the meaning of section 102(b)))
offered by the employer and instead to enroll in an Exchange-
participating health benefits plan. An employer violating such
standards shall be treated as not meeting the requirements of this
section.
PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
SEC. 321. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) In General.--Subtitle B of title I of the Employee Retirement
Income Security Act of 1974 is amended by adding at the end the
following new part:
``PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS
``SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL HEALTH
COVERAGE PARTICIPATION REQUIREMENTS.
``(a) In General.--An employer may make an election with the
Secretary to be subject to the health coverage participation
requirements.
``(b) Time and Manner.--An election under subsection (a) may be
made at such time and in such form and manner as the Secretary may
prescribe.
``SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.
``(a) In General.--If an employer makes an election to the
Secretary under section 801--
``(1) such election shall be treated as the establishment
and maintenance of a group health plan (as defined in section
733(a)) for purposes of this title, subject to section 151 of
the America's Affordable Health Choices Act of 2009, and
``(2) the health coverage participation requirements shall
be deemed to be included as terms and conditions of such plan.
``(b) Periodic Investigations To Discover Noncompliance.--The
Secretary shall regularly audit a representative sampling of employers
and group health plans and conduct investigations and other activities
under section 504 with respect to such sampling of plans so as to
discover noncompliance with the health coverage participation
requirements in connection with such plans. The Secretary shall
communicate findings of noncompliance made by the Secretary under this
subsection to the Secretary of the Treasury and the Health Choices
Commissioner. The Secretary shall take such timely enforcement action
as appropriate to achieve compliance.
``SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
``For purposes of this part, the term `health coverage
participation requirements' means the requirements of part 1 of
subtitle B of title III of division A of America's Affordable Health
Choices Act of 2009 (as in effect on the date of the enactment of such
Act).
``SEC. 804. RULES FOR APPLYING REQUIREMENTS.
``(a) Affiliated Groups.--In the case of any employer which is part
of a group of employers who are treated as a single employer under
subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue
Code of 1986, the election under section 801 shall be made by such
employer as the Secretary may provide. Any such election, once made,
shall apply to all members of such group.
``(b) Separate Elections.--Under regulations prescribed by the
Secretary, separate elections may be made under section 801 with
respect to--
``(1) separate lines of business, and
``(2) full-time employees and employees who are not full-
time employees.
``SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL
NONCOMPLIANCE.
``The Secretary may terminate the election of any employer under
section 801 if the Secretary (in coordination with the Health Choices
Commissioner) determines that such employer is in substantial
noncompliance with the health coverage participation requirements and
shall refer any such determination to the Secretary of the Treasury as
appropriate.
``SEC. 806. REGULATIONS.
``The Secretary may promulgate such regulations as may be necessary
or appropriate to carry out the provisions of this part, in accordance
with section 324(a) of the America's Affordable Health Choices Act of
2009. The Secretary may promulgate any interim final rules as the
Secretary determines are appropriate to carry out this part.''.
(b) Enforcement of Health Coverage Participation Requirements.--
Section 502 of such Act (29 U.S.C. 1132) is amended--
(1) in subsection (a)(6), by striking ``paragraph'' and all
that follows through ``subsection (c)'' and inserting
``paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) of
subsection (c)''; and
(2) in subsection (c), by redesignating the second
paragraph (10) as paragraph (12) and by inserting after the
first paragraph (10) the following new paragraph:
``(11) Health coverage participation requirements.--
``(A) Civil penalties.--In the case of any employer
who fails (during any period with respect to which an
election under section 801(a) is in effect) to satisfy
the health coverage participation requirements with
respect to any employee, the Secretary may assess a
civil penalty against the employer of $100 for each day
in the period beginning on the date such failure first
occurs and ending on the date such failure is
corrected.
``(B) Health coverage participation requirements.--
For purposes of this paragraph, the term `health
coverage participation requirements' has the meaning
provided in section 803.
``(C) Limitations on amount of penalty.--
``(i) Penalty not to apply where failure
not discovered exercising reasonable
diligence.--No penalty shall be assessed under
subparagraph (A) with respect to any failure
during any period for which it is established
to the satisfaction of the Secretary that the
employer did not know, or exercising reasonable
diligence would not have known, that such
failure existed.
``(ii) Penalty not to apply to failures
corrected within 30 days.--No penalty shall be
assessed under subparagraph (A) with respect to
any failure if--
``(I) such failure was due to
reasonable cause and not to willful
neglect, and
``(II) such failure is corrected
during the 30-day period beginning on
the 1st date that the employer knew, or
exercising reasonable diligence would
have known, that such failure existed.
``(iii) Overall limitation for
unintentional failures.--In the case of
failures which are due to reasonable cause and
not to willful neglect, the penalty assessed
under subparagraph (A) for failures during any
1-year period shall not exceed the amount equal
to the lesser of--
``(I) 10 percent of the aggregate
amount paid or incurred by the employer
(or predecessor employer) during the
preceding 1-year period for group
health plans, or
``(II) $500,000.
``(D) Advance notification of failure prior to
assessment.--Before a reasonable time prior to the
assessment of any penalty under this paragraph with
respect to any failure by an employer, the Secretary
shall inform the employer in writing of such failure
and shall provide the employer information regarding
efforts and procedures which may be undertaken by the
employer to correct such failure.
``(E) Coordination with excise tax.--Under
regulations prescribed in accordance with section 324
of the America's Affordable Health Choices Act of 2009,
the Secretary and the Secretary of the Treasury shall
coordinate the assessment of penalties under this
section in connection with failures to satisfy health
coverage participation requirements with the imposition
of excise taxes on such failures under section 4980H(b)
of the Internal Revenue Code of 1986 so as to avoid
duplication of penalties with respect to such failures.
``(F) Deposit of penalty collected.--Any amount of
penalty collected under this paragraph shall be
deposited as miscellaneous receipts in the Treasury of
the United States.''.
(c) Clerical Amendments.--The table of contents in section 1 of
such Act is amended by inserting after the item relating to section 734
the following new items:
``Part 8--National Health Coverage Participation Requirements
``Sec. 801. Election of employer to be subject to national health
coverage participation requirements.
``Sec. 802. Treatment of coverage resulting from election.
``Sec. 803. Health coverage participation requirements.
``Sec. 804. Rules for applying requirements.
``Sec. 805. Termination of election in cases of substantial
noncompliance.
``Sec. 806. Regulations.''.
(d) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2012.
SEC. 322. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
UNDER THE INTERNAL REVENUE CODE OF 1986.
(a) Failure To Elect, or Substantially Comply With, Health Coverage
Participation Requirements.--For employment tax on employers who fail
to elect, or substantially comply with, the health coverage
participation requirements described in part 1, see section 3111(c) of
the Internal Revenue Code of 1986 (as added by section 412 of this
Act).
(b) Other Failures.--For excise tax on other failures of electing
employers to comply with such requirements, see section 4980H of the
Internal Revenue Code of 1986 (as added by section 411 of this Act).
SEC. 323. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
UNDER THE PUBLIC HEALTH SERVICE ACT.
(a) In General.--Part C of title XXVII of the Public Health Service
Act is amended by adding at the end the following new section:
``SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
``(a) Election of Employer To Be Subject to National Health
Coverage Participation Requirements.--
``(1) In general.--An employer may make an election with
the Secretary to be subject to the health coverage
participation requirements.
``(2) Time and manner.--An election under paragraph (1) may
be made at such time and in such form and manner as the
Secretary may prescribe.
``(b) Treatment of Coverage Resulting From Election.--
``(1) In general.--If an employer makes an election to the
Secretary under subsection (a)--
``(A) such election shall be treated as the
establishment and maintenance of a group health plan
for purposes of this title, subject to section 151 of
the America's Affordable Health Choices Act of 2009,
and
``(B) the health coverage participation
requirements shall be deemed to be included as terms
and conditions of such plan.
``(2) Periodic investigations to determine compliance with
health coverage participation requirements.--The Secretary
shall regularly audit a representative sampling of employers
and conduct investigations and other activities with respect to
such sampling of employers so as to discover noncompliance with
the health coverage participation requirements in connection
with such employers (during any period with respect to which an
election under subsection (a) is in effect). The Secretary
shall communicate findings of noncompliance made by the
Secretary under this subsection to the Secretary of the
Treasury and the Health Choices Commissioner. The Secretary
shall take such timely enforcement action as appropriate to
achieve compliance.
``(c) Health Coverage Participation Requirements.--For purposes of
this section, the term `health coverage participation requirements'
means the requirements of part 1 of subtitle B of title III of division
A of the America's Affordable Health Choices Act of 2009 (as in effect
on the date of the enactment of this section).
``(d) Separate Elections.--Under regulations prescribed by the
Secretary, separate elections may be made under subsection (a) with
respect to full-time employees and employees who are not full-time
employees.
``(e) Termination of Election in Cases of Substantial
Noncompliance.--The Secretary may terminate the election of any
employer under subsection (a) if the Secretary (in coordination with
the Health Choices Commissioner) determines that such employer is in
substantial noncompliance with the health coverage participation
requirements and shall refer any such determination to the Secretary of
the Treasury as appropriate.
``(f) Enforcement of Health Coverage Participation Requirements.--
``(1) Civil penalties.--In the case of any employer who
fails (during any period with respect to which the election
under subsection (a) is in effect) to satisfy the health
coverage participation requirements with respect to any
employee, the Secretary may assess a civil penalty against the
employer of $100 for each day in the period beginning on the
date such failure first occurs and ending on the date such
failure is corrected.
``(2) Limitations on amount of penalty.--
``(A) Penalty not to apply where failure not
discovered exercising reasonable diligence.--No penalty
shall be assessed under paragraph (1) with respect to
any failure during any period for which it is
established to the satisfaction of the Secretary that
the employer did not know, or exercising reasonable
diligence would not have known, that such failure
existed.
``(B) Penalty not to apply to failures corrected
within 30 days.--No penalty shall be assessed under
paragraph (1) with respect to any failure if--
``(i) such failure was due to reasonable
cause and not to willful neglect, and
``(ii) such failure is corrected during the
30-day period beginning on the 1st date that
the employer knew, or exercising reasonable
diligence would have known, that such failure
existed.
``(C) Overall limitation for unintentional
failures.--In the case of failures which are due to
reasonable cause and not to willful neglect, the
penalty assessed under paragraph (1) for failures
during any 1-year period shall not exceed the amount
equal to the lesser of--
``(i) 10 percent of the aggregate amount
paid or incurred by the employer (or
predecessor employer) during the preceding
taxable year for group health plans, or
``(ii) $500,000.
``(3) Advance notification of failure prior to
assessment.--Before a reasonable time prior to the assessment
of any penalty under paragraph (1) with respect to any failure
by an employer, the Secretary shall inform the employer in
writing of such failure and shall provide the employer
information regarding efforts and procedures which may be
undertaken by the employer to correct such failure.
``(4) Actions to enforce assessments.--The Secretary may
bring a civil action in any District Court of the United States
to collect any civil penalty under this subsection.
``(5) Coordination with excise tax.--Under regulations
prescribed in accordance with section 324 of the America's
Affordable Health Choices Act of 2009, the Secretary and the
Secretary of the Treasury shall coordinate the assessment of
penalties under paragraph (1) in connection with failures to
satisfy health coverage participation requirements with the
imposition of excise taxes on such failures under section
4980H(b) of the Internal Revenue Code of 1986 so as to avoid
duplication of penalties with respect to such failures.
``(6) Deposit of penalty collected.--Any amount of penalty
collected under this subsection shall be deposited as
miscellaneous receipts in the Treasury of the United States.
``(g) Regulations.--The Secretary may promulgate such regulations
as may be necessary or appropriate to carry out the provisions of this
section, in accordance with section 324(a) of the America's Affordable
Health Choices Act of 2009. The Secretary may promulgate any interim
final rules as the Secretary determines are appropriate to carry out
this section.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to periods beginning after December 31, 2012.
SEC. 324. ADDITIONAL RULES RELATING TO HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.
(a) Assuring Coordination.--The officers consisting of the
Secretary of Labor, the Secretary of the Treasury, the Secretary of
Health and Human Services, and the Health Choices Commissioner shall
ensure, through the execution of an interagency memorandum of
understanding among such officers, that--
(1) regulations, rulings, and interpretations issued by
such officers relating to the same matter over which two or
more of such officers have responsibility under subpart B of
part 6 of subtitle B of title I of the Employee Retirement
Income Security Act of 1974, section 4980H of the Internal
Revenue Code of 1986, and section 2793 of the Public Health
Service Act are administered so as to have the same effect at
all times; and
(2) coordination of policies relating to enforcing the same
requirements through such officers in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.
(b) Multiemployer Plans.--In the case of a group health plan that
is a multiemployer plan (as defined in section 3(37) of the Employee
Retirement Income Security Act of 1974), the regulations prescribed in
accordance with subsection (a) by the officers referred to in
subsection (a) shall provide for the application of the health coverage
participation requirements to the plan sponsor and contributing
sponsors of such plan.
TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Shared Responsibility
PART 1--INDIVIDUAL RESPONSIBILITY
SEC. 401. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.
(a) In General.--Subchapter A of chapter 1 of the Internal Revenue
Code of 1986 is amended by adding at the end the following new part:
``PART VIII--HEALTH CARE RELATED TAXES
``subpart a. tax on individuals without acceptable health care
coverage.
``Subpart A--Tax on Individuals Without Acceptable Health Care Coverage
``Sec. 59B. Tax on individuals without acceptable health care coverage.
``SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.
``(a) Tax Imposed.--In the case of any individual who does not meet
the requirements of subsection (d) at any time during the taxable year,
there is hereby imposed a tax equal to 2.5 percent of the excess of--
``(1) the taxpayer's modified adjusted gross income for the
taxable year, over
``(2) the amount of gross income specified in section
6012(a)(1) with respect to the taxpayer.
``(b) Limitations.--
``(1) Tax limited to average premium.--
``(A) In general.--The tax imposed under subsection
(a) with respect to any taxpayer for any taxable year
shall not exceed the applicable national average
premium for such taxable year.
``(B) Applicable national average premium.--
``(i) In general.--For purposes of
subparagraph (A), the `applicable national
average premium' means, with respect to any
taxable year, the average premium (as
determined by the Secretary, in coordination
with the Health Choices Commissioner) for self-
only coverage under a basic plan which is
offered in a Health Insurance Exchange for the
calendar year in which such taxable year
begins.
``(ii) Failure to provide coverage for more
than one individual.--In the case of any
taxpayer who fails to meet the requirements of
subsection (e) with respect to more than one
individual during the taxable year, clause (i)
shall be applied by substituting `family
coverage' for `self-only coverage'.
``(2) Proration for part year failures.--The tax imposed
under subsection (a) with respect to any taxpayer for any
taxable year shall not exceed the amount which bears the same
ratio to the amount of tax so imposed (determined without
regard to this paragraph and after application of paragraph
(1)) as--
``(A) the aggregate periods during such taxable
year for which such individual failed to meet the
requirements of subsection (d), bears to
``(B) the entire taxable year.
``(c) Exceptions.--
``(1) Dependents.--Subsection (a) shall not apply to any
individual for any taxable year if a deduction is allowable
under section 151 with respect to such individual to another
taxpayer for any taxable year beginning in the same calendar
year as such taxable year.
``(2) Nonresident aliens.--Subsection (a) shall not apply
to any individual who is a nonresident alien.
``(3) Individuals residing outside united states.--Any
qualified individual (as defined in section 911(d)) (and any
qualifying child residing with such individual) shall be
treated for purposes of this section as covered by acceptable
coverage during the period described in subparagraph (A) or (B)
of section 911(d)(1), whichever is applicable.
``(4) Individuals residing in possessions of the united
states.--Any individual who is a bona fide resident of any
possession of the United States (as determined under section
937(a)) for any taxable year (and any qualifying child residing
with such individual) shall be treated for purposes of this
section as covered by acceptable coverage during such taxable
year.
``(5) Religious conscience exemption.--
``(A) In general.--Subsection (a) shall not apply
to any individual (and any qualifying child residing
with such individual) for any period if such individual
has in effect an exemption which certifies that such
individual is a member of a recognized religious sect
or division thereof described in section 1402(g)(1) and
an adherent of established tenets or teachings of such
sect or division as described in such section.
``(B) Exemption.--An application for the exemption
described in subparagraph (A) shall be filed with the
Secretary at such time and in such form and manner as
the Secretary may prescribe. Any such exemption granted
by the Secretary shall be effective for such period as
the Secretary determines appropriate.
``(d) Acceptable Coverage Requirement.--
``(1) In general.--The requirements of this subsection are
met with respect to any individual for any period if such
individual (and each qualifying child of such individual) is
covered by acceptable coverage at all times during such period.
``(2) Acceptable coverage.--For purposes of this section,
the term `acceptable coverage' means any of the following:
``(A) Qualified health benefits plan coverage.--
Coverage under a qualified health benefits plan (as
defined in section 100(c) of the America's Affordable
Health Choices Act of 2009).
``(B) Grandfathered health insurance coverage;
coverage under grandfathered employment-based health
plan.--Coverage under a grandfathered health insurance
coverage (as defined in subsection (a) of section 102
of the America's Affordable Health Choices Act of 2009)
or under a current employment-based health plan (within
the meaning of subsection (b) of such section).
``(C) Medicare.--Coverage under part A of title
XVIII of the Social Security Act.
``(D) Medicaid.--Coverage for medical assistance
under title XIX of the Social Security Act.
``(E) Members of the armed forces and dependents
(including tricare).--Coverage under chapter 55 of
title 10, United States Code, including similar
coverage furnished under section 1781 of title 38 of
such Code.
``(F) VA.--Coverage under the veteran's health care
program under chapter 17 of title 38, United States
Code, but only if the coverage for the individual
involved is determined by the Secretary in coordination
with the Health Choices Commissioner to be not less
than the level specified by the Secretary of the
Treasury, in coordination with the Secretary of
Veteran's Affairs and the Health Choices Commissioner,
based on the individual's priority for services as
provided under section 1705(a) of such title.
``(G) Other coverage.--Such other health benefits
coverage as the Secretary, in coordination with the
Health Choices Commissioner, recognizes for purposes of
this subsection.
``(e) Other Definitions and Special Rules.--
``(1) Qualifying child.--For purposes of this section, the
term `qualifying child' has the meaning given such term by
section 152(c).
``(2) Basic plan.--For purposes of this section, the term
`basic plan' has the meaning given such term under section
100(c) of the America's Affordable Health Choices Act of 2009.
``(3) Health insurance exchange.--For purposes of this
section, the term `Health Insurance Exchange' has the meaning
given such term under section 100(c) of the America's
Affordable Health Choices Act of 2009, including any State-
based health insurance exchange approved for operation under
section 208 of such Act.
``(4) Family coverage.--For purposes of this section, the
term `family coverage' means any coverage other than self-only
coverage.
``(5) Modified adjusted gross income.--For purposes of this
section, the term `modified adjusted gross income' means
adjusted gross income--
``(A) determined without regard to section 911, and
``(B) increased by the amount of interest received
or accrued by the taxpayer during the taxable year
which is exempt from tax.
``(6) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall not
be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or for
purposes of section 55.
``(f) Regulations.--The Secretary shall prescribe such regulations
or other guidance as may be necessary or appropriate to carry out the
purposes of this section, including regulations or other guidance
(developed in coordination with the Health Choices Commissioner) which
provide--
``(1) exemption from the tax imposed under subsection (a)
in cases of de minimis lapses of acceptable coverage, and
``(2) a process for applying for a waiver of the
application of subsection (a) in cases of hardship.''.
(b) Information Reporting.--
(1) In general.--Subpart B of part III of subchapter A of
chapter 61 of such Code is amended by inserting after section
6050W the following new section:
``SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.
``(a) Requirement of Reporting.--Every person who provides
acceptable coverage (as defined in section 59B(d)) to any individual
during any calendar year shall, at such time as the Secretary may
prescribe, make the return described in subsection (b) with respect to
such individual.
``(b) Form and Manner of Returns.--A return is described in this
subsection if such return--
``(1) is in such form as the Secretary may prescribe, and
``(2) contains--
``(A) the name, address, and TIN of the primary
insured and the name of each other individual obtaining
coverage under the policy,
``(B) the period for which each such individual was
provided with the coverage referred to in subsection
(a), and
``(C) such other information as the Secretary may
require.
``(c) Statements To Be Furnished to Individuals With Respect to
Whom Information Is Required.--Every person required to make a return
under subsection (a) shall furnish to each primary insured whose name
is required to be set forth in such return a written statement
showing--
``(1) the name and address of the person required to make
such return and the phone number of the information contact for
such person, and
``(2) the information required to be shown on the return
with respect to such individual.
The written statement required under the preceding sentence shall be
furnished on or before January 31 of the year following the calendar
year for which the return under subsection (a) is required to be made.
``(d) Coverage Provided by Governmental Units.--In the case of
coverage provided by any governmental unit or any agency or
instrumentality thereof, the officer or employee who enters into the
agreement to provide such coverage (or the person appropriately
designated for purposes of this section) shall make the returns and
statements required by this section.''.
(2) Penalty for failure to file.--
(A) Return.--Subparagraph (B) of section 6724(d)(1)
of such Code is amended by striking ``or'' at the end
of clause (xxii), by striking ``and'' at the end of
clause (xxiii) and inserting ``or'', and by adding at
the end the following new clause:
``(xxiv) section 6050X (relating to returns
relating to health insurance coverage), and''.
(B) Statement.--Paragraph (2) of section 6724(d) of
such Code is amended by striking ``or'' at the end of
subparagraph (EE), by striking the period at the end of
subparagraph (FF) and inserting ``, or'', and by
inserting after subparagraph (FF) the following new
subparagraph:
``(GG) section 6050X (relating to returns relating
to health insurance coverage).''.
(c) Return Requirement.--Subsection (a) of section 6012 of such
Code is amended by inserting after paragraph (9) the following new
paragraph:
``(10) Every individual to whom section 59B(a) applies and
who fails to meet the requirements of section 59B(d) with
respect to such individual or any qualifying child (as defined
in section 152(c)) of such individual.''.
(d) Clerical Amendments.--
(1) The table of parts for subchapter A of chapter 1 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new item:
``Part VIII. Health Care Related Taxes.''.
(2) The table of sections for subpart B of part III of
subchapter A of chapter 61 is amended by adding at the end the
following new item:
``Sec. 6050X. Returns relating to health insurance coverage.''.
(e) Section 15 Not To Apply.--The amendment made by subsection (a)
shall not be treated as a change in a rate of tax for purposes of
section 15 of the Internal Revenue Code of 1986.
(f) Effective Date.--
(1) In general.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
(2) Returns.--The amendments made by subsection (b) shall
apply to calendar years beginning after December 31, 2012.
PART 2--EMPLOYER RESPONSIBILITY
SEC. 411. ELECTION TO SATISFY HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.
(a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is
amended by adding at the end the following new section:
``SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.
``(a) Election of Employer Responsibility To Provide Health
Coverage.--
``(1) In general.--Subsection (b) shall apply to any
employer with respect to whom an election under paragraph (2)
is in effect.
``(2) Time and manner.--An employer may make an election
under this paragraph at such time and in such form and manner
as the Secretary may prescribe.
``(3) Affiliated groups.--In the case of any employer which
is part of a group of employers who are treated as a single
employer under subsection (b), (c), (m), or (o) of section 414,
the election under paragraph (2) shall be made by such person
as the Secretary may provide. Any such election, once made,
shall apply to all members of such group.
``(4) Separate elections.--Under regulations prescribed by
the Secretary, separate elections may be made under paragraph
(2) with respect to--
``(A) separate lines of business, and
``(B) full-time employees and employees who are not
full-time employees.
``(5) Termination of election in cases of substantial
noncompliance.--The Secretary may terminate the election of any
employer under paragraph (2) if the Secretary (in coordination
with the Health Choices Commissioner) determines that such
employer is in substantial noncompliance with the health
coverage participation requirements.
``(b) Excise Tax With Respect to Failure To Meet Health Coverage
Participation Requirements.--
``(1) In general.--In the case of any employer who fails
(during any period with respect to which the election under
subsection (a) is in effect) to satisfy the health coverage
participation requirements with respect to any employee to whom
such election applies, there is hereby imposed on each such
failure with respect to each such employee a tax of $100 for
each day in the period beginning on the date such failure first
occurs and ending on the date such failure is corrected.
``(2) Limitations on amount of tax.--
``(A) Tax not to apply where failure not discovered
exercising reasonable diligence.--No tax shall be
imposed by paragraph (1) on any failure during any
period for which it is established to the satisfaction
of the Secretary that the employer neither knew, nor
exercising reasonable diligence would have known, that
such failure existed.
``(B) Tax not to apply to failures corrected within
30 days.--No tax shall be imposed by paragraph (1) on
any failure if--
``(i) such failure was due to reasonable
cause and not to willful neglect, and
``(ii) such failure is corrected during the
30-day period beginning on the 1st date that
the employer knew, or exercising reasonable
diligence would have known, that such failure
existed.
``(C) Overall limitation for unintentional
failures.--In the case of failures which are due to
reasonable cause and not to willful neglect, the tax
imposed by subsection (a) for failures during the
taxable year of the employer shall not exceed the
amount equal to the lesser of--
``(i) 10 percent of the aggregate amount
paid or incurred by the employer (or
predecessor employer) during the preceding
taxable year for employment-based health plans,
or
``(ii) $500,000.
``(D) Coordination with other enforcement
provisions.--The tax imposed under paragraph (1) with
respect to any failure shall be reduced (but not below
zero) by the amount of any civil penalty collected
under section 502(c)(11) of the Employee Retirement
Income Security Act of 1974 or section 2793(g) of the
Public Health Service Act with respect to such failure.
``(c) Health Coverage Participation Requirements.--For purposes of
this section, the term `health coverage participation requirements'
means the requirements of part I of subtitle B of title III of the
America's Affordable Health Choices Act of 2009 (as in effect on the
date of the enactment of this section).''.
(b) Clerical Amendment.--The table of sections for chapter 43 of
such Code is amended by adding at the end the following new item:
``Sec. 4980H. Election to satisfy health coverage participation
requirements.''.
(c) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2012.
SEC. 412. RESPONSIBILITIES OF NONELECTING EMPLOYERS.
(a) In General.--Section 3111 of the Internal Revenue Code of 1986
is amended by redesignating subsection (c) as subsection (d) and by
inserting after subsection (b) the following new subsection:
``(c) Employers Electing to Not Provide Health Benefits.--
``(1) In general.--In addition to other taxes, there is
hereby imposed on every nonelecting employer an excise tax,
with respect to having individuals in his employ, equal to 8
percent of the wages (as defined in section 3121(a)) paid by
him with respect to employment (as defined in section 3121(b)).
``(2) Special rules for small employers.--
``(A) In general.--In the case of any employer who
is small employer for any calendar year, paragraph (1)
shall be applied by substituting the applicable
percentage determined in accordance with the following
table for `8 percent':
``If the annual payroll of such The applicable percentage is:
employer for the preceding calendar
year:
Does not exceed $250,000............. 0 percent
Exceeds $250,000, but does not exceed 2 percent
$300,000.
Exceeds $300,000, but does not exceed 4 percent
$350,000.
Exceeds $350,000, but does not exceed 6 percent
$400,000.
``(B) Small employer.--For purposes of this
paragraph, the term `small employer' means any employer
for any calendar year if the annual payroll of such
employer for the preceding calendar year does not
exceed $400,000.
``(C) Annual payroll.--For purposes of this
paragraph, the term `annual payroll' means, with
respect to any employer for any calendar year, the
aggregate wages (as defined in section 3121(a)) paid by
him with respect to employment (as defined in section
3121(b)) during such calendar year.
``(3) Nonelecting employer.--For purposes of paragraph (1),
the term `nonelecting employer' means any employer for any
period with respect to which such employer does not have an
election under section 4980H(a) in effect.
``(4) Special rule for separate elections.--In the case of
an employer who makes a separate election described in section
4980H(a)(4) for any period, paragraph (1) shall be applied for
such period by taking into account only the wages paid to
employees who are not subject to such election.
``(5) Aggregation; predecessors.--For purposes of this
subsection--
``(A) all persons treated as a single employer
under subsection (b), (c), (m), or (o) of section 414
shall be treated as 1 employer, and
``(B) any reference to any person shall be treated
as including a reference to any predecessor of such
person.''.
(b) Definitions.--Section 3121 of such Code is amended by adding at
the end the following new subsection:
``(aa) Special Rules for Tax on Employers Electing Not To Provide
Health Benefits.--For purposes of section 3111(c)--
``(1) Paragraphs (1), (5), and (19) of subsection (b) shall
not apply.
``(2) Paragraph (7) of subsection (b) shall apply by
treating all services as not covered by the retirement systems
referred to in subparagraphs (C) and (F) thereof.
``(3) Subsection (e) shall not apply and the term `State'
shall include the District of Columbia.''.
(c) Conforming Amendment.--Subsection (d) of section 3111 of such
Code, as redesignated by this section, is amended by striking ``this
section'' and inserting ``subsections (a) and (b)''.
(d) Application to Railroads.--
(1) In general.--Section 3221 of such Code is amended by
redesignating subsection (c) as subsection (d) and by inserting
after subsection (b) the following new subsection:
``(c) Employers Electing to Not Provide Health Benefits.--
``(1) In general.--In addition to other taxes, there is
hereby imposed on every nonelecting employer an excise tax,
with respect to having individuals in his employ, equal to 8
percent of the compensation paid during any calendar year by
such employer for services rendered to such employer.
``(2) Exception for small employers.--Rules similar to the
rules of section 3111(c)(2) shall apply for purposes of this
subsection.
``(3) Nonelecting employer.--For purposes of paragraph (1),
the term `nonelecting employer' means any employer for any
period with respect to which such employer does not have an
election under section 4980H(a) in effect.
``(4) Special rule for separate elections.--In the case of
an employer who makes a separate election described in section
4980H(a)(4) for any period, subsection (a) shall be applied for
such period by taking into account only the wages paid to
employees who are not subject to such election.''.
(2) Definitions.--Subsection (e) of section 3231 of such
Code is amended by adding at the end the following new
paragraph:
``(13) Special rules for tax on employers electing not to
provide health benefits.--For purposes of section 3221(c)--
``(A) Paragraph (1) shall be applied without regard
to the third sentence thereof.
``(B) Paragraph (2) shall not apply.''.
(3) Conforming amendment.--Subsection (d) of section 3221
of such Code, as redesignated by this section, is amended by
striking ``subsections (a) and (b), see section 3231(e)(2)''
and inserting ``this section, see paragraphs (2) and (13)(B) of
section 3231(e)''.
(e) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2012.
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
SEC. 421. CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES.
(a) In General.--Subpart D of part IV of subchapter A of chapter 1
of the Internal Revenue Code of 1986 (relating to business-related
credits) is amended by adding at the end the following new section:
``SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COVERAGE CREDIT.
``(a) In General.--For purposes of section 38, in the case of a
qualified small employer, the small business employee health coverage
credit determined under this section for the taxable year is an amount
equal to the applicable percentage of the qualified employee health
coverage expenses of such employer for such taxable year.
``(b) Applicable Percentage.--
``(1) In general.--For purposes of this section, the
applicable percentage is 50 percent.
``(2) Phaseout based on average compensation of
employees.--In the case of an employer whose average annual
employee compensation for the taxable year exceeds $20,000, the
percentage specified in paragraph (1) shall be reduced by a
number of percentage points which bears the same ratio to 50 as
such excess bears to $20,000.
``(c) Limitations.--
``(1) Phaseout based on employer size.--In the case of an
employer who employs more than 10 qualified employees during
the taxable year, the credit determined under subsection (a)
shall be reduced by an amount which bears the same ratio to the
amount of such credit (determined without regard to this
paragraph and after the application of the other provisions of
this section) as--
``(A) the excess of--
``(i) the number of qualified employees
employed by the employer during the taxable
year, over
``(ii) 10, bears to
``(B) 15.
``(2) Credit not allowed with respect to certain highly
compensated employees.--No credit shall be allowed under
subsection (a) with respect to qualified employee health
coverage expenses paid or incurred with respect to any employee
for any taxable year if the aggregate compensation paid by the
employer to such employee during such taxable year exceeds
$80,000.
``(d) Qualified Employee Health Coverage Expenses.--For purposes of
this section--
``(1) In general.--The term `qualified employee health
coverage expenses' means, with respect to any employer for any
taxable year, the aggregate amount paid or incurred by such
employer during such taxable year for coverage of any qualified
employee of the employer (including any family coverage which
covers such employee) under qualified health coverage.
``(2) Qualified health coverage.--The term `qualified
health coverage' means acceptable coverage (as defined in
section 59B(d)) which--
``(A) is provided pursuant to an election under
section 4980H(a), and
``(B) satisfies the requirements referred to in
section 4980H(c).
``(e) Other Definitions.--For purposes of this section--
``(1) Qualified small employer.--For purposes of this
section, the term `qualified small employer' means any employer
for any taxable year if--
``(A) the number of qualified employees employed by
such employer during the taxable year does not exceed
25, and
``(B) the average annual employee compensation of
such employer for such taxable year does not exceed the
sum of the dollar amounts in effect under subsection
(b)(2).
``(2) Qualified employee.--The term `qualified employee'
means any employee of an employer for any taxable year of the
employer if such employee received at least $5,000 of
compensation from such employer during such taxable year.
``(3) Average annual employee compensation.--The term
`average annual employee compensation' means, with respect to
any employer for any taxable year, the average amount of
compensation paid by such employer to qualified employees of
such employer during such taxable year.
``(4) Compensation.--The term `compensation' has the
meaning given such term in section 408(p)(6)(A).
``(5) Family coverage.--The term `family coverage' means
any coverage other than self-only coverage.
``(f) Special Rules.--For purposes of this section--
``(1) Special rule for partnerships and self-employed.--In
the case of a partnership (or a trade or business carried on by
an individual) which has one or more qualified employees
(determined without regard to this paragraph) with respect to
whom the election under 4980H(a) applies, each partner (or, in
the case of a trade or business carried on by an individual,
such individual) shall be treated as an employee.
``(2) Aggregation rule.--All persons treated as a single
employer under subsection (b), (c), (m), or (o) of section 414
shall be treated as 1 employer.
``(3) Denial of double benefit.--Any deduction otherwise
allowable with respect to amounts paid or incurred for health
insurance coverage to which subsection (a) applies shall be
reduced by the amount of the credit determined under this
section.
``(4) Inflation adjustment.--In the case of any taxable
year beginning after 2013, each of the dollar amounts in
subsections (b)(2), (c)(2), and (e)(2) 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 2012' 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) Credit To Be Part of General Business Credit.--Subsection (b)
of section 38 of such Code (relating to general business credit) is
amended by striking ``plus'' at the end of paragraph (34), by striking
the period at the end of paragraph (35) and inserting ``, plus'', and
by adding at the end the following new paragraph:
``(36) in the case of a qualified small employer (as
defined in section 45R(e)), the small business employee health
coverage credit determined under section 45R(a).''.
(c) Clerical Amendment.--The table of sections for subpart D of
part IV of subchapter A of chapter 1 of such Code is amended by
inserting after the item relating to section 45Q the following new
item:
``Sec. 45R. Small business employee health coverage credit.''.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
Subtitle C--Disclosures To Carry Out Health Insurance Exchange
Subsidies
SEC. 431. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE SUBSIDIES.
(a) In General.--Subsection (l) of section 6103 of the Internal
Revenue Code of 1986 is amended by adding at the end the following new
paragraph:
``(21) Disclosure of return information to carry out health
insurance exchange subsidies.--
``(A) In general.--The Secretary, upon written
request from the Health Choices Commissioner or the
head of a State-based health insurance exchange
approved for operation under section 208 of the
America's Affordable Health Choices Act of 2009, shall
disclose to officers and employees of the Health
Choices Administration or such State-based health
insurance exchange, as the case may be, return
information of any taxpayer whose income is relevant in
determining any affordability credit described in
subtitle C of title II of the America's Affordable
Health Choices Act of 2009. Such return information
shall be limited to--
``(i) taxpayer identity information with
respect to such taxpayer,
``(ii) the filing status of such taxpayer,
``(iii) the modified adjusted gross income
of such taxpayer (as defined in section
59B(e)(5)),
``(iv) the number of dependents of the
taxpayer,
``(v) such other information as is
prescribed by the Secretary by regulation as
might indicate whether the taxpayer is eligible
for such affordability credits (and the amount
thereof), and
``(vi) the taxable year with respect to
which the preceding information relates or, if
applicable, the fact that such information is
not available.
``(B) Restriction on use of disclosed
information.--Return information disclosed under
subparagraph (A) may be used by officers and employees
of the Health Choices Administration or such State-
based health insurance exchange, as the case may be,
only for the purposes of, and to the extent necessary
in, establishing and verifying the appropriate amount
of any affordability credit described in subtitle C of
title II of the America's Affordable Health Choices Act
of 2009 and providing for the repayment of any such
credit which was in excess of such appropriate
amount.''.
(b) Procedures and Recordkeeping Related to Disclosures.--Paragraph
(4) of section 6103(p) of such Code is amended--
(1) by inserting ``, or any entity described in subsection
(l)(21),'' after ``or (20)'' in the matter preceding
subparagraph (A),
(2) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii), and
(3) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (20)'' both places it appears in the
matter after subparagraph (F).
(c) Unauthorized Disclosure or Inspection.--Paragraph (2) of
section 7213(a) of such Code is amended by striking ``or (20)'' and
inserting ``(20), or (21)''.
Subtitle D--Other Revenue Provisions
PART 1--GENERAL PROVISIONS
SEC. 441. SURCHARGE ON HIGH INCOME INDIVIDUALS.
(a) In General.--Part VIII of subchapter A of chapter 1 of the
Internal Revenue Code of 1986, as added by this title, is amended by
adding at the end the following new subpart:
``Subpart B--Surcharge on High Income Individuals
``Sec. 59C. Surcharge on high income individuals.
``SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.
``(a) General Rule.--In the case of a taxpayer other than a
corporation, there is hereby imposed (in addition to any other tax
imposed by this subtitle) a tax equal to--
``(1) 1 percent of so much of the modified adjusted gross
income of the taxpayer as exceeds $350,000 but does not exceed
$500,000,
``(2) 1.5 percent of so much of the modified adjusted gross
income of the taxpayer as exceeds $500,000 but does not exceed
$1,000,000, and
``(3) 5.4 percent of so much of the modified adjusted gross
income of the taxpayer as exceeds $1,000,000.
``(b) Taxpayers Not Making a Joint Return.--In the case of any
taxpayer other than a taxpayer making a joint return under section 6013
or a surviving spouse (as defined in section 2(a)), subsection (a)
shall be applied by substituting for each of the dollar amounts therein
(after any increase determined under subsection (e)) a dollar amount
equal to--
``(1) 50 percent of the dollar amount so in effect in the
case of a married individual filing a separate return, and
``(2) 80 percent of the dollar amount so in effect in any
other case.
``(c) Adjustments Based on Federal Health Reform Savings.--
``(1) In general.--Except as provided in paragraph (2), in
the case of any taxable year beginning after December 31, 2012,
subsection (a) shall be applied--
``(A) by substituting `2 percent' for `1 percent',
and
``(B) by substituting `3 percent' for `1.5
percent'.
``(2) Adjustments based on excess federal health reform
savings.--
``(A) Exception if federal health reform savings
significantly exceeds base amount.--If the excess
Federal health reform savings is more than
$150,000,000,000 but not more than $175,000,000,000,
paragraph (1) shall not apply.
``(B) Further adjustment for additional federal
health reform savings.--If the excess Federal health
reform savings is more than $175,000,000,000,
paragraphs (1) and (2) of subsection (a) (and paragraph
(1) of this subsection) shall not apply to any taxable
year beginning after December 31, 2012.
``(C) Excess federal health reform savings.--For
purposes of this subsection, the term `excess Federal
health reform savings' means the excess of--
``(i) the Federal health reform savings,
over
``(ii) $525,000,000,000.
``(D) Federal health reform savings.--The term
`Federal health reform savings' means the sum of the
amounts described in subparagraphs (A) and (B) of
paragraph (3).
``(3) Determination of federal health reform savings.--Not
later than December 1, 2012, the Director of the Office of
Management and Budget shall--
``(A) determine, on the basis of the study
conducted under paragraph (4), the aggregate reductions
in Federal expenditures which have been achieved as a
result of the provisions of, and amendments made by,
division B of the America's Affordable Health Choices
Act of 2009 during the period beginning on October 1,
2009, and ending with the latest date with respect to
which the Director has sufficient data to make such
determination, and
``(B) estimate, on the basis of such study and the
determination under subparagraph (A), the aggregate
reductions in Federal expenditures which will be
achieved as a result of such provisions and amendments
during so much of the period beginning with fiscal year
2010 and ending with fiscal year 2019 as is not taken
into account under subparagraph (A).
``(4) Study of federal health reform savings.--The Director
of the Office of Management and Budget shall conduct a study of
the reductions in Federal expenditures during fiscal years 2010
through 2019 which are attributable to the provisions of, and
amendments made by, division B of the America's Affordable
Health Choices Act of 2009. The Director shall complete such
study not later than December 1, 2012.
``(5) Reductions in federal expenditures determined without
regard to program investments.--For purposes of paragraphs (3)
and (4), reductions in Federal expenditures shall be determined
without regard to section 1121 of the America's Affordable
Health Choices Act of 2009 and other program investments under
division B thereof.
``(d) Modified Adjusted Gross Income.--For purposes of this
section, the term `modified adjusted gross income' means adjusted gross
income reduced by any deduction allowed for investment interest (as
defined in section 163(d)). In the case of an estate or trust, adjusted
gross income shall be determined as provided in section 67(e).
``(e) Inflation Adjustments.--
``(1) In general.--In the case of taxable years beginning
after 2011, the dollar amounts in subsection (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, by substituting `calendar year
2010' for `calendar year 1992' in subparagraph (B)
thereof.
``(2) Rounding.--If any amount as adjusted under paragraph
(1) is not a multiple of $5,000, such amount shall be rounded
to the next lowest multiple of $5,000.
``(f) Special Rules.--
``(1) Nonresident alien.--In the case of a nonresident
alien individual, only amounts taken into account in connection
with the tax imposed under section 871(b) shall be taken into
account under this section.
``(2) Citizens and residents living abroad.--The dollar
amounts in effect under subsection (a) (after the application
of subsections (b) and (e)) shall be decreased by the excess
of--
``(A) the amounts excluded from the taxpayer's
gross income under section 911, over
``(B) the amounts of any deductions or exclusions
disallowed under section 911(d)(6) with respect to the
amounts described in subparagraph (A).
``(3) Charitable trusts.--Subsection (a) shall not apply to
a trust all the unexpired interests in which are devoted to one
or more of the purposes described in section 170(c)(2)(B).
``(4) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall not
be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or for
purposes of section 55.''.
(b) Clerical Amendment.--The table of subparts for part VIII of
subchapter A of chapter 1 of such Code, as added by this title, is
amended by inserting after the item relating to subpart A the following
new item:
``subpart b. surcharge on high income individuals.''.
(c) Section 15 Not To Apply.--The amendment made by subsection (a)
shall not be treated as a change in a rate of tax for purposes of
section 15 of the Internal Revenue Code of 1986.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2010.
SEC. 442. DELAY IN APPLICATION OF WORLDWIDE ALLOCATION OF INTEREST.
(a) In General.--Paragraphs (5)(D) and (6) of section 864(f) of the
Internal Revenue Code of 1986 are each amended by striking ``December
31, 2010'' and inserting ``December 31, 2019''.
(b) Transition.--Subsection (f) of section 864 of such Code is
amended by striking paragraph (7).
PART 2--PREVENTION OF TAX AVOIDANCE
SEC. 451. LIMITATION ON TREATY BENEFITS FOR CERTAIN DEDUCTIBLE
PAYMENTS.
(a) In General.--Section 894 of the Internal Revenue Code of 1986
(relating to income affected by treaty) is amended by adding at the end
the following new subsection:
``(d) Limitation on Treaty Benefits for Certain Deductible
Payments.--
``(1) In general.--In the case of any deductible related-
party payment, any withholding tax imposed under chapter 3 (and
any tax imposed under subpart A or B of this part) with respect
to such payment may not be reduced under any treaty of the
United States unless any such withholding tax would be reduced
under a treaty of the United States if such payment were made
directly to the foreign parent corporation.
``(2) Deductible related-party payment.--For purposes of
this subsection, the term `deductible related-party payment'
means any payment made, directly or indirectly, by any person
to any other person if the payment is allowable as a deduction
under this chapter and both persons are members of the same
foreign controlled group of entities.
``(3) Foreign controlled group of entities.--For purposes
of this subsection--
``(A) In general.--The term `foreign controlled
group of entities' means a controlled group of entities
the common parent of which is a foreign corporation.
``(B) Controlled group of entities.--The term
`controlled group of entities' means a controlled group
of corporations as defined in section 1563(a)(1),
except that--
``(i) `more than 50 percent' shall be
substituted for `at least 80 percent' each
place it appears therein, and
``(ii) the determination shall be made
without regard to subsections (a)(4) and (b)(2)
of section 1563.
A partnership or any other entity (other than a
corporation) shall be treated as a member of a
controlled group of entities if such entity is
controlled (within the meaning of section 954(d)(3)) by
members of such group (including any entity treated as
a member of such group by reason of this sentence).
``(4) Foreign parent corporation.--For purposes of this
subsection, the term `foreign parent corporation' means, with
respect to any deductible related-party payment, the common
parent of the foreign controlled group of entities referred to
in paragraph (3)(A).
``(5) Regulations.--The Secretary may prescribe such
regulations or other guidance as are necessary or appropriate
to carry out the purposes of this subsection, including
regulations or other guidance which provide for--
``(A) the treatment of two or more persons as
members of a foreign controlled group of entities if
such persons would be the common parent of such group
if treated as one corporation, and
``(B) the treatment of any member of a foreign
controlled group of entities as the common parent of
such group if such treatment is appropriate taking into
account the economic relationships among such
entities.''.
(b) Effective Date.--The amendment made by this section shall apply
to payments made after the date of the enactment of this Act.
SEC. 452. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE.
(a) In General.--Section 7701 of the Internal Revenue Code of 1986
is amended by redesignating subsection (o) as subsection (p) and by
inserting after subsection (n) the following new subsection:
``(o) Clarification of Economic Substance Doctrine.--
``(1) Application of doctrine.--In the case of any
transaction to which the economic substance doctrine is
relevant, such transaction shall be treated as having economic
substance only if--
``(A) the transaction changes in a meaningful way
(apart from Federal income tax effects) the taxpayer's
economic position, and
``(B) the taxpayer has a substantial purpose (apart
from Federal income tax effects) for entering into such
transaction.
``(2) Special rule where taxpayer relies on profit
potential.--
``(A) In general.--The potential for profit of a
transaction shall be taken into account in determining
whether the requirements of subparagraphs (A) and (B)
of paragraph (1) are met with respect to the
transaction only if the present value of the reasonably
expected pre-tax profit from the transaction is
substantial in relation to the present value of the
expected net tax benefits that would be allowed if the
transaction were respected.
``(B) Treatment of fees and foreign taxes.--Fees
and other transaction expenses and foreign taxes shall
be taken into account as expenses in determining pre-
tax profit under subparagraph (A).
``(3) State and local tax benefits.--For purposes of
paragraph (1), any State or local income tax effect which is
related to a Federal income tax effect shall be treated in the
same manner as a Federal income tax effect.
``(4) Financial accounting benefits.--For purposes of
paragraph (1)(B), achieving a financial accounting benefit
shall not be taken into account as a purpose for entering into
a transaction if the origin of such financial accounting
benefit is a reduction of Federal income tax.
``(5) Definitions and special rules.--For purposes of this
subsection--
``(A) Economic substance doctrine.--The term
`economic substance doctrine' means the common law
doctrine under which tax benefits under subtitle A with
respect to a transaction are not allowable if the
transaction does not have economic substance or lacks a
business purpose.
``(B) Exception for personal transactions of
individuals.--In the case of an individual, paragraph
(1) shall apply only to transactions entered into in
connection with a trade or business or an activity
engaged in for the production of income.
``(C) Other common law doctrines not affected.--
Except as specifically provided in this subsection, the
provisions of this subsection shall not be construed as
altering or supplanting any other rule of law, and the
requirements of this subsection shall be construed as
being in addition to any such other rule of law.
``(D) Determination of application of doctrine not
affected.--The determination of whether the economic
substance doctrine is relevant to a transaction (or
series of transactions) shall be made in the same
manner as if this subsection had never been enacted.
``(6) Regulations.--The Secretary shall prescribe such
regulations as may be necessary or appropriate to carry out the
purposes of this subsection.''.
(b) Effective Date.--The amendments made by this section shall
apply to transactions entered into after the date of the enactment of
this Act.
SEC. 453. PENALTIES FOR UNDERPAYMENTS.
(a) Penalty for Underpayments Attributable to Transactions Lacking
Economic Substance.--
(1) In general.--Subsection (b) of section 6662 of the
Internal Revenue Code of 1986 is amended by inserting after
paragraph (5) the following new paragraph:
``(6) Any disallowance of claimed tax benefits by reason of
a transaction lacking economic substance (within the meaning of
section 7701(o)) or failing to meet the requirements of any
similar rule of law.''.
(2) Increased penalty for nondisclosed transactions.--
Section 6662 of such Code is amended by adding at the end the
following new subsection:
``(i) Increase in Penalty in Case of Nondisclosed Noneconomic
Substance Transactions.--
``(1) In general.--In the case of any portion of an
underpayment which is attributable to one or more nondisclosed
noneconomic substance transactions, subsection (a) shall be
applied with respect to such portion by substituting `40
percent' for `20 percent'.
``(2) Nondisclosed noneconomic substance transactions.--For
purposes of this subsection, the term `nondisclosed noneconomic
substance transaction' means any portion of a transaction
described in subsection (b)(6) with respect to which the
relevant facts affecting the tax treatment are not adequately
disclosed in the return nor in a statement attached to the
return.
``(3) Special rule for amended returns.--Except as provided
in regulations, in no event shall any amendment or supplement
to a return of tax be taken into account for purposes of this
subsection if the amendment or supplement is filed after the
earlier of the date the taxpayer is first contacted by the
Secretary regarding the examination of the return or such other
date as is specified by the Secretary.''.
(3) Conforming amendment.--Subparagraph (B) of section
6662A(e)(2) of such Code is amended--
(A) by striking ``section 6662(h)'' and inserting
``subsections (h) or (i) of section 6662'', and
(B) by striking ``gross valuation misstatement
penalty'' in the heading and inserting ``certain
increased underpayment penalties''.
(b) Reasonable Cause Exception Not Applicable to Noneconomic
Substance Transactions, Tax Shelters, and Certain Large or Publicly
Traded Persons.--Subsection (c) of section 6664 of such Code is
amended--
(1) by redesignating paragraphs (2) and (3) as paragraphs
(3) and (4), respectively,
(2) by striking ``paragraph (2)'' in paragraph (4), as so
redesignated, and inserting ``paragraph (3)'', and
(3) by inserting after paragraph (1) the following new
paragraph:
``(2) Exception.--Paragraph (1) shall not apply to--
``(A) to any portion of an underpayment which is
attributable to one or more tax shelters (as defined in
section 6662(d)(2)(C)) or transactions described in
section 6662(b)(6), and
``(B) to any taxpayer if such taxpayer is a
specified person (as defined in section
6662(d)(2)(D)(ii)).''.
(c) Application of Penalty for Erroneous Claim for Refund or Credit
to Noneconomic Substance Transactions.--Section 6676 of such Code is
amended by redesignating subsection (c) as subsection (d) and inserting
after subsection (b) the following new subsection:
``(c) Noneconomic Substance Transactions Treated as Lacking
Reasonable Basis.--For purposes of this section, any excessive amount
which is attributable to any transaction described in section
6662(b)(6) shall not be treated as having a reasonable basis.''.
(d) Special Understatement Reduction Rule for Certain Large or
Publicly Traded Persons.--
(1) In general.--Paragraph (2) of section 6662(d) of such
Code is amended by adding at the end the following new
subparagraph:
``(D) Special reduction rule for certain large or
publicly traded persons.--
``(i) In general.--In the case of any
specified person--
``(I) subparagraph (B) shall not
apply, and
``(II) the amount of the
understatement under subparagraph (A)
shall be reduced by that portion of the
understatement which is attributable to
any item with respect to which the
taxpayer has a reasonable belief that
the tax treatment of such item by the
taxpayer is more likely than not the
proper tax treatment of such item.
``(ii) Specified person.--For purposes of
this subparagraph, the term `specified person'
means--
``(I) any person required to file
periodic or other reports under section
13 of the Securities Exchange Act of
1934, and
``(II) any corporation with gross
receipts in excess of $100,000,000 for
the taxable year involved.
All persons treated as a single employer under
section 52(a) shall be treated as one person
for purposes of subclause (II).''.
(2) Conforming amendment.--Subparagraph (C) of section
6662(d)(2) of such Code is amended by striking ``Subparagraph
(B)'' and inserting ``Subparagraphs (B) and (D)(i)(II)''.
(e) Effective Date.--The amendments made by this section shall
apply to transactions entered into after the date of the enactment of
this Act.
DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS
SEC. 1001. TABLE OF CONTENTS OF DIVISION.
The table of contents for this division is as follows:
DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS
Sec. 1001. Table of contents of division.
TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions Related to Medicare Part A
Part 1--Market Basket Updates
Sec. 1101. Skilled nursing facility payment update.
Sec. 1102. Inpatient rehabilitation facility payment update.
Sec. 1103. Incorporating productivity improvements into market basket
updates that do not already incorporate
such improvements.
Part 2--Other Medicare Part A Provisions
Sec. 1111. Payments to skilled nursing facilities.
Sec. 1112. Medicare DSH report and payment adjustments in response to
coverage expansion.
Subtitle B--Provisions Related to Part B
Part 1--Physicians' Services
Sec. 1121. Sustainable growth rate reform.
Sec. 1122. Misvalued codes under the physician fee schedule.
Sec. 1123. Payments for efficient areas.
Sec. 1124. Modifications to the Physician Quality Reporting Initiative
(PQRI).
Sec. 1125. Adjustment to Medicare payment localities.
Part 2--Market Basket Updates
Sec. 1131. Incorporating productivity improvements into market basket
updates that do not already incorporate
such improvements.
Part 3--Other Provisions
Sec. 1141. Rental and purchase of power-driven wheelchairs.
Sec. 1142. Extension of payment rule for brachytherapy.
Sec. 1143. Home infusion therapy report to congress.
Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost
data and other data.
Sec. 1145. Treatment of certain cancer hospitals.
Sec. 1146. Medicare Improvement Fund.
Sec. 1147. Payment for imaging services.
Sec. 1148. Durable medical equipment program improvements.
Sec. 1149. MedPAC study and report on bone mass measurement.
Subtitle C--Provisions Related to Medicare Parts A and B
Sec. 1151. Reducing potentially preventable hospital readmissions.
Sec. 1152. Post acute care services payment reform plan and bundling
pilot program.
Sec. 1153. Home health payment update for 2010.
Sec. 1154. Payment adjustments for home health care.
Sec. 1155. Incorporating productivity improvements into market basket
update for home health services.
Sec. 1156. Limitation on Medicare exceptions to the prohibition on
certain physician referrals made to
hospitals.
Sec. 1157. Institute of Medicine study of geographic adjustment factors
under Medicare.
Sec. 1158. Revision of Medicare payment systems to address geographic
inequities.
Subtitle D--Medicare Advantage Reforms
Part 1--Payment and Administration
Sec. 1161. Phase-in of payment based on fee-for-service costs.
Sec. 1162. Quality bonus payments.
Sec. 1163. Extension of Secretarial coding intensity adjustment
authority.
Sec. 1164. Simplification of annual beneficiary election periods.
Sec. 1165. Extension of reasonable cost contracts.
Sec. 1166. Limitation of waiver authority for employer group plans.
Sec. 1167. Improving risk adjustment for payments.
Sec. 1168. Elimination of MA Regional Plan Stabilization Fund.
Part 2--Beneficiary Protections and Anti-Fraud
Sec. 1171. Limitation on cost-sharing for individual health services.
Sec. 1172. Continuous open enrollment for enrollees in plans with
enrollment suspension.
Sec. 1173. Information for beneficiaries on MA plan administrative
costs.
Sec. 1174. Strengthening audit authority.
Sec. 1175. Authority to deny plan bids.
Part 3--Treatment of Special Needs Plans
Sec. 1176. Limitation on enrollment outside open enrollment period of
individuals into chronic care specialized
MA plans for special needs individuals.
Sec. 1177. Extension of authority of special needs plans to restrict
enrollment.
Subtitle E--Improvements to Medicare Part D
Sec. 1181. Elimination of coverage gap.
Sec. 1182. Discounts for certain part D drugs in original coverage gap.
Sec. 1183. Repeal of provision relating to submission of claims by
pharmacies located in or contracting with
long-term care facilities.
Sec. 1184. Including costs incurred by AIDS drug assistance programs
and Indian Health Service in providing
prescription drugs toward the annual out-
of-pocket threshold under part D.
Sec. 1185. Permitting mid-year changes in enrollment for formulary
changes that adversely impact an enrollee.
Subtitle F--Medicare Rural Access Protections
Sec. 1191. Telehealth expansion and enhancements.
Sec. 1192. Extension of outpatient hold harmless provision.
Sec. 1193. Extension of section 508 hospital reclassifications.
Sec. 1194. Extension of geographic floor for work.
Sec. 1195. Extension of payment for technical component of certain
physician pathology services.
Sec. 1196. Extension of ambulance add-ons.
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
Sec. 1201. Improving assets tests for Medicare Savings Program and low-
income subsidy program.
Sec. 1202. Elimination of part D cost-sharing for certain non-
institutionalized full-benefit dual
eligible individuals.
Sec. 1203. Eliminating barriers to enrollment.
Sec. 1204. Enhanced oversight relating to reimbursements for
retroactive low income subsidy enrollment.
Sec. 1205. Intelligent assignment in enrollment.
Sec. 1206. Special enrollment period and automatic enrollment process
for certain subsidy eligible individuals.
Sec. 1207. Application of MA premiums prior to rebate in calculation of
low income subsidy benchmark.
Subtitle B--Reducing Health Disparities
Sec. 1221. Ensuring effective communication in Medicare.
Sec. 1222. Demonstration to promote access for Medicare beneficiaries
with limited English proficiency by
providing reimbursement for culturally and
linguistically appropriate services.
Sec. 1223. IOM report on impact of language access services.
Sec. 1224. Definitions.
Subtitle C--Miscellaneous Improvements
Sec. 1231. Extension of therapy caps exceptions process.
Sec. 1232. Extended months of coverage of immunosuppressive drugs for
kidney transplant patients and other renal
dialysis provisions.
Sec. 1233. Advance care planning consultation.
Sec. 1234. Part B special enrollment period and waiver of limited
enrollment penalty for TRICARE
beneficiaries.
Sec. 1235. Exception for use of more recent tax year in case of gains
from sale of primary residence in computing
part B income-related premium.
Sec. 1236. Demonstration program on use of patient decisions aids.
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
Sec. 1301. Accountable Care Organization pilot program.
Sec. 1302. Medical home pilot program.
Sec. 1303. Payment incentive for selected primary care services.
Sec. 1304. Increased reimbursement rate for certified nurse-midwives.
Sec. 1305. Coverage and waiver of cost-sharing for preventive services.
Sec. 1306. Waiver of deductible for colorectal cancer screening tests
regardless of coding, subsequent diagnosis,
or ancillary tissue removal.
Sec. 1307. Excluding clinical social worker services from coverage
under the medicare skilled nursing facility
prospective payment system and consolidated
payment.
Sec. 1308. Coverage of marriage and family therapist services and
mental health counselor services.
Sec. 1309. Extension of physician fee schedule mental health add-on.
Sec. 1310. Expanding access to vaccines.
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
Sec. 1401. Comparative effectiveness research.
Subtitle B--Nursing Home Transparency
Part 1--Improving Transparency of Information on Skilled Nursing
Facilities and Nursing Facilities
Sec. 1411. Required disclosure of ownership and additional disclosable
parties information.
Sec. 1412. Accountability requirements.
Sec. 1413. Nursing home compare Medicare website.
Sec. 1414. Reporting of expenditures.
Sec. 1415. Standardized complaint form.
Sec. 1416. Ensuring staffing accountability.
Part 2--Targeting Enforcement
Sec. 1421. Civil money penalties.
Sec. 1422. National independent monitor pilot program.
Sec. 1423. Notification of facility closure.
Part 3--Improving Staff Training
Sec. 1431. Dementia and abuse prevention training.
Sec. 1432. Study and report on training required for certified nurse
aides and supervisory staff.
Subtitle C--Quality Measurements
Sec. 1441. Establishment of national priorities for quality
improvement.
Sec. 1442. Development of new quality measures; GAO evaluation of data
collection process for quality measurement.
Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of
quality measures.
Sec. 1444. Application of quality measures.
Sec. 1445. Consensus-based entity funding.
Subtitle D--Physician Payments Sunshine Provision
Sec. 1451. Reports on financial relationships between manufacturers and
distributors of covered drugs, devices,
biologicals, or medical supplies under
Medicare, Medicaid, or CHIP and physicians
and other health care entities and between
physicians and other health care entities.
Subtitle E--Public Reporting on Health Care-Associated Infections
Sec. 1461. Requirement for public reporting by hospitals and ambulatory
surgical centers on health care-associated
infections.
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
Sec. 1501. Distribution of unused residency positions.
Sec. 1502. Increasing training in nonprovider settings.
Sec. 1503. Rules for counting resident time for didactic and scholarly
activities and other activities.
Sec. 1504. Preservation of resident cap positions from closed
hospitals.
Sec. 1505. Improving accountability for approved medical residency
training.
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse
Sec. 1601. Increased funding and flexibility to fight fraud and abuse.
Subtitle B--Enhanced Penalties for Fraud and Abuse
Sec. 1611. Enhanced penalties for false statements on provider or
supplier enrollment applications.
Sec. 1612. Enhanced penalties for submission of false statements
material to a false claim.
Sec. 1613. Enhanced penalties for delaying inspections.
Sec. 1614. Enhanced hospice program safeguards.
Sec. 1615. Enhanced penalties for individuals excluded from program
participation.
Sec. 1616. Enhanced penalties for provision of false information by
Medicare Advantage and part D plans.
Sec. 1617. Enhanced penalties for Medicare Advantage and part D
marketing violations.
Sec. 1618. Enhanced penalties for obstruction of program audits.
Sec. 1619. Exclusion of certain individuals and entities from
participation in Medicare and State health
care programs.
Subtitle C--Enhanced Program and Provider Protections
Sec. 1631. Enhanced CMS program protection authority.
Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure
requirements relating to previous
affiliations.
Sec. 1633. Required inclusion of payment modifier for certain
evaluation and management services.
Sec. 1634. Evaluations and reports required under Medicare Integrity
Program.
Sec. 1635. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1636. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 1637. Physicians who order durable medical equipment or home
health services required to be Medicare
enrolled physicians or eligible
professionals.
Sec. 1638. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste
and abuse.
Sec. 1639. Face to face encounter with patient required before
physicians may certify eligibility for home
health services or durable medical
equipment under Medicare.
Sec. 1640. Extension of testimonial subpoena authority to program
exclusion investigations.
Sec. 1641. Required repayments of Medicare and Medicaid overpayments.
Sec. 1642. Expanded application of hardship waivers for OIG exclusions
to beneficiaries of any Federal health care
program.
Sec. 1643. Access to certain information on renal dialysis facilities.
Sec. 1644. Billing agents, clearinghouses, or other alternate payees
required to register under Medicare.
Sec. 1645. Conforming civil monetary penalties to False Claims Act
amendments.
Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and
Abuse
Sec. 1651. Access to Information Necessary to Identify Fraud, Waste,
and Abuse.
Sec. 1652. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National
Practitioner Data Bank.
Sec. 1653. Compliance with HIPAA privacy and security standards.
TITLE VII--MEDICAID AND CHIP
Subtitle A--Medicaid and Health Reform
Sec. 1701. Eligibility for individuals with income below 133\1/3\
percent of the Federal poverty level.
Sec. 1702. Requirements and special rules for certain Medicaid
eligible individuals.
Sec. 1703. CHIP and Medicaid maintenance of effort.
Sec. 1704. Reduction in Medicaid DSH.
Sec. 1705. Expanded outstationing.
Subtitle B--Prevention
Sec. 1711. Required coverage of preventive services.
Sec. 1712. Tobacco cessation.
Sec. 1713. Optional coverage of nurse home visitation services.
Sec. 1714. State eligibility option for family planning services.
Subtitle C--Access
Sec. 1721. Payments to primary care practitioners.
Sec. 1722. Medical home pilot program.
Sec. 1723. Translation or interpretation services.
Sec. 1724. Optional coverage for freestanding birth center services.
Sec. 1725. Inclusion of public health clinics under the vaccines for
children program.
Subtitle D--Coverage
Sec. 1731. Optional medicaid coverage of low-income HIV-infected
individuals.
Sec. 1732. Extending transitional Medicaid Assistance (TMA).
Sec. 1733. Requirement of 12-month continuous coverage under certain
CHIP programs.
Subtitle E--Financing
Sec. 1741. Payments to pharmacists.
Sec. 1742. Prescription drug rebates.
Sec. 1743. Extension of prescription drug discounts to enrollees of
medicaid managed care organizations.
Sec. 1744. Payments for graduate medical education.
Subtitle F--Waste, Fraud, and Abuse
Sec. 1751. Health-care acquired conditions.
Sec. 1752. Evaluations and reports required under Medicaid Integrity
Program.
Sec. 1753. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1754. Overpayments.
Sec. 1755. Managed Care Organizations.
Sec. 1756. Termination of provider participation under Medicaid and
CHIP if terminated under Medicare or other
State plan or child health plan.
Sec. 1757. Medicaid and CHIP exclusion from participation relating to
certain ownership, control, and management
affiliations.
Sec. 1758. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 1759. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 1760. Denial of payments for litigation-related misconduct.
Subtitle G--Puerto Rico and the Territories
Sec. 1771. Puerto Rico and territories.
Subtitle H--Miscellaneous
Sec. 1781. Technical corrections.
Sec. 1782. Extension of QI program.
TITLE VIII--REVENUE-RELATED PROVISIONS
Sec. 1801. Disclosures to facilitate identification of individuals
likely to be ineligible for the low-income
assistance under the Medicare prescription
drug program to assist Social Security
Administration's outreach to eligible
individuals.
Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for
Trust Fund.
TITLE IX--MISCELLANEOUS PROVISIONS
Sec. 1901. Repeal of trigger provision.
Sec. 1902. Repeal of comparative cost adjustment (CCA) program.
Sec. 1903. Extension of gainsharing demonstration.
Sec. 1904. Grants to States for quality home visitation programs for
families with young children and families
expecting children.
Sec. 1905. Improved coordination and protection for dual eligibles.
TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions Related to Medicare Part A
PART 1--MARKET BASKET UPDATES
SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.
(a) In General.--Section 1888(e)(4)(E)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--
(1) in subclause (III), by striking ``and'' at the end;
(2) by redesignating subclause (IV) as subclause (VI); and
(3) by inserting after subclause (III) the following new
subclauses:
``(IV) for each of fiscal years
2004 through 2009, the rate computed
for the previous fiscal year increased
by the skilled nursing facility market
basket percentage change for the fiscal
year involved;
``(V) for fiscal year 2010, the
rate computed for the previous fiscal
year; and''.
(b) Delayed Effective Date.--Section 1888(e)(4)(E)(ii)(V) of the
Social Security Act, as inserted by subsection (a)(3), shall not apply
to payment for days before January 1, 2010.
SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.
(a) In General.--Section 1886(j)(3)(C) of the Social Security Act
(42 U.S.C. 1395ww(j)(3)(C)) is amended by striking ``and 2009'' and
inserting ``through 2010''.
(b) Delayed Effective Date.--The amendment made by subsection (a)
shall not apply to payment units occurring before January 1, 2010.
SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET
UPDATES THAT DO NOT ALREADY INCORPORATE SUCH
IMPROVEMENTS.
(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of the Social
Security Act (42 U.S.C. 1395ww(b)(3)(B)) is amended--
(1) in clause (iii)--
(A) by striking ``(iii) For purposes of this
subparagraph,'' and inserting ``(iii)(I) For purposes
of this subparagraph, subject to the productivity
adjustment described in subclause (II),''; and
(B) by adding at the end the following new
subclause:
``(II) The productivity adjustment described in this subclause,
with respect to an increase or change for a fiscal year or year or cost
reporting period, or other annual period, is a productivity offset
equal to the percentage change in the 10-year moving average of annual
economy-wide private nonfarm business multi-factor productivity (as
recently published before the promulgation of such increase for the
year or period involved). Except as otherwise provided, any reference
to the increase described in this clause shall be a reference to the
percentage increase described in subclause (I) minus the percentage
change under this subclause.'';
(2) in the first sentence of clause (viii)(I), by inserting
``(but not below zero)'' after ``shall be reduced''; and
(3) in the first sentence of clause (ix)(I)--
(A) by inserting ``(determined without regard to
clause (iii)(II)'' after ``clause (i)'' the second time
it appears; and
(B) by inserting ``(but not below zero)'' after
``reduced''.
(b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of such Act
(42 U.S.C. 1395yy(e)(5)(B)) is amended by inserting ``subject to the
productivity adjustment described in section 1886(b)(3)(B)(iii)(II)''
after ``as calculated by the Secretary''.
(c) Long-Term Care Hospitals.--Section 1886(m) of the Social
Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the
following new paragraph:
``(3) Productivity adjustment.--In implementing the system
described in paragraph (1) for discharges occurring during the
rate year ending in 2010 or any subsequent rate year for a
hospital, to the extent that an annual percentage increase
factor applies to a base rate for such discharges for the
hospital, such factor shall be subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II).''.
(d) Inpatient Rehabilitation Facilities.--The second sentence of
section 1886(j)(3)(C) of the Social Security Act (42 U.S.C.
1395ww(j)(3)(C)) is amended by inserting ``(subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II))'' after
``appropriate percentage increase''.
(e) Psychiatric Hospitals.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww) is amended by adding at the end the following new
subsection:
``(o) Prospective Payment for Psychiatric Hospitals.--
``(1) Reference to establishment and implementation of
system.--For provisions related to the establishment and
implementation of a prospective payment system for payments
under this title for inpatient hospital services furnished by
psychiatric hospitals (as described in clause (i) of subsection
(d)(1)(B)) and psychiatric units (as described in the matter
following clause (v) of such subsection), see section 124 of
the Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 1999.
``(2) Productivity adjustment.--In implementing the system
described in paragraph (1) for discharges occurring during the
rate year ending in 2011 or any subsequent rate year for a
psychiatric hospital or unit described in such paragraph, to
the extent that an annual percentage increase factor applies to
a base rate for such discharges for the hospital or unit,
respectively, such factor shall be subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II).''.
(f) Hospice Care.--Subclause (VII) of section 1814(i)(1)(C)(ii) of
the Social Security Act (42 U.S.C. 1395f(i)(1)(C)(ii)) is amended by
inserting after ``the market basket percentage increase'' the
following: ``(which is subject to the productivity adjustment described
in section 1886(b)(3)(B)(iii)(II))''.
(g) Effective Date.--The amendments made by subsections (a), (b),
(d), and (f) shall apply to annual increases effected for fiscal years
beginning with fiscal year 2010.
PART 2--OTHER MEDICARE PART A PROVISIONS
SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.
(a) Change in Recalibration Factor.--
(1) Analysis.--The Secretary of Health and Human Services
shall conduct, using calendar year 2006 claims data, an initial
analysis comparing total payments under title XVIII of the
Social Security Act for skilled nursing facility services under
the RUG-53 and under the RUG-44 classification systems.
(2) Adjustment in recalibration factor.--Based on the
initial analysis under paragraph (1), the Secretary shall
adjust the case mix indexes under section 1888(e)(4)(G)(i) of
the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for
fiscal year 2010 by the appropriate recalibration factor as
proposed in the proposed rule for Medicare skilled nursing
facilities issued by such Secretary on May 12, 2009 (74 Federal
Register 22214 et seq.).
(b) Change in Payment for Nontherapy Ancillary (NTA) Services and
Therapy Services.--
(1) Changes under current snf classification system.--
(A) In general.--Subject to subparagraph (B), the
Secretary of Health and Human Services shall, under the
system for payment of skilled nursing facility services
under section 1888(e) of the Social Security Act (42
U.S.C. 1395yy(e)), increase payment by 10 percent for
non-therapy ancillary services (as specified by the
Secretary in the notice issued on November 27, 1998 (63
Federal Register 65561 et seq.)) and shall decrease
payment for the therapy case mix component of such
rates by 5.5 percent.
(B) Effective date.--The changes in payment
described in subparagraph (A) shall apply for days on
or after January 1, 2010, and until the Secretary
implements an alternative case mix classification
system for payment of skilled nursing facility services
under section 1888(e) of the Social Security Act (42
U.S.C. 1395yy(e)).
(C) Implementation.--Notwithstanding any other
provision of law, the Secretary may implement by
program instruction or otherwise the provisions of this
paragraph.
(2) Changes under a future snf case mix classification
system.--
(A) Analysis.--
(i) In general.--The Secretary of Health
and Human Services shall analyze payments for
non-therapy ancillary services under a future
skilled nursing facility classification system
to ensure the accuracy of payment for non-
therapy ancillary services. Such analysis shall
consider use of appropriate indicators which
may include age, physical and mental status,
ability to perform activities of daily living,
prior nursing home stay, broad RUG category,
and a proxy for length of stay.
(ii) Application.--Such analysis shall be
conducted in a manner such that the future
skilled nursing facility classification system
is implemented to apply to services furnished
during a fiscal year beginning with fiscal year
2011.
(B) Consultation.--In conducting the analysis under
subparagraph (A), the Secretary shall consult with
interested parties, including the Medicare Payment
Advisory Commission and other interested stakeholders,
to identify appropriate predictors of nontherapy
ancillary costs.
(C) Rulemaking.--The Secretary shall include the
result of the analysis under subparagraph (A) in the
fiscal year 2011 rulemaking cycle for purposes of
implementation beginning for such fiscal year.
(D) Implementation.--Subject to subparagraph (E)
and consistent with subparagraph (A)(ii), the Secretary
shall implement changes to payments for non-therapy
ancillary services (which may include a separate rate
component for non-therapy ancillary services and may
include use of a model that predicts payment amounts
applicable for non-therapy ancillary services) under
such future skilled nursing facility services
classification system as the Secretary determines
appropriate based on the analysis conducted pursuant to
subparagraph (A).
(E) Budget neutrality.--The Secretary shall
implement changes described in subparagraph (D) in a
manner such that the estimated expenditures under such
future skilled nursing facility services classification
system for a fiscal year beginning with fiscal year
2011 with such changes would be equal to the estimated
expenditures that would otherwise occur under title
XVIII of the Social Security Act under such future
skilled nursing facility services classification system
for such year without such changes.
(c) Outlier Policy for NTA and Therapy.--Section 1888(e) of the
Social Security Act (42 U.S.C. 1395yy(e)) is amended by adding at the
end the following new paragraph:
``(13) Outliers for nta and therapy.--
``(A) In general.--With respect to outliers because
of unusual variations in the type or amount of
medically necessary care, beginning with October 1,
2010, the Secretary--
``(i) shall provide for an addition or
adjustment to the payment amount otherwise made
under this section with respect to non-therapy
ancillary services in the case of such
outliers; and
``(ii) may provide for such an addition or
adjustment to the payment amount otherwise made
under this section with respect to therapy
services in the case of such outliers.
``(B) Outliers based on aggregate costs.--Outlier
adjustments or additional payments described in
subparagraph (A) shall be based on aggregate costs
during a stay in a skilled nursing facility and not on
the number of days in such stay.
``(C) Budget neutrality.--The Secretary shall
reduce estimated payments that would otherwise be made
under the prospective payment system under this
subsection with respect to a fiscal year by 2 percent.
The total amount of the additional payments or payment
adjustments for outliers made under this paragraph with
respect to a fiscal year may not exceed 2 percent of
the total payments projected or estimated to be made
based on the prospective payment system under this
subsection for the fiscal year.''.
(d) Conforming Amendments.--Section 1888(e)(8) of such Act (42
U.S.C. 1395yy(e)(8)) is amended--
(1) in subparagraph (A), by inserting ``and adjustment
under section 1111(b) of the America's Affordable Health
Choices Act of 2009;
(2) in subparagraph (B), by striking ``and'';
(3) in subparagraph (C), by striking the period and
inserting ``; and''; and
(4) by adding at the end the following new subparagraph:
``(D) the establishment of outliers under paragraph
(13).''.
SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN RESPONSE TO
COVERAGE EXPANSION.
(a) DSH Report.--
(1) In general.--Not later than January 1, 2016, the
Secretary of Health and Human Services shall submit to Congress
a report on Medicare DSH taking into account the impact of the
health care reforms carried out under division A in reducing
the number of uninsured individuals. The report shall include
recommendations relating to the following:
(A) The appropriate amount, targeting, and
distribution of Medicare DSH to compensate for higher
Medicare costs associated with serving low-income
beneficiaries (taking into account variations in the
empirical justification for Medicare DSH attributable
to hospital characteristics, including bed size),
consistent with the original intent of Medicare DSH.
(B) The appropriate amount, targeting, and
distribution of Medicare DSH to hospitals given their
continued uncompensated care costs, to the extent such
costs remain.
(2) Coordination with medicaid dsh report.--The Secretary
shall coordinate the report under this subsection with the
report on Medicaid DSH under section 1704(a).
(b) Payment Adjustments in Response to Coverage Expansion.--
(1) In general.--If there is a significant decrease in the
national rate of uninsurance as a result of this Act (as
determined under paragraph (2)(A)), then the Secretary of
Health and Human Services shall, beginning in fiscal year 2017,
implement the following adjustments to Medicare DSH:
(A) The amount of Medicare DSH shall be adjusted
based on the recommendations of the report under
subsection (a)(1)(A) and shall take into account
variations in the empirical justification for Medicare
DSH attributable to hospital characteristics, including
bed size.
(B) Subject to paragraph (3), increase Medicare DSH
for a hospital by an additional amount that is based on
the amount of uncompensated care provided by the
hospital based on criteria for uncompensated care as
determined by the Secretary, which shall exclude bad
debt.
(2) Significant decrease in national rate of uninsurance as
a result of this act.--For purposes of this subsection--
(A) In general.--There is a ``significant decrease
in the national rate of uninsurance as a result of this
Act'' if there is a decrease in the national rate of
uninsurance (as defined in subparagraph (B)) from 2012
to 2014 that exceeds 8 percentage points.
(B) National rate of uninsurance defined.--The term
``national rate of uninsurance'' means, for a year,
such rate for the under-65 population for the year as
determined and published by the Bureau of the Census in
its Current Population Survey in or about September of
the succeeding year.
(3) Uncompensated care increase.--
(A) Computation of dsh savings.--For each fiscal
year (beginning with fiscal year 2017), the Secretary
shall estimate the aggregate reduction in Medicare DSH
that will result from the adjustment under paragraph
(1)(A).
(B) Structure of payment increase.--The Secretary
shall compute the increase in Medicare DSH under
paragraph (1)(B) for a fiscal year in accordance with a
formula established by the Secretary that provides
that--
(i) the aggregate amount of such increase
for the fiscal year does not exceed 50 percent
of the aggregate reduction in Medicare DSH
estimated by the Secretary for such fiscal
year; and
(ii) hospitals with higher levels of
uncompensated care receive a greater increase.
(c) Medicare DSH.--In this section, the term ``Medicare DSH'' means
adjustments in payments under section 1886(d)(5)(F) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital
services furnished by disproportionate share hospitals.
Subtitle B--Provisions Related to Part B
PART 1--PHYSICIANS' SERVICES
SEC. 1121. SUSTAINABLE GROWTH RATE REFORM.
(a) Transitional Update for 2010.--Section 1848(d) of the Social
Security Act (42 U.S.C. 1395w-4(d)) is amended by adding at the end the
following new paragraph:
``(10) Update for 2010.--The update to the single
conversion factor established in paragraph (1)(C) for 2010
shall be the percentage increase in the MEI (as defined in
section 1842(i)(3)) for that year.''.
(b) Rebasing SGR Using 2009; Limitation on Cumulative Adjustment
Period.--Section 1848(d)(4) of such Act (42 U.S.C. 1395w-4(d)(4)) is
amended--
(1) in subparagraph (B), by striking ``subparagraph (D)''
and inserting ``subparagraphs (D) and (G)''; and
(2) by adding at the end the following new subparagraph:
``(G) Rebasing using 2009 for future update
adjustments.--In determining the update adjustment
factor under subparagraph (B) for 2011 and subsequent
years--
``(i) the allowed expenditures for 2009
shall be equal to the amount of the actual
expenditures for physicians' services during
2009; and
``(ii) the reference in subparagraph
(B)(ii)(I) to `April 1, 1996' shall be treated
as a reference to `January 1, 2009 (or, if
later, the first day of the fifth year before
the year involved)'.''.
(c) Limitation on Physicians' Services Included in Target Growth
Rate Computation to Services Covered Under Physician Fee Schedule.--
Effective for services furnished on or after January 1, 2009, section
1848(f)(4)(A) of such Act is amended striking ``(such as clinical'' and
all that follows through ``in a physician's office'' and inserting
``for which payment under this part is made under the fee schedule
under this section, for services for practitioners described in section
1842(b)(18)(C) on a basis related to such fee schedule, or for services
described in section 1861(p) (other than such services when furnished
in the facility of a provider of services)''.
(d) Establishment of Separate Target Growth Rates for Categories of
Services.--
(1) Establishment of service categories.--Subsection (j) of
section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is
amended by adding at the end the following new paragraph:
``(5) Service categories.--For services furnished on or
after January 1, 2009, each of the following categories of
physicians' services (as defined in paragraph (3)) shall be
treated as a separate `service category':
``(A) Evaluation and management services that are
procedure codes (for services covered under this title)
for--
``(i) services in the category designated
Evaluation and Management in the Health Care
Common Procedure Coding System (established by
the Secretary under subsection (c)(5) as of
December 31, 2009, and as subsequently modified
by the Secretary); and
``(ii) preventive services (as defined in
section 1861(iii)) for which payment is made
under this section.
``(B) All other services not described in
subparagraph (A).
Service categories established under this paragraph shall apply
without regard to the specialty of the physician furnishing the
service.''.
(2) Establishment of separate conversion factors for each
service category.--Subsection (d)(1) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subparagraph (A)--
(i) by designating the sentence beginning
``The conversion factor'' as clause (i) with
the heading ``Application of single conversion
factor.--'' and with appropriate indentation;
(ii) by striking ``The conversion factor''
and inserting ``Subject to clause (ii), the
conversion factor''; and
(iii) by adding at the end the following
new clause:
``(ii) Application of multiple conversion
factors beginning with 2011.--
``(I) In general.--In applying
clause (i) for years beginning with
2011, separate conversion factors shall
be established for each service
category of physicians' services (as
defined in subsection (j)(5)) and any
reference in this section to a
conversion factor for such years shall
be deemed to be a reference to the
conversion factor for each of such
categories.
``(II) Initial conversion
factors.--Such factors for 2011 shall
be based upon the single conversion
factor for the previous year multiplied
by the update established under
paragraph (11) for such category for
2011.
``(III) Updating of conversion
factors.--Such factor for a service
category for a subsequent year shall be
based upon the conversion factor for
such category for the previous year and
adjusted by the update established for
such category under paragraph (11) for
the year involved.''; and
(B) in subparagraph (D), by striking ``other
physicians' services'' and inserting ``for physicians'
services described in the service category described in
subsection (j)(5)(B)''.
(3) Establishing updates for conversion factors for service
categories.--Section 1848(d) of the Social Security Act (42
U.S.C. 1395w-4(d)), as amended by subsection (a), is amended--
(A) in paragraph (4)(C)(iii), by striking ``The
allowed'' and inserting ``Subject to paragraph (11)(B),
the allowed''; and
(B) by adding at the end the following new
paragraph:
``(11) Updates for service categories beginning with
2011.--
``(A) In general.--In applying paragraph (4) for a
year beginning with 2011, the following rules apply:
``(i) Application of separate update
adjustments for each service category.--
Pursuant to paragraph (1)(A)(ii)(I), the update
shall be made to the conversion factor for each
service category (as defined in subsection
(j)(5)) based upon an update adjustment factor
for the respective category and year and the
update adjustment factor shall be computed, for
a year, separately for each service category.
``(ii) Computation of allowed and actual
expenditures based on service categories.--In
computing the prior year adjustment component
and the cumulative adjustment component under
clauses (i) and (ii) of paragraph (4)(B), the
following rules apply:
``(I) Application based on service
categories.--The allowed expenditures
and actual expenditures shall be the
allowed and actual expenditures for the
service category, as determined under
subparagraph (B).
``(II) Application of category
specific target growth rate.--The
growth rate applied under clause
(ii)(II) of such paragraph shall be the
target growth rate for the service
category involved under subsection
(f)(5).
``(B) Determination of allowed expenditures.--In
applying paragraph (4) for a year beginning with 2010,
notwithstanding subparagraph (C)(iii) of such
paragraph, the allowed expenditures for a service
category for a year is an amount computed by the
Secretary as follows:
``(i) For 2010.--For 2010:
``(I) Total 2009 actual
expenditures for all services included
in sgr computation for each service
category.--Compute total actual
expenditures for physicians' services
(as defined in subsection (f)(4)(A))
for 2009 for each service category.
``(II) Increase by growth rate to
obtain 2010 allowed expenditures for
service category.--Compute allowed
expenditures for the service category
for 2010 by increasing the allowed
expenditures for the service category
for 2009 computed under subclause (I)
by the target growth rate for such
service category under subsection (f)
for 2010.
``(ii) For subsequent years.--For a
subsequent year, take the amount of allowed
expenditures for such category for the
preceding year (under clause (i) or this
clause) and increase it by the target growth
rate determined under subsection (f) for such
category and year.''.
(4) Application of separate target growth rates for each
category.--
(A) In general.--Section 1848(f) of the Social
Security Act (42 U.S.C. 1395w-4(f)) is amended by
adding at the end the following new paragraph:
``(5) Application of separate target growth rates for each
service category beginning with 2010.--The target growth rate
for a year beginning with 2010 shall be computed and applied
separately under this subsection for each service category (as
defined in subsection (j)(5)) and shall be computed using the
same method for computing the target growth rate except that
the factor described in paragraph (2)(C) for--
``(A) the service category described in subsection
(j)(5)(A) shall be increased by 0.02; and
``(B) the service category described in subsection
(j)(5)(B) shall be increased by 0.01.''.
(B) Use of target growth rates.--Section 1848 of
such Act is further amended--
(i) in subsection (d)--
(I) in paragraph (1)(E)(ii), by
inserting ``or target'' after
``sustainable''; and
(II) in paragraph (4)(B)(ii)(II),
by inserting ``or target'' after
``sustainable''; and
(ii) in the heading of subsection (f), by
inserting ``and Target Growth Rate'' after
``Sustainable Growth Rate'';
(iii) in subsection (f)(1)--
(I) by striking ``and'' at the end
of subparagraph (A);
(II) in subparagraph (B), by
inserting ``before 2010'' after ``each
succeeding year'' and by striking the
period at the end and inserting ``;
and''; and
(III) by adding at the end the
following new subparagraph:
``(C) November 1 of each succeeding year the target
growth rate for such succeeding year and each of the 2
preceding years.''; and
(iv) in subsection (f)(2), in the matter
before subparagraph (A), by inserting after
``beginning with 2000'' the following: ``and
ending with 2009''.
(e) Application to Accountable Care Organization Pilot Program.--In
applying the target growth rate under subsections (d) and (f) of
section 1848 of the Social Security Act to services furnished by a
practitioner to beneficiaries who are attributable to an accountable
care organization under the pilot program provided under section 1866D
of such Act, the Secretary of Health and Human Services shall develop,
not later than January 1, 2012, for application beginning with 2012, a
method that--
(1) allows each such organization to have its own
expenditure targets and updates for such practitioners, with
respect to beneficiaries who are attributable to that
organization, that are consistent with the methodologies
described in such subsection (f); and
(2) provides that the target growth rate applicable to
other physicians shall not apply to such physicians to the
extent that the physicians' services are furnished through the
accountable care organization.
In applying paragraph (1), the Secretary of Health and Human Services
may apply the difference in the update under such paragraph on a claim-
by-claim or lump sum basis and such a payment shall be taken into
account under the pilot program.
SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.
(a) In General.--Section 1848(c)(2) of the Social Security Act (42
U.S.C. 1395w-4(c)(2)) is amended by adding at the end the following new
subparagraphs:
``(K) Potentially misvalued codes.--
``(i) In general.--The Secretary shall--
``(I) periodically identify
services as being potentially misvalued
using criteria specified in clause
(ii); and
``(II) review and make appropriate
adjustments to the relative values
established under this paragraph for
services identified as being
potentially misvalued under subclause
(I).
``(ii) Identification of potentially
misvalued codes.--For purposes of identifying
potentially misvalued services pursuant to
clause (i)(I), the Secretary shall examine (as
the Secretary determines to be appropriate)
codes (and families of codes as appropriate)
for which there has been the fastest growth;
codes (and families of codes as appropriate)
that have experienced substantial changes in
practice expenses; codes for new technologies
or services within an appropriate period (such
as three years) after the relative values are
initially established for such codes; multiple
codes that are frequently billed in conjunction
with furnishing a single service; codes with
low relative values, particularly those that
are often billed multiple times for a single
treatment; codes which have not been subject to
review since the implementation of the RBRVS
(the so-called `Harvard-valued codes'); and
such other codes determined to be appropriate
by the Secretary.
``(iii) Review and adjustments.--
``(I) The Secretary may use
existing processes to receive
recommendations on the review and
appropriate adjustment of potentially
misvalued services described clause
(i)(II).
``(II) The Secretary may conduct
surveys, other data collection
activities, studies, or other analyses
as the Secretary determines to be
appropriate to facilitate the review
and appropriate adjustment described in
clause (i)(II).
``(III) The Secretary may use
analytic contractors to identify and
analyze services identified under
clause (i)(I), conduct surveys or
collect data, and make recommendations
on the review and appropriate
adjustment of services described in
clause (i)(II).
``(IV) The Secretary may coordinate
the review and appropriate adjustment
described in clause (i)(II) with the
periodic review described in
subparagraph (B).
``(V) As part of the review and
adjustment described in clause (i)(II),
including with respect to codes with
low relative values described in clause
(ii), the Secretary may make
appropriate coding revisions (including
using existing processes for
consideration of coding changes) which
may include consolidation of individual
services into bundled codes for payment
under the fee schedule under subsection
(b).
``(VI) The provisions of
subparagraph (B)(ii)(II) shall apply to
adjustments to relative value units
made pursuant to this subparagraph in
the same manner as such provisions
apply to adjustments under subparagraph
(B)(ii)(II).
``(L) Validating relative value units.--
``(i) In general.--The Secretary shall
establish a process to validate relative value
units under the fee schedule under subsection
(b).
``(ii) Components and elements of work.--
The process described in clause (i) may include
validation of work elements (such as time,
mental effort and professional judgment,
technical skill and physical effort, and stress
due to risk) involved with furnishing a service
and may include validation of the pre, post,
and intra-service components of work.
``(iii) Scope of codes.--The validation of
work relative value units shall include a
sampling of codes for services that is the same
as the codes listed under subparagraph (K)(ii).
``(iv) Methods.--The Secretary may conduct
the validation under this subparagraph using
methods described in subclauses (I) through (V)
of subparagraph (K)(iii) as the Secretary
determines to be appropriate.
``(v) Adjustments.--The Secretary shall
make appropriate adjustments to the work
relative value units under the fee schedule
under subsection (b). The provisions of
subparagraph (B)(ii)(II) shall apply to
adjustments to relative value units made
pursuant to this subparagraph in the same
manner as such provisions apply to adjustments
under subparagraph (B)(ii)(II).''.
(b) Implementation.--
(1) Funding.--For purposes of carrying out the provisions
of subparagraphs (K) and (L) of 1848(c)(2) of the Social
Security Act, as added by subsection (a), in addition to funds
otherwise available, out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services for the Center for Medicare &
Medicaid Services Program Management Account $20,000,000 for
fiscal year 2010 and each subsequent fiscal year. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
(2) Administration.--
(A) Chapter 35 of title 44, United States Code and
the provisions of the Federal Advisory Committee Act (5
U.S.C. App.) shall not apply to this section or the
amendment made by this section.
(B) Notwithstanding any other provision of law, the
Secretary may implement subparagraphs (K) and (L) of
1848(c)(2) of the Social Security Act, as added by
subsection (a), by program instruction or otherwise.
(C) Section 4505(d) of the Balanced Budget Act of
1997 is repealed.
(D) Except for provisions related to
confidentiality of information, the provisions of the
Federal Acquisition Regulation shall not apply to this
section or the amendment made by this section.
(3) Focusing cms resources on potentially overvalued
codes.--Section 1868(a) of the Social Security Act (42 U.S.C.
1395ee(a)) is repealed.
SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.
Section 1833 of the Social Security Act (42 U.S.C. 1395l) is
amended by adding at the end the following new subsection:
``(x) Incentive Payments for Efficient Areas.--
``(1) In general.--In the case of services furnished under
the physician fee schedule under section 1848 on or after
January 1, 2011, and before January 1, 2013, by a supplier that
is paid under such fee schedule in an efficient area (as
identified under paragraph (2)), in addition to the amount of
payment that would otherwise be made for such services under
this part, there also shall be paid (on a monthly or quarterly
basis) an amount equal to 5 percent of the payment amount for
the services under this part.
``(2) Identification of efficient areas.--
``(A) In general.--Based upon available data, the
Secretary shall identify those counties or equivalent
areas in the United States in the lowest fifth
percentile of utilization based on per capita spending
under this part and part A for services provided in the
most recent year for which data are available as of the
date of the enactment of this subsection, as
standardized to eliminate the effect of geographic
adjustments in payment rates.
``(B) Identification of counties where service is
furnished.--For purposes of paying the additional
amount specified in paragraph (1), if the Secretary
uses the 5-digit postal ZIP Code where the service is
furnished, the dominant county of the postal ZIP Code
(as determined by the United States Postal Service, or
otherwise) shall be used to determine whether the
postal ZIP Code is in a county described in
subparagraph (A).
``(C) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
1878, or otherwise, respecting--
``(i) the identification of a county or
other area under subparagraph (A); or
``(ii) the assignment of a postal ZIP Code
to a county or other area under subparagraph
(B).
``(D) Publication of list of counties; posting on
website.--With respect to a year for which a county or
area is identified under this paragraph, the Secretary
shall identify such counties or areas as part of the
proposed and final rule to implement the physician fee
schedule under section 1848 for the applicable year.
The Secretary shall post the list of counties
identified under this paragraph on the Internet website
of the Centers for Medicare & Medicaid Services.''.
SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY REPORTING INITIATIVE
(PQRI).
(a) Feedback.--Section 1848(m)(5) of the Social Security Act (42
U.S.C. 1395w-4(m)(5)) is amended by adding at the end the following new
subparagraph:
``(H) Feedback.--The Secretary shall provide timely
feedback to eligible professionals on the performance
of the eligible professional with respect to
satisfactorily submitting data on quality measures
under this subsection.''.
(b) Appeals.--Such section is further amended--
(1) in subparagraph (E), by striking ``There shall be'' and
inserting ``Subject to subparagraph (I), there shall be''; and
(2) by adding at the end the following new subparagraph:
``(I) Informal appeals process.--Notwithstanding
subparagraph (E), by not later than January 1, 2011,
the Secretary shall establish and have in place an
informal process for eligible professionals to appeal
the determination that an eligible professional did not
satisfactorily submit data on quality measures under
this subsection.''.
(c) Integration of Physician Quality Reporting and EHR Reporting.--
Section 1848(m) of such Act is amended by adding at the end the
following new paragraph:
``(7) Integration of physician quality reporting and ehr
reporting.--Not later than January 1, 2012, the Secretary shall
develop a plan to integrate clinical reporting on quality
measures under this subsection with reporting requirements
under subsection (o) relating to the meaningful use of
electronic health records. Such integration shall consist of
the following:
``(A) The development of measures, the reporting of
which would both demonstrate--
``(i) meaningful use of an electronic
health record for purposes of subsection (o);
and
``(ii) clinical quality of care furnished
to an individual.
``(B) The collection of health data to identify
deficiencies in the quality and coordination of care
for individuals eligible for benefits under this part.
``(C) Such other activities as specified by the
Secretary.''.
(d) Extension of Incentive Payments.--Section 1848(m)(1) of such
Act (42 U.S.C. 1395w-4(m)(1)) is amended--
(1) in subparagraph (A), by striking ``2010'' and inserting
``2012''; and
(2) in subparagraph (B)(ii), by striking ``2009 and 2010''
and inserting ``for each of the years 2009 through 2012''.
SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.
(a) In General.--Section 1848(e) of the Social Security Act (42
U.S.C.1395w-4(e)) is amended by adding at the end the following new
paragraph:
``(6) Transition to use of msas as fee schedule areas in
california.--
``(A) In general.--
``(i) Revision.--Subject to clause (ii) and
notwithstanding the previous provisions of this
subsection, for services furnished on or after
January 1, 2011, the Secretary shall revise the
fee schedule areas used for payment under this
section applicable to the State of California
using the Metropolitan Statistical Area (MSA)
iterative Geographic Adjustment Factor
methodology as follows:
``(I) The Secretary shall configure
the physician fee schedule areas using
the Core-Based Statistical Areas-
Metropolitan Statistical Areas (each in
this paragraph referred to as an
`MSA'), as defined by the Director of
the Office of Management and Budget, as
the basis for the fee schedule areas.
The Secretary shall employ an iterative
process to transition fee schedule
areas. First, the Secretary shall list
all MSAs within the State by Geographic
Adjustment Factor described in
paragraph (2) (in this paragraph
referred to as a `GAF') in descending
order. In the first iteration, the
Secretary shall compare the GAF of the
highest cost MSA in the State to the
weighted-average GAF of the group of
remaining MSAs in the State. If the
ratio of the GAF of the highest cost
MSA to the weighted-average GAF of the
rest of State is 1.05 or greater then
the highest cost MSA becomes a separate
fee schedule area.
``(II) In the next iteration, the
Secretary shall compare the MSA of the
second-highest GAF to the weighted-
average GAF of the group of remaining
MSAs. If the ratio of the second-
highest MSA's GAF to the weighted-
average of the remaining lower cost
MSAs is 1.05 or greater, the second-
highest MSA becomes a separate fee
schedule area. The iterative process
continues until the ratio of the GAF of
the highest-cost remaining MSA to the
weighted-average of the remaining
lower-cost MSAs is less than 1.05, and
the remaining group of lower cost MSAs
form a single fee schedule area, If two
MSAs have identical GAFs, they shall be
combined in the iterative comparison.
``(ii) Transition.--For services furnished
on or after January 1, 2011, and before January
1, 2016, in the State of California, after
calculating the work, practice expense, and
malpractice geographic indices described in
clauses (i), (ii), and (iii) of paragraph
(1)(A) that would otherwise apply through
application of this paragraph, the Secretary
shall increase any such index to the county-
based fee schedule area value on December 31,
2009, if such index would otherwise be less
than the value on January 1, 2010.
``(B) Subsequent revisions.--
``(i) Periodic review and adjustments in
fee schedule areas.--Subsequent to the process
outlined in paragraph (1)(C), not less often
than every three years, the Secretary shall
review and update the California Rest-of-State
fee schedule area using MSAs as defined by the
Director of the Office of Management and Budget
and the iterative methodology described in
subparagraph (A)(i).
``(ii) Link with geographic index data
revision.--The revision described in clause (i)
shall be made effective concurrently with the
application of the periodic review of the
adjustment factors required under paragraph
(1)(C) for California for 2012 and subsequent
periods. Upon request, the Secretary shall make
available to the public any county-level or MSA
derived data used to calculate the geographic
practice cost index.
``(C) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2010, for
the State of California, any reference in this section
to a fee schedule area shall be deemed a reference to
an MSA in the State.''.
(b) Conforming Amendment to Definition of Fee Schedule Area.--
Section 1848(j)(2) of the Social Security Act (42 U.S.C. 1395w(j)(2))
is amended by striking ``The term'' and inserting ``Except as provided
in subsection (e)(6)(C), the term''.
PART 2--MARKET BASKET UPDATES
SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET
UPDATES THAT DO NOT ALREADY INCORPORATE SUCH
IMPROVEMENTS.
(a) Outpatient Hospitals.--
(1) In general.--The first sentence of section
1833(t)(3)(C)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(3)(C)(iv)) is amended--
(A) by inserting ``(which is subject to the
productivity adjustment described in subclause (II) of
such section)'' after ``1886(b)(3)(B)(iii)''; and
(B) by inserting ``(but not below 0)'' after
``reduced''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply to increase factors for services furnished in years
beginning with 2010.
(b) Ambulance Services.--Section 1834(l)(3)(B) of such Act (42
U.S.C. 1395m(l)(3)(B))) is amended by inserting before the period at
the end the following: ``and, in the case of years beginning with 2010,
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II)''.
(c) Ambulatory Surgical Center Services.--Section 1833(i)(2)(D) of
such Act (42 U.S.C. 1395l(i)(2)(D)) is amended--
(1) by redesignating clause (v) as clause (vi); and
(2) by inserting after clause (iv) the following new
clause:
``(v) In implementing the system described in clause (i), for
services furnished during 2010 or any subsequent year, to the extent
that an annual percentage change factor applies, such factor shall be
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II).''.
(d) Laboratory Services.--Section 1833(h)(2)(A) of such Act (42
U.S.C. 1395l(h)(2)(A)) is amended--
(1) in clause (i), by striking ``for each of years 2009
through 2013'' and inserting ``for 2009''; and
(2) clause (ii)--
(A) by striking ``and'' at the end of subclause
(III);
(B) by striking the period at the end of subclause
(IV) and inserting ``; and''; and
(C) by adding at the end the following new
subclause:
``(V) the annual adjustment in the fee schedules determined
under clause (i) for years beginning with 2010 shall be subject
to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II).''.
(e) Certain Durable Medical Equipment.--Section 1834(a)(14) of such
Act (42 U.S.C. 1395m(a)(14)) is amended--
(1) in subparagraph (K), by inserting before the semicolon
at the end the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)'';
(2) in subparagraph (L)(i), by inserting after ``June
2013,'' the following: ``subject to the productivity adjustment
described in section 1886(b)(3)(B)(iii)(II),'';
(3) in subparagraph (L)(ii), by inserting after ``June
2013'' the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''; and
(4) in subparagraph (M), by inserting before the period at
the end the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''.
PART 3--OTHER PROVISIONS
SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.
(a) In General.--Section 1834(a)(7)(A)(iii) of the Social Security
Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is amended--
(1) in the heading, by inserting ``certain complex
rehabilitative'' after ``option for''; and
(2) by striking ``power-driven wheelchair'' and inserting
``complex rehabilitative power-driven wheelchair recognized by
the Secretary as classified within group 3 or higher''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect on January 1, 2011, and shall apply to power-driven
wheelchairs furnished on or after such date. Such amendments shall not
apply to contracts entered into under section 1847 of the Social
Security Act (42 U.S.C. 1395w-3) pursuant to a bid submitted under such
section before October 1, 2010, under subsection (a)(1)(B)(i)(I) of
such section.
SEC. 1142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY.
Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C.
1395l(t)(16)(C)), as amended by section 142 of the Medicare
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275), is amended by striking, the first place it appears, ``January 1,
2010'' and inserting ``January 1, 2012''.
SEC. 1143. HOME INFUSION THERAPY REPORT TO CONGRESS.
Not later than 12 months after the date of enactment of this Act,
the Medicare Payment Advisory Commission shall submit to Congress a
report on the following:
(1) The scope of coverage for home infusion therapy in the
fee-for-service Medicare program under title XVIII of the
Social Security Act, Medicare Advantage under part C of such
title, the veteran's health care program under chapter 17 of
title 38, United States Code, and among private payers,
including an analysis of the scope of services provided by home
infusion therapy providers to their patients in such programs.
(2) The benefits and costs of providing such coverage under
the Medicare program, including a calculation of the potential
savings achieved through avoided or shortened hospital and
nursing home stays as a result of Medicare coverage of home
infusion therapy.
(3) An assessment of sources of data on the costs of home
infusion therapy that might be used to construct payment
mechanisms in the Medicare program.
(4) Recommendations, if any, on the structure of a payment
system under the Medicare program for home infusion therapy,
including an analysis of the payment methodologies used under
Medicare Advantage plans and private health plans for the
provision of home infusion therapy and their applicability to
the Medicare program.
SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO SUBMIT COST
DATA AND OTHER DATA.
(a) Cost Reporting.--
(1) In general.--Section 1833(i) of the Social Security Act
(42 U.S.C. 1395l(i)) is amended by adding at the end the
following new paragraph:
``(8) The Secretary shall require, as a condition of the agreement
described in section 1832(a)(2)(F)(i), the submission of such cost
report as the Secretary may specify, taking into account the
requirements for such reports under section 1815 in the case of a
hospital.''.
(2) Development of cost report.--Not later than 3 years
after the date of the enactment of this Act, the Secretary of
Health and Human Services shall develop a cost report form for
use under section 1833(i)(8) of the Social Security Act, as
added by paragraph (1).
(3) Audit requirement.--The Secretary shall provide for
periodic auditing of cost reports submitted under section
1833(i)(8) of the Social Security Act, as added by paragraph
(1).
(4) Effective date.--The amendment made by paragraph (1)
shall apply to agreements applicable to cost reporting periods
beginning 18 months after the date the Secretary develops the
cost report form under paragraph (2).
(b) Additional Data on Quality.--
(1) In general.--Section 1833(i)(7) of such Act (42 U.S.C.
1395l(i)(7)) is amended--
(A) in subparagraph (B), by inserting ``subject to
subparagraph (C),'' after ``may otherwise provide,'';
and
(B) by adding at the end the following new
subparagraph:
``(C) Under subparagraph (B) the Secretary shall require the
reporting of such additional data relating to quality of services
furnished in an ambulatory surgical facility, including data on health
care associated infections, as the Secretary may specify.''.
(2) Effective date.--The amendment made by paragraph (1)
shall to reporting for years beginning with 2012.
SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS.
Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is
amended by adding at the end the following new paragraph:
``(18) Authorization of adjustment for cancer hospitals.--
``(A) Study.--The Secretary shall conduct a study
to determine if, under the system under this
subsection, costs incurred by hospitals described in
section 1886(d)(1)(B)(v) with respect to ambulatory
payment classification groups exceed those costs
incurred by other hospitals furnishing services under
this subsection (as determined appropriate by the
Secretary).
``(B) Authorization of adjustment.--Insofar as the
Secretary determines under subparagraph (A) that costs
incurred by hospitals described in section
1886(d)(1)(B)(v) exceed those costs incurred by other
hospitals furnishing services under this subsection,
the Secretary shall provide for an appropriate
adjustment under paragraph (2)(E) to reflect those
higher costs effective for services furnished on or
after January 1, 2011.''.
SEC. 1146. MEDICARE IMPROVEMENT FUND.
Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C.
1395iii(b)(1)(A)) is amended to read as follows:
``(A) the period beginning with fiscal year 2011
and ending with fiscal year 2019, $8,000,000,000;
and''.
SEC. 1147. PAYMENT FOR IMAGING SERVICES.
(a) Adjustment in Practice Expense to Reflect Higher Presumed
Utilization.--Section 1848 of the Social Security Act (42 U.S.C. 1395w)
is amended--
(1) in subsection (b)(4)--
(A) in subparagraph (B), by striking ``subparagraph
(A)'' and inserting ``this paragraph''; and
(B) by adding at the end the following new
subparagraph:
``(C) Adjustment in practice expense to reflect
higher presumed utilization.--In computing the number
of practice expense relative value units under
subsection (c)(2)(C)(ii) with respect to advanced
diagnostic imaging services (as defined in section
1834(e)(1)(B)), the Secretary shall adjust such number
of units so it reflects a 75 percent (rather than 50
percent) presumed rate of utilization of imaging
equipment.''; and
(2) in subsection (c)(2)(B)(v)(II), by inserting ``and
other provisions'' after ``OPD payment cap''.
(b) Adjustment in Technical Component ``discount'' on Single-
session Imaging to Consecutive Body Parts.--Section 1848(b)(4) of such
Act is further amended by adding at the end the following new
subparagraph:
``(D) Adjustment in technical component discount on
single-session imaging involving consecutive body
parts.--The Secretary shall increase the reduction in
expenditures attributable to the multiple procedure
payment reduction applicable to the technical component
for imaging under the final rule published by the
Secretary in the Federal Register on November 21, 2005
(part 405 of title 42, Code of Federal Regulations)
from 25 percent to 50 percent.''.
(c) Effective Date.--Except as otherwise provided, this section,
and the amendments made by this section, shall apply to services
furnished on or after January 1, 2011.
SEC. 1148. DURABLE MEDICAL EQUIPMENT PROGRAM IMPROVEMENTS.
(a) Waiver of Surety Bond Requirement.--Section 1834(a)(16) of the
Social Security Act (42 U.S.C. 1395m(a)(16)) is amended by adding at
the end the following: ``The requirement for a surety bond described in
subparagraph (B) shall not apply in the case of a pharmacy (i) that has
been enrolled under section 1866(j) as a supplier of durable medical
equipment, prosthetics, orthotics, and supplies and has been issued
(which may include renewal of) a provider number (as described in the
first sentence of this paragraph) for at least 5 years, and (ii) for
which a final adverse action (as defined in section 424.57(a) of title
42, Code of Federal Regulations) has never been imposed.''.
(b) Ensuring Supply of Oxygen Equipment.--
(1) In general.--Section 1834(a)(5)(F) of the Social
Security Act (42 U.S.C. 1395m(a)(5)(F)) is amended--
(A) in clause (ii), by striking ``After the'' and
inserting ``Except as provided in clause (iii), after
the''; and
(B) by adding at the end the following new clause:
``(iii) Continuation of supply.--In the
case of a supplier furnishing such equipment to
an individual under this subsection as of the
27th month of the 36 months described in clause
(i), the supplier furnishing such equipment as
of such month shall continue to furnish such
equipment to such individual (either directly
or though arrangements with other suppliers of
such equipment) during any subsequent period of
medical need for the remainder of the
reasonable useful lifetime of the equipment, as
determined by the Secretary, regardless of the
location of the individual, unless another
supplier has accepted responsibility for
continuing to furnish such equipment during the
remainder of such period.''.
(2) Effective date.--The amendments made by paragraph (1)
shall take effect as of the date of the enactment of this Act
and shall apply to the furnishing of equipment to individuals
for whom the 27th month of a continuous period of use of oxygen
equipment described in section 1834(a)(5)(F) of the Social
Security Act occurs on or after July 1, 2010.
(c) Treatment of Current Accreditation Applications.--Section
1834(a)(20)(F) of such Act (42 U.S.C. 1395m(a)(20)(F)) is amended--
(1) in clause (i)--
(A) by striking ``clause (ii)'' and inserting
``clauses (ii) and (iii)''; and
(B) by striking ``and'' at the end;
(2) by striking the period at the end of clause (ii)(II)
and by inserting ``; and''; and
(3) by adding at the end the following:
``(iii) the requirement for accreditation
described in clause (i) shall not apply for
purposes of supplying diabetic testing
supplies, canes, and crutches in the case of a
pharmacy that is enrolled under section 1866(j)
as a supplier of durable medical equipment,
prosthetics, orthotics, and supplies.
Any supplier that has submitted an application for
accreditation before August 1, 2009, shall be deemed as
meeting applicable standards and accreditation
requirement under this subparagraph until such time as
the independent accreditation organization takes action
on the supplier's application.''.
(d) Restoring 36-Month Oxygen Rental Period in Case of Supplier
Bankruptcy for Certain Individuals.--Section 1834(a)(5)(F) of such Act
(42 U.S.C. 1395m(a)(5)(F)) is amended by adding at the end the
following new clause:
``(iii) Exception for bankruptcy.--If a
supplier of oxygen to an individual is declared
bankrupt and its assets are liquidated and at
the time of such declaration and liquidation
more than 24 months of rental payments have
been made, the individual may begin under this
subparagraph a new 36-month rental period with
another supplier of oxygen.''.
SEC. 1149. MEDPAC STUDY AND REPORT ON BONE MASS MEASUREMENT.
(a) In General.--The Medicare Payment Advisory Commission shall
conduct a study regarding bone mass measurement, including computed
tomography, duel-energy x-ray absorptriometry, and vertebral fracture
assessment. The study shall focus on the following:
(1) An assessment of the adequacy of Medicare payment rates
for such services, taking into account costs of acquiring the
necessary equipment, professional work time, and practice
expense costs.
(2) The impact of Medicare payment changes since 2006 on
beneficiary access to bone mass measurement benefits in general
and in rural and minority communities specifically.
(3) A review of the clinically appropriate and recommended
use among Medicare beneficiaries and how usage rates among such
beneficiaries compares to such recommendations.
(4) In conjunction with the findings under (3),
recommendations, if necessary, regarding methods for reaching
appropriate use of bone mass measurement studies among Medicare
beneficiaries.
(b) Report.--The Commission shall submit a report to the Congress,
not later than 9 months after the date of the enactment of this Act,
containing a description of the results of the study conducted under
subsection (a) and the conclusions and recommendations, if any,
regarding each of the issues described in paragraphs (1), (2), (3), and
(4) of such subsection.
Subtitle C--Provisions Related to Medicare Parts A and B
SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS.
(a) Hospitals.--
(1) In general.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 1103(a), is amended
by adding at the end the following new subsection:
``(p) Adjustment to Hospital Payments for Excess Readmissions.--
``(1) In general.--With respect to payment for discharges
from an applicable hospital (as defined in paragraph (5)(C))
occurring during a fiscal year beginning on or after October 1,
2011, in order to account for excess readmissions in the
hospital, the Secretary shall reduce the payments that would
otherwise be made to such hospital under subsection (d) (or
section 1814(b)(3), as the case may be) for such a discharge by
an amount equal to the product of--
``(A) the base operating DRG payment amount (as
defined in paragraph (2)) for the discharge; and
``(B) the adjustment factor (described in paragraph
(3)(A)) for the hospital for the fiscal year.
``(2) Base operating drg payment amount.--
``(A) In general.--Except as provided in
subparagraph (B), for purposes of this subsection, the
term `base operating DRG payment amount' means, with
respect to a hospital for a fiscal year, the payment
amount that would otherwise be made under subsection
(d) for a discharge if this subsection did not apply,
reduced by any portion of such amount that is
attributable to payments under subparagraphs (B) and
(F) of paragraph (5).
``(B) Adjustments.--For purposes of subparagraph
(A), in the case of a hospital that is paid under
section 1814(b)(3), the term `base operating DRG
payment amount' means the payment amount under such
section.
``(3) Adjustment factor.--
``(A) In general.--For purposes of paragraph (1),
the adjustment factor under this paragraph for an
applicable hospital for a fiscal year is equal to the
greater of--
``(i) the ratio described in subparagraph
(B) for the hospital for the applicable period
(as defined in paragraph (5)(D)) for such
fiscal year; or
``(ii) the floor adjustment factor
specified in subparagraph (C).
``(B) Ratio.--The ratio described in this
subparagraph for a hospital for an applicable period is
equal to 1 minus the ratio of--
``(i) the aggregate payments for excess
readmissions (as defined in paragraph (4)(A))
with respect to an applicable hospital for the
applicable period; and
``(ii) the aggregate payments for all
discharges (as defined in paragraph (4)(B))
with respect to such applicable hospital for
such applicable period.
``(C) Floor adjustment factor.--For purposes of
subparagraph (A), the floor adjustment factor specified
in this subparagraph for--
``(i) fiscal year 2012 is 0.99;
``(ii) fiscal year 2013 is 0.98;
``(iii) fiscal year 2014 is 0.97; or
``(iv) a subsequent fiscal year is 0.95.
``(4) Aggregate payments, excess readmission ratio
defined.--For purposes of this subsection:
``(A) Aggregate payments for excess readmissions.--
The term `aggregate payments for excess readmissions'
means, for a hospital for a fiscal year, the sum, for
applicable conditions (as defined in paragraph (5)(A)),
of the product, for each applicable condition, of--
``(i) the base operating DRG payment amount
for such hospital for such fiscal year for such
condition;
``(ii) the number of admissions for such
condition for such hospital for such fiscal
year; and
``(iii) the excess readmissions ratio (as
defined in subparagraph (C)) for such hospital
for the applicable period for such fiscal year
minus 1.
``(B) Aggregate payments for all discharges.--The
term `aggregate payments for all discharges' means, for
a hospital for a fiscal year, the sum of the base
operating DRG payment amounts for all discharges for
all conditions from such hospital for such fiscal year.
``(C) Excess readmission ratio.--
``(i) In general.--Subject to clauses (ii)
and (iii), the term `excess readmissions ratio'
means, with respect to an applicable condition
for a hospital for an applicable period, the
ratio (but not less than 1.0) of--
``(I) the risk adjusted
readmissions based on actual
readmissions, as determined consistent
with a readmission measure methodology
that has been endorsed under paragraph
(5)(A)(ii)(I), for an applicable
hospital for such condition with
respect to the applicable period; to
``(II) the risk adjusted expected
readmissions (as determined consistent
with such a methodology) for such
hospital for such condition with
respect to such applicable period.
``(ii) Exclusion of certain readmissions.--
For purposes of clause (i), with respect to a
hospital, excess readmissions shall not include
readmissions for an applicable condition for
which there are fewer than a minimum number (as
determined by the Secretary) of discharges for
such applicable condition for the applicable
period and such hospital.
``(iii) Adjustment.--In order to promote a
reduction over time in the overall rate of
readmissions for applicable conditions, the
Secretary may provide, beginning with
discharges for fiscal year 2014, for the
determination of the excess readmissions ratio
under subparagraph (C) to be based on a ranking
of hospitals by readmission ratios (from lower
to higher readmission ratios) normalized to a
benchmark that is lower than the 50th
percentile.
``(5) Definitions.--For purposes of this subsection:
``(A) Applicable condition.--The term `applicable
condition' means, subject to subparagraph (B), a
condition or procedure selected by the Secretary among
conditions and procedures for which--
``(i) readmissions (as defined in
subparagraph (E)) that represent conditions or
procedures that are high volume or high
expenditures under this title (or other
criteria specified by the Secretary); and
``(ii) measures of such readmissions--
``(I) have been endorsed by the
entity with a contract under section
1890(a); and
``(II) such endorsed measures have
appropriate exclusions for readmissions
that are unrelated to the prior
discharge (such as a planned
readmission or transfer to another
applicable hospital).
``(B) Expansion of applicable conditions.--
Beginning with fiscal year 2013, the Secretary shall
expand the applicable conditions beyond the 3
conditions for which measures have been endorsed as
described in subparagraph (A)(ii)(I) as of the date of
the enactment of this subsection to the additional 4
conditions that have been so identified by the Medicare
Payment Advisory Commission in its report to Congress
in June 2007 and to other conditions and procedures
which may include an all-condition measure of
readmissions, as determined appropriate by the
Secretary. In expanding such applicable conditions, the
Secretary shall seek the endorsement described in
subparagraph (A)(ii)(I) but may apply such measures
without such an endorsement.
``(C) Applicable hospital.--The term `applicable
hospital' means a subsection (d) hospital or a hospital
that is paid under section 1814(b)(3).
``(D) Applicable period.--The term `applicable
period' means, with respect to a fiscal year, such
period as the Secretary shall specify for purposes of
determining excess readmissions.
``(E) Readmission.--The term `readmission' means,
in the case of an individual who is discharged from an
applicable hospital, the admission of the individual to
the same or another applicable hospital within a time
period specified by the Secretary from the date of such
discharge. Insofar as the discharge relates to an
applicable condition for which there is an endorsed
measure described in subparagraph (A)(ii)(I), such time
period (such as 30 days) shall be consistent with the
time period specified for such measure.
``(6) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the determination of base operating DRG
payment amounts;
``(B) the methodology for determining the
adjustment factor under paragraph (3), including excess
readmissions ratio under paragraph (4)(C), aggregate
payments for excess readmissions under paragraph
(4)(A), and aggregate payments for all discharges under
paragraph (4)(B), and applicable periods and applicable
conditions under paragraph (5);
``(C) the measures of readmissions as described in
paragraph (5)(A)(ii); and
``(D) the determination of a targeted hospital
under paragraph (8)(B)(i), the increase in payment
under paragraph (8)(B)(ii), the aggregate cap under
paragraph (8)(C)(i), the hospital-specific limit under
paragraph (8)(C)(ii), and the form of payment made by
the Secretary under paragraph (8)(D).
``(7) Monitoring inappropriate changes in admissions
practices.--The Secretary shall monitor the activities of
applicable hospitals to determine if such hospitals have taken
steps to avoid patients at risk in order to reduce the
likelihood of increasing readmissions for applicable
conditions. If the Secretary determines that such a hospital
has taken such a step, after notice to the hospital and
opportunity for the hospital to undertake action to alleviate
such steps, the Secretary may impose an appropriate sanction.
``(8) Assistance to certain hospitals.--
``(A) In general.--For purposes of providing funds
to applicable hospitals to take steps described in
subparagraph (E) to address factors that may impact
readmissions of individuals who are discharged from
such a hospital, for fiscal years beginning on or after
October 1, 2011, the Secretary shall make a payment
adjustment for a hospital described in subparagraph
(B), with respect to each such fiscal year, by a
percent estimated by the Secretary to be consistent
with subparagraph (C).
``(B) Targeted hospitals.--Subparagraph (A) shall
apply to an applicable hospital that--
``(i) received (or, in the case of an
1814(b)(3) hospital, otherwise would have been
eligible to receive) $10,000,000 or more in
disproportionate share payments using the
latest available data as estimated by the
Secretary; and
``(ii) provides assurances satisfactory to
the Secretary that the increase in payment
under this paragraph shall be used for purposes
described in subparagraph (E).
``(C) Caps.--
``(i) Aggregate cap.--The aggregate amount
of the payment adjustment under this paragraph
for a fiscal year shall not exceed 5 percent of
the estimated difference in the spending that
would occur for such fiscal year with and
without application of the adjustment factor
described in paragraph (3) and applied pursuant
to paragraph (1).
``(ii) Hospital-specific limit.--The
aggregate amount of the payment adjustment for
a hospital under this paragraph shall not
exceed the estimated difference in spending
that would occur for such fiscal year for such
hospital with and without application of the
adjustment factor described in paragraph (3)
and applied pursuant to paragraph (1).
``(D) Form of payment.--The Secretary may make the
additional payments under this paragraph on a lump sum
basis, a periodic basis, a claim by claim basis, or
otherwise.
``(E) Use of additional payment.--Funding under
this paragraph shall be used by targeted hospitals for
transitional care activities designed to address the
patient noncompliance issues that result in higher than
normal readmission rates, such as one or more of the
following:
``(i) Providing care coordination services
to assist in transitions from the targeted
hospital to other settings.
``(ii) Hiring translators and interpreters.
``(iii) Increasing services offered by
discharge planners.
``(iv) Ensuring that individuals receive a
summary of care and medication orders upon
discharge.
``(v) Developing a quality improvement plan
to assess and remedy preventable readmission
rates.
``(vi) Assigning discharged individuals to
a medical home.
``(vii) Doing other activities as
determined appropriate by the Secretary.
``(F) GAO report on use of funds.--Not later than 3
years after the date on which funds are first made
available under this paragraph, the Comptroller General
of the United States shall submit to Congress a report
on the use of such funds.
``(G) Disproportionate share hospital payment.--In
this paragraph, the term `disproportionate share
hospital payment' means an additional payment amount
under subsection (d)(5)(F).''.
(b) Application to Critical Access Hospitals.--Section 1814(l) of
the Social Security Act (42 U.S.C. 1395f(l)) is amended--
(1) in paragraph (5)--
(A) by striking ``and'' at the end of subparagraph
(C);
(B) by striking the period at the end of
subparagraph (D) and inserting ``; and'';
(C) by inserting at the end the following new
subparagraph:
``(E) The methodology for determining the adjustment factor
under paragraph (5), including the determination of aggregate
payments for actual and expected readmissions, applicable
periods, applicable conditions and measures of readmissions.'';
and
(D) by redesignating such paragraph as paragraph
(6); and
(2) by inserting after paragraph (4) the following new
paragraph:
``(5) The adjustment factor described in section 1886(p)(3) shall
apply to payments with respect to a critical access hospital with
respect to a cost reporting period beginning in fiscal year 2012 and
each subsequent fiscal year (after application of paragraph (4) of this
subsection) in a manner similar to the manner in which such section
applies with respect to a fiscal year to an applicable hospital as
described in section 1886(p)(2).''.
(c) Post Acute Care Providers.--
(1) Interim policy.--
(A) In general.--With respect to a readmission to
an applicable hospital or a critical access hospital
(as described in section 1814(l) of the Social Security
Act) from a post acute care provider (as defined in
paragraph (3)) and such a readmission is not governed
by section 412.531 of title 42, Code of Federal
Regulations, if the claim submitted by such a post-
acute care provider under title XVIII of the Social
Security Act indicates that the individual was
readmitted to a hospital from such a post-acute care
provider or admitted from home and under the care of a
home health agency within 30 days of an initial
discharge from an applicable hospital or critical
access hospital, the payment under such title on such
claim shall be the applicable percent specified in
subparagraph (B) of the payment that would otherwise be
made under the respective payment system under such
title for such post-acute care provider if this
subsection did not apply.
(B) Applicable percent defined.--For purposes of
subparagraph (A), the applicable percent is--
(i) for fiscal or rate year 2012 is 0.996;
(ii) for fiscal or rate year 2013 is 0.993;
and
(iii) for fiscal or rate year 2014 is 0.99.
(C) Effective date.--Subparagraph (1) shall apply
to discharges or services furnished (as the case may be
with respect to the applicable post acute care
provider) on or after the first day of the fiscal year
or rate year, beginning on or after October 1, 2011,
with respect to the applicable post acute care
provider.
(2) Development and application of performance measures.--
(A) In general.--The Secretary of Health and Human
Services shall develop appropriate measures of
readmission rates for post acute care providers. The
Secretary shall seek endorsement of such measures by
the entity with a contract under section 1890(a) of the
Social Security Act but may adopt and apply such
measures under this paragraph without such an
endorsement. The Secretary shall expand such measures
in a manner similar to the manner in which applicable
conditions are expanded under paragraph (5)(B) of
section 1886(p) of the Social Security Act, as added by
subsection (a).
(B) Implementation.--The Secretary shall apply, on
or after October 1, 2014, with respect to post acute
care providers, policies similar to the policies
applied with respect to applicable hospitals and
critical access hospitals under the amendments made by
subsection (a). The provisions of paragraph (1) shall
apply with respect to any period on or after October 1,
2014, and before such application date described in the
previous sentence in the same manner as such provisions
apply with respect to fiscal or rate year 2014.
(C) Monitoring and penalties.--The provisions of
paragraph (7) of such section 1886(p) shall apply to
providers under this paragraph in the same manner as
they apply to hospitals under such section.
(3) Definitions.--For purposes of this subsection:
(A) Post acute care provider.--The term ``post
acute care provider'' means--
(i) a skilled nursing facility (as defined
in section 1819(a) of the Social Security Act);
(ii) an inpatient rehabilitation facility
(described in section 1886(h)(1)(A) of such
Act);
(iii) a home health agency (as defined in
section 1861(o) of such Act); and
(iv) a long term care hospital (as defined
in section 1861(ccc) of such Act).
(B) Other terms.--The terms ``applicable
condition'', ``applicable hospital'', and
``readmission'' have the meanings given such terms in
section 1886(p)(5) of the Social Security Act, as added
by subsection (a)(1).
(d) Physicians.--
(1) Study.--The Secretary of Health and Human Services
shall conduct a study to determine how the readmissions policy
described in the previous subsections could be applied to
physicians.
(2) Considerations.--In conducting the study, the Secretary
shall consider approaches such as--
(A) creating a new code (or codes) and payment
amount (or amounts) under the fee schedule in section
1848 of the Social Security Act (in a budget neutral
manner) for services furnished by an appropriate
physician who sees an individual within the first week
after discharge from a hospital or critical access
hospital;
(B) developing measures of rates of readmission for
individuals treated by physicians;
(C) applying a payment reduction for physicians who
treat the patient during the initial admission that
results in a readmission; and
(D) methods for attributing payments or payment
reductions to the appropriate physician or physicians.
(3) Report.--The Secretary shall issue a public report on
such study not later than the date that is one year after the
date of the enactment of this Act.
(e) Funding.--For purposes of carrying out the provisions of this
section, in addition to funds otherwise available, out of any funds in
the Treasury not otherwise appropriated, there are appropriated to the
Secretary of Health and Human Services for the Center for Medicare &
Medicaid Services Program Management Account $25,000,000 for each
fiscal year beginning with 2010. Amounts appropriated under this
subsection for a fiscal year shall be available until expended.
SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING
PILOT PROGRAM.
(a) Plan.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a detailed plan to reform payment for post acute care
(PAC) services under the Medicare program under title XVIII of
the Social Security Act (in this section referred to as the
``Medicare program)''. The goals of such payment reform are
to--
(A) improve the coordination, quality, and
efficiency of such services; and
(B) improve outcomes for individuals such as
reducing the need for readmission to hospitals from
providers of such services.
(2) Bundling post acute services.--The plan described in
paragraph (1) shall include detailed specifications for a
bundled payment for post acute services (in this section
referred to as the ``post acute care bundle''), and may include
other approaches determined appropriate by the Secretary.
(3) Post acute services.--For purposes of this section, the
term ``post acute services'' means services for which payment
may be made under the Medicare program that are furnished by
skilled nursing facilities, inpatient rehabilitation
facilities, long term care hospitals, hospital based outpatient
rehabilitation facilities and home health agencies to an
individual after discharge of such individual from a hospital,
and such other services determined appropriate by the
Secretary.
(b) Details.--The plan described in subsection (a)(1) shall include
consideration of the following issues:
(1) The nature of payments under a post acute care bundle,
including the type of provider or entity to whom payment should
be made, the scope of activities and services included in the
bundle, whether payment for physicians' services should be
included in the bundle, and the period covered by the bundle.
(2) Whether the payment should be consolidated with the
payment under the inpatient prospective system under section
1886 of the Social Security Act (in this section referred to as
MS-DRGs) or a separate payment should be established for such
bundle, and if a separate payment is established, whether it
should be made only upon use of post acute care services or for
every discharge.
(3) Whether the bundle should be applied across all
categories of providers of inpatient services (including
critical access hospitals) and post acute care services or
whether it should be limited to certain categories of
providers, services, or discharges, such as high volume or high
cost MS-DRGs.
(4) The extent to which payment rates could be established
to achieve offsets for efficiencies that could be expected to
be achieved with a bundle payment, whether such rates should be
established on a national basis or for different geographic
areas, should vary according to discharge, case mix, outliers,
and geographic differences in wages or other appropriate
adjustments, and how to update such rates.
(5) The nature of protections needed for individuals under
a system of bundled payments to ensure that individuals receive
quality care, are furnished the level and amount of services
needed as determined by an appropriate assessment instrument,
are offered choice of provider, and the extent to which
transitional care services would improve quality of care for
individuals and the functioning of a bundled post-acute system.
(6) The nature of relationships that may be required
between hospitals and providers of post acute care services to
facilitate bundled payments, including the application of
gainsharing, anti-referral, anti-kickback, and anti-trust laws.
(7) Quality measures that would be appropriate for
reporting by hospitals and post acute providers (such as
measures that assess changes in functional status and quality
measures appropriate for each type of post acute services
provider including how the reporting of such quality measures
could be coordinated with other reporting of such quality
measures by such providers otherwise required).
(8) How cost-sharing for a post acute care bundle should be
treated relative to current rules for cost-sharing for
inpatient hospital, home health, skilled nursing facility, and
other services.
(9) How other programmatic issues should be treated in a
post acute care bundle, including rules specific to various
types of post-acute providers such as the post-acute transfer
policy, three-day hospital stay to qualify for services
furnished by skilled nursing facilities, and the coordination
of payments and care under the Medicare program and the
Medicaid program.
(10) Such other issues as the Secretary deems appropriate.
(c) Consultations and Analysis.--
(1) Consultation with stakeholders.--In developing the plan
under subsection (a)(1), the Secretary shall consult with
relevant stakeholders and shall consider experience with such
research studies and demonstrations that the Secretary
determines appropriate.
(2) Analysis and data collection.--In developing such plan,
the Secretary shall--
(A) analyze the issues described in subsection (b)
and other issues that the Secretary determines
appropriate;
(B) analyze the impacts (including geographic
impacts) of post acute service reform approaches,
including bundling of such services on individuals,
hospitals, post acute care providers, and physicians;
(C) use existing data (such as data submitted on
claims) and collect such data as the Secretary
determines are appropriate to develop such plan
required in this section; and
(D) if patient functional status measures are
appropriate for the analysis, to the extent practical,
build upon the CARE tool being developed pursuant to
section 5008 of the Deficit Reduction Act of 2005.
(d) Administration.--
(1) Funding.--For purposes of carrying out the provisions
of this section, in addition to funds otherwise available, out
of any funds in the Treasury not otherwise appropriated, there
are appropriated to the Secretary for the Center for Medicare &
Medicaid Services Program Management Account $15,000,000 for
each of the fiscal years 2010 through 2012. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
(2) Expedited data collection.--Chapter 35 of title 44,
United States Code shall not apply to this section.
(e) Public Reports.--
(1) Interim reports.--The Secretary shall issue interim
public reports on a periodic basis on the plan described in
subsection (a)(1), the issues described in subsection (b), and
impact analyses as the Secretary determines appropriate.
(2) Final report.--Not later than the date that is 3 years
after the date of the enactment of this Act, the Secretary
shall issue a final public report on such plan, including
analysis of issues described in subsection (b) and impact
analyses.
(f) Conversion of Acute Care Episode Demonstration to Pilot Program
and Expansion To Include Post Acute Services.--
(1) In general.--Part E of title XVIII of the Social
Security Act is amended by inserting after section 1866C the
following new section:
``SEC. 1866D. CONVERSION OF ACUTE CARE EPISODE DEMONSTRATION TO PILOT
PROGRAM AND EXPANSION TO INCLUDE POST ACUTE SERVICES.
``(a) In General.--By not later than January 1, 2011, the Secretary
shall, for the purpose of promoting the use of bundled payments to
promote efficient and high quality delivery of care--
``(1) convert the acute care episode demonstration program
conducted under section 1866C to a pilot program; and
``(2) subject to subsection (c), expand such program as so
converted to include post acute services and such other
services the Secretary determines to be appropriate, which may
include transitional services.
``(b) Scope.--The pilot program under subsection (a) may include
additional geographic areas and additional conditions which account for
significant program spending, as defined by the Secretary. Nothing in
this subsection shall be construed as limiting the number of hospital
and physician groups or the number of hospital and post-acute provider
groups that may participate in the pilot program.
``(c) Limitation.--The Secretary shall only expand the pilot
program under subsection (a)(2) if the Secretary finds that--
``(1) the demonstration program under section 1866C and
pilot program under this section maintain or increase the
quality of care received by individuals enrolled under this
title; and
``(2) such demonstration program and pilot program reduce
program expenditures and, based on the certification under
subsection (d), that the expansion of such pilot program would
result in estimated spending that would be less than what
spending would otherwise be in the absence of this section.
``(d) Certification.--For purposes of subsection (c), the Chief
Actuary of the Centers for Medicare & Medicaid Services shall certify
whether expansion of the pilot program under this section would result
in estimated spending that would be less than what spending would
otherwise be in the absence of this section.
``(e) Voluntary Participation.--Nothing in this paragraph shall be
construed as requiring the participation of an entity in the pilot
program under this section.''.
(2) Conforming amendment.--Section 1866C(b) of the Social
Security Act (42 U.S.C. 1395cc-3(b)) is amended by striking
``The Secretary'' and inserting ``Subject to section 1866D, the
Secretary''.
SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.
Section 1895(b)(3)(B)(ii) of the Social Security Act (42 U.S.C.
1395fff(b)(3)(B)(ii)) is amended--
(1) in subclause (IV), by striking ``and'';
(2) by redesignating subclause (V) as subclause (VII); and
(3) by inserting after subclause (IV) the following new
subclauses:
``(V) 2007, 2008, and 2009, subject
to clause (v), the home health market
basket percentage increase;
``(VI) 2010, subject to clause (v),
0 percent; and''.
SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.
(a) Acceleration of Adjustment for Case Mix Changes.--Section
1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B))
is amended--
(1) in clause (iv), by striking ``Insofar as'' and
inserting ``Subject to clause (vi), insofar as''; and
(2) by adding at the end the following new clause:
``(vi) Special rule for case mix changes
for 2011.--
``(I) In general.--With respect to
the case mix adjustments established in
section 484.220(a) of title 42, Code of
Federal Regulations, the Secretary
shall apply, in 2010, the adjustment
established in paragraph (3) of such
section for 2011, in addition to
applying the adjustment established in
paragraph (2) for 2010.
``(II) Construction.--Nothing in
this clause shall be construed as
limiting the amount of adjustment for
case mix for 2010 or 2011 if more
recent data indicate an appropriate
adjustment that is greater than the
amount established in the section
described in subclause (I).''.
(b) Rebasing Home Health Prospective Payment Amount.--Section
1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A))
is amended--
(1) in clause (i)--
(A) in subclause (III), by inserting ``and before
2011'' after ``after the period described in subclause
(II)''; and
(B) by inserting after subclause (III) the
following new subclauses:
``(IV) Subject to clause (iii)(I),
for 2011, such amount (or amounts)
shall be adjusted by a uniform
percentage determined to be appropriate
by the Secretary based on analysis of
factors such as changes in the average
number and types of visits in an
episode, the change in intensity of
visits in an episode, growth in cost
per episode, and other factors that the
Secretary considers to be relevant.
``(V) Subject to clause (iii)(II),
for a year after 2011, such a amount
(or amounts) shall be equal to the
amount (or amounts) determined under
this clause for the previous year,
updated under subparagraph (B).''; and
(2) by adding at the end the following new clause:
``(iii) Special rule in case of inability
to effect timely rebasing.--
``(I) Application of proxy amount
for 2011.--If the Secretary is not able
to compute the amount (or amounts)
under clause (i)(IV) so as to permit,
on a timely basis, the application of
such clause for 2011, the Secretary
shall substitute for such amount (or
amounts) 95 percent of the amount (or
amounts) that would otherwise be
specified under clause (i)(III) if it
applied for 2011.
``(II) Adjustment for subsequent
years based on data.--If the Secretary
applies subclause (I), the Secretary
before July 1, 2011, shall compare the
amount (or amounts) applied under such
subclause with the amount (or amounts)
that should have been applied under
clause (i)(IV). The Secretary shall
decrease or increase the prospective
payment amount (or amounts) under
clause (i)(V) for 2012 (or, at the
Secretary's discretion, over a period
of several years beginning with 2012)
by the amount (if any) by which the
amount (or amounts) applied under
subclause (I) is greater or less,
respectively, than the amount (or
amounts) that should have been applied
under clause (i)(IV).''.
SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET
UPDATE FOR HOME HEALTH SERVICES.
(a) In General.--Section 1895(b)(3)(B) of the Social Security Act
(42 U.S.C. 1395fff(b)(3)(B)) is amended--
(1) in clause (iii), by inserting ``(including being
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II))'' after ``in the same manner''; and
(2) in clause (v)(I), by inserting ``(but not below 0)''
after ``reduced''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to home health market basket percentage increases for years
beginning with 2010.
SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE PROHIBITION ON
CERTAIN PHYSICIAN REFERRALS MADE TO HOSPITALS.
(a) In General.--Section 1877 of the Social Security Act (42 U.S.C.
1395nn) is amended--
(1) in subsection (d)(2)--
(A) in subparagraph (A), by striking ``and'' at the
end;
(B) in subparagraph (B), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(C) in the case where the entity is a hospital,
the hospital meets the requirements of paragraph
(3)(D).'';
(2) in subsection (d)(3)--
(A) in subparagraph (B), by striking ``and'' at the
end;
(B) in subparagraph (C), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(D) the hospital meets the requirements described
in subsection (i)(1).'';
(3) by amending subsection (f) to read as follows:
``(f) Reporting and Disclosure Requirements.--
``(1) In general.--Each entity providing covered items or
services for which payment may be made under this title shall
provide the Secretary with the information concerning the
entity's ownership, investment, and compensation arrangements,
including--
``(A) the covered items and services provided by
the entity, and
``(B) the names and unique physician identification
numbers of all physicians with an ownership or
investment interest (as described in subsection
(a)(2)(A)), or with a compensation arrangement (as
described in subsection (a)(2)(B)), in the entity, or
whose immediate relatives have such an ownership or
investment interest or who have such a compensation
relationship with the entity.
Such information shall be provided in such form, manner, and at
such times as the Secretary shall specify. The requirement of
this subsection shall not apply to designated health services
provided outside the United States or to entities which the
Secretary determines provide services for which payment may be
made under this title very infrequently.
``(2) Requirements for hospitals with physician ownership
or investment.--In the case of a hospital that meets the
requirements described in subsection (i)(1), the hospital
shall--
``(A) submit to the Secretary an initial report,
and periodic updates at a frequency determined by the
Secretary, containing a detailed description of the
identity of each physician owner and physician investor
and any other owners or investors of the hospital;
``(B) require that any referring physician owner or
investor discloses to the individual being referred, by
a time that permits the individual to make a meaningful
decision regarding the receipt of services, as
determined by the Secretary, the ownership or
investment interest, as applicable, of such referring
physician in the hospital; and
``(C) disclose the fact that the hospital is
partially or wholly owned by one or more physicians or
has one or more physician investors--
``(i) on any public website for the
hospital; and
``(ii) in any public advertising for the
hospital.
The information to be reported or disclosed under this
paragraph shall be provided in such form, manner, and at such
times as the Secretary shall specify. The requirements of this
paragraph shall not apply to designated health services
furnished outside the United States or to entities which the
Secretary determines provide services for which payment may be
made under this title very infrequently.
``(3) Publication of information.--The Secretary shall
publish, and periodically update, the information submitted by
hospitals under paragraph (2)(A) on the public Internet website
of the Centers for Medicare & Medicaid Services.'';
(4) by amending subsection (g)(5) to read as follows:
``(5) Failure to report or disclose information.--
``(A) Reporting.--Any person who is required, but
fails, to meet a reporting requirement of paragraphs
(1) and (2)(A) of subsection (f) is subject to a civil
money penalty of not more than $10,000 for each day for
which reporting is required to have been made.
``(B) Disclosure.--Any physician who is required,
but fails, to meet a disclosure requirement of
subsection (f)(2)(B) or a hospital that is required,
but fails, to meet a disclosure requirement of
subsection (f)(2)(C) is subject to a civil money
penalty of not more than $10,000 for each case in which
disclosure is required to have been made.
``(C) Application.--The provisions of section 1128A
(other than the first sentence of subsection (a) and
other than subsection (b)) shall apply to a civil money
penalty under subparagraphs (A) and (B) in the same
manner as such provisions apply to a penalty or
proceeding under section 1128A(a).''; and
(5) by adding at the end the following new subsection:
``(i) Requirements To Qualify for Rural Provider and Hospital
Ownership Exceptions to Self-referral Prohibition.--
``(1) Requirements described.--For purposes of subsection
(d)(3)(D), the requirements described in this paragraph are as
follows:
``(A) Provider agreement.--The hospital had--
``(i) physician ownership or investment on
January 1, 2009; and
``(ii) a provider agreement under section
1866 in effect on such date.
``(B) Prohibition on physician ownership or
investment.--The percentage of the total value of the
ownership or investment interests held in the hospital,
or in an entity whose assets include the hospital, by
physician owners or investors in the aggregate does not
exceed such percentage as of the date of enactment of
this subsection.
``(C) Prohibition on expansion of facility
capacity.--Except as provided in paragraph (2), the
number of operating rooms, procedure rooms, or beds of
the hospital at any time on or after the date of the
enactment of this subsection are no greater than the
number of operating rooms, procedure rooms, or beds,
respectively, as of such date.
``(D) Ensuring bona fide ownership and
investment.--
``(i) Any ownership or investment interests
that the hospital offers to a physician are not
offered on more favorable terms than the terms
offered to a person who is not in a position to
refer patients or otherwise generate business
for the hospital.
``(ii) The hospital (or any investors in
the hospital) does not directly or indirectly
provide loans or financing for any physician
owner or investor in the hospital.
``(iii) The hospital (or any investors in
the hospital) does not directly or indirectly
guarantee a loan, make a payment toward a loan,
or otherwise subsidize a loan, for any
physician owner or investor or group of
physician owners or investors that is related
to acquiring any ownership or investment
interest in the hospital.
``(iv) Ownership or investment returns are
distributed to each owner or investor in the
hospital in an amount that is directly
proportional to the ownership or investment
interest of such owner or investor in the
hospital.
``(v) The investment interest of the owner
or investor is directly proportional to the
owner's or investor's capital contributions
made at the time the ownership or investment
interest is obtained.
``(vi) Physician owners and investors do
not receive, directly or indirectly, any
guaranteed receipt of or right to purchase
other business interests related to the
hospital, including the purchase or lease of
any property under the control of other owners
or investors in the hospital or located near
the premises of the hospital.
``(vii) The hospital does not offer a
physician owner or investor the opportunity to
purchase or lease any property under the
control of the hospital or any other owner or
investor in the hospital on more favorable
terms than the terms offered to a person that
is not a physician owner or investor.
``(viii) The hospital does not condition
any physician ownership or investment interests
either directly or indirectly on the physician
owner or investor making or influencing
referrals to the hospital or otherwise
generating business for the hospital.
``(E) Patient safety.--In the case of a hospital
that does not offer emergency services, the hospital
has the capacity to--
``(i) provide assessment and initial
treatment for medical emergencies; and
``(ii) if the hospital lacks additional
capabilities required to treat the emergency
involved, refer and transfer the patient with
the medical emergency to a hospital with the
required capability.
``(F) Limitation on application to certain
converted facilities.--The hospital was not converted
from an ambulatory surgical center to a hospital on or
after the date of enactment of this subsection.
``(2) Exception to prohibition on expansion of facility
capacity.--
``(A) Process.--
``(i) Establishment.--The Secretary shall
establish and implement a process under which a
hospital may apply for an exception from the
requirement under paragraph (1)(C).
``(ii) Opportunity for community input.--
The process under clause (i) shall provide
persons and entities in the community in which
the hospital applying for an exception is
located with the opportunity to provide input
with respect to the application.
``(iii) Timing for implementation.--The
Secretary shall implement the process under
clause (i) on the date that is one month after
the promulgation of regulations described in
clause (iv).
``(iv) Regulations.--Not later than the
first day of the month beginning 18 months
after the date of the enactment of this
subsection, the Secretary shall promulgate
regulations to carry out the process under
clause (i). The Secretary may issue such
regulations as interim final regulations.
``(B) Frequency.--The process described in
subparagraph (A) shall permit a hospital to apply for
an exception up to once every 2 years.
``(C) Permitted increase.--
``(i) In general.--Subject to clause (ii)
and subparagraph (D), a hospital granted an
exception under the process described in
subparagraph (A) may increase the number of
operating rooms, procedure rooms, or beds of
the hospital above the baseline number of
operating rooms, procedure rooms, or beds,
respectively, of the hospital (or, if the
hospital has been granted a previous exception
under this paragraph, above the number of
operating rooms, procedure rooms, or beds,
respectively, of the hospital after the
application of the most recent increase under
such an exception).
``(ii) 100 percent increase limitation.--
The Secretary shall not permit an increase in
the number of operating rooms, procedure rooms,
or beds of a hospital under clause (i) to the
extent such increase would result in the number
of operating rooms, procedure rooms, or beds of
the hospital exceeding 200 percent of the
baseline number of operating rooms, procedure
rooms, or beds of the hospital.
``(iii) Baseline number of operating rooms,
procedure rooms, or beds.--In this paragraph,
the term `baseline number of operating rooms,
procedure rooms, or beds' means the number of
operating rooms, procedure rooms, or beds of a
hospital as of the date of enactment of this
subsection.
``(D) Increase limited to facilities on the main
campus of the hospital.--Any increase in the number of
operating rooms, procedure rooms, or beds of a hospital
pursuant to this paragraph may only occur in facilities
on the main campus of the hospital.
``(E) Conditions for approval of an increase in
facility capacity.--The Secretary may grant an
exception under the process described in subparagraph
(A) only to a hospital--
``(i) that is located in a county in which
the percentage increase in the population
during the most recent 5-year period for which
data are available is estimated to be at least
150 percent of the percentage increase in the
population growth of the State in which the
hospital is located during that period, as
estimated by Bureau of the Census and available
to the Secretary;
``(ii) whose annual percent of total
inpatient admissions that represent inpatient
admissions under the program under title XIX is
estimated to be equal to or greater than the
average percent with respect to such admissions
for all hospitals located in the county in
which the hospital is located;
``(iii) that does not discriminate against
beneficiaries of Federal health care programs
and does not permit physicians practicing at
the hospital to discriminate against such
beneficiaries;
``(iv) that is located in a State in which
the average bed capacity in the State is
estimated to be less than the national average
bed capacity;
``(v) that has an average bed occupancy
rate that is estimated to be greater than the
average bed occupancy rate in the State in
which the hospital is located; and
``(vi) that meets other conditions as
determined by the Secretary.
``(F) Procedure rooms.--In this subsection, the
term `procedure rooms' includes rooms in which
catheterizations, angiographies, angiograms, and
endoscopies are furnished, but such term shall not
include emergency rooms or departments (except for
rooms in which catheterizations, angiographies,
angiograms, and endoscopies are furnished).
``(G) Publication of final decisions.--Not later
than 120 days after receiving a complete application
under this paragraph, the Secretary shall publish on
the public Internet website of the Centers for Medicare
& Medicaid Services the final decision with respect to
such application.
``(H) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the exception process
under this paragraph, including the establishment of
such process, and any determination made under such
process.
``(3) Physician owner or investor defined.--For purposes of
this subsection and subsection (f)(2), the term `physician
owner or investor' means a physician (or an immediate family
member of such physician) with a direct or an indirect
ownership or investment interest in the hospital.
``(4) Patient safety requirement.--In the case of a
hospital to which the requirements of paragraph (1) apply,
insofar as the hospital admits a patient and does not have any
physician available on the premises 24 hours per day, 7 days
per week, before admitting the patient--
``(A) the hospital shall disclose such fact to the
patient; and
``(B) following such disclosure, the hospital shall
receive from the patient a signed acknowledgment that
the patient understands such fact.
``(5) Clarification.--Nothing in this subsection shall be
construed as preventing the Secretary from terminating a
hospital's provider agreement if the hospital is not in
compliance with regulations pursuant to section 1866.''.
(b) Verifying Compliance.--The Secretary of Health and Human
Services shall establish policies and procedures to verify compliance
with the requirements described in subsections (i)(1) and (i)(4) of
section 1877 of the Social Security Act, as added by subsection (a)(5).
The Secretary may use unannounced site reviews of hospitals and audits
to verify compliance with such requirements.
(c) Implementation.--
(1) Funding.--For purposes of carrying out the amendments
made by subsection (a) and the provisions of subsection (b), in
addition to funds otherwise available, out of any funds in the
Treasury not otherwise appropriated there are appropriated to
the Secretary of Health and Human Services for the Centers for
Medicare & Medicaid Services Program Management Account
$5,000,000 for each fiscal year beginning with fiscal year
2010. Amounts appropriated under this paragraph for a fiscal
year shall be available until expended.
(2) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to the amendments made by subsection (a)
and the provisions of subsection (b).
SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC ADJUSTMENT FACTORS
UNDER MEDICARE.
(a) In General.--The Secretary of Health and Human Services shall
enter into a contract with the Institute of Medicine of the National
Academy of Science to conduct a comprehensive empirical study, and
provide recommendations as appropriate, on the accuracy of the
geographic adjustment factors established under sections 1848(e) and
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-4(e),
11395ww(d)(3)).
(b) Matters Included.--Such study shall include an evaluation and
assessment of the following with respect to such adjustment factors:
(1) Empirical validity of the adjustment factors.
(2) Methodology used to determine the adjustment factors.
(3) Measures used for the adjustment factors, taking into
account--
(A) timeliness of data and frequency of revisions
to such data;
(B) sources of data and the degree to which such
data are representative of costs; and
(C) operational costs of providers who participate
in Medicare.
(c) Evaluation.--Such study shall, within the context of the United
States health care marketplace, evaluate and consider the following:
(1) The effect of the adjustment factors on the level and
distribution of the health care workforce and resources,
including--
(A) recruitment and retention that takes into
account workforce mobility between urban and rural
areas;
(B) ability of hospitals and other facilities to
maintain an adequate and skilled workforce; and
(C) patient access to providers and needed medical
technologies.
(2) The effect of the adjustment factors on population
health and quality of care.
(3) The effect of the adjustment factors on the ability of
providers to furnish efficient, high value care.
(d) Report.--The contract under subsection (a) shall provide for
the Institute of Medicine to submit, not later than one year after the
date of the enactment of this Act, to the Secretary and the Congress a
report containing results and recommendations of the study conducted
under this section.
(e) Funding.--There are authorized to be appropriated to carry out
this section such sums as may be necessary.
SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO ADDRESS GEOGRAPHIC
INEQUITIES.
(a) In General.--The Secretary of Health and Human Services, taking
into account the recommendations made in the report under section
1157(d), shall include in the proposed rules published to implement
changes to payment systems for physicians and hospitals under sections
1848(e) and 1886(d)(3)(E), respectively, of the Social Security Act,
proposals to revise geographic adjustment factors for such payment
systems for services furnished under the Medicare program. Such
proposed rules shall be published in the rulemaking period immediately
following submission of the report under section 1157(d).
(b) Payment Adjustments.--
(1) Funding for improvements.--In making any changes to the
geographic adjustment factors in accordance with subsection
(a), the Secretary shall use funds made available for such
purposes under subsection (c).
(2) Ensuring fairness.--In carrying out this subsection,
the Secretary shall not change payment rates to be less than
they would have been had this section not been enacted.
(c) Funding.--Amounts in the Medicare Improvement Fund under
section 1898 of the Social Security Act (42 U.S.C. 1395iii), as amended
by section 1146, shall be available to the Secretary to make changes to
the geographic adjustments factors established under sections 1848(e)
and 1886(d)(3)(E) of the Social Security Act. For such purpose, such
funds shall be available for expenditure for services furnished before
January 1, 2014, and shall not exceed the total amounts available under
such Fund for such period. No more than one-half of such amounts shall
be available for expenditure for services furnished in any one payment
year.
Subtitle D--Medicare Advantage Reforms
PART 1--PAYMENT AND ADMINISTRATION
SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR-SERVICE COSTS.
Section 1853 of the Social Security Act (42 U.S.C. 1395w-23) is
amended--
(1) in subsection (j)(1)(A)--
(A) by striking ``beginning with 2007'' and
inserting ``for 2007, 2008, 2009, and 2010''; and
(B) by inserting after ``(k)(1)'' the following:
``, or, beginning with 2011, \1/12\ of the blended
benchmark amount determined under subsection (n)(1)'';
and
(2) by adding at the end the following new subsection:
``(n) Determination of Blended Benchmark Amount.--
``(1) In general.--For purposes of subsection (j), subject
to paragraphs (3) and (4), the term `blended benchmark amount'
means for an area--
``(A) for 2011 the sum of--
``(i) \2/3\ of the applicable amount (as
defined in subsection (k)) for the area and
year; and
``(ii) \1/3\ of the amount specified in
paragraph (2) for the area and year;
``(B) for 2012 the sum of--
``(i) \1/3\ of the applicable amount for
the area and year; and
``(ii) \2/3\ of the amount specified in
paragraph (2) for the area and year; and
``(C) for a subsequent year the amount specified in
paragraph (2) for the area and year.
``(2) Specified amount.--The amount specified in this
paragraph for an area and year is the amount specified in
subsection (c)(1)(D)(i) for the area and year adjusted (in a
manner specified by the Secretary) to take into account the
phase-out in the indirect costs of medical education from
capitation rates described in subsection (k)(4).
``(3) Fee-for-service payment floor.--In no case shall the
blended benchmark amount for an area and year be less than the
amount specified in paragraph (2).
``(4) Exception for pace plans.--This subsection shall not
apply to payments to a PACE program under section 1894.''.
SEC. 1162. QUALITY BONUS PAYMENTS.
(a) In General.--Section 1853 of the Social Security Act (42 U.S.C.
1395w-23), as amended by section 1161, is amended--
(1) in subsection (j), by inserting ``subject to subsection
(o),'' after ``For purposes of this part''; and
(2) by adding at the end the following new subsection:
``(o) Quality Based Payment Adjustment.--
``(1) High quality plan adjustment.--For years beginning
with 2011, in the case of a Medicare Advantage plan that is
identified (under paragraph (3)(E)(ii)) as a high quality MA
plan with respect to the year, the blended benchmark amount
under subsection (n)(1) shall be increased--
``(A) for 2011, by 1.0 percent;
``(B) for 2012, by 2.0 percent; and
``(C) for a subsequent year, by 3.0 percent.
``(2) Improved quality plan adjustment.--For years
beginning with 2011, in the case of a Medicare Advantage plan
that is identified (under paragraph (3)(E)(iii)) as an improved
quality MA plan with respect to the year, blended benchmark
amount under subsection (n)(1) shall be increased--
``(A) for 2011, by 0.33 percent;
``(B) for 2012, by 0.66 percent; and
``(C) for a subsequent year, by 1.0 percent.
``(3) Determinations of quality.--
``(A) Quality performance.--The Secretary shall
provide for the computation of a quality performance
score for each Medicare Advantage plan to be applied
for each year beginning with 2010.
``(B) Computation of score.--
``(i) For years before 2014.--For years
before 2014, the quality performance score for
a Medicare Advantage plan shall be computed
based on a blend (as designated by the
Secretary) of the plan's performance on--
``(I) HEDIS effectiveness of care
quality measures;
``(II) CAHPS quality measures; and
``(III) such other measures of
clinical quality as the Secretary may
specify.
Such measures shall be risk-adjusted as the
Secretary deems appropriate.
``(ii) Establishment of outcome-based
measures.--By not later than for 2013 the
Secretary shall implement reporting
requirements for quality under this section on
measures selected under clause (iii) that
reflect the outcomes of care experienced by
individuals enrolled in Medicare Advantage
plans (in addition to measures described in
clause (i)). Such measures may include--
``(I) measures of rates of
admission and readmission to a
hospital;
``(II) measures of prevention
quality, such as those established by
the Agency for Healthcare Research and
Quality (that include hospital
admission rates for specified
conditions);
``(III) measures of patient
mortality and morbidity following
surgery;
``(IV) measures of health
functioning (such as limitations on
activities of daily living) and
survival for patients with chronic
diseases;
``(V) measures of patient safety;
and
``(VI) other measure of outcomes
and patient quality of life as
determined by the Secretary.
Such measures shall be risk-adjusted as the
Secretary deems appropriate. In determining the
quality measures to be used under this clause,
the Secretary shall take into consideration the
recommendations of the Medicare Payment
Advisory Commission in its report to Congress
under section 168 of the Medicare Improvements
for Patients and Providers Act of 2008 (Public
Law 110-275) and shall provide preference to
measures collected on and comparable to
measures used in measuring quality under parts
A and B.
``(iii) Rules for selection of measures.--
The Secretary shall select measures for
purposes of clause (ii) consistent with the
following:
``(I) The Secretary shall provide
preference to clinical quality measures
that have been endorsed by the entity
with a contract with the Secretary
under section 1890(a).
``(II) Prior to any measure being
selected under this clause, the
Secretary shall publish in the Federal
Register such measure and provide for a
period of public comment on such
measure.
``(iv) Transitional use of blend.--For
payments for 2014 and 2015, the Secretary may
compute the quality performance score for a
Medicare Advantage plan based on a blend of the
measures specified in clause (i) and the
measures described in clause (ii) and selected
under clause (iii).
``(v) Use of quality outcomes measures.--
For payments beginning with 2016, the
preponderance of measures used under this
paragraph shall be quality outcomes measures
described in clause (ii) and selected under
clause (iii).
``(C) Data used in computing score.--Such score for
application for--
``(i) payments in 2011 shall be based on
quality performance data for plans for 2009;
and
``(ii) payments in 2012 and a subsequent
year shall be based on quality performance data
for plans for the second preceding year.
``(D) Reporting of data.--Each Medicare Advantage
organization shall provide for the reporting to the
Secretary of quality performance data described in
subparagraph (B) (in order to determine a quality
performance score under this paragraph) in such time
and manner as the Secretary shall specify.
``(E) Ranking of plans.--
``(i) Initial ranking.--Based on the
quality performance score described in
subparagraph (B) achieved with respect to a
year, the Secretary shall rank plan
performance--
``(I) from highest to lowest based
on absolute scores; and
``(II) from highest to lowest based
on percentage improvement in the score
for the plan from the previous year.
A plan which does not report quality
performance data under subparagraph (D) shall
be counted, for purposes of such ranking, as
having the lowest plan performance and lowest
percentage improvement.
``(ii) Identification of high quality plans
in top quintile based on projected
enrollment.--The Secretary shall, based on the
scores for each plan under clause (i)(I) and
the Secretary's projected enrollment for each
plan and subject to clause (iv), identify those
Medicare Advantage plans with the highest score
that, based upon projected enrollment, are
projected to include in the aggregate 20
percent of the total projected enrollment for
the year. For purposes of this subsection, a
plan so identified shall be referred to in this
subsection as a `high quality MA plan'.
``(iii) Identification of improved quality
plans in top quintile based on projected
enrollment.--The Secretary shall, based on the
percentage improvement score for each plan
under clause (i)(II) and the Secretary's
projected enrollment for each plan and subject
to clause (iv), identify those Medicare
Advantage plans with the greatest percentage
improvement score that, based upon projected
enrollment, are projected to include in the
aggregate 20 percent of the total projected
enrollment for the year. For purposes of this
subsection, a plan so identified that is not a
high quality plan for the year shall be
referred to in this subsection as an `improved
quality MA plan'.
``(iv) Authority to disqualify certain
plans.--In applying clauses (ii) and (iii), the
Secretary may determine not to identify a
Medicare Advantage plan if the Secretary has
identified deficiencies in the plan's
compliance with rules for such plans under this
part.
``(F) Notification.--The Secretary, in the annual
announcement required under subsection (b)(1)(B) in
2011 and each succeeding year, shall notify the
Medicare Advantage organization that is offering a high
quality plan or an improved quality plan of such
identification for the year and the quality performance
payment adjustment for such plan for the year. The
Secretary shall provide for publication on the website
for the Medicare program of the information described
in the previous sentence.''.
SEC. 1163. EXTENSION OF SECRETARIAL CODING INTENSITY ADJUSTMENT
AUTHORITY.
Section 1853(a)(1)(C)(ii) of the Social Security Act (42 U.S.C.
1395w-23(a)(1)(C)(ii)) is amended--
(1) in the matter before subclause (I), by striking
``through 2010'' and inserting ``and each subsequent year'';
and
(2) in subclause (II)--
(A) by inserting ``periodically'' before ``conduct
an analysis'';
(B) by inserting ``on a timely basis'' after ``are
incorporated''; and
(C) by striking ``only for 2008, 2009, and 2010''
and inserting ``for 2008 and subsequent years''.
SEC. 1164. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS.
(a) 2 Week Processing Period for Annual Enrollment Period (AEP).--
Paragraph (3)(B) of section 1851(e) of the Social Security Act (42
U.S.C. 1395w-21(e)) is amended--
(1) by striking ``and'' at the end of clause (iii);
(2) in clause (iv)--
(A) by striking ``and succeeding years'' and
inserting ``, 2008, 2009, and 2010''; and
(B) by striking the period at the end and inserting
``; and''; and
(3) by adding at the end the following new clause:
``(v) with respect to 2011 and succeeding
years, the period beginning on November 1 and
ending on December 15 of the year before such
year.''.
(b) Elimination of 3-month Additional Open Enrollment Period
(OEP).--Effective for plan years beginning with 2011, paragraph (2) of
such section is amended by striking subparagraph (C).
SEC. 1165. EXTENSION OF REASONABLE COST CONTRACTS.
Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)) is amended--
(1) in clause (ii), by striking ``January 1, 2010'' and
inserting ``January 1, 2012''; and
(2) in clause (iii), by striking ``the service area for the
year'' and inserting ``the portion of the plan's service area
for the year that is within the service area of a reasonable
cost reimbursement contract''.
SEC. 1166. LIMITATION OF WAIVER AUTHORITY FOR EMPLOYER GROUP PLANS.
(a) In General.--The first sentence of paragraph (2) of section
1857(i) of the Social Security Act (42 U.S.C. 1395w-27(i)) is amended
by inserting before the period at the end the following: ``, but only
if 90 percent of the Medicare Advantage eligible individuals enrolled
under such plan reside in a county in which the MA organization offers
an MA local plan''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply for plan years beginning on or after January 1, 2011, and shall
not apply to plans which were in effect as of December 31, 2010.
SEC. 1167. IMPROVING RISK ADJUSTMENT FOR PAYMENTS.
(a) Report to Congress.--Not later than 1 year after the date of
the enactment of this Act, the Secretary of Health and Human Services
shall submit to Congress a report that evaluates the adequacy of the
risk adjustment system under section 1853(a)(1)(C) of the Social
Security Act (42 U.S.C. 1395-23(a)(1)(C)) in predicting costs for
beneficiaries with chronic or co-morbid conditions, beneficiaries
dually-eligible for Medicare and Medicaid, and non-Medicaid eligible
low-income beneficiaries; and the need and feasibility of including
further gradations of diseases or conditions and multiple years of
beneficiary data.
(b) Improvements to Risk Adjustment.--Not later than January 1,
2012, the Secretary shall implement necessary improvements to the risk
adjustment system under section 1853(a)(1)(C) of the Social Security
Act (42 U.S.C. 1395-23(a)(1)(C)), taking into account the evaluation
under subsection (a).
SEC. 1168. ELIMINATION OF MA REGIONAL PLAN STABILIZATION FUND.
(a) In General.--Section 1858 of the Social Security Act (42 U.S.C.
1395w-27a) is amended by striking subsection (e).
(b) 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.
PART 2--BENEFICIARY PROTECTIONS AND ANTI-FRAUD
SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL HEALTH SERVICES.
(a) In General.--Section 1852(a)(1) of the Social Security Act (42
U.S.C. 1395w-22(a)(1)) is amended--
(1) in subparagraph (A), by inserting before the period at
the end the following: ``with cost-sharing that is no greater
(and may be less) than the cost-sharing that would otherwise be
imposed under such program option'';
(2) in subparagraph (B)(i), by striking ``or an actuarially
equivalent level of cost-sharing as determined in this part'';
and
(3) by amending clause (ii) of subparagraph (B) to read as
follows:
``(ii) Permitting use of flat copayment or
per diem rate.--Nothing in clause (i) shall be
construed as prohibiting a Medicare Advantage
plan from using a flat copayment or per diem
rate, in lieu of the cost-sharing that would be
imposed under part A or B, so long as the
amount of the cost-sharing imposed does not
exceed the amount of the cost-sharing that
would be imposed under the respective part if
the individual were not enrolled in a plan
under this part.''.
(b) Limitation for Dual Eligibles and Qualified Medicare
Beneficiaries.--Section 1852(a) of such Act is amended by adding at the
end the following new paragraph:
``(7) Limitation on cost-sharing for dual eligibles and
qualified medicare beneficiaries.--In the case of a individual
who is a full-benefit dual eligible individual (as defined in
section 1935(c)(6)) or a qualified medicare beneficiary (as
defined in section 1905(p)(1)) who is enrolled in a Medicare
Advantage plan, the plan may not impose cost-sharing that
exceeds the amount of cost-sharing that would be permitted with
respect to the individual under this title and title XIX if the
individual were not enrolled with such plan.''.
(c) Effective Dates.--
(1) The amendments made by subsection (a) shall apply to
plan years beginning on or after January 1, 2011.
(2) The amendments made by subsection (b) shall apply to
plan years beginning on or after January 1, 2011.
SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLLEES IN PLANS WITH
ENROLLMENT SUSPENSION.
Section 1851(e)(4) of the Social Security Act (42 U.S.C.
1395w(e)(4)) is amended--
(1) in subparagraph (C), by striking at the end ``or'';
(2) in subparagraph (D)--
(A) by inserting ``, taking into account the health
or well-being of the individual'' before the period;
and
(B) by redesignating such subparagraph as
subparagraph (E); and
(3) by inserting after subparagraph (C) the following new
subparagraph:
``(D) the individual is enrolled in an MA plan and
enrollment in the plan is suspended under paragraph
(2)(B) or (3)(C) of section 1857(g) because of a
failure of the plan to meet applicable requirements;
or''.
SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN ADMINISTRATIVE
COSTS.
(a) Disclosure of Medical Loss Ratios and Other Expense Data.--
Section 1851 of the Social Security Act (42 U.S.C. 1395w-21), as
previously amended by this subtitle, is amended by adding at the end
the following new subsection:
``(p) Publication of Medical Loss Ratios and Other Cost-related
Information.--
``(1) In general.--The Secretary shall publish, not later
than November 1 of each year (beginning with 2011), for each MA
plan contract, the medical loss ratio of the plan in the
previous year.
``(2) Submission of data.--
``(A) In general.--Each MA organization shall
submit to the Secretary, in a form and manner specified
by the Secretary, data necessary for the Secretary to
publish the medical loss ratio on a timely basis.
``(B) Data for 2010 and 2011.--The data submitted
under subparagraph (A) for 2010 and for 2011 shall be
consistent in content with the data reported as part of
the MA plan bid in June 2009 for 2010.
``(C) Use of standardized elements and
definitions.--The data to be submitted under
subparagraph (A) relating to medical loss ratio for a
year, beginning with 2012, shall be submitted based on
the standardized elements and definitions developed
under paragraph (3).
``(3) Development of data reporting standards.--
``(A) In general.--The Secretary shall develop and
implement standardized data elements and definitions
for reporting under this subsection, for contract years
beginning with 2012, of data necessary for the
calculation of the medical loss ratio for MA plans. Not
later than December 31, 2010, the Secretary shall
publish a report describing the elements and
definitions so developed.
``(B) Consultation.--The Secretary shall consult
with the Health Choices Commissioner, representatives
of MA organizations, experts on health plan accounting
systems, and representatives of the National
Association of Insurance Commissioners, in the
development of such data elements and definitions.
``(4) Medical loss ratio to be defined.--For purposes of
this part, the term `medical loss ratio' has the meaning given
such term by the Secretary, taking into account the meaning
given such term by the Health Choices Commissioner under
section 116 of the America's Affordable Health Choices Act of
2009.''.
(b) Minimum Medical Loss Ratio.--Section 1857(e) of the Social
Security Act (42 U.S.C. 1395w-27(e)) is amended by adding at the end
the following new paragraph:
``(4) Requirement for minimum medical loss ratio.--If the
Secretary determines for a contract year (beginning with 2014)
that an MA plan has failed to have a medical loss ratio (as
defined in section 1851(p)(4)) of at least .85--
``(A) the Secretary shall require the Medicare
Advantage organization offering the plan to give
enrollees a rebate (in the second succeeding contract
year) of premiums under this part (or part B or part D,
if applicable) by such amount as would provide for a
benefits ratio of at least .85;
``(B) for 3 consecutive contract years, the
Secretary shall not permit the enrollment of new
enrollees under the plan for coverage during the second
succeeding contract year; and
``(C) the Secretary shall terminate the plan
contract if the plan fails to have such a medical loss
ratio for 5 consecutive contract years.''.
SEC. 1174. STRENGTHENING AUDIT AUTHORITY.
(a) For Part C Payments Risk Adjustment.--Section 1857(d)(1) of the
Social Security Act (42 U.S.C. 1395w-27(d)(1)) is amended by inserting
after ``section 1858(c))'' the following: ``, and data submitted with
respect to risk adjustment under section 1853(a)(3)''.
(b) Enforcement of Audits and Deficiencies.--
(1) In general.--Section 1857(e) of such Act, as amended by
section 1173, is amended by adding at the end the following new
paragraph:
``(5) Enforcement of audits and deficiencies.--
``(A) Information in contract.--The Secretary shall
require that each contract with an MA organization
under this section shall include terms that inform the
organization of the provisions in subsection (d).
``(B) Enforcement authority.--The Secretary is
authorized, in connection with conducting audits and
other activities under subsection (d), to take such
actions, including pursuit of financial recoveries,
necessary to address deficiencies identified in such
audits or other activities.''.
(2) Application under part d.--For provision applying the
amendment made by paragraph (1) to prescription drug plans
under part D, see section 1860D-12(b)(3)(D) of the Social
Security Act.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act and shall apply to
audits and activities conducted for contract years beginning on or
after January 1, 2011.
SEC. 1175. AUTHORITY TO DENY PLAN BIDS.
(a) In General.--Section 1854(a)(5) of the Social Security Act (42
U.S.C. 1395w-24(a)(5)) is amended by adding at the end the following
new subparagraph:
``(C) Rejection of bids.--Nothing in this section
shall be construed as requiring the Secretary to accept
any or every bid by an MA organization under this
subsection.''.
(b) Application Under Part D.--Section 1860D-11(d) of such Act (42
U.S.C. 1395w-111(d)) is amended by adding at the end the following new
paragraph:
``(3) Rejection of bids.--Paragraph (5)(C) of section
1854(a) shall apply with respect to bids under this section in
the same manner as it applies to bids by an MA organization
under such section.''.
(c) Effective Date.--The amendments made by this section shall
apply to bids for contract years beginning on or after January 1, 2011.
PART 3--TREATMENT OF SPECIAL NEEDS PLANS
SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN ENROLLMENT PERIOD OF
INDIVIDUALS INTO CHRONIC CARE SPECIALIZED MA PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
Section 1859(f)(4) of the Social Security Act (42 U.S.C. 1395w-
28(f)(4)) is amended by adding at the end the following new
subparagraph:
``(C) The plan does not enroll an individual on or
after January 1, 2011, other than during an annual,
coordinated open enrollment period or when at the time
of the diagnosis of the disease or condition that
qualifies the individual as an individual described in
subsection (b)(6)(B)(iii).''.
SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO RESTRICT
ENROLLMENT.
(a) In General.--Section 1859(f)(1) of the Social Security Act (42
U.S.C. 1395w-28(f)(1)) is amended by striking ``January 1, 2011'' and
inserting ``January 1, 2013 (or January 1, 2016, in the case of a plan
described in section 1177(b)(1) of the America's Affordable Health
Choices Act of 2009)''.
(b) Grandfathering of Certain Plans.--
(1) Plans described.--For purposes of section 1859(f)(1) of
the Social Security Act (42 U.S.C. 1395w-28(f)(1)), a plan
described in this paragraph is a plan that had a contract with
a State that had a State program to operate an integrated
Medicaid-Medicare program that had been approved by the Centers
for Medicare & Medicaid Services as of January 1, 2004.
(2) Analysis; report.--The Secretary of Health and Human
Services shall provide, through a contract with an independent
health services evaluation organization, for an analysis of the
plans described in paragraph (1) with regard to the impact of
such plans on cost, quality of care, patient satisfaction, and
other subjects as specified by the Secretary. Not later than
December 31, 2011, the Secretary shall submit to Congress a
report on such analysis and shall include in such report such
recommendations with regard to the treatment of such plans as
the Secretary deems appropriate.
Subtitle E--Improvements to Medicare Part D
SEC. 1181. ELIMINATION OF COVERAGE GAP.
(a) In General.--Section 1860D-2(b) of such Act (42 U.S.C. 1395w-
102(b)) is amended--
(1) in paragraph (3)(A), by striking ``paragraph (4)'' and
inserting ``paragraphs (4) and (7)'';
(2) in paragraph (4)(B)(i), by inserting ``subject to
paragraph (7)'' after ``purposes of this part''; and
(3) by adding at the end the following new paragraph:
``(7) Phased-in elimination of coverage gap.--
``(A) In general.--For each year beginning with
2011, the Secretary shall consistent with this
paragraph progressively increase the initial coverage
limit (described in subsection (b)(3)) and decrease the
annual out-of-pocket threshold from the amounts
otherwise computed until there is a continuation of
coverage from the initial coverage limit for
expenditures incurred through the total amount of
expenditures at which benefits are available under
paragraph (4).
``(B) Increase in initial coverage limit.--For a
year beginning with 2011, the initial coverage limit
otherwise computed without regard to this paragraph
shall be increased by \1/2\ of the cumulative phase-in
percentage (as defined in subparagraph (D)(ii) for the
year) times the out-of-pocket gap amount (as defined in
subparagraph (E)) for the year.
``(C) Decrease in annual out-of-pocket threshold.--
For a year beginning with 2011, the annual out-of-
pocket threshold otherwise computed without regard to
this paragraph shall be decreased by \1/2\ of the
cumulative phase-in percentage of the out-of-pocket gap
amount for the year multiplied by 1.75.
``(D) Phase-in.--For purposes of this paragraph:
``(i) Annual phase-in percentage.--The term
`annual phase-in percentage' means--
``(I) for 2011, 13 percent;
``(II) for 2012, 2013, 2014, and
2015, 5 percent;
``(III) for 2016 through 2018, 7.5
percent; and
``(IV) for 2019 and each subsequent
year, 10 percent.
``(ii) Cumulative phase-in percentage.--The
term `cumulative phase-in percentage' means for
a year the sum of the annual phase-in
percentage for the year and the annual phase-in
percentages for each previous year beginning
with 2011, but in no case more than 100
percent.
``(E) Out-of-pocket gap amount.--For purposes of
this paragraph, the term `out-of-pocket gap amount'
means for a year the amount by which--
``(i) the annual out-of-pocket threshold
specified in paragraph (4)(B) for the year (as
determined as if this paragraph did not apply),
exceeds
``(ii) the sum of--
``(I) the annual deductible under
paragraph (1) for the year; and
``(II) \1/4\ of the amount by which
the initial coverage limit under
paragraph (3) for the year (as
determined as if this paragraph did not
apply) exceeds such annual
deductible.''.
(b) Requiring Drug Manufacturers To Provide Drug Rebates for Full-
Benefit Dual Eligibles.--
(1) In general.--Section 1860D-2 of the Social Security Act
(42 U.S.C. 1396r-8) is amended--
(A) in subsection (e)(1), in the matter before
subparagraph (A), by inserting ``and subsection (f)''
after ``this subsection''; and
(B) by adding at the end the following new
subsection:
``(f) Prescription Drug Rebate Agreement for Full-Benefit Dual
Eligible Individuals.--
``(1) In general.--In this part, the term `covered part D
drug' does not include any drug or biologic that is
manufactured by a manufacturer that has not entered into and
have in effect a rebate agreement described in paragraph (2).
``(2) Rebate agreement.--A rebate agreement under this
subsection shall require the manufacturer to provide to the
Secretary a rebate for each rebate period (as defined in
paragraph (6)(B)) ending after December 31, 2010, in the amount
specified in paragraph (3) for any covered part D drug of the
manufacturer dispensed after December 31, 2010, to any full-
benefit dual eligible individual (as defined in paragraph
(6)(A)) for which payment was made by a PDP sponsor under part
D or a MA organization under part C for such period. Such
rebate shall be paid by the manufacturer to the Secretary not
later than 30 days after the date of receipt of the information
described in section 1860D-12(b)(7), including as such section
is applied under section 1857(f)(3).
``(3) Rebate for full-benefit dual eligible medicare drug
plan enrollees.--
``(A) In general.--The amount of the rebate
specified under this paragraph for a manufacturer for a
rebate period, with respect to each dosage form and
strength of any covered part D drug provided by such
manufacturer and dispensed to a full-benefit dual
eligible individual, shall be equal to the product of--
``(i) the total number of units of such
dosage form and strength of the drug so
provided and dispensed for which payment was
made by a PDP sponsor under part D or a MA
organization under part C for the rebate period
(as reported under section 1860D-12(b)(7),
including as such section is applied under
section 1857(f)(3)); and
``(ii) the amount (if any) by which--
``(I) the Medicaid rebate amount
(as defined in subparagraph (B)) for
such form, strength, and period,
exceeds
``(II) the average Medicare drug
program full-benefit dual eligible
rebate amount (as defined in
subparagraph (C)) for such form,
strength, and period.
``(B) Medicaid rebate amount.--For purposes of this
paragraph, the term `Medicaid rebate amount' means,
with respect to each dosage form and strength of a
covered part D drug provided by the manufacturer for a
rebate period--
``(i) in the case of a single source drug
or an innovator multiple source drug, the
amount specified in paragraph (1)(A)(ii) of
section 1927(b) plus the amount, if any,
specified in paragraph (2)(A)(ii) of such
section, for such form, strength, and period;
or
``(ii) in the case of any other covered
outpatient drug, the amount specified in
paragraph (3)(A)(i) of such section for such
form, strength, and period.
``(C) Average medicare drug program full-benefit
dual eligible rebate amount.--For purposes of this
subsection, the term `average Medicare drug program
full-benefit dual eligible rebate amount' means, with
respect to each dosage form and strength of a covered
part D drug provided by a manufacturer for a rebate
period, the sum, for all PDP sponsors under part D and
MA organizations administering a MA-PD plan under part
C, of--
``(i) the product, for each such sponsor or
organization, of--
``(I) the sum of all rebates,
discounts, or other price concessions
(not taking into account any rebate
provided under paragraph (2) for such
dosage form and strength of the drug
dispensed, calculated on a per-unit
basis, but only to the extent that any
such rebate, discount, or other price
concession applies equally to drugs
dispensed to full-benefit dual eligible
Medicare drug plan enrollees and drugs
dispensed to PDP and MA-PD enrollees
who are not full-benefit dual eligible
individuals; and
``(II) the number of the units of
such dosage and strength of the drug
dispensed during the rebate period to
full-benefit dual eligible individuals
enrolled in the prescription drug plans
administered by the PDP sponsor or the
MA-PD plans administered by the MA-PD
organization; divided by
``(ii) the total number of units of such
dosage and strength of the drug dispensed
during the rebate period to full-benefit dual
eligible individuals enrolled in all
prescription drug plans administered by PDP
sponsors and all MA-PD plans administered by
MA-PD organizations.
``(4) Length of agreement.--The provisions of paragraph (4)
of section 1927(b) (other than clauses (iv) and (v) of
subparagraph (B)) shall apply to rebate agreements under this
subsection in the same manner as such paragraph applies to a
rebate agreement under such section.
``(5) Other terms and conditions.--The Secretary shall
establish other terms and conditions of the rebate agreement
under this subsection, including terms and conditions related
to compliance, that are consistent with this subsection.
``(6) Definitions.--In this subsection and section 1860D-
12(b)(7):
``(A) Full-benefit dual eligible individual.--The
term `full-benefit dual eligible individual' has the
meaning given such term in section 1935(c)(6).
``(B) Rebate period.--The term `rebate period' has
the meaning given such term in section 1927(k)(8).''.
(2) Reporting requirement for the determination and payment
of rebates by manufactures related to rebate for full-benefit
dual eligible medicare drug plan enrollees.--
(A) Requirements for pdp sponsors.--Section 1860D-
12(b) of the Social Security Act (42 U.S.C. 1395w-
112(b)) is amended by adding at the end the following
new paragraph:
``(7) Reporting requirement for the determination and
payment of rebates by manufacturers related to rebate for full-
benefit dual eligible medicare drug plan enrollees.--
``(A) In general.--For purposes of the rebate under
section 1860D-2(f) for contract years beginning on or
after January 1, 2011, each contract entered into with
a PDP sponsor under this part with respect to a
prescription drug plan shall require that the sponsor
comply with subparagraphs (B) and (C).
``(B) Report form and contents.--Not later than 60
days after the end of each rebate period (as defined in
section 1860D-2(f)(6)(B)) within such a contract year
to which such section applies, a PDP sponsor of a
prescription drug plan under this part shall report to
each manufacturer--
``(i) information (by National Drug Code
number) on the total number of units of each
dosage, form, and strength of each drug of such
manufacturer dispensed to full-benefit dual
eligible Medicare drug plan enrollees under any
prescription drug plan operated by the PDP
sponsor during the rebate period;
``(ii) information on the price discounts,
price concessions, and rebates for such drugs
for such form, strength, and period;
``(iii) information on the extent to which
such price discounts, price concessions, and
rebates apply equally to full-benefit dual
eligible Medicare drug plan enrollees and PDP
enrollees who are not full-benefit dual
eligible Medicare drug plan enrollees; and
``(iv) any additional information that the
Secretary determines is necessary to enable the
Secretary to calculate the average Medicare
drug program full-benefit dual eligible rebate
amount (as defined in paragraph (3)(C) of such
section), and to determine the amount of the
rebate required under this section, for such
form, strength, and period.
Such report shall be in a form consistent with a
standard reporting format established by the Secretary.
``(C) Submission to secretary.--Each PDP sponsor
shall promptly transmit a copy of the information
reported under subparagraph (B) to the Secretary for
the purpose of audit oversight and evaluation.
``(D) Confidentiality of information.--The
provisions of subparagraph (D) of section 1927(b)(3),
relating to confidentiality of information, shall apply
to information reported by PDP sponsors under this
paragraph in the same manner that such provisions apply
to information disclosed by manufacturers or
wholesalers under such section, except--
``(i) that any reference to `this section'
in clause (i) of such subparagraph shall be
treated as being a reference to this section;
``(ii) the reference to the Director of the
Congressional Budget Office in clause (iii) of
such subparagraph shall be treated as including
a reference to the Medicare Payment Advisory
Commission; and
``(iii) clause (iv) of such subparagraph
shall not apply.
``(E) Oversight.--Information reported under this
paragraph may be used by the Inspector General of the
Department of Health and Human Services for the
statutorily authorized purposes of audit,
investigation, and evaluations.
``(F) Penalties for failure to provide timely
information and provision of false information.--In the
case of a PDP sponsor--
``(i) that fails to provide information
required under subparagraph (B) on a timely
basis, the sponsor is subject to a civil money
penalty in the amount of $10,000 for each day
in which such information has not been
provided; or
``(ii) that knowingly (as defined in
section 1128A(i)) provides false information
under such subparagraph, the sponsor is subject
to a civil money penalty in an amount not to
exceed $100,000 for each item of false
information.
Such civil money penalties are in addition to other
penalties as may be prescribed by law. The provisions
of section 1128A (other than subsections (a) and (b))
shall apply to a civil money penalty under this
subparagraph in the same manner as such provisions
apply to a penalty or proceeding under section
1128A(a).''.
(B) Application to ma organizations.--Section
1857(f)(3) of the Social Security Act (42 U.S.C. 1395w-
27(f)(3)) is amended by adding at the end the
following:
``(D) Reporting requirement related to rebate for
full-benefit dual eligible medicare drug plan
enrollees.--Section 1860D-12(b)(7).''.
(3) Deposit of rebates into medicare prescription drug
account.--Section 1860D-16(c) of such Act (42 U.S.C. 1395w-
116(c)) is amended by adding at the end the following new
paragraph:
``(6) Rebate for full-benefit dual eligible medicare drug
plan enrollees.--Amounts paid under a rebate agreement under
section 1860D-2(f) shall be deposited into the Account and
shall be used to pay for all or part of the gradual elimination
of the coverage gap under section 1860D-2(b)(7).''.
SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN ORIGINAL COVERAGE GAP.
Section 1860D-2 of the Social Security Act (42 U.S.C. 1395w-102),
as amended by section 1181(a), is amended--
(1) in subsection (b)(4)(C)(ii), by inserting ``subject to
subsection (g)(2)(C),'' after ``(ii)'';
(2) in subsection (e)(1), in the matter before subparagraph
(A), by striking ``subsection (f)'' and inserting ``subsections
(f) and (g)'' after ``this subsection''; and
(3) by adding at the end the following new subsection:
``(g) Requirement for Manufacturer Discount Agreement for Certain
Qualifying Drugs.--
``(1) In general.--In this part, the term `covered part D
drug' does not include any drug or biologic that is
manufactured by a manufacturer that has not entered into and
have in effect for all qualifying drugs (as defined in
paragraph (5)(A)) a discount agreement described in paragraph
(2).
``(2) Discount agreement.--
``(A) Periodic discounts.--A discount agreement
under this paragraph shall require the manufacturer
involved to provide, to each PDP sponsor with respect
to a prescription drug plan or each MA organization
with respect to each MA-PD plan, a discount in an
amount specified in paragraph (3) for qualifying drugs
(as defined in paragraph (5)(A)) of the manufacturer
dispensed to a qualifying enrollee after December 31,
2010, insofar as the individual is in the original gap
in coverage (as defined in paragraph (5)(E)).
``(B) Discount agreement.--Insofar as not
inconsistent with this subsection, the Secretary shall
establish terms and conditions of such agreement,
including terms and conditions relating to compliance,
similar to the terms and conditions for rebate
agreements under paragraphs (2), (3), and (4) of
section 1927(b), except that--
``(i) discounts shall be applied under this
subsection to prescription drug plans and MA-PD
plans instead of State plans under title XIX;
``(ii) PDP sponsors and MA organizations
shall be responsible, instead of States, for
provision of necessary utilization information
to drug manufacturers; and
``(iii) sponsors and MA organizations shall
be responsible for reporting information on
drug-component negotiated price, instead of
other manufacturer prices.
``(C) Counting discount toward true out-of-pocket
costs.--Under the discount agreement, in applying
subsection (b)(4), with regard to subparagraph (C)(i)
of such subsection, if a qualified enrollee purchases
the qualified drug insofar as the enrollee is in an
actual gap of coverage (as defined in paragraph
(5)(D)), the amount of the discount under the agreement
shall be treated and counted as costs incurred by the
plan enrollee.
``(3) Discount amount.--The amount of the discount
specified in this paragraph for a discount period for a plan is
equal to 50 percent of the amount of the drug-component
negotiated price (as defined in paragraph (5)(C)) for
qualifying drugs for the period involved.
``(4) Additional terms.--In the case of a discount provided
under this subsection with respect to a prescription drug plan
offered by a PDP sponsor or an MA-PD plan offered by an MA
organization, if a qualified enrollee purchases the qualified
drug--
``(A) insofar as the enrollee is in an actual gap
of coverage (as defined in paragraph (5)(D)), the
sponsor or plan shall provide the discount to the
enrollee at the time the enrollee pays for the drug;
and
``(B) insofar as the enrollee is in the portion of
the original gap in coverage (as defined in paragraph
(5)(E)) that is not in the actual gap in coverage, the
discount shall not be applied against the negotiated
price (as defined in subsection (d)(1)(B)) for the
purpose of calculating the beneficiary payment.
``(5) Definitions.--In this subsection:
``(A) Qualifying drug.--The term `qualifying drug'
means, with respect to a prescription drug plan or MA-
PD plan, a drug or biological product that--
``(i)(I) is a drug produced or distributed
under an original new drug application approved
by the Food and Drug Administration, including
a drug product marketed by any cross-licensed
producers or distributors operating under the
new drug application;
``(II) is a drug that was originally
marketed under an original new drug application
approved by the Food and Drug Administration;
or
``(III) is a biological product as approved
under Section 351(a) of the Public Health
Services Act;
``(ii) is covered under the formulary of
the plan; and
``(iii) is dispensed to an individual who
is in the original gap in coverage.
``(B) Qualifying enrollee.--The term `qualifying
enrollee' means an individual enrolled in a
prescription drug plan or MA-PD plan other than such an
individual who is a subsidy-eligible individual (as
defined in section 1860D-14(a)(3)).
``(C) Drug-component negotiated price.--The term
`drug-component negotiated price' means, with respect
to a qualifying drug, the negotiated price (as defined
in subsection (d)(1)(B)), as determined without regard
to any dispensing fee, of the drug under the
prescription drug plan or MA-PD plan involved.
``(D) Actual gap in coverage.--The term `actual gap
in coverage' means the gap in prescription drug
coverage that occurs between the initial coverage limit
(as modified under subparagraph (B) of subsection
(b)(7)) and the annual out-of-pocket threshold (as
modified under subparagraph (C) of such subsection).
``(E) Original gap in coverage.--The term `original
in gap coverage' means the gap in prescription drug
coverage that would occur between the initial coverage
limit (described in subsection (b)(3)) and the out-of-
pocket threshold (as defined in subsection (b)(4))(B)
if subsection (b)(7) did not apply.''.
SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMISSION OF CLAIMS BY
PHARMACIES LOCATED IN OR CONTRACTING WITH LONG-TERM CARE
FACILITIES.
(a) Part D Submission.--Section 1860D-12(b) of the Social Security
Act (42 U.S.C. 1395w-112(b)), as amended by section 172(a)(1) of Public
Law 110-275, is amended by striking paragraph (5) and redesignating
paragraph (6) and paragraph (7), as added by section 1181(b)(2), as
paragraph (5) and paragraph (6), respectively.
(b) Submission to MA-PD Plans.--Section 1857(f)(3) of the Social
Security Act (42 U.S.C. 1395w-27(f)(3)), as added by section 171(b) of
Public Law 110-275 and amended by section 172(a)(2) of such Public Law,
is amended by striking subparagraph (B) and redesignating subparagraph
(C) as subparagraph (B).
(c) Effective Date.--The amendments made by this section shall
apply for contract years beginning with 2010.
SEC. 1184. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE PROGRAMS
AND INDIAN HEALTH SERVICE IN PROVIDING PRESCRIPTION DRUGS
TOWARD THE ANNUAL OUT-OF-POCKET THRESHOLD UNDER PART D.
(a) In General.--Section 1860D-2(b)(4)(C) of the Social Security
Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by striking ``such costs shall be treated as
incurred only if'' and inserting ``subject to clause
(iii), such costs shall be treated as incurred only
if'';
(B) by striking ``, under section 1860D-14, or
under a State Pharmaceutical Assistance Program''; and
(C) by striking the period at the end and inserting
``; and''; and
(3) by inserting after clause (ii) the following new
clause:
``(iii) such costs shall be treated as
incurred and shall not be considered to be
reimbursed under clause (ii) if such costs are
borne or paid--
``(I) under section 1860D-14;
``(II) under a State Pharmaceutical
Assistance Program;
``(III) by the Indian Health
Service, an Indian tribe or tribal
organization, or an urban Indian
organization (as defined in section 4
of the Indian Health Care Improvement
Act); or
``(IV) under an AIDS Drug
Assistance Program under part B of
title XXVI of the Public Health Service
Act.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to costs incurred on or after January 1, 2011.
SEC. 1185. PERMITTING MID-YEAR CHANGES IN ENROLLMENT FOR FORMULARY
CHANGES THAT ADVERSELY IMPACT AN ENROLLEE.
(a) In General.--Section 1860D-1(b)(3) of the Social Security Act
(42 U.S.C. 1395w-101(b)(3)) is amended by adding at the end the
following new subparagraph:
``(F) Change in formulary resulting in increase in
cost-sharing.--
``(i) In general.--Except as provided in
clause (ii), in the case of an individual
enrolled in a prescription drug plan (or MA-PD
plan) who has been prescribed and is using a
covered part D drug while so enrolled, if the
formulary of the plan is materially changed
(other than at the end of a contract year) so
to reduce the coverage (or increase the cost-
sharing) of the drug under the plan.
``(ii) Exception.--Clause (i) shall not
apply in the case that a drug is removed from
the formulary of a plan because of a recall or
withdrawal of the drug issued by the Food and
Drug Administration, because the drug is
replaced with a generic drug that is a
therapeutic equivalent, or because of
utilization management applied to--
``(I) a drug whose labeling
includes a boxed warning required by
the Food and Drug Administration under
section 210.57(c)(1) of title 21, Code
of Federal Regulations (or a successor
regulation); or
``(II) a drug required under
subsection (c)(2) of section 505-1 of
the Federal Food, Drug, and Cosmetic
Act to have a Risk Evaluation and
Management Strategy that includes
elements under subsection (f) of such
section.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to contract years beginning on or after January 1, 2011.
Subtitle F--Medicare Rural Access Protections
SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS.
(a) Additional Telehealth Site.--
(1) In general.--Paragraph (4)(C)(ii) of section 1834(m) of
the Social Security Act (42 U.S.C. 1395m(m)) is amended by
adding at the end the following new subclause:
``(IX) A renal dialysis facility.''
(2) Effective date.--The amendment made by paragraph (1)
shall apply to services furnished on or after January 1, 2011.
(b) Telehealth Advisory Committee.--
(1) Establishment.--Section 1868 of the Social Security Act
(42 U.S.C. 1395ee) is amended--
(A) in the heading, by adding at the end the
following: ``telehealth advisory committee''; and
(B) by adding at the end the following new
subsection:
``(c) Telehealth Advisory Committee.--
``(1) In general.--The Secretary shall appoint a Telehealth
Advisory Committee (in this subsection referred to as the
`Advisory Committee') to make recommendations to the Secretary
on policies of the Centers for Medicare & Medicaid Services
regarding telehealth services as established under section
1834(m), including the appropriate addition or deletion of
services (and HCPCS codes) to those specified in paragraphs
(4)(F)(i) and (4)(F)(ii) of such section and for authorized
payment under paragraph (1) of such section.
``(2) Membership; terms.--
``(A) Membership.--
``(i) In general.--The Advisory Committee
shall be composed of 9 members, to be appointed
by the Secretary, of whom--
``(I) 5 shall be practicing
physicians;
``(II) 2 shall be practicing non-
physician health care practitioners;
and
``(III) 2 shall be administrators
of telehealth programs.
``(ii) Requirements for appointing
members.--In appointing members of the Advisory
Committee, the Secretary shall--
``(I) ensure that each member has
prior experience with the practice of
telemedicine or telehealth;
``(II) give preference to
individuals who are currently providing
telemedicine or telehealth services or
who are involved in telemedicine or
telehealth programs;
``(III) ensure that the membership
of the Advisory Committee represents a
balance of specialties and geographic
regions; and
``(IV) take into account the
recommendations of stakeholders.
``(B) Terms.--The members of the Advisory Committee
shall serve for such term as the Secretary may specify.
``(C) Conflicts of interest.--An advisory committee
member may not participate with respect to a particular
matter considered in an advisory committee meeting if
such member (or an immediate family member of such
member) has a financial interest that could be affected
by the advice given to the Secretary with respect to
such matter.
``(3) Meetings.--The Advisory Committee shall meet twice
each calendar year and at such other times as the Secretary may
provide.
``(4) Permanent committee.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply to the
Advisory Committee.''
(2) Following recommendations.--Section 1834(m)(4)(F) of
such Act (42 U.S.C. 1395m(m)(4)(F)) is amended by adding at the
end the following new clause:
``(iii) Recommendations of the telehealth
advisory committee.--In making determinations
under clauses (i) and (ii), the Secretary shall
take into account the recommendations of the
Telehealth Advisory Committee (established
under section 1868(c)) when adding or deleting
services (and HCPCS codes) and in establishing
policies of the Centers for Medicare & Medicaid
Services regarding the delivery of telehealth
services. If the Secretary does not implement
such a recommendation, the Secretary shall
publish in the Federal Register a statement
regarding the reason such recommendation was
not implemented.''
(3) Waiver of administrative limitation.--The Secretary of
Health and Human Services shall establish the Telehealth
Advisory Committee under the amendment made by paragraph (1)
notwithstanding any limitation that may apply to the number of
advisory committees that may be established (within the
Department of Health and Human Services or otherwise).
SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.
Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C.
1395l(t)(7)(D)(i)) is amended--
(1) in subclause (II)--
(A) in the first sentence, by striking ```2010''and
inserting ``2012''; and
(B) in the second sentence, by striking ``or 2009''
and inserting ``, 2009, 2010, or 2011''; and
(2) in subclause (III), by striking ``January 1, 2010'' and
inserting ``January 1, 2012''.
SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL RECLASSIFICATIONS.
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, 2011''.
SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``before January 1, 2010'' and
inserting ``before January 1, 2012''.
SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN
PHYSICIAN PATHOLOGY SERVICES.
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000 (as enacted into law by section
1(a)(6) of Public Law 106-554), as amended by section 732 of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), and section 136 of the Medicare Improvements for Patients and
Providers Act of 1008 (Public Law 110-275), is amended by striking
``and 2009'' and inserting ``2009, 2010, and 2011''.
SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS.
(a) In General.--Section 1834(l)(13) of the Social Security Act (42
U.S.C. 1395m(l)(13)) is amended--
(1) in subparagraph (A)--
(A) in the matter preceding clause (i), by striking
``before January 1, 2010'' and inserting ``before
January 1, 2012''; and
(B) in each of clauses (i) and (ii), by striking
``before January 1, 2010'' and inserting ``before
January 1, 2012''.
(b) Air Ambulance Improvements.--Section 146(b)(1) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275) is amended by striking ``ending on December 31, 2009'' and
inserting ``ending on December 31, 2011''.
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS PROGRAM AND LOW-
INCOME SUBSIDY PROGRAM.
(a) Application of Highest Level Permitted Under LIS to All Subsidy
Eligible Individuals.--
(1) In general.--Section 1860D-14(a)(1) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)) is amended in the
matter before subparagraph (A), by inserting ``(or, beginning
with 2012, paragraph (3)(E))'' after ``paragraph (3)(D)''.
(2) Annual increase in lis resource test.--Section 1860D-
14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w-114(a)(3)(E)(i)) is
amended--
(A) by striking ``and'' at the end of subclause
(I);
(B) in subclause (II), by inserting ``(before
2012)'' after ``subsequent year'';
(C) by striking the period at the end of subclause
(II) and inserting a semicolon;
(D) by inserting after subclause (II) the following
new subclauses:
``(III) for 2012, $17,000 (or
$34,000 in the case of the combined
value of the individual's assets or
resources and the assets or resources
of the individual's spouse); and
``(IV) for a subsequent year, the
dollar amounts specified in this
subclause (or subclause (III)) for the
previous year increased by the annual
percentage increase in the consumer
price index (all items; U.S. city
average) as of September of such
previous year.''; and
(E) in the last sentence, by inserting ``or (IV)''
after ``subclause (II)''.
(3) Application of lis test under medicare savings
program.--Section 1905(p)(1)(C) of such Act (42 U.S.C.
1396d(p)(1)(C)) is amended--
(A) by striking ``effective beginning with January
1, 2010'' and inserting ``effective for the period
beginning with January 1, 2010, and ending with
December 31, 2011''; and
(B) by inserting before the period at the end the
following: ``or, effective beginning with January 1,
2012, whose resources (as so determined) do not exceed
the maximum resource level applied for the year under
subparagraph (E) of section 1860D-14(a)(3) (determined
without regard to the life insurance policy exclusion
provided under subparagraph (G) of such section)
applicable to an individual or to the individual and
the individual's spouse (as the case may be)''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to eligibility determinations for income-related subsidies and
medicare cost-sharing furnished for periods beginning on or after
January 1, 2012.
SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR CERTAIN NON-
INSTITUTIONALIZED FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.
(a) In General.--Section 1860D-14(a)(1)(D)(i) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended--
(1) by striking ``Institutionalized individuals.--In'' and
inserting ``Elimination of cost-sharing for certain full-
benefit dual eligible individuals.--
``(I) Institutionalized
individuals.--In''; and
(2) by adding at the end the following new subclause:
``(II) Certain other individuals.--
In the case of an individual who is a
full-benefit dual eligible individual
and with respect to whom there has been
a determination that but for the
provision of home and community based
care (whether under section 1915, 1932,
or under a waiver under section 1115)
the individual would require the level
of care provided in a hospital or a
nursing facility or intermediate care
facility for the mentally retarded the
cost of which could be reimbursed under
the State plan under title XIX, the
elimination of any beneficiary
coinsurance described in section 1860D-
2(b)(2) (for all amounts through the
total amount of expenditures at which
benefits are available under section
1860D-2(b)(4)).''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to drugs dispensed on or after January 1, 2011.
SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT.
(a) Administrative Verification of Income and Resources Under the
Low-income Subsidy Program.--
(1) In general.--Clause (iii) of section 1860D-14(a)(3)(E)
of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(E)) is
amended to read as follows:
``(iii) Certification of income and
resources.--For purposes of applying this
section--
``(I) an individual shall be
permitted to apply on the basis of
self-certification of income and
resources; and
``(II) matters attested to in the
application shall be subject to
appropriate methods of verification
without the need of the individual to
provide additional documentation,
except in extraordinary situations as
determined by the Commissioner.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply beginning January 1, 2010.
(b) Disclosures To Facilitate Identification of Individuals Likely
To Be Ineligible for the Low-income Assistance Under the Medicare
Prescription Drug Program To Assist Social Security Administration's
Outreach to Eligible Individuals.--For provision authorizing disclosure
of return information to facilitate identification of individuals
likely to be ineligible for low-income subsidies under Medicare
prescription drug program, see section 1801.
SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR
RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.
(a) In General.--In the case of a retroactive LIS enrollment
beneficiary who is enrolled under a prescription drug plan under part D
of title XVIII of the Social Security Act (or an MA-PD plan under part
C of such title), the beneficiary (or any eligible third party) is
entitled to reimbursement by the plan for covered drug costs incurred
by the beneficiary during the retroactive coverage period of the
beneficiary in accordance with subsection (b) and in the case of such a
beneficiary described in subsection (c)(4)(A)(i), such reimbursement
shall be made automatically by the plan upon receipt of appropriate
notice the beneficiary is eligible for assistance described in such
subsection (c)(4)(A)(i) without further information required to be
filed with the plan by the beneficiary.
(b) Administrative Requirements Relating to Reimbursements.--
(1) Line-item description.--Each reimbursement made by a
prescription drug plan or MA-PD plan under subsection (a) shall
include a line-item description of the items for which the
reimbursement is made.
(2) Timing of reimbursements.--A prescription drug plan or
MA-PD plan must make a reimbursement under subsection (a) to a
retroactive LIS enrollment beneficiary, with respect to a
claim, not later than 45 days after--
(A) in the case of a beneficiary described in
subsection (c)(4)(A)(i), the date on which the plan
receives notice from the Secretary that the beneficiary
is eligible for assistance described in such
subsection; or
(B) in the case of a beneficiary described in
subsection (c)(4)(A)(ii), the date on which the
beneficiary files the claim with the plan.
(3) Reporting requirement.--For each month beginning with
January 2011, each prescription drug plan and each MA-PD plan
shall report to the Secretary the following:
(A) The number of claims the plan has readjudicated
during the month due to a beneficiary becoming
retroactively eligible for subsidies available under
section 1860D-14 of the Social Security Act.
(B) The total value of the readjudicated claim
amount for the month.
(C) The Medicare Health Insurance Claims Number of
beneficiaries for whom claims were readjudicated.
(D) For the claims described in subparagraphs (A)
and (B), an attestation to the Administrator of the
Centers for Medicare & Medicaid Services of the total
amount of reimbursement the plan has provided to
beneficiaries for premiums and cost-sharing that the
beneficiary overpaid for which the plan received
payment from the Centers for Medicare & Medicaid
Services.
(c) Definitions.--For purposes of this section:
(1) Covered drug costs.--The term ``covered drug costs''
means, with respect to a retroactive LIS enrollment beneficiary
enrolled under a prescription drug plan under part D of title
XVIII of the Social Security Act (or an MA-PD plan under part C
of such title), the amount by which--
(A) the costs incurred by such beneficiary during
the retroactive coverage period of the beneficiary for
covered part D drugs, premiums, and cost-sharing under
such title; exceeds
(B) such costs that would have been incurred by
such beneficiary during such period if the beneficiary
had been both enrolled in the plan and recognized by
such plan as qualified during such period for the low
income subsidy under section 1860D-14 of the Social
Security Act to which the individual is entitled.
(2) Eligible third party.--The term ``eligible third
party'' means, with respect to a retroactive LIS enrollment
beneficiary, an organization or other third party that is owed
payment on behalf of such beneficiary for covered drug costs
incurred by such beneficiary during the retroactive coverage
period of such beneficiary.
(3) Retroactive coverage period.--The term ``retroactive
coverage period'' means--
(A) with respect to a retroactive LIS enrollment
beneficiary described in paragraph (4)(A)(i), the
period--
(i) beginning on the effective date of the
assistance described in such paragraph for
which the individual is eligible; and
(ii) ending on the date the plan
effectuates the status of such individual as so
eligible; and
(B) with respect to a retroactive LIS enrollment
beneficiary described in paragraph (4)(A)(ii), the
period--
(i) beginning on the date the individual is
both entitled to benefits under part A, or
enrolled under part B, of title XVIII of the
Social Security Act and eligible for medical
assistance under a State plan under title XIX
of such Act; and
(ii) ending on the date the plan
effectuates the status of such individual as a
full-benefit dual eligible individual (as
defined in section 1935(c)(6) of such Act).
(4) Retroactive lis enrollment beneficiary.--
(A) In general.--The term ``retroactive LIS
enrollment beneficiary'' means an individual who--
(i) is enrolled in a prescription drug plan
under part D of title XVIII of the Social
Security Act (or an MA-PD plan under part C of
such title) and subsequently becomes eligible
as a full-benefit dual eligible individual (as
defined in section 1935(c)(6) of such Act), an
individual receiving a low-income subsidy under
section 1860D-14 of such Act, an individual
receiving assistance under the Medicare Savings
Program implemented under clauses (i), (iii),
and (iv) of section 1902(a)(10)(E) of such Act,
or an individual receiving assistance under the
supplemental security income program under
section 1611 of such Act; or
(ii) subject to subparagraph (B)(i), is a
full-benefit dual eligible individual (as
defined in section 1935(c)(6) of such Act) who
is automatically enrolled in such a plan under
section 1860D-1(b)(1)(C) of such Act.
(B) Exception for beneficiaries enrolled in rfp
plan.--
(i) In general.--In no case shall an
individual described in subparagraph (A)(ii)
include an individual who is enrolled, pursuant
to a RFP contract described in clause (ii), in
a prescription drug plan offered by the sponsor
of such plan awarded such contract.
(ii) RFP contract described.--The RFP
contract described in this section is a
contract entered into between the Secretary and
a sponsor of a prescription drug plan pursuant
to the Centers for Medicare & Medicaid
Services' request for proposals issued on
February 17, 2009, relating to Medicare part D
retroactive coverage for certain low income
beneficiaries, or a similar subsequent request
for proposals.
SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT.
(a) In General.--Section 1860D-1(b)(1)(C) of the Social Security
Act (42 U.S.C. 1395w-101(b)(1)(C)) is amended by adding after ``PDP
region'' the following: ``or through use of an intelligent assignment
process that is designed to maximize the access of such individual to
necessary prescription drugs while minimizing costs to such individual
and to the program under this part to the greatest extent possible. In
the case the Secretary enrolls such individuals through use of an
intelligent assignment process, such process shall take into account
the extent to which prescription drugs necessary for the individual are
covered in the case of a PDP sponsor of a prescription drug plan that
uses a formulary, the use of prior authorization or other restrictions
on access to coverage of such prescription drugs by such a sponsor, and
the overall quality of a prescription drug plan as measured by quality
ratings established by the Secretary.''
(b) Effective Date.--The amendment made by subsection (a) shall
take effect for contract years beginning with 2012.
SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT PROCESS
FOR CERTAIN SUBSIDY ELIGIBLE INDIVIDUALS.
(a) Special Enrollment Period.--Section 1860D-1(b)(3)(D) of the
Social Security Act (42 U.S.C. 1395w-101(b)(3)(D)) is amended to read
as follows:
``(D) Subsidy eligible individuals.--In the case of
an individual (as determined by the Secretary) who is
determined under subparagraph (B) of section 1860D-
14(a)(3) to be a subsidy eligible individual.''.
(b) Automatic Enrollment.--Section 1860D-1(b)(1) of the Social
Security Act (42 U.S.C. 1395w-101(b)(1)) is amended by adding at the
end the following new subparagraph:
``(D) Special rule for subsidy eligible
individuals.--The process established under
subparagraph (A) shall include, in the case of an
individual described in section 1860D-1(b)(3)(D) who
fails to enroll in a prescription drug plan or an MA-PD
plan during the special enrollment established under
such section applicable to such individual, the
application of the assignment process described in
subparagraph (C) to such individual in the same manner
as such assignment process applies to a part D eligible
individual described in such subparagraph (C). Nothing
in the previous sentence shall prevent an individual
described in such sentence from declining enrollment in
a plan determined appropriate by the Secretary (or in
the program under this part) or from changing such
enrollment.''.
(c) Effective Date.--The amendments made by this section shall
apply to subsidy determinations made for months beginning with January
2011.
SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO REBATE IN CALCULATION OF
LOW INCOME SUBSIDY BENCHMARK.
(a) In General.--Section 1860D-14(b)(2)(B)(iii) of the Social
Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is amended by
inserting before the period the following: ``before the application of
the monthly rebate computed under section 1854(b)(1)(C)(i) for that
plan and year involved''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to subsidy determinations made for months beginning with January
2011.
Subtitle B--Reducing Health Disparities
SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.
(a) Ensuring Effective Communication by the Centers for Medicare &
Medicaid Services.--
(1) Study on medicare payments for language services.--The
Secretary of Health and Human Services shall conduct a study
that examines the extent to which Medicare service providers
utilize, offer, or make available language services for
beneficiaries who are limited English proficient and ways that
Medicare should develop payment systems for language services.
(2) Analyses.--The study shall include an analysis of each
of the following:
(A) How to develop and structure appropriate
payment systems for language services for all Medicare
service providers.
(B) The feasibility of adopting a payment
methodology for on-site interpreters, including
interpreters who work as independent contractors and
interpreters who work for agencies that provide on-site
interpretation, pursuant to which such interpreters
could directly bill Medicare for services provided in
support of physician office services for an LEP
Medicare patient.
(C) The feasibility of Medicare contracting
directly with agencies that provide off-site
interpretation including telephonic and video
interpretation pursuant to which such contractors could
directly bill Medicare for the services provided in
support of physician office services for an LEP
Medicare patient.
(D) The feasibility of modifying the existing
Medicare resource-based relative value scale (RBRVS) by
using adjustments (such as multipliers or add-ons) when
a patient is LEP.
(E) How each of options described in a previous
paragraph would be funded and how such funding would
affect physician payments, a physician's practice, and
beneficiary cost-sharing.
(F) The extent to which providers under parts A and
B of title XVIII of the Social Security Act, MA
organizations offering Medicare Advantage plans under
part C of such title and PDP sponsors of a prescription
drug plan under part D of such title utilize, offer, or
make available language services for beneficiaries with
limited English proficiency.
(G) The nature and type of language services
provided by States under title XIX of the Social
Security Act and the extent to which such services
could be utilized by beneficiaries and providers under
title XVIII of such Act.
(3) Variation in payment system described.--The payment
systems described in paragraph (2)(A) may allow variations
based upon types of service providers, available delivery
methods, and costs for providing language services including
such factors as--
(A) the type of language services provided (such as
provision of health care or health care related
services directly in a non-English language by a
bilingual provider or use of an interpreter);
(B) type of interpretation services provided (such
as in-person, telephonic, video interpretation);
(C) the methods and costs of providing language
services (including the costs of providing language
services with internal staff or through contract with
external independent contractors or agencies, or both);
(D) providing services for languages not frequently
encountered in the United States; and
(E) providing services in rural areas.
(4) Report.--The Secretary shall submit a report on the
study conducted under subsection (a) to appropriate committees
of Congress not later than 12 months after the date of the
enactment of this Act.
(5) Exemption from paperwork reduction act.--Chapter 35 of
title 44, United States Code (commonly known as the ``Paperwork
Reduction Act''), shall not apply for purposes of carrying out
this subsection.
(6) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection such sums as
are necessary.
(b) Health Plans.--Section 1857(g)(1) of the Social Security Act
(42 U.S.C. 1395w-27(g)(1)) is amended--
(1) by striking ``or'' at the end of subparagraph (F);
(2) by adding ``or'' at the end of subparagraph (G); and
(3) by inserting after subparagraph (G) the following new
subparagraph:
``(H) fails substantially to provide language
services to limited English proficient beneficiaries
enrolled in the plan that are required under law;''.
SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE BENEFICIARIES
WITH LIMITED ENGLISH PROFICIENCY BY PROVIDING
REIMBURSEMENT FOR CULTURALLY AND LINGUISTICALLY
APPROPRIATE SERVICES.
(a) In General.--Not later than 6 months after the date of the
completion of the study described in section 1221(a), the Secretary,
acting through the Centers for Medicare & Medicaid Services, shall
carry out a demonstration program under which the Secretary shall award
not fewer than 24 3-year grants to eligible Medicare service providers
(as described in subsection (b)(1)) to improve effective communication
between such providers and Medicare beneficiaries who are living in
communities where racial and ethnic minorities, including populations
that face language barriers, are underserved with respect to such
services. In designing and carrying out the demonstration the Secretary
shall take into consideration the results of the study conducted under
section 1221(a) and adjust, as appropriate, the distribution of grants
so as to better target Medicare beneficiaries who are in the greatest
need of language services. The Secretary shall not authorize a grant
larger than $500,000 over three years for any grantee.
(b) Eligibility; Priority.--
(1) Eligibility.--To be eligible to receive a grant under
subsection (a) an entity shall--
(A) be--
(i) a provider of services under part A of
title XVIII of the Social Security Act;
(ii) a service provider under part B of
such title;
(iii) a part C organization offering a
Medicare part C plan under part C of such
title; or
(iv) a PDP sponsor of a prescription drug
plan under part D of such title; and
(B) prepare and submit to the Secretary an
application, at such time, in such manner, and
accompanied by such additional information as the
Secretary may require.
(2) Priority.--
(A) Distribution.--To the extent feasible, in
awarding grants under this section, the Secretary shall
award--
(i) at least 6 grants to providers of
services described in paragraph (1)(A)(i);
(ii) at least 6 grants to service providers
described in paragraph (1)(A)(ii);
(iii) at least 6 grants to organizations
described in paragraph (1)(A)(iii); and
(iv) at least 6 grants to sponsors
described in paragraph (1)(A)(iv).
(B) For community organizations.--The Secretary
shall give priority to applicants that have developed
partnerships with community organizations or with
agencies with experience in language access.
(C) Variation in grantees.--The Secretary shall
also ensure that the grantees under this section
represent, among other factors, variations in--
(i) different types of language services
provided and of service providers and
organizations under parts A through D of title
XVIII of the Social Security Act;
(ii) languages needed and their frequency
of use;
(iii) urban and rural settings;
(iv) at least two geographic regions, as
defined by the Secretary; and
(v) at least two large metropolitan
statistical areas with diverse populations.
(c) Use of Funds.--
(1) In general.--A grantee shall use grant funds received
under this section to pay for the provision of competent
language services to Medicare beneficiaries who are limited
English proficient. Competent interpreter services may be
provided through on-site interpretation, telephonic
interpretation, or video interpretation or direct provision of
health care or health care related services by a bilingual
health care provider. A grantee may use bilingual providers,
staff, or contract interpreters. A grantee may use grant funds
to pay for competent translation services. A grantee may use up
to 10 percent of the grant funds to pay for administrative
costs associated with the provision of competent language
services and for reporting required under subsection (e).
(2) Organizations.--Grantees that are part C organizations
or PDP sponsors must ensure that their network providers
receive at least 50 percent of the grant funds to pay for the
provision of competent language services to Medicare
beneficiaries who are limited English proficient, including
physicians and pharmacies.
(3) Determination of payments for language services.--
Payments to grantees shall be calculated based on the estimated
numbers of limited English proficient Medicare beneficiaries in
a grantee's service area utilizing--
(A) data on the numbers of limited English
proficient individuals who speak English less than
``very well'' from the most recently available data
from the Bureau of the Census or other State-based
study the Secretary determines likely to yield accurate
data regarding the number of such individuals served by
the grantee; or
(B) the grantee's own data if the grantee routinely
collects data on Medicare beneficiaries' primary
language in a manner determined by the Secretary to
yield accurate data and such data shows greater numbers
of limited English proficient individuals than the data
listed in subparagraph (A).
(4) Limitations.--
(A) Reporting.--Payments shall only be provided
under this section to grantees that report their costs
of providing language services as required under
subsection (e) and may be modified annually at the
discretion of the Secretary. If a grantee fails to
provide the reports under such section for the first
year of a grant, the Secretary may terminate the grant
and solicit applications from new grantees to
participate in the subsequent two years of the
demonstration program.
(B) Type of services.--
(i) In general.--Subject to clause (ii),
payments shall be provided under this section
only to grantees that utilize competent
bilingual staff or competent interpreter or
translation services which--
(I) if the grantee operates in a
State that has statewide health care
interpreter standards, meet the State
standards currently in effect; or
(II) if the grantee operates in a
State that does not have statewide
health care interpreter standards,
utilizes competent interpreters who
follow the National Council on
Interpreting in Health Care's Code of
Ethics and Standards of Practice.
(ii) Exemptions.--The requirements of
clause (i) shall not apply--
(I) in the case of a Medicare
beneficiary who is limited English
proficient (who has been informed in
the beneficiary's primary language of
the availability of free interpreter
and translation services) and who
requests the use of family, friends, or
other persons untrained in
interpretation or translation and the
grantee documents the request in the
beneficiary's record; and
(II) in the case of a medical
emergency where the delay directly
associated with obtaining a competent
interpreter or translation services
would jeopardize the health of the
patient.
Nothing in clause (ii)(II) shall be construed
to exempt emergency rooms or similar entities
that regularly provide health care services in
medical emergencies from having in place
systems to provide competent interpreter and
translation services without undue delay.
(d) Assurances.--Grantees under this section shall--
(1) ensure that appropriate clinical and support staff
receive ongoing education and training in linguistically
appropriate service delivery;
(2) ensure the linguistic competence of bilingual
providers;
(3) offer and provide appropriate language services at no
additional charge to each patient with limited English
proficiency at all points of contact, in a timely manner during
all hours of operation;
(4) notify Medicare beneficiaries of their right to receive
language services in their primary language;
(5) post signage in the languages of the commonly
encountered group or groups present in the service area of the
organization; and
(6) ensure that--
(A) primary language data are collected for
recipients of language services; and
(B) consistent with the privacy protections
provided under the regulations promulgated pursuant to
section 264(c) of the Health Insurance Portability and
Accountability Act of 1996 (42 U.S.C. 1320d-2 note), if
the recipient of language services is a minor or is
incapacitated, the primary language of the parent or
legal guardian is collected and utilized.
(e) Reporting Requirements.--Grantees under this section shall
provide the Secretary with reports at the conclusion of the each year
of a grant under this section. Each report shall include at least the
following information:
(1) The number of Medicare beneficiaries to whom language
services are provided.
(2) The languages of those Medicare beneficiaries.
(3) The types of language services provided (such as
provision of services directly in non-English language by a
bilingual health care provider or use of an interpreter).
(4) Type of interpretation (such as in-person, telephonic,
or video interpretation).
(5) The methods of providing language services (such as
staff or contract with external independent contractors or
agencies).
(6) The length of time for each interpretation encounter.
(7) The costs of providing language services (which may be
actual or estimated, as determined by the Secretary).
(f) No Cost Sharing.--Limited English proficient Medicare
beneficiaries shall not have to pay cost-sharing or co-pays for
language services provided through this demonstration program.
(g) Evaluation and Report.--The Secretary shall conduct an
evaluation of the demonstration program under this section and shall
submit to the appropriate committees of Congress a report not later
than 1 year after the completion of the program. The report shall
include the following:
(1) An analysis of the patient outcomes and costs of
furnishing care to the limited English proficient Medicare
beneficiaries participating in the project as compared to such
outcomes and costs for limited English proficient Medicare
beneficiaries not participating.
(2) The effect of delivering culturally and linguistically
appropriate services on beneficiary access to care, utilization
of services, efficiency and cost-effectiveness of health care
delivery, patient satisfaction, and select health outcomes.
(3) Recommendations, if any, regarding the extension of
such project to the entire Medicare program.
(h) General Provisions.--Nothing in this section shall be construed
to limit otherwise existing obligations of recipients of Federal
financial assistance under title VI of the Civil Rights Act of 1964 (42
U.S.C. 2000(d) et seq.) or any other statute.
(i) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section $16,000,000 for each fiscal year
of the demonstration program.
SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.
(a) In General.--The Secretary of Health and Human Services shall
enter into an arrangement with the Institute of Medicine under which
the Institute will prepare and publish, not later than 3 years after
the date of the enactment of this Act, a report on the impact of
language access services on the health and health care of limited
English proficient populations.
(b) Contents.--Such report shall include--
(1) recommendations on the development and implementation
of policies and practices by health care organizations and
providers for limited English proficient patient populations;
(2) a description of the effect of providing language
access services on quality of health care and access to care
and reduced medical error; and
(3) a description of the costs associated with or savings
related to provision of language access services.
SEC. 1224. DEFINITIONS.
In this subtitle:
(1) Bilingual.--The term ``bilingual'' with respect to an
individual means a person who has sufficient degree of
proficiency in two languages and can ensure effective
communication can occur in both languages.
(2) Competent interpreter services.--The term ``competent
interpreter services'' means a trans-language rendition of a
spoken message in which the interpreter comprehends the source
language and can speak comprehensively in the target language
to convey the meaning intended in the source language. The
interpreter knows health and health-related terminology and
provides accurate interpretations by choosing equivalent
expressions that convey the best matching and meaning to the
source language and captures, to the greatest possible extent,
all nuances intended in the source message.
(3) Competent translation services.--The term ``competent
translation services'' means a trans-language rendition of a
written document in which the translator comprehends the source
language and can write comprehensively in the target language
to convey the meaning intended in the source language. The
translator knows health and health-related terminology and
provides accurate translations by choosing equivalent
expressions that convey the best matching and meaning to the
source language and captures, to the greatest possible extent,
all nuances intended in the source document.
(4) Effective communication.--The term ``effective
communication'' means an exchange of information between the
provider of health care or health care-related services and the
limited English proficient recipient of such services that
enables limited English proficient individuals to access,
understand, and benefit from health care or health care-related
services.
(5) Interpreting/interpretation.--The terms
``interpreting'' and ``interpretation'' mean the transmission
of a spoken message from one language into another, faithfully,
accurately, and objectively.
(6) Health care services.--The term ``health care
services'' means services that address physical as well as
mental health conditions in all care settings.
(7) Health care-related services.--The term ``health care-
related services'' means human or social services programs or
activities that provide access, referrals or links to health
care.
(8) Language access.--The term ``language access'' means
the provision of language services to an LEP individual
designed to enhance that individual's access to, understanding
of or benefit from health care or health care-related services.
(9) Language services.--The term ``language services''
means provision of health care services directly in a non-
English language, interpretation, translation, and non-English
signage.
(10) Limited english proficient.--The term ``limited
English proficient'' or ``LEP'' with respect to an individual
means an individual who speaks a primary language other than
English and who cannot speak, read, write or understand the
English language at a level that permits the individual to
effectively communicate with clinical or nonclinical staff at
an entity providing health care or health care related
services.
(11) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual entitled to benefits under
part A of title XVIII of the Social Security Act or enrolled
under part B of such title.
(12) Medicare program.--The term ``Medicare program'' means
the programs under parts A through D of title XVIII of the
Social Security Act.
(13) Service provider.--The term ``service provider''
includes all suppliers, providers of services, or entities
under contract to provide coverage, items or services under any
part of title XVIII of the Social Security Act.
Subtitle C--Miscellaneous Improvements
SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS PROCESS.
Section 1833(g)(5) of the Social Security Act (42 U.S.C.
1395l(g)(5)), as amended by section 141 of the Medicare Improvements
for Patients and Providers Act of 2008 (Public Law 110-275), is amended
by striking ``December 31, 2009'' and inserting ``December 31, 2011''.
SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNOSUPPRESSIVE DRUGS FOR
KIDNEY TRANSPLANT PATIENTS AND OTHER RENAL DIALYSIS
PROVISIONS.
(a) Provision of Appropriate Coverage of Immunosuppressive Drugs
Under the Medicare Program for Kidney Transplant Recipients.--
(1) Continued entitlement to immunosuppressive drugs.--
(A) Kidney transplant recipients.--Section
226A(b)(2) of the Social Security Act (42 U.S.C. 426-
1(b)(2)) is amended by inserting ``(except for coverage
of immunosuppressive drugs under section
1861(s)(2)(J))'' before ``, with the thirty-sixth
month''.
(B) Application.--Section 1836 of such Act (42
U.S.C. 1395o) is amended--
(i) by striking ``Every individual who''
and inserting ``(a) In General.--Every
individual who''; and
(ii) by adding at the end the following new
subsection:
``(b) Special Rules Applicable to Individuals Only Eligible for
Coverage of Immunosuppressive Drugs.--
``(1) In general.--In the case of an individual whose
eligibility for benefits under this title has ended on or after
January 1, 2012, except for the coverage of immunosuppressive
drugs by reason of section 226A(b)(2), the following rules
shall apply:
``(A) The individual shall be deemed to be enrolled
under this part for purposes of receiving coverage of
such drugs.
``(B) The individual shall be responsible for
providing for payment of the portion of the premium
under section 1839 which is not covered under the
Medicare savings program (as defined in section
1144(c)(7)) in order to receive such coverage.
``(C) The provision of such drugs shall be subject
to the application of--
``(i) the deductible under section 1833(b);
and
``(ii) the coinsurance amount applicable
for such drugs (as determined under this part).
``(D) If the individual is an inpatient of a
hospital or other entity, the individual is entitled to
receive coverage of such drugs under this part.
``(2) Establishment of procedures in order to implement
coverage.--The Secretary shall establish procedures for--
``(A) identifying individuals that are entitled to
coverage of immunosuppressive drugs by reason of
section 226A(b)(2); and
``(B) distinguishing such individuals from
individuals that are enrolled under this part for the
complete package of benefits under this part.''.
(C) Technical amendment to correct duplicate
subsection designation.--Subsection (d) of section 226A
of such Act (42 U.S.C. 426-1), as added by section
201(a)(3)(D)(ii) of the Social Security Independence
and Program Improvements Act of 1994 (Public Law 103-
296; 108 Stat. 1497), is redesignated as subsection
(d).
(2) Extension of secondary payer requirements for esrd
beneficiaries.--Section 1862(b)(1)(C) of such Act (42 U.S.C.
1395y(b)(1)(C)) is amended by adding at the end the following
new sentence: ``With regard to immunosuppressive drugs
furnished on or after the date of the enactment of the
America's Affordable Health Choices Act of 2009, this
subparagraph shall be applied without regard to any time
limitation.''.
(b) Medicare Coverage for ESRD Patients.--Section 1881 of such Act
is further amended--
(1) in subsection (b)(14)(B)(iii), by inserting ``,
including oral drugs that are not the oral equivalent of an
intravenous drug (such as oral phosphate binders and
calcimimetics),'' after ``other drugs and biologicals'';
(2) in subsection (b)(14)(E)(ii)--
(A) in the first sentence--
(i) by striking ``a one-time election to be
excluded from the phase-in'' and inserting ``an
election, with respect to 2011, 2012, or 2013,
to be excluded from the phase-in (or the
remainder of the phase-in)''; and
(ii) by adding at the end the following:
``for such year and for each subsequent year
during the phase-in described in clause (i)'';
and
(B) in the second sentence--
(i) by striking ``January 1, 2011'' and
inserting ``the first date of such year''; and
(ii) by inserting ``and at a time'' after
``form and manner''; and
(3) in subsection (h)(4)(E), by striking ``lesser'' and
inserting ``greater''.
SEC. 1233. ADVANCE CARE PLANNING CONSULTATION.
(a) Medicare.--
(1) In general.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x) is amended--
(A) in subsection (s)(2)--
(i) by striking ``and'' at the end of
subparagraph (DD);
(ii) by adding ``and'' at the end of
subparagraph (EE); and
(iii) by adding at the end the following
new subparagraph:
``(FF) advance care planning consultation (as defined in
subsection (hhh)(1));''; and
(B) by adding at the end the following new
subsection:
``Advance Care Planning Consultation
``(hhh)(1) Subject to paragraphs (3) and (4), the term `advance
care planning consultation' means a consultation between the individual
and a practitioner described in paragraph (2) regarding advance care
planning, if, subject to paragraph (3), the individual involved has not
had such a consultation within the last 5 years. Such consultation
shall include the following:
``(A) An explanation by the practitioner of advance care
planning, including key questions and considerations, important
steps, and suggested people to talk to.
``(B) An explanation by the practitioner of advance
directives, including living wills and durable powers of
attorney, and their uses.
``(C) An explanation by the practitioner of the role and
responsibilities of a health care proxy.
``(D) The provision by the practitioner of a list of
national and State-specific resources to assist consumers and
their families with advance care planning, including the
national toll-free hotline, the advance care planning
clearinghouses, and State legal service organizations
(including those funded through the Older Americans Act of
1965).
``(E) An explanation by the practitioner of the continuum
of end-of-life services and supports available, including
palliative care and hospice, and benefits for such services and
supports that are available under this title.
``(F)(i) Subject to clause (ii), an explanation of orders
regarding life sustaining treatment or similar orders, which
shall include--
``(I) the reasons why the development of such an
order is beneficial to the individual and the
individual's family and the reasons why such an order
should be updated periodically as the health of the
individual changes;
``(II) the information needed for an individual or
legal surrogate to make informed decisions regarding
the completion of such an order; and
``(III) the identification of resources that an
individual may use to determine the requirements of the
State in which such individual resides so that the
treatment wishes of that individual will be carried out
if the individual is unable to communicate those
wishes, including requirements regarding the
designation of a surrogate decisionmaker (also known as
a health care proxy).
``(ii) The Secretary shall limit the requirement for
explanations under clause (i) to consultations furnished in a
State--
``(I) in which all legal barriers have been
addressed for enabling orders for life sustaining
treatment to constitute a set of medical orders
respected across all care settings; and
``(II) that has in effect a program for orders for
life sustaining treatment described in clause (iii).
``(iii) A program for orders for life sustaining treatment
for a States described in this clause is a program that--
``(I) ensures such orders are standardized and
uniquely identifiable throughout the State;
``(II) distributes or makes accessible such orders
to physicians and other health professionals that
(acting within the scope of the professional's
authority under State law) may sign orders for life
sustaining treatment;
``(III) provides training for health care
professionals across the continuum of care about the
goals and use of orders for life sustaining treatment;
and
``(IV) is guided by a coalition of stakeholders
includes representatives from emergency medical
services, emergency department physicians or nurses,
state long-term care association, state medical
association, state surveyors, agency responsible for
senior services, state department of health, state
hospital association, home health association, state
bar association, and state hospice association.
``(2) A practitioner described in this paragraph is--
``(A) a physician (as defined in subsection (r)(1)); and
``(B) a nurse practitioner or physician's assistant who has
the authority under State law to sign orders for life
sustaining treatments.
``(3)(A) An initial preventive physical examination under
subsection (WW), including any related discussion during such
examination, shall not be considered an advance care planning
consultation for purposes of applying the 5-year limitation under
paragraph (1).
``(B) An advance care planning consultation with respect to an
individual may be conducted more frequently than provided under
paragraph (1) if there is a significant change in the health condition
of the individual, including diagnosis of a chronic, progressive, life-
limiting disease, a life-threatening or terminal diagnosis or life-
threatening injury, or upon admission to a skilled nursing facility, a
long-term care facility (as defined by the Secretary), or a hospice
program.
``(4) A consultation under this subsection may include the
formulation of an order regarding life sustaining treatment or a
similar order.
``(5)(A) For purposes of this section, the term `order regarding
life sustaining treatment' means, with respect to an individual, an
actionable medical order relating to the treatment of that individual
that--
``(i) is signed and dated by a physician (as defined in
subsection (r)(1)) or another health care professional (as
specified by the Secretary and who is acting within the scope
of the professional's authority under State law in signing such
an order, including a nurse practitioner or physician
assistant) and is in a form that permits it to stay with the
individual and be followed by health care professionals and
providers across the continuum of care;
``(ii) effectively communicates the individual's
preferences regarding life sustaining treatment, including an
indication of the treatment and care desired by the individual;
``(iii) is uniquely identifiable and standardized within a
given locality, region, or State (as identified by the
Secretary); and
``(iv) may incorporate any advance directive (as defined in
section 1866(f)(3)) if executed by the individual.
``(B) The level of treatment indicated under subparagraph (A)(ii)
may range from an indication for full treatment to an indication to
limit some or all or specified interventions. Such indicated levels of
treatment may include indications respecting, among other items--
``(i) the intensity of medical intervention if the patient
is pulse less, apneic, or has serious cardiac or pulmonary
problems;
``(ii) the individual's desire regarding transfer to a
hospital or remaining at the current care setting;
``(iii) the use of antibiotics; and
``(iv) the use of artificially administered nutrition and
hydration.''.
(2) Payment.--Section 1848(j)(3) of such Act (42 U.S.C.
1395w-4(j)(3)) is amended by inserting ``(2)(FF),'' after
``(2)(EE),''.
(3) Frequency limitation.--Section 1862(a) of such Act (42
U.S.C. 1395y(a)) is amended--
(A) in paragraph (1)--
(i) in subparagraph (N), by striking
``and'' at the end;
(ii) in subparagraph (O) by striking the
semicolon at the end and inserting ``, and'';
and
(iii) by adding at the end the following
new subparagraph:
``(P) in the case of advance care planning
consultations (as defined in section 1861(hhh)(1)),
which are performed more frequently than is covered
under such section;''; and
(B) in paragraph (7), by striking ``or (K)'' and
inserting ``(K), or (P)''.
(4) Effective date.--The amendments made by this subsection
shall apply to consultations furnished on or after January 1,
2011.
(b) Expansion of Physician Quality Reporting Initiative for End of
Life Care.--
(1) Physician's quality reporting initiative.--Section
1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2))
is amended by adding at the end the following new paragraphs:
``(3) Physician's quality reporting initiative.--
``(A) In general.--For purposes of reporting data
on quality measures for covered professional services
furnished during 2011 and any subsequent year, to the
extent that measures are available, the Secretary shall
include quality measures on end of life care and
advanced care planning that have been adopted or
endorsed by a consensus-based organization, if
appropriate. Such measures shall measure both the
creation of and adherence to orders for life-sustaining
treatment.
``(B) Proposed set of measures.--The Secretary
shall publish in the Federal Register proposed quality
measures on end of life care and advanced care planning
that the Secretary determines are described in
subparagraph (A) and would be appropriate for eligible
professionals to use to submit data to the Secretary.
The Secretary shall provide for a period of public
comment on such set of measures before finalizing such
proposed measures.''.
(c) Inclusion of Information in Medicare & You Handbook.--
(1) Medicare & you handbook.--
(A) In general.--Not later than 1 year after the
date of the enactment of this Act, the Secretary of
Health and Human Services shall update the online
version of the Medicare & You Handbook to include the
following:
(i) An explanation of advance care planning
and advance directives, including--
(I) living wills;
(II) durable power of attorney;
(III) orders of life-sustaining
treatment; and
(IV) health care proxies.
(ii) A description of Federal and State
resources available to assist individuals and
their families with advance care planning and
advance directives, including--
(I) available State legal service
organizations to assist individuals
with advance care planning, including
those organizations that receive
funding pursuant to the Older Americans
Act of 1965 (42 U.S.C. 93001 et seq.);
(II) website links or addresses for
State-specific advance directive forms;
and
(III) any additional information,
as determined by the Secretary.
(B) Update of paper and subsequent versions.--The
Secretary shall include the information described in
subparagraph (A) in all paper and electronic versions
of the Medicare & You Handbook that are published on or
after the date that is 1 year after the date of the
enactment of this Act.
SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND WAIVER OF LIMITED
ENROLLMENT PENALTY FOR TRICARE BENEFICIARIES.
(a) Part B Special Enrollment Period.--
(1) In general.--Section 1837 of the Social Security Act
(42 U.S.C. 1395p) is amended by adding at the end the following
new subsection:
``(l)(1) In the case of any individual who is a covered beneficiary
(as defined in section 1072(5) of title 10, United States Code) at the
time the individual is entitled to hospital insurance benefits under
part A under section 226(b) or section 226A and who is eligible to
enroll but who has elected not to enroll (or to be deemed enrolled)
during the individual's initial enrollment period, there shall be a
special enrollment period described in paragraph (2).
``(2) The special enrollment period described in this paragraph,
with respect to an individual, is the 12-month period beginning on the
day after the last day of the initial enrollment period of the
individual or, if later, the 12-month period beginning with the month
the individual is notified of enrollment under this section.
``(3) In the case of an individual who enrolls during the special
enrollment period provided under paragraph (1), the coverage period
under this part shall begin on the first day of the month in which the
individual enrolls or, at the option of the individual, on the first
day of the second month following the last month of the individual's
initial enrollment period.
``(4) The Secretary of Defense shall establish a method for
identifying individuals described in paragraph (1) and providing notice
to them of their eligibility for enrollment during the special
enrollment period described in paragraph (2).''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to elections made on or after the date of the
enactment of this Act.
(b) Waiver of Increase of Premium.--
(1) In general.--Section 1839(b) of the Social Security Act
(42 U.S.C. 1395r(b)) is amended by striking ``section
1837(i)(4)'' and inserting ``subsection (i)(4) or (l) of
section 1837''.
(2) Effective date.--
(A) In general.--The amendment made by paragraph
(1) shall apply with respect to elections made on or
after the date of the enactment of this Act.
(B) Rebates for certain disabled and esrd
beneficiaries.--
(i) In general.--With respect to premiums
for months on or after January 2005 and before
the month of the enactment of this Act, no
increase in the premium shall be effected for a
month in the case of any individual who is a
covered beneficiary (as defined in section
1072(5) of title 10, United States Code) at the
time the individual is entitled to hospital
insurance benefits under part A of title XVIII
of the Social Security Act under section 226(b)
or 226A of such Act, and who is eligible to
enroll, but who has elected not to enroll (or
to be deemed enrolled), during the individual's
initial enrollment period, and who enrolls
under this part within the 12-month period that
begins on the first day of the month after the
month of notification of entitlement under this
part.
(ii) Consultation with department of
defense.--The Secretary of Health and Human
Services shall consult with the Secretary of
Defense in identifying individuals described in
this paragraph.
(iii) Rebates.--The Secretary of Health and
Human Services shall establish a method for
providing rebates of premium increases paid for
months on or after January 1, 2005, and before
the month of the enactment of this Act for
which a penalty was applied and collected.
SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX YEAR IN CASE OF GAINS
FROM SALE OF PRIMARY RESIDENCE IN COMPUTING PART B
INCOME-RELATED PREMIUM.
(a) In General.--Section 1839(i)(4)(C)(ii)(II) of the Social
Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is amended by inserting
``sale of primary residence,'' after ``divorce of such individual,''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to premiums and payments for years beginning with 2011.
SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PATIENT DECISIONS AIDS.
(a) In General.--The Secretary of Health and Human Services shall
establish a shared decision making demonstration program (in this
subsection referred to as the ``program'') under the Medicare program
using patient decision aids to meet the objective of improving the
understanding by Medicare beneficiaries of their medical treatment
options, as compared to comparable Medicare beneficiaries who do not
participate in a shared decision making process using patient decision
aids.
(b) Sites.--
(1) Enrollment.--The Secretary shall enroll in the program
not more than 30 eligible providers who have experience in
implementing, and have invested in the necessary infrastructure
to implement, shared decision making using patient decision
aids.
(2) Application.--An eligible provider seeking to
participate in the program shall submit to the Secretary an
application at such time and containing such information as the
Secretary may require.
(3) Preference.--In enrolling eligible providers in the
program, the Secretary shall give preference to eligible
providers that--
(A) have documented experience in using patient
decision aids for the conditions identified by the
Secretary and in using shared decision making;
(B) have the necessary information technology
infrastructure to collect the information required by
the Secretary for reporting purposes; and
(C) are trained in how to use patient decision aids
and shared decision making.
(c) Follow-up Counseling Visit.--
(1) In general.--An eligible provider participating in the
program shall routinely schedule Medicare beneficiaries for a
counseling visit after the viewing of such a patient decision
aid to answer any questions the beneficiary may have with
respect to the medical care of the condition involved and to
assist the beneficiary in thinking through how their
preferences and concerns relate to their medical care.
(2) Payment for follow-up counseling visit.--The Secretary
shall establish procedures for making payments for such
counseling visits provided to Medicare beneficiaries under the
program. Such procedures shall provide for the establishment--
(A) of a code (or codes) to represent such
services; and
(B) of a single payment amount for such service
that includes the professional time of the health care
provider and a portion of the reasonable costs of the
infrastructure of the eligible provider such as would
be made under the applicable payment systems to that
provider for similar covered services.
(d) Costs of Aids.--An eligible provider participating in the
program shall be responsible for the costs of selecting, purchasing,
and incorporating such patient decision aids into the provider's
practice, and reporting data on quality and outcome measures under the
program.
(e) Funding.--The Secretary shall provide for the transfer from the
Federal Supplementary Medical Insurance Trust Fund established under
section 1841 of the Social Security Act (42 U.S.C. 1395t) of such funds
as are necessary for the costs of carrying out the program.
(f) Waiver Authority.--The Secretary may waive such requirements of
titles XI and XVIII of the Social Security Act (42 U.S.C. 1301 et seq.
and 1395 et seq.) as may be necessary for the purpose of carrying out
the program.
(g) Report.--Not later than 12 months after the date of completion
of the program, the Secretary shall submit to Congress a report on such
program, together with recommendations for such legislation and
administrative action as the Secretary determines to be appropriate.
The final report shall include an evaluation of the impact of the use
of the program on health quality, utilization of health care services,
and on improving the quality of life of such beneficiaries.
(h) Definitions.--In this section:
(1) Eligible provider.--The term ``eligible provider''
means the following:
(A) A primary care practice.
(B) A specialty practice.
(C) A multispecialty group practice.
(D) A hospital.
(E) A rural health clinic.
(F) A federally qualified health center (as defined
in section 1861(aa)(4) of the Social Security Act (42
U.S.C. 1395x(aa)(4)).
(G) An integrated delivery system.
(H) A State cooperative entity that includes the
State government and at least one other health care
provider which is set up for the purpose of testing
shared decision making and patient decision aids.
(2) Patient decision aid.--The term ``patient decision
aid'' means an educational tool (such as the Internet, a video,
or a pamphlet) that helps patients (or, if appropriate, the
family caregiver of the patient) understand and communicate
their beliefs and preferences related to their treatment
options, and to decide with their health care provider what
treatments are best for them based on their treatment options,
scientific evidence, circumstances, beliefs, and preferences.
(3) Shared decision making.--The term ``shared decision
making'' means a collaborative process between patient and
clinician that engages the patient in decision making, provides
patients with information about trade-offs among treatment
options, and facilitates the incorporation of patient
preferences and values into the medical plan.
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.
Title XVIII of the Social Security Act is amended by inserting
after section 1866C the following new section:
``accountable care organization pilot program
``Sec. 1866D. (a) In General.--The Secretary shall conduct a pilot
program (in this section referred to as the `pilot program') to test
different payment incentive models, including (to the extent
practicable) the specific payment incentive models described in
subsection (c), designed to reduce the growth of expenditures and
improve health outcomes in the provision of items and services under
this title to applicable beneficiaries (as defined in subsection (d))
by qualifying accountable care organizations (as defined in subsection
(b)(1)) in order to--
``(1) promote accountability for a patient population and
coordinate items and services under parts A and B;
``(2) encourage investment in infrastructure and redesigned
care processes for high quality and efficient service delivery;
and
``(3) reward physician practices and other physician
organizational models for the provision of high quality and
efficient health care services.
``(b) Qualifying Accountable Care Organizations (ACOs).--
``(1) Qualifying aco defined.--In this section:
``(A) In general.--The terms `qualifying
accountable care organization' and `qualifying ACO'
mean a group of physicians or other physician
organizational model (as defined in subparagraph (D))
that--
``(i) is organized at least in part for the
purpose of providing physicians' services; and
``(ii) meets such criteria as the Secretary
determines to be appropriate to participate in
the pilot program, including the criteria
specified in paragraph (2).
``(B) Inclusion of other providers.--Nothing in
this subsection shall be construed as preventing a
qualifying ACO from including a hospital or any other
provider of services or supplier furnishing items or
services for which payment may be made under this title
that is affiliated with the ACO under an arrangement
structured so that such provider or supplier
participates in the pilot program and shares in any
incentive payments under the pilot program.
``(C) Physician.--The term `physician' includes,
except as the Secretary may otherwise provide, any
individual who furnishes services for which payment may
be made as physicians' services.
``(D) Other physician organizational model.--The
term `other physician organization model' means, with
respect to a qualifying ACO any model of organization
under which physicians enter into agreements with other
providers for the purposes of participation in the
pilot program in order to provide high quality and
efficient health care services and share in any
incentive payments under such program.
``(E) Other services.--Nothing in this paragraph
shall be construed as preventing a qualifying ACO from
furnishing items or services, for which payment may not
be made under this title, for purposes of achieving
performance goals under the pilot program.
``(2) Qualifying criteria.--The following are criteria
described in this paragraph for an organized group of
physicians to be a qualifying ACO:
``(A) The group has a legal structure that would
allow the group to receive and distribute incentive
payments under this section.
``(B) The group includes a sufficient number of
primary care physicians for the applicable
beneficiaries for whose care the group is accountable
(as determined by the Secretary).
``(C) The group reports on quality measures in such
form, manner, and frequency as specified by the
Secretary (which may be for the group, for providers of
services and suppliers, or both).
``(D) The group reports to the Secretary (in a
form, manner and frequency as specified by the
Secretary) such data as the Secretary determines
appropriate to monitor and evaluate the pilot program.
``(E) The group provides notice to applicable
beneficiaries regarding the pilot program (as
determined appropriate by the Secretary).
``(F) The group contributes to a best practices
network or website, that shall be maintained by the
Secretary for the purpose of sharing strategies on
quality improvement, care coordination, and efficiency
that the groups believe are effective.
``(G) The group utilizes patient-centered processes
of care, including those that emphasize patient and
caregiver involvement in planning and monitoring of
ongoing care management plan.
``(H) The group meets other criteria determined to
be appropriate by the Secretary.
``(c) Specific Payment Incentive Models.--The specific payment
incentive models described in this subsection are the following:
``(1) Performance target model.--Under the performance
target model under this paragraph (in this paragraph referred
to as the `performance target model'):
``(A) In general.--A qualifying ACO qualifies to
receive an incentive payment if expenditures for
applicable beneficiaries are less than a target
spending level or a target rate of growth. The
incentive payment shall be made only if savings are
greater than would result from normal variation in
expenditures for items and services covered under parts
A and B.
``(B) Computation of performance target.--
``(i) In general.--The Secretary shall
establish a performance target for each
qualifying ACO comprised of a base amount
(described in clause (ii)) increased to the
current year by an adjustment factor (described
in clause (iii)). Such a target may be
established on a per capita basis, as the
Secretary determines to be appropriate.
``(ii) Base amount.--For purposes of clause
(i), the base amount in this subparagraph is
equal to the average total payments (or allowed
charges) under parts A and B (and may include
part D, if the Secretary determines
appropriate) for applicable beneficiaries for
whom the qualifying ACO furnishes items and
services in a base period determined by the
Secretary. Such base amount may be determined
on a per capita basis.
``(iii) Adjustment factor.--For purposes of
clause (i), the adjustment factor in this
clause may equal an annual per capita amount
that reflects changes in expenditures from the
period of the base amount to the current year
that would represent an appropriate performance
target for applicable beneficiaries (as
determined by the Secretary). Such adjustment
factor may be determined as an amount or rate,
may be determined on a national, regional,
local, or organization-specific basis, and may
be determined on a per capita basis. Such
adjustment factor also may be adjusted for risk
as determined appropriate by the Secretary.
``(iv) Rebasing.--Under this model the
Secretary shall periodically rebase the base
expenditure amount described in clause (ii).
``(C) Meeting target.--
``(i) In general.--Subject to clause (ii),
a qualifying ACO that meet or exceeds annual
quality and performance targets for a year
shall receive an incentive payment for such
year equal to a portion (as determined
appropriate by the Secretary) of the amount by
which payments under this title for such year
relative are estimated to be below the
performance target for such year, as determined
by the Secretary. The Secretary may establish a
cap on incentive payments for a year for a
qualifying ACO.
``(ii) Limitation.--The Secretary shall
limit incentive payments to each qualifying ACO
under this paragraph as necessary to ensure
that the aggregate expenditures with respect to
applicable beneficiaries for such ACOs under
this title (inclusive of incentive payments
described in this subparagraph) do not exceed
the amount that the Secretary estimates would
be expended for such ACO for such beneficiaries
if the pilot program under this section were
not implemented.
``(D) Reporting and other requirements.--In
carrying out such model, the Secretary may (as the
Secretary determines to be appropriate) incorporate
reporting requirements, incentive payments, and
penalties related to the physician quality reporting
initiative (PQRI), electronic prescribing, electronic
health records, and other similar initiatives under
section 1848, and may use alternative criteria than
would otherwise apply under such section for
determining whether to make such payments. The
incentive payments described in this subparagraph shall
not be included in the limit described in subparagraph
(C)(ii) or in the performance target model described in
this paragraph.
``(2) Partial capitation model.--
``(A) In general.--Subject to subparagraph (B), a
partial capitation model described in this paragraph
(in this paragraph referred to as a `partial capitation
model') is a model in which a qualifying ACO would be
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 a qualifying ACO for applicable beneficiaries for a
year under the partial capitation model shall be
established in a manner that does not result in
spending more for such ACO for such beneficiaries than
would otherwise be expended for such ACO for such
beneficiaries for such year if the pilot program were
not implemented, as estimated by the Secretary.
``(3) Other payment models.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may develop other payment models that meet
the goals of this pilot program to improve quality and
efficiency.
``(B) No additional program expenditures.--
Subparagraph (B) of paragraph (2) shall apply to a
payment model under subparagraph (A) in a similar
manner as such subparagraph (B) applies to the payment
model under paragraph (2).
``(d) Applicable Beneficiaries.--
``(1) In general.--In this section, the term `applicable
beneficiary' means, with respect to a qualifying ACO, an
individual who--
``(A) is enrolled under part B and entitled to
benefits under part A;
``(B) is not enrolled in a Medicare Advantage plan
under part C or a PACE program under section 1894; and
``(C) meets such other criteria as the Secretary
determines appropriate, which may include criteria
relating to frequency of contact with physicians in the
ACO.
``(2) Following applicable beneficiaries.--The Secretary
may monitor data on expenditures and quality of services under
this title after an applicable beneficiary discontinues
receiving services under this title through a qualifying ACO.
``(e) Implementation.--
``(1) Starting date.--The pilot program shall begin no
later than January 1, 2012. An agreement with a qualifying ACO
under the pilot program may cover a multi-year period of
between 3 and 5 years.
``(2) Waiver.--The Secretary may waive such provisions of
this title (including section 1877) and title XI in the manner
the Secretary determines necessary in order implement the pilot
program.
``(3) Performance results reports.--The Secretary shall
report performance results to qualifying ACOs under the pilot
program at least annually.
``(4) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the elements, parameters, scope, and duration
of the pilot program;
``(B) the selection of qualifying ACOs for the
pilot program;
``(C) the establishment of targets, measurement of
performance, determinations with respect to whether
savings have been achieved and the amount of savings;
``(D) determinations regarding whether, to whom,
and in what amounts incentive payments are paid; and
``(E) decisions about the extension of the program
under subsection (g), expansion of the program under
subsection (h) or extensions under subsection (i).
``(5) Administration.--Chapter 35 of title 44, United
States Code shall not apply to this section.
``(f) Evaluation; Monitoring.--
``(1) In general.--The Secretary shall evaluate the payment
incentive model for each qualifying ACO under the pilot program
to assess impacts on beneficiaries, providers of services,
suppliers and the program under this title. The Secretary shall
make such evaluation publicly available within 60 days of the
date of completion of such report.
``(2) Monitoring.--The Inspector General of the Department
of Health and Human Services shall provide for monitoring of
the operation of ACOs under the pilot program with regard to
violations of section 1877 (popularly known as the `Stark
law').
``(g) Extension of Pilot Agreement With Successful Organizations.--
``(1) Reports to congress.--Not later than 2 years after
the date the first agreement is entered into under this
section, and biennially thereafter for six years, the Secretary
shall submit to Congress and make publicly available a report
on the use of authorities under the pilot program. Each report
shall address the impact of the use of those authorities on
expenditures, access, and quality under this title.
``(2) Extension.--Subject to the report provided under
paragraph (1), with respect to a qualifying ACO, the Secretary
may extend the duration of the agreement for such ACO under the
pilot program as the Secretary determines appropriate if--
``(A) the ACO receives incentive payments with
respect to any of the first 4 years of the pilot
agreement and is consistently meeting quality
standards; or
``(B) the ACO is consistently exceeding quality
standards and is not increasing spending under the
program.
``(3) Termination.--The Secretary may terminate an
agreement with a qualifying ACO under the pilot program if such
ACO did not receive incentive payments or consistently failed
to meet quality standards in any of the first 3 years under the
program.
``(h) Expansion to Additional ACOs.--
``(1) Testing and refinement of payment incentive models.--
Subject to the evaluation described in subsection (f), the
Secretary may enter into agreements under the pilot program
with additional qualifying ACOs to further test and refine
payment incentive models with respect to qualifying ACOs.
``(2) Expanding use of successful models to program
implementation.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may issue regulations to implement, on a
permanent basis, 1 or more models if, and to the extent
that, such models are beneficial to the program under
this title, as determined by the Secretary.
``(B) Certification.--The Chief Actuary of the
Centers for Medicare & Medicaid Services shall certify
that 1 or more of such models described in subparagraph
(A) would result in estimated spending that would be
less than what spending would otherwise be estimated to
be in the absence of such expansion.
``(i) Treatment of Physician Group Practice Demonstration.--
``(1) Extension.--The Secretary may enter in to an
agreement with a qualifying ACO under the demonstration under
section 1866A, subject to rebasing and other modifications
deemed appropriate by the Secretary, until the pilot program
under this section is operational.
``(2) Transition.--For purposes of extension of an
agreement with a qualifying ACO under subsection (g)(2), the
Secretary shall treat receipt of an incentive payment for a
year by an organization under the physician group practice
demonstration pursuant to section 1866A as a year for which an
incentive payment is made under such subsection, as long as
such practice group practice organization meets the criteria
under subsection (b)(2).
``(j) Additional Provisions.--
``(1) Authority for separate incentive arrangements.--The
Secretary may create separate incentive arrangements (including
using multiple years of data, varying thresholds, varying
shared savings amounts, and varying shared savings limits) for
different categories of qualifying ACOs to reflect natural
variations in data availability, variation in average annual
attributable expenditures, program integrity, and other matters
the Secretary deems appropriate.
``(2) Encouragement of participation of smaller
organizations.--In order to encourage the participation of
smaller accountable care organizations under the pilot program,
the Secretary may limit a qualifying ACO's exposure to high
cost patients under the program.
``(3) Involvement in private payer arrangements.--Nothing
in this section shall be construed as preventing qualifying
ACOs participating in the pilot program from negotiating
similar contracts with private payers.
``(4) Antidiscrimination limitation.--The Secretary shall
not enter into an agreement with an entity to provide health
care items or services under the pilot program, or with an
entity to administer the program, unless such entity guarantees
that it will not deny, limit, or condition the coverage or
provision of benefits under the program, for individuals
eligible to be enrolled under such program, based on any health
status-related factor described in section 2702(a)(1) of the
Public Health Service Act.
``(5) Construction.--Nothing in this section shall be
construed to compel or require an organization to use an
organization-specific target growth rate for an accountable
care organization under this section for purposes of section
1848.
``(6) Funding.--For purposes of administering and carrying
out the pilot program, other than for payments for items and
services furnished under this title and incentive payments
under subsection (c)(1), in addition to funds otherwise
appropriated, there are appropriated to the Secretary for the
Center for Medicare & Medicaid Services Program Management
Account $25,000,000 for each of fiscal years 2010 through 2014
and $20,000,000 for fiscal year 2015. Amounts appropriated
under this paragraph for a fiscal year shall be available until
expended.''.
SEC. 1302. MEDICAL HOME PILOT PROGRAM.
(a) In General.--Title XVIII of the Social Security Act is amended
by inserting after section 1866D, as inserted by section 1301, the
following new section:
``medical home pilot program
``Sec. 1866E. (a) Establishment and Medical Home Models.--
``(1) Establishment of pilot program.--The Secretary shall
establish a medical home pilot program (in this section
referred to as the `pilot program') for the purpose of
evaluating the feasibility and advisability of reimbursing
qualified patient-centered medical homes for furnishing medical
home services (as defined under subsection (b)(1)) to high need
beneficiaries (as defined in subsection (d)(1)(C)) and to
targeted high need beneficiaries (as defined in subsection
(c)(1)(C)).
``(2) Scope.--Subject to subsection (g), the pilot program
shall include urban, rural, and underserved areas.
``(3) Models of medical homes in the pilot program.--The
pilot program shall evaluate each of the following medical home
models:
``(A) Independent patient-centered medical home
model.--Independent patient-centered medical home model
under subsection (c).
``(B) Community-based medical home model.--
Community-based medical home model under subsection
(d).
``(4) Participation of nurse practitioners and physician
assistants.--
``(A) Nothing in this section shall be construed as
preventing a nurse practitioner from leading a patient
centered medical home so long as--
``(i) all the requirements of this section
are met; and
``(ii) the nurse practitioner is acting
consistently with State law.
``(B) Nothing in this section shall be construed as
preventing a physician assistant from participating in
a patient centered medical home so long as--
``(i) all the requirements of this section
are met; and
``(ii) the physician assistant is acting
consistently with State law.
``(b) Definitions.--For purposes of this section:
``(1) Patient-centered medical home services.--The term
`patient-centered medical home services' means services that--
``(A) provide beneficiaries with direct and ongoing
access to a primary care or principal care by a
physician or nurse practitioner who accepts
responsibility for providing first contact, continuous
and comprehensive care to such beneficiary;
``(B) coordinate the care provided to a beneficiary
by a team of individuals at the practice level across
office, institutional and home settings led by a
primary care or principal care physician or nurse
practitioner, as needed and appropriate;
``(C) provide for all the patient's health care
needs or take responsibility for appropriately
arranging care with other qualified providers for all
stages of life;
``(D) provide continuous access to care and
communication with participating beneficiaries;
``(E) provide support for patient self-management,
proactive and regular patient monitoring, support for
family caregivers, use patient-centered processes, and
coordination with community resources;
``(F) integrate readily accessible, clinically
useful information on participating patients that
enables the practice to treat such patients
comprehensively and systematically; and
``(G) implement evidence-based guidelines and apply
such guidelines to the identified needs of
beneficiaries over time and with the intensity needed
by such beneficiaries.
``(2) Primary care.--The term `primary care' means health
care that is provided by a physician or nurse practitioner who
practices in the field of family medicine, general internal
medicine, geriatric medicine, or pediatric medicine.
``(3) Principal care.--The term `principal care' means
integrated, accessible health care that is provided by a
physician who is a medical subspecialist that addresses the
majority of the personal health care needs of patients with
chronic conditions requiring the subspecialist's expertise, and
for whom the subspecialist assumes care management.
``(c) Independent Patient-Centered Medical Home Model.--
``(1) In general.--
``(A) Payment authority.--Under the independent
patient-centered medical home model under this
subsection, the Secretary shall make payments for
medical home services furnished by an independent
patient-centered medical home (as defined in
subparagraph (B)) pursuant to paragraph (3)(B) for a
targeted high need beneficiaries (as defined in
subparagraph (C)).
``(B) Independent patient-centered medical home
defined.--In this section, the term `independent
patient-centered medical home' means a physician-
directed or nurse-practitioner-directed practice that
is qualified under paragraph (2) as--
``(i) providing beneficiaries with patient-
centered medical home services; and
``(ii) meets such other requirements as the
Secretary may specify.
``(C) Targeted high need beneficiary defined.--For
purposes of this subsection, the term `targeted high
need beneficiary' means a high need beneficiary who,
based on a risk score as specified by the Secretary, is
generally within the upper 50th percentile of Medicare
beneficiaries.
``(D) Beneficiary election to participate.--The
Secretary shall determine an appropriate method of
ensuring that beneficiaries have agreed to participate
in the pilot program.
``(E) Implementation.--The pilot program under this
subsection shall begin no later than 6 months after the
date of the enactment of this section.
``(2) standard setting and qualification process for
patient-centered medical homes.--The Secretary shall review
alternative models for standard setting and qualification, and
shall establish a process--
``(A) to establish standards to enable medical
practices to qualify as patient-centered medical homes;
and
``(B) to initially provide for the review and
certification of medical practices as meeting such
standards.
``(3) Payment.--
``(A) Establishment of methodology.--The Secretary
shall establish a methodology for the payment for
medical home services furnished by independent patient-
centered medical homes. Under such methodology, the
Secretary shall adjust payments to medical homes based
on beneficiary risk scores to ensure that higher
payments are made for higher risk beneficiaries.
``(B) Per beneficiary per month payments.--Under
such payment methodology, the Secretary shall pay
independent patient-centered medical homes a monthly
fee for each targeted high need beneficiary who
consents to receive medical home services through such
medical home.
``(C) Prospective payment.--The fee under
subparagraph (B) shall be paid on a prospective basis.
``(D) Amount of payment.--In determining the amount
of such fee, the Secretary shall consider the
following:
``(i) The clinical work and practice
expenses involved in providing the medical home
services provided by the independent patient-
centered medical home (such as providing
increased access, care coordination, population
disease management, and teaching self-care
skills for managing chronic illnesses) for
which payment is not made under this title as
of the date of the enactment of this section.
``(ii) Allow for differential payments
based on capabilities of the independent
patient-centered medical home.
``(iii) Use appropriate risk-adjustment in
determining the amount of the per beneficiary
per month payment under this paragraph in a
manner that ensures that higher payments are
made for higher risk beneficiaries.
``(4) Encouraging participation of variety of practices.--
The pilot program under this subsection shall be designed to
include the participation of physicians in practices with fewer
than 10 full-time equivalent physicians, as well as physicians
in larger practices, particularly in underserved and rural
areas, as well as federally qualified community health centers,
and rural health centers.
``(5) No duplication in pilot participation.--A physician
in a group practice that participates in the accountable care
organization pilot program under section 1866D shall not be
eligible to participate in the pilot program under this
subsection, unless the pilot program under this section has
been implemented on a permanent basis under subsection (e)(3).
``(d) Community-Based Medical Home Model.--
``(1) In general.--
``(A) Authority for payments.--Under the community-
based medical home model under this subsection (in this
section referred to as the `CBMH model'), the Secretary
shall make payments for the furnishing of medical home
services by a community-based medical home (as defined
in subparagraph (B)) pursuant to paragraph (5)(B) for
high need beneficiaries.
``(B) Community-based medical home defined.--In
this section, the term `community-based medical home'
means a nonprofit community-based or State-based
organization that is certified under paragraph (2) as
meeting the following requirements:
``(i) The organization provides
beneficiaries with medical home services.
``(ii) The organization provides medical
home services under the supervision of and in
close collaboration with the primary care or
principal care physician or nurse practitioner
designated by the beneficiary as his or her
community-based medical home provider.
``(iii) The organization employs community
health workers, including nurses or other non-
physician practitioners, lay health workers, or
other persons as determined appropriate by the
Secretary, that assist the primary or principal
care physician or nurse practitioner in chronic
care management activities such as teaching
self-care skills for managing chronic
illnesses, transitional care services, care
plan setting, medication therapy management
services for patients with multiple chronic
diseases, or help beneficiaries access the
health care and community-based resources in
their local geographic area.
``(iv) The organization meets such other
requirements as the Secretary may specify.
``(C) High need beneficiary.--In this section, the
term `high need beneficiary' means an individual who
requires regular medical monitoring, advising, or
treatment.
``(2) Qualification process for community-based medical
homes.--The Secretary shall establish a process--
``(A) for the initial qualification of community-
based or State-based organizations as community-based
medical homes; and
``(B) to provide for the review and qualification
of such community-based and State-based organizations
pursuant to criteria established by the Secretary.
``(3) Duration.--The pilot program for community-based
medical homes under this subsection shall start no later than 2
years after the date of the enactment of this section. Each
demonstration site under the pilot program shall operate for a
period of up to 5 years after the initial implementation phase,
without regard to the receipt of a initial implementation
funding under subsection (i).
``(4) Preference.--In selecting sites for the CBMH model,
the Secretary may give preference to--
``(A) applications from geographic areas that
propose to coordinate health care services for
chronically ill beneficiaries across a variety of
health care settings, such as primary care physician
practices with fewer than 10 physicians, specialty
physicians, nurse practitioner practices, Federally
qualified health centers, rural health clinics, and
other settings;
``(B) applications that include other payors that
furnish medical home services for chronically ill
patients covered by such payors; and
``(C) applications from States that propose to use
the medical home model to coordinate health care
services for individuals enrolled under this title,
individuals enrolled under title XIX, and full-benefit
dual eligible individuals (as defined in section
1935(c)(6)) with chronic diseases across a variety of
health care settings.
``(5) Payments.--
``(A) Establishment of methodology.--The Secretary
shall establish a methodology for the payment for
medical home services furnished under the CBMH model.
``(B) Per beneficiary per month payments.--Under
such payment methodology, the Secretary shall make two
separate monthly payments for each high need
beneficiary who consents to receive medical home
services through such medical home, as follows:
``(i) Payment to community-based
organization.--One monthly payment to a
community-based or State-based organization.
``(ii) Payment to primary or principal care
practice.--One monthly payment to the primary
or principal care practice for such
beneficiary.
``(C) Prospective payment.--The payments under
subparagraph (B) shall be paid on a prospective basis.
``(D) Amount of payment.--In determining the amount
of such payment, the Secretary shall consider the
following:
``(i) The clinical work and practice
expenses involved in providing the medical home
services provided by the community-based
medical home (such as providing increased
access, care coordination, care plan setting,
population disease management, and teaching
self-care skills for managing chronic
illnesses) for which payment is not made under
this title as of the date of the enactment of
this section.
``(ii) Use appropriate risk-adjustment in
determining the amount of the per beneficiary
per month payment under this paragraph.
``(6) Initial implementation funding.--The Secretary may
make available initial implementation funding to a community
based or State-based organization or a State that is
participating in the pilot program under this subsection. Such
organization shall provide the Secretary with a detailed
implementation plan that includes how such funds will be used.
``(e) Expansion of Program.--
``(1) Evaluation of cost and quality.--The Secretary shall
evaluate the pilot program to determine--
``(A) the extent to which medical homes result in--
``(i) improvement in the quality and
coordination of health care services,
particularly with regard to the care of complex
patients;
``(ii) improvement in reducing health
disparities;
``(iii) reductions in preventable
hospitalizations;
``(iv) prevention of readmissions;
``(v) reductions in emergency room visits;
``(vi) improvement in health outcomes,
including patient functional status where
applicable;
``(vii) improvement in patient
satisfaction;
``(viii) improved efficiency of care such
as reducing duplicative diagnostic tests and
laboratory tests; and
``(ix) reductions in health care
expenditures; and
``(B) the feasability and advisability of
reimbursing medical homes for medical home services
under this title on a permanent basis.
``(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the Secretary
shall submit to Congress and make available to the public a
report on the findings of the evaluation under paragraph (1).
``(3) Expansion of program.--
``(A) In general.--Subject to the results of the
evaluation under paragraph (1) and subparagraph (B),
the Secretary may issue regulations to implement, on a
permanent basis, one or more models, if, and to the
extent that such model or models, are beneficial to the
program under this title, including that such
implementation will improve quality of care, as
determined by the Secretary.
``(B) Certification requirement.--The Secretary may
not issue such regulations unless the Chief Actuary of
the Centers for Medicare & Medicaid Services certifies
that the expansion of the components of the pilot
program described in subparagraph (A) would result in
estimated spending under this title that would be no
more than the level of spending that the Secretary
estimates would otherwise be spent under this title in
the absence of such expansion.
``(f) Administrative Provisions.--
``(1) No duplication in payments.--During any month, the
Secretary may not make payments under this section under more
than one model or through more than one medical home under any
model for the furnishing of medical home services to an
individual.
``(2) No effect on payment for evaluation and management
services.--Payments made under this section are in addition to,
and have no effect on the amount of, payment for evaluation and
management services made under this title.
``(3) Administration.--Chapter 35 of title 44, United
States Code shall not apply to this section.
``(g) Funding.--
``(1) Operational costs.--For purposes of administering and
carrying out the pilot program (including the design,
implementation, technical assistance for and evaluation of such
program), in addition to funds otherwise available, there shall
be transferred from the Federal Supplementary Medical Insurance
Trust Fund under section 1841 to the Secretary for the Centers
for Medicare & Medicaid Services Program Management Account
$6,000,000 for each of fiscal years 2010 through 2014. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
``(2) Patient-centered medical home services.--In addition
to funds otherwise available, there shall be available to the
Secretary for the Centers for Medicare & Medicaid Services,
from the Federal Supplementary Medical Insurance Trust Fund
under section 1841--
``(A) $200,000,000 for each of fiscal years 2010
through 2014 for payments for medical home services
under subsection (c)(3); and
``(B) $125,000,000 for each of fiscal years 2012
through 2016, for payments under subsection (d)(5).
Amounts available under this paragraph for a fiscal year shall
be available until expended.
``(3) Initial implementation.--In addition to funds
otherwise available, there shall be available to the Secretary
for the Centers for Medicare & Medicaid Services, from the
Federal Supplementary Medical Insurance Trust Fund under
section 1841, $2,500,000 for each of fiscal years 2010 through
2012, under subsection (d)(6). Amounts available under this
paragraph for a fiscal year shall be available until expended.
``(h) Treatment of TRHCA Medicare Medical Home Demonstration
Funding.--
``(1) In addition to funds otherwise available for payment
of medical home services under subsection (c)(3), there shall
also be available the amount provided in subsection (g) of
section 204 of division B of the Tax Relief and Health Care Act
of 2006 (42 U.S.C. 1395b-1 note).
``(2) Notwithstanding section 1302(c) of the America's
Affordable Health Choices Act of 2009, in addition to funds
provided in paragraph (1) and subsection (g)(2)(A), the funding
for medical home services that would otherwise have been
available if such section 204 medical home demonstration had
been implemented (without regard to subsection (g) of such
section) shall be available to the independent patient-centered
medical home model described in subsection (c).''.
(b) Effective Date.--The amendment made by this section shall apply
to services furnished on or after the date of the enactment of this
Act.
(c) Conforming Repeal.--Section 204 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395b-1 note), as amended by
section 133(a)(2) of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275), is repealed.
SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY CARE SERVICES.
(a) In General.--Section 1833 of the Social Security Act is amended
by inserting after subsection (o) the following new subsection:
``(p) Primary Care Payment Incentives.--
``(1) In general.--In the case of primary care services (as
defined in paragraph (2)) furnished on or after January 1,
2011, by a primary care practitioner (as defined in paragraph
(3)) for which amounts are payable under section 1848, in
addition to the amount otherwise paid under this part there
shall also be paid to the practitioner (or to an employer or
facility in the cases described in clause (A) of section
1842(b)(6)) (on a monthly or quarterly basis) from the Federal
Supplementary Medical Insurance Trust Fund an amount equal 5
percent (or 10 percent if the practitioner predominately
furnishes such services in an area that is designated (under
section 332(a)(1)(A) of the Public Health Service Act) as a
primary care health professional shortage area.
``(2) Primary care services defined.--In this subsection,
the term `primary care services'--
``(A) means services which are evaluation and
management services as defined in section
1848(j)(5)(A); and
``(B) includes services furnished by another health
care professional that would be described in
subparagraph (A) if furnished by a physician.
``(3) Primary care practitioner defined.--In this
subsection, the term `primary care practitioner'--
``(A) means a physician or other health care
practitioner (including a nurse practitioner) who--
``(i) specializes in family medicine,
general internal medicine, general pediatrics,
geriatrics, or obstetrics and gynecology; and
``(ii) has allowed charges for primary care
services that account for at least 50 percent
of the physician's or practitioner's total
allowed charges under section 1848, as
determined by the Secretary for the most recent
period for which data are available; and
``(B) includes a physician assistant who is under
the supervision of a practitioner described in
subparagraph (A).
``(4) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise, respecting--
``(A) any determination or designation under this
subsection;
``(B) the identification of services as primary
care services under this subsection; and
``(C) the identification of a practitioner as a
primary care practitioner under this subsection.
``(5) Coordination with other payments.--
``(A) With other primary care incentives.--The
provisions of this subsection shall not be taken into
account in applying subsections (m) and (u) and any
payment under such subsections shall not be taken into
account in computing payments under this subsection.
``(B) With quality incentives.--Payments under this
subsection shall not be taken into account in
determining the amounts that would otherwise be paid
under this part for purposes of section
1834(g)(2)(B).''.
(b) Conforming Amendments.--
(1) Section 1833 of such Act (42 U.S.C. 1395l(m)) is
amended by redesignating paragraph (4) as paragraph (5) and by
inserting after paragraph (3) the following new paragraph:
``(4) The provisions of this subsection shall not be taken into
account in applying subsections (m) or (u) and any payment under such
subsections shall not be taken into account in computing payments under
this subsection.''.
(2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w-
4(m)(5)(B)) is amended by inserting ``, (p),'' after ``(m)''.
(3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w-
4(o)(1)(B)(iv)) is amended by inserting ``primary care'' before
``health professional shortage area''.
SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-MIDWIVES.
(a) In General.--Section 1833(a)(1)(K) of the Social Security Act
(42 U.S.C.1395l(a)(1)(K)) is amended by striking ``(but in no event''
and all that follows through ``performed by a physician)''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to services furnished on or after January 1, 2011.
SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES.
(a) Medicare Covered Preventive Services Defined.--Section 1861 of
the Social Security Act (42 U.S.C. 1395x), as amended by section
1235(a)(2), is amended by adding at the end the following new
subsection:
``Medicare Covered Preventive Services
``(iii)(1) Subject to the succeeding provisions of this subsection,
the term `Medicare covered preventive services' means the following:
``(A) Prostate cancer screening tests (as defined in
subsection (oo)).
``(B) Colorectal cancer screening tests (as defined in
subsection (pp) and when applicable as described in section
1305).
``(C) Diabetes outpatient self-management training services
(as defined in subsection (qq)).
``(D) Screening for glaucoma for certain individuals (as
described in subsection (s)(2)(U)).
``(E) Medical nutrition therapy services for certain
individuals (as described in subsection (s)(2)(V)).
``(F) An initial preventive physical examination (as
defined in subsection (ww)).
``(G) Cardiovascular screening blood tests (as defined in
subsection (xx)(1)).
``(H) Diabetes screening tests (as defined in subsection
(yy)).
``(I) Ultrasound screening for abdominal aortic aneurysm
for certain individuals (as described in described in
subsection (s)(2)(AA)).
``(J) Pneumococcal and influenza vaccines and their
administration (as described in subsection (s)(10)(A)) and
hepatitis B vaccine and its administration for certain
individuals (as described in subsection (s)(10)(B)).
``(K) Screening mammography (as defined in subsection
(jj)).
``(L) Screening pap smear and screening pelvic exam (as
defined in subsection (nn)).
``(M) Bone mass measurement (as defined in subsection
(rr)).
``(N) Kidney disease education services (as defined in
subsection (ggg)).
``(O) Additional preventive services (as defined in
subsection (ddd)).
``(2) With respect to specific Medicare covered preventive
services, the limitations and conditions described in the provisions
referenced in paragraph (1) with respect to such services shall
apply.''.
(b) Payment and Elimination of Cost-sharing.--
(1) In general.--
(A) In general.--Section 1833(a) of the Social
Security Act (42 U.S.C. 1395l(a)) is amended by adding
after and below paragraph (9) the following:
``With respect to Medicare covered preventive services, in any case in
which the payment rate otherwise provided under this part is computed
as a percent of less than 100 percent of an actual charge, fee schedule
rate, or other rate, such percentage shall be increased to 100
percent.''.
(B) Application to sigmoidoscopies and
colonoscopies.--Section 1834(d) of such Act (42 U.S.C.
1395m(d)) is amended--
(i) in paragraph (2)(C), by amending clause
(ii) to read as follows:
``(ii) No coinsurance.--In the case of a
beneficiary who receives services described in
clause (i), there shall be no coinsurance
applied.''; and
(ii) in paragraph (3)(C), by amending
clause (ii) to read as follows:
``(ii) No coinsurance.--In the case of a
beneficiary who receives services described in
clause (i), there shall be no coinsurance
applied.''.
(2) Elimination of coinsurance in outpatient hospital
settings.--
(A) Exclusion from opd fee schedule.--Section
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(1)(B)(iv)) is amended by striking ``screening
mammography (as defined in section 1861(jj)) and
diagnostic mammography'' and inserting ``diagnostic
mammograms and Medicare covered preventive services (as
defined in section 1861(iii)(1))''.
(B) Conforming amendments.--Section 1833(a)(2) of
the Social Security Act (42 U.S.C. 1395l(a)(2)) is
amended--
(i) in subparagraph (F), by striking
``and'' after the semicolon at the end;
(ii) in subparagraph (G)(ii), by adding
``and'' at the end; and
(iii) by adding at the end the following
new subparagraph:
``(H) with respect to additional preventive
services (as defined in section 1861(ddd)) furnished by
an outpatient department of a hospital, the amount
determined under paragraph (1)(W);''.
(3) Waiver of application of deductible for all preventive
services.--The first sentence of section 1833(b) of the Social
Security Act (42 U.S.C. 1395l(b)) is amended--
(A) in clause (1), by striking ``items and services
described in section 1861(s)(10)(A)'' and inserting
``Medicare covered preventive services (as defined in
section 1861(iii))'';
(B) by inserting ``and'' before ``(4)''; and
(C) by striking clauses (5) through (8).
(4) Application to providers of services.--Section
1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii))
is amended by inserting ``other than for Medicare covered
preventive services and'' after ``for such items and services
(''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2011.
SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER SCREENING TESTS
REGARDLESS OF CODING, SUBSEQUENT DIAGNOSIS, OR ANCILLARY
TISSUE REMOVAL.
(a) In General.--Section 1833(b) of the Social Security Act (42
U.S.C. 1395l(b)), as amended by section 1305(b)(3), is amended by
adding at the end the following new sentence: ``Clause (1) of the first
sentence of this subsection shall apply with respect to a colorectal
cancer screening test regardless of the code that is billed for the
establishment of a diagnosis as a result of the test, or for the
removal of tissue or other matter or other procedure that is furnished
in connection with, as a result of, and in the same clinical encounter
as, the screening test.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to items and services furnished on or after January 1, 2011.
SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE
UNDER THE MEDICARE SKILLED NURSING FACILITY PROSPECTIVE
PAYMENT SYSTEM AND CONSOLIDATED PAYMENT.
(a) In General.--Section 1888(e)(2)(A)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting ``clinical
social worker services,'' after ``qualified psychologist services,''.
(b) Conforming Amendment.--Section 1861(hh)(2) of the Social
Security Act (42 U.S.C. 1395x(hh)(2)) is amended by striking ``and
other than services furnished to an inpatient of a skilled nursing
facility which the facility is required to provide as a requirement for
participation''.
(c) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after July 1, 2010.
SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND
MENTAL HEALTH COUNSELOR SERVICES.
(a) Coverage of Marriage and Family Therapist Services.--
(1) Coverage of services.--Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as amended by section
1235, is amended--
(A) in subparagraph (EE), by striking ``and'' at
the end;
(B) in subparagraph (FF), by adding ``and'' at the
end; and
(C) by adding at the end the following new
subparagraph:
``(GG) marriage and family therapist services (as
defined in subsection (jjj));''.
(2) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x), as amended by sections 1235 and 1305, is
amended by adding at the end the following new subsection:
``Marriage and Family Therapist Services
``(jjj)(1) The term `marriage and family therapist services' means
services performed by a marriage and family therapist (as defined in
paragraph (2)) for the diagnosis and treatment of mental illnesses,
which the marriage and family therapist is legally authorized to
perform under State law (or the State regulatory mechanism provided by
State law) of the State in which such services are performed, as would
otherwise be covered if furnished by a physician or as incident to a
physician's professional service, but only if no facility or other
provider charges or is paid any amounts with respect to the furnishing
of such services.
``(2) The term `marriage and family therapist' means an individual
who--
``(A) possesses a master's or doctoral degree which
qualifies for licensure or certification as a marriage and
family therapist pursuant to State law;
``(B) after obtaining such degree has performed at least 2
years of clinical supervised experience in marriage and family
therapy; and
``(C) is licensed or certified as a marriage and family
therapist in the State in which marriage and family therapist
services are performed.''.
(3) Provision for payment under part b.--Section
1832(a)(2)(B) of the Social Security Act (42 U.S.C.
1395k(a)(2)(B)) is amended by adding at the end the following
new clause:
``(v) marriage and family therapist
services;''.
(4) Amount of payment.--
(A) In general.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)) is amended--
(i) by striking ``and'' before ``(W)''; and
(ii) by inserting before the semicolon at
the end the following: ``, and (X) with respect
to marriage and family therapist services under
section 1861(s)(2)(GG), the amounts paid shall
be 80 percent of the lesser of the actual
charge for the services or 75 percent of the
amount determined for payment of a psychologist
under clause (L)''.
(B) Development of criteria with respect to
consultation with a health care professional.--The
Secretary of Health and Human Services shall, taking
into consideration concerns for patient
confidentiality, develop criteria with respect to
payment for marriage and family therapist services for
which payment may be made directly to the marriage and
family therapist under part B of title XVIII of the
Social Security Act (42 U.S.C. 1395j et seq.) under
which such a therapist must agree to consult with a
patient's attending or primary care physician or nurse
practitioner in accordance with such criteria.
(5) Exclusion of marriage and family therapist services
from skilled nursing facility prospective payment system.--
Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 1307(a), is amended
by inserting ``marriage and family therapist services (as
defined in subsection (jjj)(1)),'' after ``clinical social
worker services,''.
(6) Coverage of marriage and family therapist services
provided in rural health clinics and federally qualified health
centers.--Section 1861(aa)(1)(B) of the Social Security Act (42
U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a
clinical social worker (as defined in subsection (hh)(1)),''
and inserting ``, by a clinical social worker (as defined in
subsection (hh)(1)), or by a marriage and family therapist (as
defined in subsection (jjj)(2)),''.
(7) Inclusion of marriage and family therapists as
practitioners for assignment of claims.--Section 1842(b)(18)(C)
of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is
amended by adding at the end the following new clause:
``(vii) A marriage and family therapist (as defined in
section 1861(jjj)(2)).''.
(b) Coverage of Mental Health Counselor Services.--
(1) Coverage of services.--Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as previously amended, is
further amended--
(A) in subparagraph (FF), by striking ``and'' at
the end;
(B) in subparagraph (GG), by inserting ``and'' at
the end; and
(C) by adding at the end the following new
subparagraph:
``(HH) mental health counselor services (as defined in
subsection (kkk)(1));''.
(2) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x), as previously amended, is amended by adding
at the end the following new subsection:
``Mental Health Counselor Services
``(kkk)(1) The term `mental health counselor services' means
services performed by a mental health counselor (as defined in
paragraph (2)) for the diagnosis and treatment of mental illnesses
which the mental health counselor is legally authorized to perform
under State law (or the State regulatory mechanism provided by the
State law) of the State in which such services are performed, as would
otherwise be covered if furnished by a physician or as incident to a
physician's professional service, but only if no facility or other
provider charges or is paid any amounts with respect to the furnishing
of such services.
``(2) The term `mental health counselor' means an individual who--
``(A) possesses a master's or doctor's degree which
qualifies the individual for licensure or certification for the
practice of mental health counseling in the State in which the
services are performed;
``(B) after obtaining such a degree has performed at least
2 years of supervised mental health counselor practice; and
``(C) is licensed or certified as a mental health counselor
or professional counselor by the State in which the services
are performed.''.
(3) Provision for payment under part b.--Section
1832(a)(2)(B) of the Social Security Act (42 U.S.C.
1395k(a)(2)(B)), as amended by subsection (a)(3), is further
amended--
(A) by striking ``and'' at the end of clause (iv);
(B) by adding ``and'' at the end of clause (v); and
(C) by adding at the end the following new clause:
``(vi) mental health counselor services;''.
(4) Amount of payment.--
(A) In general.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)), as amended by
subsection (a), is further amended--
(i) by striking ``and''before ``(X)''; and
(ii) by inserting before the semicolon at
the end the following: ``, and (Y), with
respect to mental health counselor services
under section 1861(s)(2)(HH), the amounts paid
shall be 80 percent of the lesser of the actual
charge for the services or 75 percent of the
amount determined for payment of a psychologist
under clause (L)''.
(B) Development of criteria with respect to
consultation with a physician.--The Secretary of Health
and Human Services shall, taking into consideration
concerns for patient confidentiality, develop criteria
with respect to payment for mental health counselor
services for which payment may be made directly to the
mental health counselor under part B of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.) under
which such a counselor must agree to consult with a
patient's attending or primary care physician in
accordance with such criteria.
(5) Exclusion of mental health counselor services from
skilled nursing facility prospective payment system.--Section
1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 1307(a) and
subsection (a), is amended by inserting ``mental health
counselor services (as defined in section 1861(kkk)(1)),''
after ``marriage and family therapist services (as defined in
subsection (jjj)(1)),''.
(6) Coverage of mental health counselor services provided
in rural health clinics and federally qualified health
centers.--Section 1861(aa)(1)(B) of the Social Security Act (42
U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is
amended by striking ``or by a marriage and family therapist (as
defined in subsection (jjj)(2)),'' and inserting ``by a
marriage and family therapist (as defined in subsection
(jjj)(2)), or a mental health counselor (as defined in
subsection (kkk)(2)),''.
(7) Inclusion of mental health counselors as practitioners
for assignment of claims.--Section 1842(b)(18)(C) of the Social
Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by
subsection (a)(7), is amended by adding at the end the
following new clause:
``(viii) A mental health counselor (as defined in section
1861(kkk)(2)).''.
(c) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2011.
SEC. 1309. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON.
Section 138(a)(1) of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275) is amended by striking
``December 31, 2009'' and inserting ``December 31, 2011''.
SEC. 1310. EXPANDING ACCESS TO VACCINES.
(a) In General.--Paragraph (10) of section 1861(s) of the Social
Security Act (42 U.S.C. 1395w(s)) is amended to read as follows:
``(10) federally recommended vaccines (as defined in
subsection (lll)) and their respective administration;''.
(b) Federally Recommended Vaccines Defined.--Section 1861 of such
Act is further amended by adding at the end the following new
subsection:
``Federally Recommended Vaccines
``(lll) The term `federally recommended vaccine' means an approved
vaccine recommended by the Advisory Committee on Immunization Practices
(an advisory committee established by the Secretary, acting through the
Director of the Centers for Disease Control and Prevention).''.
(c) Conforming Amendments.--
(1) Section 1833 of such Act (42 U.S.C. 1395l) is amended,
in each of subsections (a)(1)(B), (a)(2)(G), (a)(3)(A), and
(b)(1) (as amended by section 1305(b)), by striking
``1861(s)(10)(A)'' or ``1861(s)(10)(B)'' and inserting
``1861(s)(10)'' each place it appears.
(2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C.
1395u(o)(1)(A)(iv)) is amended--
(A) by striking ``subparagraph (A) or (B) of''; and
(B) by inserting before the period the following:
``and before January 1, 2011, and influenza vaccines
furnished on or after January 1, 2011''.
(3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w-
3a(c)(6)) is amended by striking subparagraph (G) and inserting
the following:
``(G) Implementation.--Chapter 35 of title 44,
United States Code shall not apply to manufacturer
provision of information pursuant to section
1927(b)(3)(A)(iii) for purposes of implementation of
this section.''.
(4) Section 1860D-2(e)(1)(B) of such Act (42 U.S.C. 1395w-
102(e)(1)(B)) is amended by striking ``such term includes a
vaccine'' and all that follows through ``its administration)
and''.
(5) Section 1861(ww)(2)(A) of such Act (42 U.S.C.
1395x(ww)(2)(A))) is amended by striking ``Pneumococcal,
influenza, and hepatitis B and administration'' and inserting
``Federally recommended vaccines (as defined in subsection
(lll)) and their respective administration''.
(6) Section 1861(iii)(1) of such Act, as added by section
1305(a), is amended by amending subparagraph (J) to read as
follows:
``(J) Federally recommended vaccines (as defined in
subsection (lll)) and their respective administration.''.
(7) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C.
1396r-8(b)(3)(A)(iii)) is amended, in the matter following
subclause (III), by inserting ``(A)(iv) (including influenza
vaccines furnished on or after January 1, 2011),'' after
``described in subparagraph.''
(d) Effective Dates.--The amendments made by--
(1) this section (other than by subsection (c)(7)) shall
apply to vaccines administered on or after January 1, 2011; and
(2) by subsection (c)(7) shall apply to calendar quarters
beginning on or after January 1, 2010.
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH.
(a) In General.--title XI of the Social Security Act is amended by
adding at the end the following new part:
``Part D--Comparative Effectiveness Research
``comparative effectiveness research
``Sec. 1181. (a) Center for Comparative Effectiveness Research
Established.--
``(1) In general.--The Secretary shall establish within the
Agency for Healthcare Research and Quality a Center for
Comparative Effectiveness Research (in this section referred to
as the `Center') to conduct, support, and synthesize research
(including research conducted or supported under section 1013
of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003) with respect to the outcomes,
effectiveness, and appropriateness of health care services and
procedures in order to identify the manner in which diseases,
disorders, and other health conditions can most effectively and
appropriately be prevented, diagnosed, treated, and managed
clinically.
``(2) Duties.--The Center shall--
``(A) conduct, support, and synthesize research
relevant to the comparative effectiveness of the full
spectrum of health care items, services and systems,
including pharmaceuticals, medical devices, medical and
surgical procedures, and other medical interventions;
``(B) conduct and support systematic reviews of
clinical research, including original research
conducted subsequent to the date of the enactment of
this section;
``(C) continuously develop rigorous scientific
methodologies for conducting comparative effectiveness
studies, and use such methodologies appropriately;
``(D) submit to the Comparative Effectiveness
Research Commission, the Secretary, and Congress
appropriate relevant reports described in subsection
(d)(2); and
``(E) encourage, as appropriate, the development
and use of clinical registries and the development of
clinical effectiveness research data networks from
electronic health records, post marketing drug and
medical device surveillance efforts, and other forms of
electronic health data.
``(3) Powers.--
``(A) Obtaining official data.--The Center may
secure directly from any department or agency of the
United States information necessary to enable it to
carry out this section. Upon request of the Center, the
head of that department or agency shall furnish that
information to the Center on an agreed upon schedule.
``(B) Data collection.--In order to carry out its
functions, the Center shall--
``(i) utilize existing information, both
published and unpublished, where possible,
collected and assessed either by its own staff
or under other arrangements made in accordance
with this section,
``(ii) carry out, or award grants or
contracts for, original research and
experimentation, where existing information is
inadequate, and
``(iii) adopt procedures allowing any
interested party to submit information for the
use by the Center and Commission under
subsection (b) in making reports and
recommendations.
``(C) Access of gao to information.--The
Comptroller General shall have unrestricted access to
all deliberations, records, and nonproprietary data of
the Center and Commission under subsection (b),
immediately upon request.
``(D) Periodic audit.--The Center and Commission
under subsection (b) shall be subject to periodic audit
by the Comptroller General.
``(b) Oversight by Comparative Effectiveness Research Commission.--
``(1) In general.--The Secretary shall establish an
independent Comparative Effectiveness Research Commission (in
this section referred to as the `Commission') to oversee and
evaluate the activities carried out by the Center under
subsection (a), subject to the authority of the Secretary, to
ensure such activities result in highly credible research and
information resulting from such research.
``(2) Duties.--The Commission shall--
``(A) determine national priorities for research
described in subsection (a) and in making such
determinations consult with a broad array of public and
private stakeholders, including patients and health
care providers and payers;
``(B) monitor the appropriateness of use of the
CERTF described in subsection (g) with respect to the
timely production of comparative effectiveness research
determined to be a national priority under subparagraph
(A);
``(C) identify highly credible research methods and
standards of evidence for such research to be
considered by the Center;
``(D) review the methodologies developed by the
center under subsection (a)(2)(C);
``(E) not later than one year after the date of the
enactment of this section, enter into an arrangement
under which the Institute of Medicine of the National
Academy of Sciences shall conduct an evaluation and
report on standards of evidence for such research;
``(F) support forums to increase stakeholder
awareness and permit stakeholder feedback on the
efforts of the Center to advance methods and standards
that promote highly credible research;
``(G) make recommendations for policies that would
allow for public access of data produced under this
section, in accordance with appropriate privacy and
proprietary practices, while ensuring that the
information produced through such data is timely and
credible;
``(H) appoint a clinical perspective advisory panel
for each research priority determined under
subparagraph (A), which shall consult with patients and
advise the Center on research questions, methods, and
evidence gaps in terms of clinical outcomes for the
specific research inquiry to be examined with respect
to such priority to ensure that the information
produced from such research is clinically relevant to
decisions made by clinicians and patients at the point
of care;
``(I) make recommendations for the priority for
periodic reviews of previous comparative effectiveness
research and studies conducted by the Center under
subsection (a);
``(J) routinely review processes of the Center with
respect to such research to confirm that the
information produced by such research is objective,
credible, consistent with standards of evidence
established under this section, and developed through a
transparent process that includes consultations with
appropriate stakeholders; and
``(K) make recommendations to the center for the
broad dissemination of the findings of research
conducted and supported under this section that enables
clinicians, patients, consumers, and payers to make
more informed health care decisions that improve
quality and value.
``(3) Composition of commission.--
``(A) In general.--The members of the Commission
shall consist of--
``(i) the Director of the Agency for
Healthcare Research and Quality;
``(ii) the Chief Medical Officer of the
Centers for Medicare & Medicaid Services; and
``(iii) 15 additional members who shall
represent broad constituencies of stakeholders
including clinicians, patients, researchers,
third-party payers, consumers of Federal and
State beneficiary programs.
Of such members, at least 9 shall be practicing
physicians, health care practitioners, consumers, or
patients.
``(B) Qualifications.--
``(i) Diverse representation of
perspectives.--The members of the Commission
shall represent a broad range of perspectives
and shall collectively have experience in the
following areas:
``(I) Epidemiology.
``(II) Health services research.
``(III) Bioethics.
``(IV) Decision sciences.
``(V) Health disparities.
``(VI) Economics.
``(ii) Diverse representation of health
care community.--At least one member shall
represent each of the following health care
communities:
``(I) Patients.
``(II) Health care consumers.
``(III) Practicing Physicians,
including surgeons.
``(IV) Other health care
practitioners engaged in clinical care.
``(V) Employers.
``(VI) Public payers.
``(VII) Insurance plans.
``(VIII) Clinical researchers who
conduct research on behalf of
pharmaceutical or device manufacturers.
``(C) Limitation.--No more than 3 of the Members of
the Commission may be representatives of pharmaceutical
or device manufacturers and such representatives shall
be clinical researchers described under subparagraph
(B)(ii)(VIII).
``(4) Appointment.--
``(A) In general.--The Secretary shall appoint the
members of the Commission.
``(B) Consultation.--In considering candidates for
appointment to the Commission, the Secretary may
consult with the Government Accountability Office and
the Institute of Medicine of the National Academy of
Sciences.
``(5) Chairman; vice chairman.--The Secretary shall
designate a member of the Commission, at the time of
appointment of the member, as Chairman and a member as Vice
Chairman for that term of appointment, except that in the case
of vacancy of the Chairmanship or Vice Chairmanship, the
Secretary may designate another member for the remainder of
that member's term. The Chairman shall serve as an ex officio
member of the National Advisory Council of the Agency for
Health Care Research and Quality under section 931(c)(3)(B) of
the Public Health Service Act.
``(6) Terms.--
``(A) In general.--Except as provided in
subparagraph (B), each member of the Commission shall
be appointed for a term of 4 years.
``(B) Terms of initial appointees.--Of the members
first appointed--
``(i) 8 shall be appointed for a term of 4
years; and
``(ii) 7 shall be appointed for a term of 3
years.
``(7) Coordination.--To enhance effectiveness and
coordination, the Secretary is encouraged, to the greatest
extent possible, to seek coordination between the Commission
and the National Advisory Council of the Agency for Healthcare
Research and Quality.
``(8) Conflicts of interest.--
``(A) In general.--In appointing the members of the
Commission or a clinical perspective advisory panel
described in paragraph (2)(H), the Secretary or the
Commission, respectively, shall take into consideration
any financial interest (as defined in subparagraph
(D)), consistent with this paragraph, and develop a
plan for managing any identified conflicts.
``(B) Evaluation and criteria.--When considering an
appointment to the Commission or a clinical perspective
advisory panel described paragraph (2)(H) the Secretary
or the Commission shall review the expertise of the
individual and the financial disclosure report filed by
the individual pursuant to the Ethics in Government Act
of 1978 for each individual under consideration for the
appointment, so as to reduce the likelihood that an
appointed individual will later require a written
determination as referred to in section 208(b)(1) of
title 18, United States Code, a written certification
as referred to in section 208(b)(3) of title 18, United
States Code, or a waiver as referred to in subparagraph
(D)(iii) for service on the Commission at a meeting of
the Commission.
``(C) Disclosures; prohibitions on participation;
waivers.--
``(i) Disclosure of financial interest.--
Prior to a meeting of the Commission or a
clinical perspective advisory panel described
in paragraph (2)(H) regarding a `particular
matter' (as that term is used in section 208 of
title 18, United States Code), each member of
the Commission or the clinical perspective
advisory panel who is a full-time Government
employee or special Government employee shall
disclose to the Secretary financial interests
in accordance with subsection (b) of such
section 208.
``(ii) Prohibitions on participation.--
Except as provided under clause (iii), a member
of the Commission or a clinical perspective
advisory panel described in paragraph (2)(H)
may not participate with respect to a
particular matter considered in meeting of the
Commission or the clinical perspective advisory
panel if such member (or an immediate family
member of such member) has a financial interest
that could be affected by the advice given to
the Secretary with respect to such matter,
excluding interests exempted in regulations
issued by the Director of the Office of
Government Ethics as too remote or
inconsequential to affect the integrity of the
services of the Government officers or
employees to which such regulations apply.
``(iii) Waiver.--If the Secretary
determines it necessary to afford the
Commission or a clinical perspective advisory
panel described in paragraph 2(H) essential
expertise, the Secretary may grant a waiver of
the prohibition in clause (ii) to permit a
member described in such subparagraph to--
``(I) participate as a non-voting
member with respect to a particular
matter considered in a Commission or a
clinical perspective advisory panel
meeting; or
``(II) participate as a voting
member with respect to a particular
matter considered in a Commission or a
clinical perspective advisory panel
meeting.
``(iv) Limitation on waivers and other
exceptions.--
``(I) Determination of allowable
exceptions for the commission.--The
number of waivers granted to members of
the Commission cannot exceed one-half
of the total number of members for the
Commission.
``(II) Prohibition on voting status
on clinical perspective advisory
panels.--No voting member of any
clinical perspective advisory panel
shall be in receipt of a waiver. No
more than two nonvoting members of any
clinical perspective advisory panel
shall receive a waiver.
``(D) Financial interest defined.--For purposes of
this paragraph, the term `financial interest' means a
financial interest under section 208(a) of title 18,
United States Code.
``(9) Compensation.--While serving on the business of the
Commission (including travel time), a member of the Commission
shall be entitled to compensation at the per diem equivalent of
the rate provided for level IV of the Executive Schedule under
section 5315 of title 5, United States Code; and while so
serving away from home and the member's regular place of
business, a member may be allowed travel expenses, as
authorized by the Director of the Commission.
``(10) Availability of reports.--The Commission shall
transmit to the Secretary a copy of each report submitted under
this subsection and shall make such reports available to the
public.
``(11) Director and staff; experts and consultants.--
Subject to such review as the Secretary deems necessary to
assure the efficient administration of the Commission, the
Commission may--
``(A) appoint an Executive Director (subject to the
approval of the Secretary) and such other personnel as
Federal employees under section 2105 of title 5, United
States Code, as may be necessary to carry out its
duties (without regard to the provisions of title 5,
United States Code, governing appointments in the
competitive service);
``(B) seek such assistance and support as may be
required in the performance of its duties from
appropriate Federal departments and agencies;
``(C) enter into contracts or make other
arrangements, as may be necessary for the conduct of
the work of the Commission (without regard to section
3709 of the Revised Statutes (41 U.S.C. 5));
``(D) make advance, progress, and other payments
which relate to the work of the Commission;
``(E) provide transportation and subsistence for
persons serving without compensation; and
``(F) prescribe such rules and regulations as it
deems necessary with respect to the internal
organization and operation of the Commission.
``(c) Research Requirements.--Any research conducted, supported, or
synthesized under this section shall meet the following requirements:
``(1) Ensuring transparency, credibility, and access.--
``(A) The establishment of the agenda and conduct
of the research shall be insulated from inappropriate
political or stakeholder influence.
``(B) Methods of conducting such research shall be
scientifically based.
``(C) All aspects of the prioritization of
research, conduct of the research, and development of
conclusions based on the research shall be transparent
to all stakeholders.
``(D) The process and methods for conducting such
research shall be publicly documented and available to
all stakeholders.
``(E) Throughout the process of such research, the
Center shall provide opportunities for all stakeholders
involved to review and provide public comment on the
methods and findings of such research.
``(2) Use of clinical perspective advisory panels.--The
research shall meet a national research priority determined
under subsection (b)(2)(A) and shall consider advice given to
the Center by the clinical perspective advisory panel for the
national research priority.
``(3) Stakeholder input.--
``(A) In general.--The Commission shall consult
with patients, health care providers, health care
consumer representatives, and other appropriate
stakeholders with an interest in the research through a
transparent process recommended by the Commission.
``(B) Specific areas of consultation.--Consultation
shall include where deemed appropriate by the
Commission--
``(i) recommending research priorities and
questions;
``(ii) recommending research methodologies;
and
``(iii) advising on and assisting with
efforts to disseminate research findings.
``(C) Ombudsman.--The Secretary shall designate a
patient ombudsman. The ombudsman shall--
``(i) serve as an available point of
contact for any patients with an interest in
proposed comparative effectiveness studies by
the Center; and
``(ii) ensure that any comments from
patients regarding proposed comparative
effectiveness studies are reviewed by the
Commission.
``(4) Taking into account potential differences.--Research
shall--
``(A) be designed, as appropriate, to take into
account the potential for differences in the
effectiveness of health care items and services used
with various subpopulations such as racial and ethnic
minorities, women, different age groups (including
children, adolescents, adults, and seniors), and
individuals with different comorbidities; and
``(B) seek, as feasible and appropriate, to include
members of such subpopulations as subjects in the
research.
``(d) Public Access to Comparative Effectiveness Information.--
``(1) In general.--Not later than 90 days after receipt by
the Center or Commission, as applicable, of a relevant report
described in paragraph (2) made by the Center, Commission, or
clinical perspective advisory panel under this section,
appropriate information contained in such report shall be
posted on the official public Internet site of the Center and
of the Commission, as applicable.
``(2) Relevant reports described.--For purposes of this
section, a relevant report is each of the following submitted
by the Center or a grantee or contractor of the Center:
``(A) Any interim or progress reports as deemed
appropriate by the Secretary.
``(B) Stakeholder comments.
``(C) A final report.
``(e) Dissemination and Incorporation of Comparative Effectiveness
Information.--
``(1) Dissemination.--The Center shall provide for the
dissemination of appropriate findings produced by research
supported, conducted, or synthesized under this section to
health care providers, patients, vendors of health information
technology focused on clinical decision support, appropriate
professional associations, and Federal and private health
plans, and other relevant stakeholders. In disseminating such
findings the Center shall--
``(A) convey findings of research so that they are
comprehensible and useful to patients and providers in
making health care decisions;
``(B) discuss findings and other considerations
specific to certain sub-populations, risk factors, and
comorbidities as appropriate;
``(C) include considerations such as limitations of
research and what further research may be needed, as
appropriate;
``(D) not include any data that the dissemination
of which would violate the privacy of research
participants or violate any confidentiality agreements
made with respect to the use of data under this
section; and
``(E) assist the users of health information
technology focused on clinical decision support to
promote the timely incorporation of such findings into
clinical practices and promote the ease of use of such
incorporation.
``(2) Dissemination protocols and strategies.--The Center
shall develop protocols and strategies for the appropriate
dissemination of research findings in order to ensure effective
communication of findings and the use and incorporation of such
findings into relevant activities for the purpose of informing
higher quality and more effective and efficient decisions
regarding medical items and services. In developing and
adopting such protocols and strategies, the Center shall
consult with stakeholders concerning the types of dissemination
that will be most useful to the end users of information and
may provide for the utilization of multiple formats for
conveying findings to different audiences, including
dissemination to individuals with limited English proficiency.
``(f) Reports to Congress.--
``(1) Annual reports.--Beginning not later than one year
after the date of the enactment of this section, the Director
of the Agency of Healthcare Research and Quality and the
Commission shall submit to Congress an annual report on the
activities of the Center and the Commission, as well as the
research, conducted under this section. Each such report shall
include a discussion of the Center's compliance with subsection
(c)(B)(4), including any reasons for lack of complicance with
such subsection.
``(2) Recommendation for fair share per capita amount for
all-payer financing.--Beginning not later than December 31,
2011, the Secretary shall submit to Congress an annual
recommendation for a fair share per capita amount described in
subsection (c)(1) of section 9511 of the Internal Revenue Code
of 1986 for purposes of funding the CERTF under such section.
``(3) Analysis and review.--Not later than December 31,
2013, the Secretary, in consultation with the Commission, shall
submit to Congress a report on all activities conducted or
supported under this section as of such date. Such report shall
include an evaluation of the overall costs of such activities
and an analysis of the backlog of any research proposals
approved by the Commission but not funded.
``(g) Funding of Comparative Effectiveness Research.--For fiscal
year 2010 and each subsequent fiscal year, amounts in the Comparative
Effectiveness Research Trust Fund (referred to in this section as the
`CERTF') under section 9511 of the Internal Revenue Code of 1986 shall
be available, without the need for further appropriations and without
fiscal year limitation, to the Secretary to carry out this section.
``(h) Construction.--Nothing in this section shall be construed to
permit the Commission or the Center to mandate coverage, reimbursement,
or other policies for any public or private payer.''.
(b) Comparative Effectiveness Research Trust Fund; Financing for
the Trust Fund.--For provision establishing a Comparative Effectiveness
Research Trust Fund and financing such Trust Fund, see section 1802.
Subtitle B--Nursing Home Transparency
PART 1--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING
FACILITIES AND NURSING FACILITIES
SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL DISCLOSABLE
PARTIES INFORMATION.
(a) In General.--Section 1124 of the Social Security Act (42 U.S.C.
1320a-3) is amended by adding at the end the following new subsection:
``(c) Required Disclosure of Ownership and Additional Disclosable
Parties Information.--
``(1) Disclosure.--A facility (as defined in paragraph
(7)(B)) shall have the information described in paragraph (3)
available--
``(A) during the period beginning on the date of
the enactment of this subsection and ending on the date
such information is made available to the public under
section 1411(b) of the America's Affordable Health
Choices Act of 2009, for submission to the Secretary,
the Inspector General of the Department of Health and
Human Services, the State in which the facility is
located, and the State long-term care ombudsman in the
case where the Secretary, the Inspector General, the
State, or the State long-term care ombudsman requests
such information; and
``(B) beginning on the effective date of the final
regulations promulgated under paragraph (4)(A), for
reporting such information in accordance with such
final regulations.
Nothing in subparagraph (A) shall be construed as authorizing a
facility to dispose of or delete information described in such
subparagraph after the effective date of the final regulations
promulgated under paragraph (4)(A).
``(2) Public availability of information.--During the
period described in paragraph (1)(A), a facility shall--
``(A) make the information described in paragraph
(3) available to the public upon request and update
such information as may be necessary to reflect changes
in such information; and
``(B) post a notice of the availability of such
information in the lobby of the facility in a prominent
manner.
``(3) Information described.--
``(A) In general.--The following information is
described in this paragraph:
``(i) The information described in
subsections (a) and (b), subject to
subparagraph (C).
``(ii) The identity of and information on--
``(I) each member of the governing
body of the facility, including the
name, title, and period of service of
each such member;
``(II) each person or entity who is
an officer, director, member, partner,
trustee, or managing employee of the
facility, including the name, title,
and date of start of service of each
such person or entity; and
``(III) each person or entity who
is an additional disclosable party of
the facility.
``(iii) The organizational structure of
each person and entity described in subclauses
(II) and (III) of clause (ii) and a description
of the relationship of each such person or
entity to the facility and to one another.
``(B) Special rule where information is already
reported or submitted.--To the extent that information
reported by a facility to the Internal Revenue Service
on Form 990, information submitted by a facility to the
Securities and Exchange Commission, or information
otherwise submitted to the Secretary or any other
Federal agency contains the information described in
clauses (i), (ii), or (iii) of subparagraph (A), the
Secretary may allow, to the extent practicable, such
Form or such information to meet the requirements of
paragraph (1) and to be submitted in a manner specified
by the Secretary.
``(C) Special rule.--In applying subparagraph
(A)(i)--
``(i) with respect to subsections (a) and
(b), `ownership or control interest' shall
include direct or indirect interests, including
such interests in intermediate entities; and
``(ii) subsection (a)(3)(A)(ii) shall
include the owner of a whole or part interest
in any mortgage, deed of trust, note, or other
obligation secured, in whole or in part, by the
entity or any of the property or assets
thereof, if the interest is equal to or exceeds
5 percent of the total property or assets of
the entirety.
``(4) Reporting.--
``(A) In general.--Not later than the date that is
2 years after the date of the enactment of this
subsection, the Secretary shall promulgate regulations
requiring, effective on the date that is 90 days after
the date on which such final regulations are published
in the Federal Register, a facility to report the
information described in paragraph (3) to the Secretary
in a standardized format, and such other regulations as
are necessary to carry out this subsection. Such final
regulations shall ensure that the facility certifies,
as a condition of participation and payment under the
program under title XVIII or XIX, that the information
reported by the facility in accordance with such final
regulations is accurate and current.
``(B) Guidance.--The Secretary shall provide
guidance and technical assistance to States on how to
adopt the standardized format under subparagraph (A).
``(5) No effect on existing reporting requirements.--
Nothing in this subsection shall reduce, diminish, or alter any
reporting requirement for a facility that is in effect as of
the date of the enactment of this subsection.
``(6) Definitions.--In this subsection:
``(A) Additional disclosable party.--The term
`additional disclosable party' means, with respect to a
facility, any person or entity who--
``(i) exercises operational, financial, or
managerial control over the facility or a part
thereof, or provides policies or procedures for
any of the operations of the facility, or
provides financial or cash management services
to the facility;
``(ii) leases or subleases real property to
the facility, or owns a whole or part interest
equal to or exceeding 5 percent of the total
value of such real property;
``(iii) lends funds or provides a financial
guarantee to the facility in an amount which is
equal to or exceeds $50,000; or
``(iv) provides management or
administrative services, clinical consulting
services, or accounting or financial services
to the facility.
``(B) Facility.--The term `facility' means a
disclosing entity which is--
``(i) a skilled nursing facility (as
defined in section 1819(a)); or
``(ii) a nursing facility (as defined in
section 1919(a)).
``(C) Managing employee.--The term `managing
employee' means, with respect to a facility, an
individual (including a general manager, business
manager, administrator, director, or consultant) who
directly or indirectly manages, advises, or supervises
any element of the practices, finances, or operations
of the facility.
``(D) Organizational structure.--The term
`organizational structure' means, in the case of--
``(i) a corporation, the officers,
directors, and shareholders of the corporation
who have an ownership interest in the
corporation which is equal to or exceeds 5
percent;
``(ii) a limited liability company, the
members and managers of the limited liability
company (including, as applicable, what
percentage each member and manager has of the
ownership interest in the limited liability
company);
``(iii) a general partnership, the partners
of the general partnership;
``(iv) a limited partnership, the general
partners and any limited partners of the
limited partnership who have an ownership
interest in the limited partnership which is
equal to or exceeds 10 percent;
``(v) a trust, the trustees of the trust;
``(vi) an individual, contact information
for the individual; and
``(vii) any other person or entity, such
information as the Secretary determines
appropriate.''.
(b) Public Availability of Information.--
(1) In general.--Not later than the date that is 1 year
after the date on which the final regulations promulgated under
section 1124(c)(4)(A) of the Social Security Act, as added by
subsection (a), are published in the Federal Register, the
information reported in accordance with such final regulations
shall be made available to the public in accordance with
procedures established by the Secretary.
(2) Definitions.--In this subsection:
(A) Nursing facility.--The term ``nursing
facility'' has the meaning given such term in section
1919(a) of the Social Security Act (42 U.S.C.
1396r(a)).
(B) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(C) Skilled nursing facility.--The term ``skilled
nursing facility'' has the meaning given such term in
section 1819(a) of the Social Security Act (42 U.S.C.
1395i-3(a)).
(c) Conforming Amendments.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by
striking subparagraph (B) and redesignating subparagraph (C) as
subparagraph (B).
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking
subparagraph (B) and redesignating subparagraph (C) as
subparagraph (B).
SEC. 1412. ACCOUNTABILITY REQUIREMENTS.
(a) Effective Compliance and Ethics Programs.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by
section 1411(c)(1), is amended by adding at the end the
following new subparagraph:
``(C) Compliance and ethics programs.--
``(i) Requirement.--On or after the date
that is 36 months after the date of the
enactment of this subparagraph, a skilled
nursing facility shall, with respect to the
entity that operates the facility (in this
subparagraph referred to as the `operating
organization' or `organization'), have in
operation a compliance and ethics program that
is effective in preventing and detecting
criminal, civil, and administrative violations
under this Act and in promoting quality of care
consistent with regulations developed under
clause (ii).
``(ii) Development of regulations.--
``(I) In general.--Not later than
the date that is 2 years after such
date of the enactment, the Secretary,
in consultation with the Inspector
General of the Department of Health and
Human Services, shall promulgate
regulations for an effective compliance
and ethics program for operating
organizations, which may include a
model compliance program.
``(II) Design of regulations.--Such
regulations with respect to specific
elements or formality of a program may
vary with the size of the organization,
such that larger organizations should
have a more formal and rigorous program
and include established written
policies defining the standards and
procedures to be followed by its
employees. Such requirements shall
specifically apply to the corporate
level management of multi-unit nursing
home chains.
``(III) Evaluation.--Not later than
3 years after the date of promulgation
of regulations under this clause, the
Secretary shall complete an evaluation
of the compliance and ethics programs
required to be established under this
subparagraph. Such evaluation shall
determine if such programs led to
changes in deficiency citations,
changes in quality performance, or
changes in other metrics of resident
quality of care. The Secretary shall
submit to Congress a report on such
evaluation and shall include in such
report such recommendations regarding
changes in the requirements for such
programs as the Secretary determines
appropriate.
``(iii) Requirements for compliance and
ethics programs.--In this subparagraph, the
term `compliance and ethics program' means,
with respect to a skilled nursing facility, a
program of the operating organization that--
``(I) has been reasonably designed,
implemented, and enforced so that it
generally will be effective in
preventing and detecting criminal,
civil, and administrative violations
under this Act and in promoting quality
of care; and
``(II) includes at least the
required components specified in clause
(iv).
``(iv) Required components of program.--The
required components of a compliance and ethics
program of an organization are the following:
``(I) The organization must have
established compliance standards and
procedures to be followed by its
employees, contractors, and other
agents that are reasonably capable of
reducing the prospect of criminal,
civil, and administrative violations
under this Act.
``(II) Specific individuals within
high-level personnel of the
organization must have been assigned
overall responsibility to oversee
compliance with such standards and
procedures and have sufficient
resources and authority to assure such
compliance.
``(III) The organization must have
used due care not to delegate
substantial discretionary authority to
individuals whom the organization knew,
or should have known through the
exercise of due diligence, had a
propensity to engage in criminal,
civil, and administrative violations
under this Act.
``(IV) The organization must have
taken steps to communicate effectively
its standards and procedures to all
employees and other agents, such as by
requiring participation in training
programs or by disseminating
publications that explain in a
practical manner what is required.
``(V) The organization must have
taken reasonable steps to achieve
compliance with its standards, such as
by utilizing monitoring and auditing
systems reasonably designed to detect
criminal, civil, and administrative
violations under this Act by its
employees and other agents and by
having in place and publicizing a
reporting system whereby employees and
other agents could report violations by
others within the organization without
fear of retribution.
``(VI) The standards must have been
consistently enforced through
appropriate disciplinary mechanisms,
including, as appropriate, discipline
of individuals responsible for the
failure to detect an offense.
``(VII) After an offense has been
detected, the organization must have
taken all reasonable steps to respond
appropriately to the offense and to
prevent further similar offenses,
including repayment of any funds to
which it was not entitled and any
necessary modification to its program
to prevent and detect criminal, civil,
and administrative violations under
this Act.
``(VIII) The organization must
periodically undertake reassessment of
its compliance program to identify
changes necessary to reflect changes
within the organization and its
facilities.
``(v) Coordination.--The provisions of this
subparagraph shall apply with respect to a
skilled nursing facility in lieu of section
1874(d).''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by section
1411(c)(2), is amended by adding at the end the following new
subparagraph:
``(C) Compliance and ethics program.--
``(i) Requirement.--On or after the date
that is 36 months after the date of the
enactment of this subparagraph, a nursing
facility shall, with respect to the entity that
operates the facility (in this subparagraph
referred to as the `operating organization' or
`organization'), have in operation a compliance
and ethics program that is effective in
preventing and detecting criminal, civil, and
administrative violations under this Act and in
promoting quality of care consistent with
regulations developed under clause (ii).
``(ii) Development of regulations.--
``(I) In general.--Not later than
the date that is 2 years after such
date of the enactment, the Secretary,
in consultation with the Inspector
General of the Department of Health and
Human Services, shall develop
regulations for an effective compliance
and ethics program for operating
organizations, which may include a
model compliance program.
``(II) Design of regulations.--Such
regulations with respect to specific
elements or formality of a program may
vary with the size of the organization,
such that larger organizations should
have a more formal and rigorous program
and include established written
policies defining the standards and
procedures to be followed by its
employees. Such requirements may
specifically apply to the corporate
level management of multi-unit nursing
home chains.
``(III) Evaluation.--Not later than
3 years after the date of promulgation
of regulations under this clause the
Secretary shall complete an evaluation
of the compliance and ethics programs
required to be established under this
subparagraph. Such evaluation shall
determine if such programs led to
changes in deficiency citations,
changes in quality performance, or
changes in other metrics of resident
quality of care. The Secretary shall
submit to Congress a report on such
evaluation and shall include in such
report such recommendations regarding
changes in the requirements for such
programs as the Secretary determines
appropriate.
``(iii) Requirements for compliance and
ethics programs.--In this subparagraph, the
term `compliance and ethics program' means,
with respect to a nursing facility, a program
of the operating organization that--
``(I) has been reasonably designed,
implemented, and enforced so that it
generally will be effective in
preventing and detecting criminal,
civil, and administrative violations
under this Act and in promoting quality
of care; and
``(II) includes at least the
required components specified in clause
(iv).
``(iv) Required components of program.--The
required components of a compliance and ethics
program of an organization are the following:
``(I) The organization must have
established compliance standards and
procedures to be followed by its
employees and other agents that are
reasonably capable of reducing the
prospect of criminal, civil, and
administrative violations under this
Act.
``(II) Specific individuals within
high-level personnel of the
organization must have been assigned
overall responsibility to oversee
compliance with such standards and
procedures and has sufficient resources
and authority to assure such
compliance.
``(III) The organization must have
used due care not to delegate
substantial discretionary authority to
individuals whom the organization knew,
or should have known through the
exercise of due diligence, had a
propensity to engage in criminal,
civil, and administrative violations
under this Act.
``(IV) The organization must have
taken steps to communicate effectively
its standards and procedures to all
employees and other agents, such as by
requiring participation in training
programs or by disseminating
publications that explain in a
practical manner what is required.
``(V) The organization must have
taken reasonable steps to achieve
compliance with its standards, such as
by utilizing monitoring and auditing
systems reasonably designed to detect
criminal, civil, and administrative
violations under this Act by its
employees and other agents and by
having in place and publicizing a
reporting system whereby employees and
other agents could report violations by
others within the organization without
fear of retribution.
``(VI) The standards must have been
consistently enforced through
appropriate disciplinary mechanisms,
including, as appropriate, discipline
of individuals responsible for the
failure to detect an offense.
``(VII) After an offense has been
detected, the organization must have
taken all reasonable steps to respond
appropriately to the offense and to
prevent further similar offenses,
including repayment of any funds to
which it was not entitled and any
necessary modification to its program
to prevent and detect criminal, civil,
and administrative violations under
this Act.
``(VIII) The organization must
periodically undertake reassessment of
its compliance program to identify
changes necessary to reflect changes
within the organization and its
facilities.
``(v) Coordination.--The provisions of this
subparagraph shall apply with respect to a
nursing facility in lieu of section
1902(a)(77).''.
(b) Quality Assurance and Performance Improvement Program.--
(1) Skilled nursing facilities.--Section 1819(b)(1)(B) of
the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
(A) by striking ``assurance'' and inserting
``assurance and quality assurance and performance
improvement program'';
(B) by designating the matter beginning with ``A
nursing facility'' as a clause (i) with the heading
``In general.--'' and the appropriate indentation; and
(C) by adding at the end the following new clause:
``(ii) Quality assurance and performance
improvement program.--
``(I) In general.--Not later than
December 31, 2011, the Secretary shall
establish and implement a quality
assurance and performance improvement
program (in this clause referred to as
the `QAPI program') for skilled nursing
facilities, including multi-unit chains
of such facilities. Under the QAPI
program, the Secretary shall establish
standards relating to such facilities
and provide technical assistance to
such facilities on the development of
best practices in order to meet such
standards. Not later than 1 year after
the date on which the regulations are
promulgated under subclause (II), a
skilled nursing facility must submit to
the Secretary a plan for the facility
to meet such standards and implement
such best practices, including how to
coordinate the implementation of such
plan with quality assessment and
assurance activities conducted under
clause (i).
``(II) Regulations.--The Secretary
shall promulgate regulations to carry
out this clause.''.
(2) Nursing facilities.--Section 1919(b)(1)(B) of the
Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
(A) by striking ``assurance'' and inserting
``assurance and quality assurance and performance
improvement program'';
(B) by designating the matter beginning with ``A
nursing facility'' as a clause (i) with the heading
``In general.--'' and the appropriate indentation; and
(C) by adding at the end the following new clause:
``(ii) Quality assurance and performance
improvement program.--
``(I) In general.--Not later than
December 31, 2011, the Secretary shall
establish and implement a quality
assurance and performance improvement
program (in this clause referred to as
the `QAPI program') for nursing
facilities, including multi-unit chains
of such facilities. Under the QAPI
program, the Secretary shall establish
standards relating to such facilities
and provide technical assistance to
such facilities on the development of
best practices in order to meet such
standards. Not later than 1 year after
the date on which the regulations are
promulgated under subclause (II), a
nursing facility must submit to the
Secretary a plan for the facility to
meet such standards and implement such
best practices, including how to
coordinate the implementation of such
plan with quality assessment and
assurance activities conducted under
clause (i).
``(II) Regulations.--The Secretary
shall promulgate regulations to carry
out this clause.''.
(3) Proposal to revise quality assurance and performance
improvement programs.--The Secretary shall include in the
proposed rule published under section 1888(e) of the Social
Security Act (42 U.S.C. 1395yy(e)(5)(A)) for the subsequent
fiscal year to the extent otherwise authorized under section
1819(b)(1)(B) or 1819(d)(1)(C) of the Social Security Act or
other statutory or regulatory authority, one or more proposals
for skilled nursing facilities to modify and strengthen quality
assurance and performance improvement programs in such
facilities. At the time of publication of such proposed rule
and to the extent otherwise authorized under section
1919(b)(1)(B) or 1919(d)(1)(C) of such Act or other regulatory
authority.
(4) Facility plan.--Not later than 1 year after the date on
which the regulations are promulgated under subclause (II) of
clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of the
Social Security Act, as added by paragraphs (1) and (2), a
skilled nursing facility and a nursing facility must submit to
the Secretary a plan for the facility to meet the standards
under such regulations and implement such best practices,
including how to coordinate the implementation of such plan
with quality assessment and assurance activities conducted
under clause (i) of such sections.
(c) GAO Study on Nursing Facility Undercapitalization.--
(1) In general.--The Comptroller General of the United
States shall conduct a study that examines the following:
(A) The extent to which corporations that own or
operate large numbers of nursing facilities, taking
into account ownership type (including private equity
and control interests), are undercapitalizing such
facilities.
(B) The effects of such undercapitalization on
quality of care, including staffing and food costs, at
such facilities.
(C) Options to address such undercapitalization,
such as requirements relating to surety bonds,
liability insurance, or minimum capitalization.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report on the study conducted under paragraph (1).
(3) Nursing facility.--In this subsection, the term
``nursing facility'' includes a skilled nursing facility.
SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819 of the Social Security Act
(42 U.S.C. 1395i-3) is amended--
(A) by redesignating subsection (i) as subsection
(j); and
(B) by inserting after subsection (h) the following
new subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that
the Department of Health and Human Services includes,
as part of the information provided for comparison of
nursing homes on the official Internet website of the
Federal Government for Medicare beneficiaries (commonly
referred to as the `Nursing Home Compare' Medicare
website) (or a successor website), the following
information in a manner that is prominent, easily
accessible, readily understandable to consumers of
long-term care services, and searchable:
``(i) Information that is reported to the
Secretary under section 1124(c)(4).
``(ii) Information on the `Special Focus
Facility program' (or a successor program)
established by the Centers for Medicare and
Medicaid Services, according to procedures
established by the Secretary. Such procedures
shall provide for the inclusion of information
with respect to, and the names and locations
of, those facilities that, since the previous
quarter--
``(I) were newly enrolled in the
program;
``(II) are enrolled in the program
and have failed to significantly
improve;
``(III) are enrolled in the program
and have significantly improved;
``(IV) have graduated from the
program; and
``(V) have closed voluntarily or no
longer participate under this title.
``(iii) Staffing data for each facility
(including resident census data and data on the
hours of care provided per resident per day)
based on data submitted under subsection
(b)(8)(C), including information on staffing
turnover and tenure, in a format that is
clearly understandable to consumers of long-
term care services and allows such consumers to
compare differences in staffing between
facilities and State and national averages for
the facilities. Such format shall include--
``(I) concise explanations of how
to interpret the data (such as a plain
English explanation of data reflecting
`nursing home staff hours per resident
day');
``(II) differences in types of
staff (such as training associated with
different categories of staff);
``(III) the relationship between
nurse staffing levels and quality of
care; and
``(IV) an explanation that
appropriate staffing levels vary based
on patient case mix.
``(iv) Links to State Internet websites
with information regarding State survey and
certification programs, links to Form 2567
State inspection reports (or a successor form)
on such websites, information to guide
consumers in how to interpret and understand
such reports, and the facility plan of
correction or other response to such report.
``(v) The standardized complaint form
developed under subsection (f)(8), including
explanatory material on what complaint forms
are, how they are used, and how to file a
complaint with the State survey and
certification program and the State long-term
care ombudsman program.
``(vi) Summary information on the number,
type, severity, and outcome of substantiated
complaints.
``(vii) The number of adjudicated instances
of criminal violations by employees of a a
nursing facility--
``(I) that were committed inside
the facility;
``(II) with respect to such
instances of violations or crimes
committed inside of the facility that
were the violations or crimes of abuse,
neglect, and exploitation, criminal
sexual abuse, or other violations or
crimes that resulted in serious bodily
injury; and
``(III) the number of civil
monetary penalties levied against the
facility, employees, contractors, and
other agents.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in
clause (ii), the Secretary shall ensure that
the information described in subparagraph (A)
is included on such website (or a successor
website) not later than 1 year after the date
of the enactment of this subsection.
``(ii) Exception.--The Secretary shall
ensure that the information described in
subparagraph (A)(i) and (A)(iii) is included on
such website (or a successor website) not later
than the date on which the requirements under
section 1124(c)(4) and subsection (b)(8)(C)(ii)
are implemented.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of
presentation, timeliness, and comprehensiveness
of information reported on such website as of
the day before the date of the enactment of
this subsection; and
``(ii) not later than 1 year after the date
of the enactment of this subsection, to modify
or revamp such website in accordance with the
review conducted under clause (i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman
programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups; and
``(iv) any other representatives of
programs or groups the Secretary determines
appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1819(g)(5) of the Social
Security Act (42 U.S.C. 1395i-3(g)(5)) is amended by
adding at the end the following new subparagraph:
``(E) Submission of survey and certification
information to the secretary.--In order to improve the
timeliness of information made available to the public
under subparagraph (A) and provided on the Nursing Home
Compare Medicare website under subsection (i), each
State shall submit information respecting any survey or
certification made respecting a skilled nursing
facility (including any enforcement actions taken by
the State) to the Secretary not later than the date on
which the State sends such information to the facility.
The Secretary shall use the information submitted under
the preceding sentence to update the information
provided on the Nursing Home Compare Medicare website
as expeditiously as practicable but not less frequently
than quarterly.''.
(B) Effective date.--The amendment made by this
paragraph shall take effect 1 year after the date of
the enactment of this Act.
(3) Special focus facility program.--Section 1819(f) of
such Act is amended by adding at the end the following new
paragraph:
``(8) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a
special focus facility program for enforcement of
requirements for skilled nursing facilities that the
Secretary has identified as having substantially failed
to meet applicable requirement of this Act.
``(B) Periodic surveys.--Under such program the
Secretary shall conduct surveys of each facility in the
program not less than once every 6 months.''.
(b) Nursing Facilities.--
(1) In general.--Section 1919 of the Social Security Act
(42 U.S.C. 1396r) is amended--
(A) by redesignating subsection (i) as subsection
(j); and
(B) by inserting after subsection (h) the following
new subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that
the Department of Health and Human Services includes,
as part of the information provided for comparison of
nursing homes on the official Internet website of the
Federal Government for Medicare beneficiaries (commonly
referred to as the `Nursing Home Compare' Medicare
website) (or a successor website), the following
information in a manner that is prominent, easily
accessible, readily understandable to consumers of
long-term care services, and searchable:
``(i) Staffing data for each facility
(including resident census data and data on the
hours of care provided per resident per day)
based on data submitted under subsection
(b)(8)(C)(ii), including information on
staffing turnover and tenure, in a format that
is clearly understandable to consumers of long-
term care services and allows such consumers to
compare differences in staffing between
facilities and State and national averages for
the facilities. Such format shall include--
``(I) concise explanations of how
to interpret the data (such as plain
English explanation of data reflecting
`nursing home staff hours per resident
day');
``(II) differences in types of
staff (such as training associated with
different categories of staff);
``(III) the relationship between
nurse staffing levels and quality of
care; and
``(IV) an explanation that
appropriate staffing levels vary based
on patient case mix.
``(ii) Links to State Internet websites
with information regarding State survey and
certification programs, links to Form 2567
State inspection reports (or a successor form)
on such websites, information to guide
consumers in how to interpret and understand
such reports, and the facility plan of
correction or other response to such report.
``(iii) The standardized complaint form
developed under subsection (f)(10), including
explanatory material on what complaint forms
are, how they are used, and how to file a
complaint with the State survey and
certification program and the State long-term
care ombudsman program.
``(iv) Summary information on the number,
type, severity, and outcome of substantiated
complaints.
``(v) The number of adjudicated instances
of criminal violations by employees of a
nursing facility--
``(I) that were committed inside of
the facility; and
``(II) with respect to such
instances of violations or crimes
committed outside of the facility, that
were the violations or crimes that
resulted in the serious bodily injury
of an elder.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in
clause (ii), the Secretary shall ensure that
the information described in subparagraph (A)
is included on such website (or a successor
website) not later than 1 year after the date
of the enactment of this subsection.
``(ii) Exception.--The Secretary shall
ensure that the information described in
subparagraph (A)(i) and (A)(iii) is included on
such website (or a successor website) not later
than the date on which the requirements under
section 1124(c)(4) and subsection (b)(8)(C)(ii)
are implemented.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of
presentation, timeliness, and comprehensiveness
of information reported on such website as of
the day before the date of the enactment of
this subsection; and
``(ii) not later than 1 year after the date
of the enactment of this subsection, to modify
or revamp such website in accordance with the
review conducted under clause (i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman
programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups;
``(iv) skilled nursing facility employees
and their representatives; and
``(v) any other representatives of programs
or groups the Secretary determines
appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1919(g)(5) of the Social
Security Act (42 U.S.C. 1396r(g)(5)) is amended by
adding at the end the following new subparagraph:
``(E) Submission of survey and certification
information to the secretary.--In order to improve the
timeliness of information made available to the public
under subparagraph (A) and provided on the Nursing Home
Compare Medicare website under subsection (i), each
State shall submit information respecting any survey or
certification made respecting a nursing facility
(including any enforcement actions taken by the State)
to the Secretary not later than the date on which the
State sends such information to the facility. The
Secretary shall use the information submitted under the
preceding sentence to update the information provided
on the Nursing Home Compare Medicare website as
expeditiously as practicable but not less frequently
than quarterly.''.
(B) Effective date.--The amendment made by this
paragraph shall take effect 1 year after the date of
the enactment of this Act.
(3) Special focus facility program.--Section 1919(f) of
such Act is amended by adding at the end of the following new
paragraph:
``(10) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a
special focus facility program for enforcement of
requirements for nursing facilities that the Secretary
has identified as having substantially failed to meet
applicable requirements of this Act.
``(B) Periodic surveys.--Under such program the
Secretary shall conduct surveys of each facility in the
program not less often than once every 6 months.''.
(c) Availability of Reports on Surveys, Certifications, and
Complaint Investigations.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by
sections 1411 and 1412, is amended by adding at the end the
following new subparagraph:
``(D) Availability of survey, certification, and
complaint investigation reports.--A skilled nursing
facility must--
``(i) have reports with respect to any
surveys, certifications, and complaint
investigations made respecting the facility
during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of
such reports in areas of the facility that are
prominent and accessible to the public.
The facility shall not make available under clause (i)
identifying information about complainants or
residents.''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by sections
1411 and 1412, is amended by adding at the end the following
new subparagraph:
``(D) Availability of survey, certification, and
complaint investigation reports.--A nursing facility
must--
``(i) have reports with respect to any
surveys, certifications, and complaint
investigations made respecting the facility
during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of
such reports in areas of the facility that are
prominent and accessible to the public.
The facility shall not make available under clause (i)
identifying information about complainants or
residents.''.
(3) Effective date.--The amendments made by this subsection
shall take effect 1 year after the date of the enactment of
this Act.
(d) Guidance to States on Form 2567 State Inspection Reports and
Complaint Investigation Reports.--
(1) Guidance.--The Secretary of Health and Human Services
(in this subtitle referred to as the ``Secretary'') shall
provide guidance to States on how States can establish
electronic links to Form 2567 State inspection reports (or a
successor form), complaint investigation reports, and a
facility's plan of correction or other response to such Form
2567 State inspection reports (or a successor form) on the
Internet website of the State that provides information on
skilled nursing facilities and nursing facilities and the
Secretary shall, if possible, include such information on
Nursing Home Compare.
(2) Requirement.--Section 1902(a)(9) of the Social Security
Act (42 U.S.C. 1396a(a)(9)) is amended--
(A) by striking ``and'' at the end of subparagraph
(B);
(B) by striking the semicolon at the end of
subparagraph (C) and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(D) that the State maintain a consumer-oriented
website providing useful information to consumers
regarding all skilled nursing facilities and all
nursing facilities in the State, including for each
facility, Form 2567 State inspection reports (or a
successor form), complaint investigation reports, the
facility's plan of correction, and such other
information that the State or the Secretary considers
useful in assisting the public to assess the quality of
long term care options and the quality of care provided
by individual facilities;''.
(3) Definitions.--In this subsection:
(A) Nursing facility.--The term ``nursing
facility'' has the meaning given such term in section
1919(a) of the Social Security Act (42 U.S.C.
1396r(a)).
(B) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(C) Skilled nursing facility.--The term ``skilled
nursing facility'' has the meaning given such term in
section 1819(a) of the Social Security Act (42 U.S.C.
1395i-3(a)).
SEC. 1414. REPORTING OF EXPENDITURES.
Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is
amended by adding at the end the following new subsection:
``(f) Reporting of Direct Care Expenditures.--
``(1) In general.--For cost reports submitted under this
title for cost reporting periods beginning on or after the date
that is 3 years after the date of the enactment of this
subsection, skilled nursing facilities shall separately report
expenditures for wages and benefits for direct care staff
(breaking out (at a minimum) registered nurses, licensed
professional nurses, certified nurse assistants, and other
medical and therapy staff).
``(2) Modification of form.--The Secretary, in consultation
with private sector accountants experienced with skilled
nursing facility cost reports, shall redesign such reports to
meet the requirement of paragraph (1) not later than 1 year
after the date of the enactment of this subsection.
``(3) Categorization by functional accounts.--Not later
than 30 months after the date of the enactment of this
subsection, the Secretary, working in consultation with the
Medicare Payment Advisory Commission, the Inspector General of
the Department of Health and Human Services, and other expert
parties the Secretary determines appropriate, shall take the
expenditures listed on cost reports, as modified under
paragraph (1), submitted by skilled nursing facilities and
categorize such expenditures, regardless of any source of
payment for such expenditures, for each skilled nursing
facility into the following functional accounts on an annual
basis:
``(A) Spending on direct care services (including
nursing, therapy, and medical services).
``(B) Spending on indirect care (including
housekeeping and dietary services).
``(C) Capital assets (including building and land
costs).
``(D) Administrative services costs.
``(4) Availability of information submitted.--The Secretary
shall establish procedures to make information on expenditures
submitted under this subsection readily available to interested
parties upon request, subject to such requirements as the
Secretary may specify under the procedures established under
this paragraph.''.
SEC. 1415. STANDARDIZED COMPLAINT FORM.
(a) Skilled Nursing Facilities.--
(1) Development by the secretary.--Section 1819(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)), as amended by
section 1413(a)(3), is amended by adding at the end the
following new paragraph:
``(9) Standardized complaint form.--The Secretary shall
develop a standardized complaint form for use by a resident (or
a person acting on the resident's behalf) in filing a complaint
with a State survey and certification agency and a State long-
term care ombudsman program with respect to a skilled nursing
facility.''.
(2) State requirements.--Section 1819(e) of the Social
Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the
end the following new paragraph:
``(6) Complaint processes and whistle-blower protection.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under subsection
(f)(9) available upon request to--
``(i) a resident of a skilled nursing
facility;
``(ii) any person acting on the resident's
behalf; and
``(iii) any person who works at a skilled
nursing facility or is a representative of such
a worker.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to
ensure that a resident, the legal representative of a
resident of a skilled nursing facility, or other
responsible party is not retaliated against if the
resident, legal representative, or responsible party
has complained, in good faith, about the quality of
care or other issues relating to the skilled nursing
facility, that the legal representative of a resident
of a skilled nursing facility or other responsible
party is not denied access to such resident or
otherwise retaliated against if such representative
party has complained, in good faith, about the quality
of care provided by the facility or other issues
relating to the facility, and that a person who works
at a skilled nursing facility is not retaliated against
if the worker has complained, in good faith, about
quality of care or services or an issue relating to the
quality of care or services provided at the facility,
whether the resident, legal representative, other
responsible party, or worker used the form developed
under subsection (f)(9) or some other method for
submitting the complaint. Such complaint resolution
process shall include--
``(i) procedures to assure accurate
tracking of complaints received, including
notification to the complainant that a
complaint has been received;
``(ii) procedures to determine the likely
severity of a complaint and for the
investigation of the complaint;
``(iii) deadlines for responding to a
complaint and for notifying the complainant of
the outcome of the investigation; and
``(iv) procedures to ensure that the
identity of the complainant will be kept
confidential.
``(C) Whistleblower protection.--
``(i) Prohibition against retaliation.--No
person who works at a skilled nursing facility
may be penalized, discriminated, or retaliated
against with respect to any aspect of
employment, including discharge, promotion,
compensation, terms, conditions, or privileges
of employment, or have a contract for services
terminated, because the person (or anyone
acting at the person's request) complained, in
good faith, about the quality of care or
services provided by a nursing facility or
about other issues relating to quality of care
or services, whether using the form developed
under subsection (f)(9) or some other method
for submitting the complaint.
``(ii) Retaliatory reporting.--A skilled
nursing facility may not file a complaint or a
report against a person who works (or has
worked at the facility with the appropriate
State professional disciplinary agency because
the person (or anyone acting at the person's
request) complained in good faith, as described
in clause (i).
``(iii) Commencement of action.--Any person
who believes the person has been penalized,
discriminated, or retaliated against or had a
contract for services terminated in violation
of clause (i) or against whom a complaint has
been filed in violation of clause (ii) may
bring an action at law or equity in the
appropriate district court of the United
States, which shall have jurisdiction over such
action without regard to the amount in
controversy or the citizenship of the parties,
and which shall have jurisdiction to grant
complete relief, including, but not limited to,
injunctive relief (such as reinstatement,
compensatory damages (which may include
reimbursement of lost wages, compensation, and
benefits), costs of litigation (including
reasonable attorney and expert witness fees),
exemplary damages where appropriate, and such
other relief as the court deems just and
proper.
``(iv) Rights not waivable.--The rights
protected by this paragraph may not be
diminished by contract or other agreement, and
nothing in this paragraph shall be construed to
diminish any greater or additional protection
provided by Federal or State law or by contract
or other agreement.
``(v) Requirement to post notice of
employee rights.--Each skilled nursing facility
shall post conspicuously in an appropriate
location a sign (in a form specified by the
Secretary) specifying the rights of persons
under this paragraph and including a statement
that an employee may file a complaint with the
Secretary against a skilled nursing facility
that violates the provisions of this paragraph
and information with respect to the manner of
filing such a complaint.
``(D) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a resident
of a skilled nursing facility (or a person acting on
the resident's behalf) from submitting a complaint in a
manner or format other than by using the standardized
complaint form developed under subsection (f)(9)
(including submitting a complaint orally).
``(E) Good faith defined.--For purposes of this
paragraph, an individual shall be deemed to be acting
in good faith with respect to the filing of a complaint
if the individual reasonably believes--
``(i) the information reported or disclosed
in the complaint is true; and
``(ii) the violation of this title has
occurred or may occur in relation to such
information.''.
(b) Nursing Facilities.--
(1) Development by the secretary.--Section 1919(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)), as amended by
section 1413(b), is amended by adding at the end the following
new paragraph:
``(11) Standardized complaint form.--The Secretary shall
develop a standardized complaint form for use by a resident (or
a person acting on the resident's behalf) in filing a complaint
with a State survey and certification agency and a State long-
term care ombudsman program with respect to a nursing
facility.''.
(2) State requirements.--Section 1919(e) of the Social
Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the
end the following new paragraph:
``(8) Complaint processes and whistleblower protection.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under subsection
(f)(11) available upon request to--
``(i) a resident of a nursing facility;
``(ii) any person acting on the resident's
behalf; and
``(iii) any person who works at a nursing
facility or a representative of such a worker.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to
ensure that a resident, the legal representative of a
resident of a nursing facility, or other responsible
party is not retaliated against if the resident, legal
representative, or responsible party has complained, in
good faith, about the quality of care or other issues
relating to the nursing facility, that the legal
representative of a resident of a nursing facility or
other responsible party is not denied access to such
resident or otherwise retaliated against if such
representative party has complained, in good faith,
about the quality of care provided by the facility or
other issues relating to the facility, and that a
person who works at a nursing facility is not
retaliated against if the worker has complained, in
good faith, about quality of care or services or an
issue relating to the quality of care or services
provided at the facility, whether the resident, legal
representative, other responsible party, or worker used
the form developed under subsection (f)(11) or some
other method for submitting the complaint. Such
complaint resolution process shall include--
``(i) procedures to assure accurate
tracking of complaints received, including
notification to the complainant that a
complaint has been received;
``(ii) procedures to determine the likely
severity of a complaint and for the
investigation of the complaint;
``(iii) deadlines for responding to a
complaint and for notifying the complainant of
the outcome of the investigation; and
``(iv) procedures to ensure that the
identity of the complainant will be kept
confidential.
``(C) Whistleblower protection.--
``(i) Prohibition against retaliation.--No
person who works at a nursing facility may be
penalized, discriminated, or retaliated against
with respect to any aspect of employment,
including discharge, promotion, compensation,
terms, conditions, or privileges of employment,
or have a contract for services terminated,
because the person (or anyone acting at the
person's request) complained, in good faith,
about the quality of care or services provided
by a nursing facility or about other issues
relating to quality of care or services,
whether using the form developed under
subsection (f)(11) or some other method for
submitting the complaint.
``(ii) Retaliatory reporting.--A nursing
facility may not file a complaint or a report
against a person who works (or has worked at
the facility with the appropriate State
professional disciplinary agency because the
person (or anyone acting at the person's
request) complained in good faith, as described
in clause (i).
``(iii) Commencement of action.--Any person
who believes the person has been penalized,
discriminated, or retaliated against or had a
contract for services terminated in violation
of clause (i) or against whom a complaint has
been filed in violation of clause (ii) may
bring an action at law or equity in the
appropriate district court of the United
States, which shall have jurisdiction over such
action without regard to the amount in
controversy or the citizenship of the parties,
and which shall have jurisdiction to grant
complete relief, including, but not limited to,
injunctive relief (such as reinstatement,
compensatory damages (which may include
reimbursement of lost wages, compensation, and
benefits), costs of litigation (including
reasonable attorney and expert witness fees),
exemplary damages where appropriate, and such
other relief as the court deems just and
proper.
``(iv) Rights not waivable.--The rights
protected by this paragraph may not be
diminished by contract or other agreement, and
nothing in this paragraph shall be construed to
diminish any greater or additional protection
provided by Federal or State law or by contract
or other agreement.
``(v) Requirement to post notice of
employee rights.--Each nursing facility shall
post conspicuously in an appropriate location a
sign (in a form specified by the Secretary)
specifying the rights of persons under this
paragraph and including a statement that an
employee may file a complaint with the
Secretary against a nursing facility that
violates the provisions of this paragraph and
information with respect to the manner of
filing such a complaint.
``(D) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a resident
of a nursing facility (or a person acting on the
resident's behalf) from submitting a complaint in a
manner or format other than by using the standardized
complaint form developed under subsection (f)(11)
(including submitting a complaint orally).
``(E) Good faith defined.--For purposes of this
paragraph, an individual shall be deemed to be acting
in good faith with respect to the filing of a complaint
if the individual reasonably believes--
``(i) the information reported or disclosed
in the complaint is true; and
``(ii) the violation of this title has
occurred or may occur in relation to such
information.''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 1416. ENSURING STAFFING ACCOUNTABILITY.
(a) Skilled Nursing Facilities.--Section 1819(b)(8) of the Social
Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by adding at the end
the following new subparagraph:
``(C) Submission of staffing information based on
payroll data in a uniform format.--Beginning not later
than 2 years after the date of the enactment of this
subparagraph, and after consulting with State long-term
care ombudsman programs, consumer advocacy groups,
provider stakeholder groups, employees and their
representatives, and other parties the Secretary deems
appropriate, the Secretary shall require a skilled
nursing facility to electronically submit to the
Secretary direct care staffing information (including
information with respect to agency and contract staff)
based on payroll and other verifiable and auditable
data in a uniform format (according to specifications
established by the Secretary in consultation with such
programs, groups, and parties). Such specifications
shall require that the information submitted under the
preceding sentence--
``(i) specify the category of work a
certified employee performs (such as whether
the employee is a registered nurse, licensed
practical nurse, licensed vocational nurse,
certified nursing assistant, therapist, or
other medical personnel);
``(ii) include resident census data and
information on resident case mix;
``(iii) include a regular reporting
schedule; and
``(iv) include information on employee
turnover and tenure and on the hours of care
provided by each category of certified
employees referenced in clause (i) per resident
per day.
Nothing in this subparagraph shall be construed as
preventing the Secretary from requiring submission of
such information with respect to specific categories,
such as nursing staff, before other categories of
certified employees. Information under this
subparagraph with respect to agency and contract staff
shall be kept separate from information on employee
staffing.''.
(b) Nursing Facilities.--Section 1919(b)(8) of the Social Security
Act (42 U.S.C. 1396r(b)(8)) is amended by adding at the end the
following new subparagraph:
``(C) Submission of staffing information based on
payroll data in a uniform format.--Beginning not later
than 2 years after the date of the enactment of this
subparagraph, and after consulting with State long-term
care ombudsman programs, consumer advocacy groups,
provider stakeholder groups, employees and their
representatives, and other parties the Secretary deems
appropriate, the Secretary shall require a nursing
facility to electronically submit to the Secretary
direct care staffing information (including information
with respect to agency and contract staff) based on
payroll and other verifiable and auditable data in a
uniform format (according to specifications established
by the Secretary in consultation with such programs,
groups, and parties). Such specifications shall require
that the information submitted under the preceding
sentence--
``(i) specify the category of work a
certified employee performs (such as whether
the employee is a registered nurse, licensed
practical nurse, licensed vocational nurse,
certified nursing assistant, therapist, or
other medical personnel);
``(ii) include resident census data and
information on resident case mix;
``(iii) include a regular reporting
schedule; and
``(iv) include information on employee
turnover and tenure and on the hours of care
provided by each category of certified
employees referenced in clause (i) per resident
per day.
Nothing in this subparagraph shall be construed as
preventing the Secretary from requiring submission of
such information with respect to specific categories,
such as nursing staff, before other categories of
certified employees. Information under this
subparagraph with respect to agency and contract staff
shall be kept separate from information on employee
staffing.''.
PART 2--TARGETING ENFORCEMENT
SEC. 1421. CIVIL MONEY PENALTIES.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(h)(2)(B)(ii) of the Social
Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended to
read as follows:
``(ii) Authority with respect to civil
money penalties.--
``(I) Amount.--The Secretary may
impose a civil money penalty in the
applicable per instance or per day
amount (as defined in subclause (II)
and (III)) for each day or instance,
respectively, of noncompliance (as
determined appropriate by the
Secretary).
``(II) Applicable per instance
amount.--In this clause, the term
`applicable per instance amount'
means--
``(aa) in the case where
the deficiency is found to be a
direct proximate cause of death
of a resident of the facility,
an amount not to exceed
$100,000;
``(bb) in each case of a
deficiency where the facility
is cited for actual harm or
immediate jeopardy, an amount
not less than $3,050 and not
more than $25,000; and
``(cc) in each case of any
other deficiency, an amount not
less than $250 and not to
exceed $3050.
``(III) Applicable per day
amount.--In this clause, the term
`applicable per day amount' means--
``(aa) in each case of a
deficiency where the facility
is cited for actual harm or
immediate jeopardy, an amount
not less than $3,050 and not
more than $25,000; and
``(bb) in each case of any
other deficiency, an amount not
less than $250 and not to
exceed $3,050.
``(IV) Reduction of civil money
penalties in certain circumstances.--
Subject to subclauses (V) and (VI), in
the case where a facility self-reports
and promptly corrects a deficiency for
which a penalty was imposed under this
clause not later than 10 calendar days
after the date of such imposition, the
Secretary may reduce the amount of the
penalty imposed by not more than 50
percent.
``(V) Prohibition on reduction for
certain deficiencies.--
``(aa) Repeat
deficiencies.--The Secretary
may not reduce under subclause
(IV) the amount of a penalty if
the deficiency is a repeat
deficiency.
``(bb) Certain other
deficiencies.--The Secretary
may not reduce under subclause
(IV) the amount of a penalty if
the penalty is imposed for a
deficiency described in
subclause (II)(aa) or (III)(aa)
and the actual harm or
widespread harm immediately
jeopardizes the health or
safety of a resident or
residents of the facility, or
if the penalty is imposed for a
deficiency described in
subclause (II)(bb).
``(VI) Limitation on aggregate
reductions.--The aggregate reduction in
a penalty under subclause (IV) may not
exceed 35 percent on the basis of self-
reporting, on the basis of a waiver or
an appeal (as provided for under
regulations under section 488.436 of
title 42, Code of Federal Regulations),
or on the basis of both.
``(VII) Collection of civil money
penalties.--In the case of a civil
money penalty imposed under this
clause, the Secretary--
``(aa) subject to item
(cc), shall, not later than 30
days after the date of
imposition of the penalty,
provide the opportunity for the
facility to participate in an
independent informal dispute
resolution process which
generates a written record
prior to the collection of such
penalty, but such opportunity
shall not affect the
responsibility of the State
survey agency for making final
recommendations for such
penalties;
``(bb) in the case where
the penalty is imposed for each
day of noncompliance, shall not
impose a penalty for any day
during the period beginning on
the initial day of the
imposition of the penalty and
ending on the day on which the
informal dispute resolution
process under item (aa) is
completed;
``(cc) may provide for the
collection of such civil money
penalty and the placement of
such amounts collected in an
escrow account under the
direction of the Secretary on
the earlier of the date on
which the informal dispute
resolution process under item
(aa) is completed or the date
that is 90 days after the date
of the imposition of the
penalty;
``(dd) may provide that
such amounts collected are kept
in such account pending the
resolution of any subsequent
appeals;
``(ee) in the case where
the facility successfully
appeals the penalty, may
provide for the return of such
amounts collected (plus
interest) to the facility; and
``(ff) in the case where
all such appeals are
unsuccessful, may provide that
some portion of such amounts
collected may be used to
support activities that benefit
residents, including assistance
to support and protect
residents of a facility that
closes (voluntarily or
involuntarily) or is
decertified (including
offsetting costs of relocating
residents to home and
community-based settings or
another facility), projects
that support resident and
family councils and other
consumer involvement in
assuring quality care in
facilities, and facility
improvement initiatives
approved by the Secretary
(including joint training of
facility staff and surveyors,
technical assistance for
facilities under quality
assurance programs, the
appointment of temporary
management, and other
activities approved by the
Secretary).
``(VIII) Procedure.--The provisions
of section 1128A (other than
subsections (a) and (b) and except to
the extent that such provisions require
a hearing prior to the imposition of a
civil money penalty) shall apply to a
civil money penalty under this clause
in the same manner as such provisions
apply to a penalty or proceeding under
section 1128A(a).''.
(2) Conforming amendment.--The second sentence of section
1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-3(h)(5))
is amended by inserting ``(ii),'' after ``(i),''.
(b) Nursing Facilities.--
(1) Penalties imposed by the state.--
(A) In general.--Section 1919(h)(2) of the Social
Security Act (42 U.S.C. 1396r(h)(2)) is amended--
(i) in subparagraph (A)(ii), by striking
the first sentence and inserting the following:
``A civil money penalty in accordance with
subparagraph (G).''; and
(ii) by adding at the end the following new
subparagraph:
``(G) Civil money penalties.--
``(i) In general.--The State may impose a
civil money penalty under subparagraph (A)(ii)
in the applicable per instance or per day
amount (as defined in subclause (II) and (III))
for each day or instance, respectively, of
noncompliance (as determined appropriate by the
Secretary).
``(ii) Applicable per instance amount.--In
this subparagraph, the term `applicable per
instance amount' means--
``(I) in the case where the
deficiency is found to be a direct
proximate cause of death of a resident
of the facility, an amount not to
exceed $100,000;
``(II) in each case of a deficiency
where the facility is cited for actual
harm or immediate jeopardy, an amount
not less than $3,050 and not more than
$25,000; and
``(III) in each case of any other
deficiency, an amount not less than
$250 and not to exceed $3,050.
``(iii) Applicable per day amount.--In this
subparagraph, the term `applicable per day
amount' means--
``(I) in each case of a deficiency
where the facility is cited for actual
harm or immediate jeopardy, an amount
not less than $3,050 and not more than
$25,000; and
``(II) in each case of any other
deficiency, an amount not less than
$250 and not to exceed $3,050.
``(iv) Reduction of civil money penalties
in certain circumstances.--Subject to clauses
(v) and (vi), in the case where a facility
self-reports and promptly corrects a deficiency
for which a penalty was imposed under
subparagraph (A)(ii) not later than 10 calendar
days after the date of such imposition, the
State may reduce the amount of the penalty
imposed by not more than 50 percent.
``(v) Prohibition on reduction for certain
deficiencies.--
``(I) Repeat deficiencies.--The
State may not reduce under clause (iv)
the amount of a penalty if the State
had reduced a penalty imposed on the
facility in the preceding year under
such clause with respect to a repeat
deficiency.
``(II) Certain other
deficiencies.--The State may not reduce
under clause (iv) the amount of a
penalty if the penalty is imposed for a
deficiency described in clause (ii)(II)
or (iii)(I) and the actual harm or
widespread harm that immediately
jeopardizes the health or safety of a
resident or residents of the facility,
or if the penalty is imposed for a
deficiency described in clause (ii)(I).
``(III) Limitation on aggregate
reductions.--The aggregate reduction in
a penalty under clause (iv) may not
exceed 35 percent on the basis of self-
reporting, on the basis of a waiver or
an appeal (as provided for under
regulations under section 488.436 of
title 42, Code of Federal Regulations),
or on the basis of both.
``(iv) Collection of civil money
penalties.--In the case of a civil money
penalty imposed under subparagraph (A)(ii), the
State--
``(I) subject to subclause (III),
shall, not later than 30 days after the
date of imposition of the penalty,
provide the opportunity for the
facility to participate in an
independent informal dispute resolution
process which generates a written
record prior to the collection of such
penalty, but such opportunity shall not
affect the responsibility of the State
survey agency for making final
recommendations for such penalties;
``(II) in the case where the
penalty is imposed for each day of
noncompliance, shall not impose a
penalty for any day during the period
beginning on the initial day of the
imposition of the penalty and ending on
the day on which the informal dispute
resolution process under subclause (I)
is completed;
``(III) may provide for the
collection of such civil money penalty
and the placement of such amounts
collected in an escrow account under
the direction of the State on the
earlier of the date on which the
informal dispute resolution process
under subclause (I) is completed or the
date that is 90 days after the date of
the imposition of the penalty;
``(IV) may provide that such
amounts collected are kept in such
account pending the resolution of any
subsequent appeals;
``(V) in the case where the
facility successfully appeals the
penalty, may provide for the return of
such amounts collected (plus interest)
to the facility; and
``(VI) in the case where all such
appeals are unsuccessful, may provide
that such funds collected shall be used
for the purposes described in the
second sentence of subparagraph
(A)(ii).''.
(B) Conforming amendment.--The second sentence of
section 1919(h)(2)(A)(ii) of the Social Security Act
(42 U.S.C. 1396r(h)(2)(A)(ii)) is amended by inserting
before the period at the end the following: ``, and
some portion of such funds may be used to support
activities that benefit residents, including assistance
to support and protect residents of a facility that
closes (voluntarily or involuntarily) or is decertified
(including offsetting costs of relocating residents to
home and community-based settings or another facility),
projects that support resident and family councils and
other consumer involvement in assuring quality care in
facilities, and facility improvement initiatives
approved by the Secretary (including joint training of
facility staff and surveyors, providing technical
assistance to facilities under quality assurance
programs, the appointment of temporary management, and
other activities approved by the Secretary)''.
(2) Penalties imposed by the secretary.--
(A) In general.--Section 1919(h)(3)(C)(ii) of the
Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is
amended to read as follows:
``(ii) Authority with respect to civil
money penalties.--
``(I) Amount.--Subject to subclause
(II), the Secretary may impose a civil
money penalty in an amount not to
exceed $10,000 for each day or each
instance of noncompliance (as
determined appropriate by the
Secretary).
``(II) Reduction of civil money
penalties in certain circumstances.--
Subject to subclause (III), in the case
where a facility self-reports and
promptly corrects a deficiency for
which a penalty was imposed under this
clause not later than 10 calendar days
after the date of such imposition, the
Secretary may reduce the amount of the
penalty imposed by not more than 50
percent.
``(III) Prohibition on reduction
for repeat deficiencies.--The Secretary
may not reduce the amount of a penalty
under subclause (II) if the Secretary
had reduced a penalty imposed on the
facility in the preceding year under
such subclause with respect to a repeat
deficiency.
``(IV) Collection of civil money
penalties.--In the case of a civil
money penalty imposed under this
clause, the Secretary--
``(aa) subject to item
(bb), shall, not later than 30
days after the date of
imposition of the penalty,
provide the opportunity for the
facility to participate in an
independent informal dispute
resolution process which
generates a written record
prior to the collection of such
penalty;
``(bb) in the case where
the penalty is imposed for each
day of noncompliance, shall not
impose a penalty for any day
during the period beginning on
the initial day of the
imposition of the penalty and
ending on the day on which the
informal dispute resolution
process under item (aa) is
completed;
``(cc) may provide for the
collection of such civil money
penalty and the placement of
such amounts collected in an
escrow account under the
direction of the Secretary on
the earlier of the date on
which the informal dispute
resolution process under item
(aa) is completed or the date
that is 90 days after the date
of the imposition of the
penalty;
``(dd) may provide that
such amounts collected are kept
in such account pending the
resolution of any subsequent
appeals;
``(ee) in the case where
the facility successfully
appeals the penalty, may
provide for the return of such
amounts collected (plus
interest) to the facility; and
``(ff) in the case where
all such appeals are
unsuccessful, may provide that
some portion of such amounts
collected may be used to
support activities that benefit
residents, including assistance
to support and protect
residents of a facility that
closes (voluntarily or
involuntarily) or is
decertified (including
offsetting costs of relocating
residents to home and
community-based settings or
another facility), projects
that support resident and
family councils and other
consumer involvement in
assuring quality care in
facilities, and facility
improvement initiatives
approved by the Secretary
(including joint training of
facility staff and surveyors,
technical assistance for
facilities under quality
assurance programs, the
appointment of temporary
management, and other
activities approved by the
Secretary).
``(V) Procedure.--The provisions of
section 1128A (other than subsections
(a) and (b) and except to the extent
that such provisions require a hearing
prior to the imposition of a civil
money penalty) shall apply to a civil
money penalty under this clause in the
same manner as such provisions apply to
a penalty or proceeding under section
1128A(a).''.
(B) Conforming amendment.--Section 1919(h)(8) of
the Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is
amended by inserting ``and in paragraph (3)(C)(ii)''
after ``paragraph (2)(A)''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM.
(a) Establishment.--
(1) In general.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall establish a pilot program (in this section
referred to as the ``pilot program'') to develop, test, and
implement use of an independent monitor to oversee interstate
and large intrastate chains of skilled nursing facilities and
nursing facilities.
(2) Selection.--The Secretary shall select chains of
skilled nursing facilities and nursing facilities described in
paragraph (1) to participate in the pilot program from among
those chains that submit an application to the Secretary at
such time, in such manner, and containing such information as
the Secretary may require.
(3) Duration.--The Secretary shall conduct the pilot
program for a two-year period.
(4) Implementation.--The Secretary shall implement the
pilot program not later than one year after the date of the
enactment of this Act.
(b) Requirements.--The Secretary shall evaluate chains selected to
participate in the pilot program based on criteria selected by the
Secretary, including where evidence suggests that one or more
facilities of the chain are experiencing serious safety and quality of
care problems. Such criteria may include the evaluation of a chain that
includes one or more facilities participating in the ``Special Focus
Facility'' program (or a successor program) or one or more facilities
with a record of repeated serious safety and quality of care
deficiencies.
(c) Responsibilities of the Independent Monitor.--An independent
monitor that enters into a contract with the Secretary to participate
in the conduct of such program shall--
(1) conduct periodic reviews and prepare root-cause quality
and deficiency analyses of a chain to assess if facilities of
the chain are in compliance with State and Federal laws and
regulations applicable to the facilities;
(2) undertake sustained oversight of the chain, whether
publicly or privately held, to involve the owners of the chain
and the principal business partners of such owners in
facilitating compliance by facilities of the chain with State
and Federal laws and regulations applicable to the facilities;
(3) analyze the management structure, distribution of
expenditures, and nurse staffing levels of facilities of the
chain in relation to resident census, staff turnover rates, and
tenure;
(4) report findings and recommendations with respect to
such reviews, analyses, and oversight to the chain and
facilities of the chain, to the Secretary and to relevant
States; and
(5) publish the results of such reviews, analyses, and
oversight.
(d) Implementation of Recommendations.--
(1) Receipt of finding by chain.--Not later than 10 days
after receipt of a finding of an independent monitor under
subsection (c)(4), a chain participating in the pilot program
shall submit to the independent monitor a report--
(A) outlining corrective actions the chain will
take to implement the recommendations in such report;
or
(B) indicating that the chain will not implement
such recommendations and why it will not do so.
(2) Receipt of report by independent monitor.--Not later
than 10 days after the date of receipt of a report submitted by
a chain under paragraph (1), an independent monitor shall
finalize its recommendations and submit a report to the chain
and facilities of the chain, the Secretary, and the State (or
States) involved, as appropriate, containing such final
recommendations.
(e) Cost of Appointment.--A chain shall be responsible for a
portion of the costs associated with the appointment of independent
monitors under the pilot program. The chain shall pay such portion to
the Secretary (in an amount and in accordance with procedures
established by the Secretary).
(f) Waiver Authority.--The Secretary may waive such requirements of
titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et
seq.; 1396 et seq.) as may be necessary for the purpose of carrying out
the pilot program.
(g) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary to carry out this section.
(h) Definitions.--In this section:
(1) Facility.--The term ``facility'' means a skilled
nursing facility or a nursing facility.
(2) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Assistant
Secretary for Planning and Evaluation.
(4) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(i) Evaluation and Report.--
(1) Evaluation.--The Inspector General of the Department of
Health and Human Services shall evaluate the pilot program.
Such evaluation shall--
(A) determine whether the independent monitor
program should be established on a permanent basis; and
(B) if the Inspector General determines that the
independent monitor program should be established on a
permanent basis, recommend appropriate procedures and
mechanisms for such establishment.
(2) Report.--Not later than 180 days after the completion
of the pilot program, the Inspector General shall submit to
Congress and the Secretary a report containing the results of
the evaluation conducted under paragraph (1), together with
recommendations for such legislation and administrative action
as the Inspector General determines appropriate.
SEC. 1423. NOTIFICATION OF FACILITY CLOSURE.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(c) of the Social Security Act
(42 U.S.C. 1395i-3(c)) is amended by adding at the end the
following new paragraph:
``(7) Notification of facility closure.--
``(A) In general.--Any individual who is the
administrator of a skilled nursing facility must--
``(i) submit to the Secretary, the State
long-term care ombudsman, residents of the
facility, and the legal representatives of such
residents or other responsible parties, written
notification of an impending closure--
``(I) subject to subclause (II),
not later than the date that is 60 days
prior to the date of such closure; and
``(II) in the case of a facility
where the Secretary terminates the
facility's participation under this
title, not later than the date that the
Secretary determines appropriate;
``(ii) ensure that the facility does not
admit any new residents on or after the date on
which such written notification is submitted;
and
``(iii) include in the notice a plan for
the transfer and adequate relocation of the
residents of the facility by a specified date
prior to closure that has been approved by the
State, including assurances that the residents
will be transferred to the most appropriate
facility or other setting in terms of quality,
services, and location, taking into
consideration the needs and best interests of
each resident.
``(B) Relocation.--
``(i) In general.--The State shall ensure
that, before a facility closes, all residents
of the facility have been successfully
relocated to another facility or an alternative
home and community-based setting.
``(ii) Continuation of payments until
residents relocated.--The Secretary may, as the
Secretary determines appropriate, continue to
make payments under this title with respect to
residents of a facility that has submitted a
notification under subparagraph (A) during the
period beginning on the date such notification
is submitted and ending on the date on which
the resident is successfully relocated.''.
(2) Conforming amendments.--Section 1819(h)(4) of the
Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
(A) in the first sentence, by striking ``the
Secretary shall terminate'' and inserting ``the
Secretary, subject to subsection (c)(7), shall
terminate''; and
(B) in the second sentence, by striking
``subsection (c)(2)'' and inserting ``paragraphs (2)
and (7) of subsection (c)''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(c) of the Social Security Act
(42 U.S.C. 1396r(c)) is amended by adding at the end the
following new paragraph:
``(9) Notification of facility closure.--
``(A) In general.--Any individual who is an
administrator of a nursing facility must--
``(i) submit to the Secretary, the State
long-term care ombudsman, residents of the
facility, and the legal representatives of such
residents or other responsible parties, written
notification of an impending closure--
``(I) subject to subclause (II),
not later than the date that is 60 days
prior to the date of such closure; and
``(II) in the case of a facility
where the Secretary terminates the
facility's participation under this
title, not later than the date that the
Secretary determines appropriate;
``(ii) ensure that the facility does not
admit any new residents on or after the date on
which such written notification is submitted;
and
``(iii) include in the notice a plan for
the transfer and adequate relocation of the
residents of the facility by a specified date
prior to closure that has been approved by the
State, including assurances that the residents
will be transferred to the most appropriate
facility or other setting in terms of quality,
services, and location, taking into
consideration the needs and best interests of
each resident.
``(B) Relocation.--
``(i) In general.--The State shall ensure
that, before a facility closes, all residents
of the facility have been successfully
relocated to another facility or an alternative
home and community-based setting.
``(ii) Continuation of payments until
residents relocated.--The Secretary may, as the
Secretary determines appropriate, continue to
make payments under this title with respect to
residents of a facility that has submitted a
notification under subparagraph (A) during the
period beginning on the date such notification
is submitted and ending on the date on which
the resident is successfully relocated.''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
PART 3--IMPROVING STAFF TRAINING
SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.
(a) Skilled Nursing Facilities.--Section 1819(f)(2)(A)(i)(I) of the
Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by
inserting ``(including, in the case of initial training and, if the
Secretary determines appropriate, in the case of ongoing training,
dementia management training and resident abuse prevention training)''
after ``curriculum''.
(b) Nursing Facilities.--Section 1919(f)(2)(A)(i)(I) of the Social
Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by inserting
``(including, in the case of initial training and, if the Secretary
determines appropriate, in the case of ongoing training, dementia
management training and resident abuse prevention training)'' after
``curriculum''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR CERTIFIED NURSE
AIDES AND SUPERVISORY STAFF.
(a) Study.--
(1) In general.--The Secretary shall conduct a study on the
content of training for certified nurse aides and supervisory
staff of skilled nursing facilities and nursing facilities. The
study shall include an analysis of the following:
(A) Whether the number of initial training hours
for certified nurse aides required under sections
1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the
Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II);
1396r(f)(2)(A)(i)(II)) should be increased from 75 and,
if so, what the required number of initial training
hours should be, including any recommendations for the
content of such training (including training related to
dementia).
(B) Whether requirements for ongoing training under
such sections 1819(f)(2)(A)(i)(II) and
1919(f)(2)(A)(i)(II) should be increased from 12 hours
per year, including any recommendations for the content
of such training.
(2) Consultation.--In conducting the analysis under
paragraph (1)(A), the Secretary shall consult with States that,
as of the date of the enactment of this Act, require more than
75 hours of training for certified nurse aides.
(3) Definitions.--In this section:
(A) Nursing facility.--The term ``nursing
facility'' has the meaning given such term in section
1919(a) of the Social Security Act (42 U.S.C.
1396r(a)).
(B) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services, acting through
the Assistant Secretary for Planning and Evaluation.
(C) Skilled nursing facility.--The term ``skilled
nursing facility'' has the meaning given such term in
section 1819(a) of the Social Security Act (42 U.S.C.
1395(a)).
(b) Report.--Not later than 2 years after the date of the enactment
of this Act, the Secretary shall submit to Congress a report containing
the results of the study conducted under subsection (a), together with
recommendations for such legislation and administrative action as the
Secretary determines appropriate.
Subtitle C--Quality Measurements
SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR QUALITY
IMPROVEMENT.
Title XI of the Social Security Act, as amended by section 1401(a),
is further amended by adding at the end the following new part:
``Part E--Quality Improvement
``establishment of national priorities for performance improvement
``Sec. 1191. (a) Establishment of National Priorities by the
Secretary.--The Secretary shall establish and periodically update, not
less frequently than triennially, national priorities for performance
improvement.
``(b) Recommendations for National Priorities.--In establishing and
updating national priorities under subsection (a), the Secretary shall
solicit and consider recommendations from multiple outside
stakeholders.
``(c) Considerations in Setting National Priorities.--With respect
to such priorities, the Secretary shall ensure that priority is given
to areas in the delivery of health care services in the United States
that--
``(1) contribute to a large burden of disease, including
those that address the health care provided to patients with
prevalent, high-cost chronic diseases;
``(2) have the greatest potential to decrease morbidity and
mortality in this country, including those that are designed to
eliminate harm to patients;
``(3) have the greatest potential for improving the
performance, affordability, and patient-centeredness of health
care, including those due to variations in care;
``(4) address health disparities across groups and areas;
and
``(5) have the potential for rapid improvement due to
existing evidence, standards of care or other reasons.
``(d) Definitions.--In this part:
``(1) Consensus-based entity.--The term `consensus-based
entity' means an entity with a contract with the Secretary
under section 1890.
``(2) Quality measure.--The term `quality measure' means a
national consensus standard for measuring the performance and
improvement of population health, or of institutional providers
of services, physicians, and other health care practitioners in
the delivery of health care services.
``(e) Funding.--
``(1) In general.--The Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance
Trust Fund under section 1841 (in such proportion as the
Secretary determines appropriate), of $2,000,000, for the
activities under this section for each of the fiscal years 2010
through 2014.
``(2) Authorization of appropriations.--For purposes of
carrying out the provisions of this section, in addition to
funds otherwise available, out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services $2,000,000 for each of the fiscal
years 2010 through 2014.''.
SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; GAO EVALUATION OF DATA
COLLECTION PROCESS FOR QUALITY MEASUREMENT.
Part E of title XI of the Social Security Act, as added by section
1441, is amended by adding at the end the following new sections:
``SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES.
``(a) Agreements With Qualified Entities.--
``(1) In general.--The Secretary shall enter into
agreements with qualified entities to develop quality measures
for the delivery of health care services in the United States.
``(2) Form of agreements.--The Secretary may carry out
paragraph (1) by contract, grant, or otherwise.
``(3) Recommendations of consensus-based entity.--In
carrying out this section, the Secretary shall--
``(A) seek public input; and
``(B) take into consideration recommendations of
the consensus-based entity with a contract with the
Secretary under section 1890(a).
``(b) Determination of Areas Where Quality Measures Are Required.--
Consistent with the national priorities established under this part and
with the programs administered by the Centers for Medicare & Medicaid
Services and in consultation with other relevant Federal agencies, the
Secretary shall determine areas in which quality measures for assessing
health care services in the United States are needed.
``(c) Development of Quality Measures.--
``(1) Patient-centered and population-based measures.--
Quality measures developed under agreements under subsection
(a) shall be designed--
``(A) to assess outcomes and functional status of
patients;
``(B) to assess the continuity and coordination of
care and care transitions for patients across providers
and health care settings, including end of life care;
``(C) to assess patient experience and patient
engagement;
``(D) to assess the safety, effectiveness, and
timeliness of care;
``(E) to assess health disparities including those
associated with individual race, ethnicity, age,
gender, place of residence or language;
``(F) to assess the efficiency and resource use in
the provision of care;
``(G) to the extent feasible, to be collected as
part of health information technologies supporting
better delivery of health care services;
``(H) to be available free of charge to users for
the use of such measures; and
``(I) to assess delivery of health care services to
individuals regardless of age.
``(2) Availability of measures.--The Secretary shall make
quality measures developed under this section available to the
public.
``(3) Testing of proposed measures.--The Secretary may use
amounts made available under subsection (f) to fund the testing
of proposed quality measures by qualified entities. Testing
funded under this paragraph shall include testing of the
feasibility and usability of proposed measures.
``(4) Updating of endorsed measures.--The Secretary may use
amounts made available under subsection (f) to fund the
updating (and testing, if applicable) by consensus-based
entities of quality measures that have been previously endorsed
by such an entity as new evidence is developed, in a manner
consistent with section 1890(b)(3).
``(d) Qualified Entities.--Before entering into agreements with a
qualified entity, the Secretary shall ensure that the entity is a
public, nonprofit or academic institution with technical expertise in
the area of health quality measurement.
``(e) Application for Grant.--A grant may be made under this
section only if an application for the grant is submitted to the
Secretary and the application is in such form, is made in such manner,
and contains such agreements, assurances, and information as the
Secretary determines to be necessary to carry out this section.
``(f) Funding.--
``(1) In general.--The Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance
Trust Fund under section 1841 (in such proportion as the
Secretary determines appropriate), of $25,000,000, to the
Secretary for purposes of carrying out this section for each of
the fiscal years 2010 through 2014.
``(2) Authorization of appropriations.--For purposes of
carrying out the provisions of this section, in addition to
funds otherwise available, out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services $25,000,000 for each of the fiscal
years 2010 through 2014.
``SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROCESS FOR QUALITY
MEASUREMENT.
``(a) GAO Evaluations.--The Comptroller General of the United
States shall conduct periodic evaluations of the implementation of the
data collection processes for quality measures used by the Secretary.
``(b) Considerations.--In carrying out the evaluation under
subsection (a), the Comptroller General shall determine--
``(1) whether the system for the collection of data for
quality measures provides for validation of data as relevant
and scientifically credible;
``(2) whether data collection efforts under the system use
the most efficient and cost-effective means in a manner that
minimizes administrative burden on persons required to collect
data and that adequately protects the privacy of patients'
personal health information and provides data security;
``(3) whether standards under the system provide for an
appropriate opportunity for physicians and other clinicians and
institutional providers of services to review and correct
findings; and
``(4) the extent to which quality measures are consistent
with section 1192(c)(1) or result in direct or indirect costs
to users of such measures.
``(c) Report.--The Comptroller General shall submit reports to
Congress and to the Secretary containing a description of the findings
and conclusions of the results of each such evaluation.''.
SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT INTO SELECTION OF
QUALITY MEASURES.
Section 1808 of the Social Security Act (42 U.S.C. 1395b-9) is
amended by adding at the end the following new subsection:
``(d) Multi-stakeholder Pre-rulemaking Input Into Selection of
Quality Measures.--
``(1) List of measures.--Not later than December 1 before
each year (beginning with 2011), the Secretary shall make
public a list of measures being considered for selection for
quality measurement by the Secretary in rulemaking with respect
to payment systems under this title beginning in the payment
year beginning in such year and for payment systems beginning
in the calendar year following such year, as the case may be.
``(2) Consultation on selection of endorsed quality
measures.--A consensus-based entity that has entered into a
contract under section 1890 shall, as part of such contract,
convene multi-stakeholder groups to provide recommendations on
the selection of individual or composite quality measures, for
use in reporting performance information to the public or for
use in public health care programs.
``(3) Multi-stakeholder input.--Not later than February 1
of each year (beginning with 2011), the consensus-based entity
described in paragraph (2) shall transmit to the Secretary the
recommendations of multi-stakeholder groups provided under
paragraph (2). Such recommendations shall be included in the
transmissions the consensus-based entity makes to the Secretary
under the contract provided for under section 1890.
``(4) Requirement for transparency in process.--
``(A) In general.--In convening multi-stakeholder
groups under paragraph (2) with respect to the
selection of quality measures, the consensus-based
entity described in such paragraph shall provide for an
open and transparent process for the activities
conducted pursuant to such convening.
``(B) Selection of organizations participating in
multi-stakeholder groups.--The process under paragraph
(2) shall ensure that the selection of representatives
of multi-stakeholder groups includes provision for
public nominations for, and the opportunity for public
comment on, such selection.
``(5) Use of input.--The respective proposed rule shall
contain a summary of the recommendations made by the multi-
stakeholder groups under paragraph (2), as well as other
comments received regarding the proposed measures, and the
extent to which such proposed rule follows such recommendations
and the rationale for not following such recommendations.
``(6) Multi-stakeholder groups.--For purposes of this
subsection, the term `multi-stakeholder groups' means, with
respect to a quality measure, a voluntary collaborative of
organizations representing persons interested in or affected by
the use of such quality measure, such as the following:
``(A) Hospitals and other institutional providers.
``(B) Physicians.
``(C) Health care quality alliances.
``(D) Nurses and other health care practitioners.
``(E) Health plans.
``(F) Patient advocates and consumer groups.
``(G) Employers.
``(H) Public and private purchasers of health care
items and services.
``(I) Labor organizations.
``(J) Relevant departments or agencies of the
United States.
``(K) Biopharmaceutical companies and manufacturers
of medical devices.
``(L) Licensing, credentialing, and accrediting
bodies.
``(7) Funding.--
``(A) In general.--The Secretary shall provide for
the transfer, from the Federal Hospital Insurance Trust
Fund under section 1817 and the Federal Supplementary
Medical Insurance Trust Fund under section 1841 (in
such proportion as the Secretary determines
appropriate), of $1,000,000, to the Secretary for
purposes of carrying out this subsection for each of
the fiscal years 2010 through 2014.
``(B) Authorization of appropriations.--For
purposes of carrying out the provisions of this
subsection, in addition to funds otherwise available,
out of any funds in the Treasury not otherwise
appropriated, there are appropriated to the Secretary
of Health and Human Services $1,000,000 for each of the
fiscal years 2010 through 2014.''.
SEC. 1444. APPLICATION OF QUALITY MEASURES.
(a) Inpatient Hospital Services.--Section 1886(b)(3)(B) of such Act
(42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at the end the
following new clause:
``(x)(I) Subject to subclause (II), for purposes of reporting data
on quality measures for inpatient hospital services furnished during
fiscal year 2012 and each subsequent fiscal year, the quality measures
specified under clause (viii) shall be measures selected by the
Secretary from measures that have been endorsed by the entity with a
contract with the Secretary under section 1890(a).
``(II) In the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical quality
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. The Secretary shall submit such a non-endorsed measure to
the entity for consideration for endorsement. If the entity considers
but does not endorse such a measure and if the Secretary does not
phase-out use of such measure, the Secretary shall include the
rationale for continued use of such a measure in rulemaking.''.
(b) Outpatient Hospital Services.--Section 1833(t)(17) of such Act
(42 U.S.C. 1395l(t)(17)) is amended by adding at the end the following
new subparagraph:
``(F) Use of endorsed quality measures.--The
provisions of clause (x) of section 1886(b)(3)(C) shall
apply to quality measures for covered OPD services
under this paragraph in the same manner as such
provisions apply to quality measures for inpatient
hospital services.''.
(c) Physicians' Services.--Section 1848(k)(2)(C)(ii) of such Act
(42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended by adding at the end the
following: ``The Secretary shall submit such a non-endorsed measure to
the entity for consideration for endorsement. If the entity considers
but does not endorse such a measure and if the Secretary does not
phase-out use of such measure, the Secretary shall include the
rationale for continued use of such a measure in rulemaking.''.
(d) Renal Dialysis Services.--Section 1881(h)(2)(B)(ii) of such Act
(42 U.S.C. 1395rr(h)(2)(B)(ii)) is amended by adding at the end the
following: ``The Secretary shall submit such a non-endorsed measure to
the entity for consideration for endorsement. If the entity considers
but does not endorse such a measure and if the Secretary does not
phase-out use of such measure, the Secretary shall include the
rationale for continued use of such a measure in rulemaking.''.
(e) Endorsement of Standards.--Section 1890(b)(2) of the Social
Security Act (42 U.S.C. 1395aaa(b)(2)) is amended by adding after and
below subparagraph (B) the following:
```If the entity does not endorse a measure, such entity shall
explain the reasons and provide suggestions about changes to
such measure that might make it a potentially endorsable
measure.'''.
(f) Effective Date.--Except as otherwise provided, the amendments
made by this section shall apply to quality measures applied for
payment years beginning with 2012 or fiscal year 2012, as the case may
be.
SEC. 1445. CONSENSUS-BASED ENTITY FUNDING.
Section 1890(d) of the Social Security Act (42 U.S.C. 1395aaa(d))
is amended by striking ``for each of fiscal years 2009 through 2012''
and inserting ``for fiscal year 2009, and $12,000,000 for each of the
fiscal years 2010 through 2012.''
Subtitle D--Physician Payments Sunshine Provision
SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BETWEEN MANUFACTURERS AND
DISTRIBUTORS OF COVERED DRUGS, DEVICES, BIOLOGICALS, OR
MEDICAL SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND
PHYSICIANS AND OTHER HEALTH CARE ENTITIES AND BETWEEN
PHYSICIANS AND OTHER HEALTH CARE ENTITIES.
(a) In General.--Part A of title XI of the Social Security Act (42
U.S.C. 1301 et seq.), as amended by section 1631(a), is further amended
by inserting after section 1128G the following new section:
``SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS' FINANCIAL RELATIONSHIPS
WITH MANUFACTURERS AND DISTRIBUTORS OF COVERED DRUGS,
DEVICES, BIOLOGICALS, OR MEDICAL SUPPLIES UNDER MEDICARE,
MEDICAID, OR CHIP AND WITH ENTITIES THAT BILL FOR
SERVICES UNDER MEDICARE.
``(a) Reporting of Payments or Other Transfers of Value.--
``(1) In general.--Except as provided in this subsection,
not later than March 31, 2011, and annually thereafter, each
applicable manufacturer or distributor that provides a payment
or other transfer of value to a covered recipient, or to an
entity or individual at the request of or designated on behalf
of a covered recipient, shall submit to the Secretary, in such
electronic form as the Secretary shall require, the following
information with respect to the preceding calendar year:
``(A) With respect to the covered recipient, the
recipient's name, business address, physician
specialty, and national provider identifier.
``(B) With respect to the payment or other transfer
of value, other than a drug sample--
``(i) its value and date;
``(ii) the name of the related drug,
device, or supply, if available; and
``(iii) a description of its form,
indicated (as appropriate for all that apply)
as--
``(I) cash or a cash equivalent;
``(II) in-kind items or services;
``(III) stock, a stock option, or
any other ownership interest, dividend,
profit, or other return on investment;
or
``(IV) any other form (as defined
by the Secretary).
``(C) With respect to a drug sample, the name,
number, date, and dosage units of the sample.
``(2) Aggregate reporting.--Information submitted by an
applicable manufacturer or distributor under paragraph (1)
shall include the aggregate amount of all payments or other
transfers of value provided by the manufacturer or distributor
to covered recipients (and to entities or individuals at the
request of or designated on behalf of a covered recipient)
during the year involved, including all payments and transfers
of value regardless of whether such payments or transfer of
value were individually disclosed.
``(3) Special rule for certain payments or other transfers
of value.--In the case where an applicable manufacturer or
distributor provides a payment or other transfer of value to an
entity or individual at the request of or designated on behalf
of a covered recipient, the manufacturer or distributor shall
disclose that payment or other transfer of value under the name
of the covered recipient.
``(4) Delayed reporting for payments made pursuant to
product development agreements.--In the case of a payment or
other transfer of value made to a covered recipient by an
applicable manufacturer or distributor pursuant to a product
development agreement for services furnished in connection with
the development of a new drug, device, biological, or medical
supply, the applicable manufacturer or distributor may report
the value and recipient of such payment or other transfer of
value in the first reporting period under this subsection in
the next reporting deadline after the earlier of the following:
``(A) The date of the approval or clearance of the
covered drug, device, biological, or medical supply by
the Food and Drug Administration.
``(B) Two calendar years after the date such
payment or other transfer of value was made.
``(5) Delayed reporting for payments made pursuant to
clinical investigations.--In the case of a payment or other
transfer of value made to a covered recipient by an applicable
manufacturer or distributor in connection with a clinical
investigation regarding a new drug, device, biological, or
medical supply, the applicable manufacturer or distributor may
report as required under this section in the next reporting
period under this subsection after the earlier of the
following:
``(A) The date that the clinical investigation is
registered on the website maintained by the National
Institutes of Health pursuant to section 671 of the
Food and Drug Administration Amendments Act of 2007.
``(B) Two calendar years after the date such
payment or other transfer of value was made.
``(6) Confidentiality.--Information described in paragraph
(4) or (5) shall be considered confidential and shall not be
subject to disclosure under section 552 of title 5, United
States Code, or any other similar Federal, State, or local law,
until or after the date on which the information is made
available to the public under such paragraph.
``(b) Reporting of Ownership Interest by Physicians in Hospitals
and Other Entities That Bill Medicare.--Not later than March 31 of each
year (beginning with 2011), each hospital or other health care entity
(not including a Medicare Advantage organization) that bills the
Secretary under part A or part B of title XVIII for services shall
report on the ownership shares (other than ownership shares described
in section 1877(c)) of each physician who, directly or indirectly, owns
an interest in the entity. In this subsection, the term `physician'
includes a physician's immediate family members (as defined for
purposes of section 1877(a)).
``(c) Public Availability.--
``(1) In general.--The Secretary shall establish procedures
to ensure that, not later than September 30, 2011, and on June
30 of each year beginning thereafter, the information submitted
under subsections (a) and (b), other than information regard
drug samples, with respect to the preceding calendar year is
made available through an Internet website that--
``(A) is searchable and is in a format that is
clear and understandable;
``(B) contains information that is presented by the
name of the applicable manufacturer or distributor, the
name of the covered recipient, the business address of
the covered recipient, the specialty (if applicable) of
the covered recipient, the value of the payment or
other transfer of value, the date on which the payment
or other transfer of value was provided to the covered
recipient, the form of the payment or other transfer of
value, indicated (as appropriate) under subsection
(a)(1)(B)(ii), the nature of the payment or other
transfer of value, indicated (as appropriate) under
subsection (a)(1)(B)(iii), and the name of the covered
drug, device, biological, or medical supply, as
applicable;
``(C) contains information that is able to be
easily aggregated and downloaded;
``(D) contains a description of any enforcement
actions taken to carry out this section, including any
penalties imposed under subsection (d), during the
preceding year;
``(E) contains background information on industry-
physician relationships;
``(F) in the case of information submitted with
respect to a payment or other transfer of value
described in subsection (a)(5), lists such information
separately from the other information submitted under
subsection (a) and designates such separately listed
information as funding for clinical research;
``(G) contains any other information the Secretary
determines would be helpful to the average consumer;
and
``(H) provides the covered recipient an opportunity
to submit corrections to the information made available
to the public with respect to the covered recipient.
``(2) Accuracy of reporting.--The accuracy of the
information that is submitted under subsections (a) and (b) and
made available under paragraph (1) shall be the responsibility
of the applicable manufacturer or distributor of a covered
drug, device, biological, or medical supply reporting under
subsection (a) or hospital or other health care entity
reporting physician ownership under subsection (b). The
Secretary shall establish procedures to ensure that the covered
recipient is provided with an opportunity to submit corrections
to the manufacturer, distributor, hospital, or other entity
reporting under subsection (a) or (b) with regard to
information made public with respect to the covered recipient
and, under such procedures, the corrections shall be
transmitted to the Secretary.
``(3) Special rule for drug samples.--Information relating
to drug samples provided under subsection (a) shall not be made
available to the public by the Secretary but may be made
available outside the Department of Health and Human Services
by the Secretary for research or legitimate business purposes
pursuant to data use agreements.
``(4) Special rule for national provider identifiers.--
Information relating to national provider identifiers provided
under subsection (a) shall not be made available to the public
by the Secretary but may be made available outside the
Department of Health and Human Services by the Secretary for
research or legitimate business purposes pursuant to data use
agreements.
``(d) Penalties for Noncompliance.--
``(1) Failure to report.--
``(A) In general.--Subject to subparagraph (B),
except as provided in paragraph (2), any applicable
manufacturer or distributor that fails to submit
information required under subsection (a) in a timely
manner in accordance with regulations promulgated to
carry out such subsection, and any hospital or other
entity that fails to submit information required under
subsection (b) in a timely manner in accordance with
regulations promulgated to carry out such subsection
shall be subject to a civil money penalty of not less
than $1,000, but not more than $10,000, for each
payment or other transfer of value or ownership or
investment interest not reported as required under such
subsection. Such penalty shall be imposed and collected
in the same manner as civil money penalties under
subsection (a) of section 1128A are imposed and
collected under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect
to each annual submission of information under
subsection (a) by an applicable manufacturer or
distributor or other entity shall not exceed $150,000.
``(2) Knowing failure to report.--
``(A) In general.--Subject to subparagraph (B), any
applicable manufacturer or distributor that knowingly
fails to submit information required under subsection
(a) in a timely manner in accordance with regulations
promulgated to carry out such subsection and any
hospital or other entity that fails to submit
information required under subsection (b) in a timely
manner in accordance with regulations promulgated to
carry out such subsection, shall be subject to a civil
money penalty of not less than $10,000, but not more
than $100,000, for each payment or other transfer of
value or ownership or investment interest not reported
as required under such subsection. Such penalty shall
be imposed and collected in the same manner as civil
money penalties under subsection (a) of section 1128A
are imposed and collected under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect
to each annual submission of information under
subsection (a) or (b) by an applicable manufacturer,
distributor, or entity shall not exceed $1,000,000, or,
if greater, 0.1 percentage of the total annual revenues
of the manufacturer, distributor, or entity.
``(3) Use of funds.--Funds collected by the Secretary as a
result of the imposition of a civil money penalty under this
subsection shall be used to carry out this section.
``(4) Enforcement through state attorneys general.--The
attorney general of a State, after providing notice to the
Secretary of an intent to proceed under this paragraph in a
specific case and providing the Secretary with an opportunity
to bring an action under this subsection and the Secretary
declining such opportunity, may proceed under this subsection
against a manufacturer or distributor in the State.
``(e) Annual Report to Congress.--Not later than April 1 of each
year beginning with 2011, the Secretary shall submit to Congress a
report that includes the following:
``(1) The information submitted under this section during
the preceding year, aggregated for each applicable manufacturer
or distributor of a covered drug, device, biological, or
medical supply that submitted such information during such
year.
``(2) A description of any enforcement actions taken to
carry out this section, including any penalties imposed under
subsection (d), during the preceding year.
``(f) Definitions.--In this section:
``(1) Applicable manufacturer; applicable distributor.--The
term `applicable manufacturer' means a manufacturer of a
covered drug, device, biological, or medical supply, and the
term `applicable distributor' means a distributor of a covered
drug, device, or medical supply.
``(2) Clinical investigation.--The term `clinical
investigation' means any experiment involving one or more human
subjects, or materials derived from human subjects, in which a
drug or device is administered, dispensed, or used.
``(3) Covered drug, device, biological, or medical
supply.--The term `covered' means, with respect to a drug,
device, biological, or medical supply, such a drug, device,
biological, or medical supply for which payment is available
under title XVIII or a State plan under title XIX or XXI (or a
waiver of such a plan).
``(4) Covered recipient.--The term `covered recipient'
means the following:
``(A) A physician.
``(B) A physician group practice.
``(C) Any other prescriber of a covered drug,
device, biological, or medical supply.
``(D) A pharmacy or pharmacist.
``(E) A health insurance issuer, group health plan,
or other entity offering a health benefits plan,
including any employee of such an issuer, plan, or
entity.
``(F) A pharmacy benefit manager, including any
employee of such a manager.
``(G) A hospital.
``(H) A medical school.
``(I) A sponsor of a continuing medical education
program.
``(J) A patient advocacy or disease specific group.
``(K) A organization of health care professionals.
``(L) A biomedical researcher.
``(M) A group purchasing organization.
``(5) Distributor of a covered drug, device, or medical
supply.--The term `distributor of a covered drug, device, or
medical supply' means any entity which is engaged in the
marketing or distribution of a covered drug, device, or medical
supply (or any subsidiary of or entity affiliated with such
entity), but does not include a wholesale pharmaceutical
distributor.
``(6) Employee.--The term `employee' has the meaning given
such term in section 1877(h)(2).
``(7) Knowingly.--The term `knowingly' has the meaning
given such term in section 3729(b) of title 31, United States
Code.
``(8) Manufacturer of a covered drug, device, biological,
or medical supply.--The term `manufacturer of a covered drug,
device, biological, or medical supply' means any entity which
is engaged in the production, preparation, propagation,
compounding, conversion, processing, marketing, or distribution
of a covered drug, device, biological, or medical supply (or
any subsidiary of or entity affiliated with such entity).
``(9) Payment or other transfer of value.--
``(A) In general.--The term `payment or other
transfer of value' means a transfer of anything of
value for or of any of the following:
``(i) Gift, food, or entertainment.
``(ii) Travel or trip.
``(iii) Honoraria.
``(iv) Research funding or grant.
``(v) Education or conference funding.
``(vi) Consulting fees.
``(vii) Ownership or investment interest
and royalties or license fee.
``(B) Inclusions.--Subject to subparagraph (C), the
term `payment or other transfer of value' includes any
compensation, gift, honorarium, speaking fee,
consulting fee, travel, services, dividend, profit
distribution, stock or stock option grant, or any
ownership or investment interest held by a physician in
a manufacturer (excluding a dividend or other profit
distribution from, or ownership or investment interest
in, a publicly traded security or mutual fund (as
described in section 1877(c))).
``(C) Exclusions.--The term `payment or other
transfer of value' does not include the following:
``(i) Any payment or other transfer of
value provided by an applicable manufacturer or
distributor to a covered recipient where the
amount transferred to, requested by, or
designated on behalf of the covered recipient
does not exceed $5.
``(ii) The loan of a covered device for a
short-term trial period, not to exceed 90 days,
to permit evaluation of the covered device by
the covered recipient.
``(iii) Items or services provided under a
contractual warranty, including the replacement
of a covered device, where the terms of the
warranty are set forth in the purchase or lease
agreement for the covered device.
``(iv) A transfer of anything of value to a
covered recipient when the covered recipient is
a patient and not acting in the professional
capacity of a covered recipient.
``(v) In-kind items used for the provision
of charity care.
``(vi) A dividend or other profit
distribution from, or ownership or investment
interest in, a publicly traded security and
mutual fund (as described in section 1877(c)).
``(vii) Compensation paid by a manufacturer
or distributor of a covered drug, device,
biological, or medical supply to a covered
recipient who is directly employed by and works
solely for such manufacturer or distributor.
``(viii) Any discount or cash rebate.
``(10) Physician.--The term `physician' has the meaning
given that term in section 1861(r). For purposes of this
section, such term does not include a physician who is an
employee of the applicable manufacturer that is required to
submit information under subsection (a).
``(g) Annual Reports to States.--Not later than April 1 of each
year beginning with 2011, the Secretary shall submit to States a report
that includes a summary of the information submitted under subsections
(a) and (d) during the preceding year with respect to covered
recipients or other hospitals and entities in the State.
``(h) Relation to State Laws.--
``(1) In general.--Effective on January 1, 2011, subject to
paragraph (2), the provisions of this section shall preempt any
law or regulation of a State or of a political subdivision of a
State that requires an applicable manufacturer and applicable
distributor (as such terms are defined in subsection (f)) to
disclose or report, in any format, the type of information
(described in subsection (a)) regarding a payment or other
transfer of value provided by the manufacturer to a covered
recipient (as so defined).
``(2) No preemption of additional requirements.--Paragraph
(1) shall not preempt any law or regulation of a State or of a
political subdivision of a State that requires any of the
following:
``(A) The disclosure or reporting of information
not of the type required to be disclosed or reported
under this section.
``(B) The disclosure or reporting, in any format,
of the type of information required to be disclosed or
reported under this section to a Federal, State, or
local governmental agency for public health
surveillance, investigation, or other public health
purposes or health oversight purposes.
``(C) The discovery or admissibility of information
described in this section in a criminal, civil, or
administrative proceeding.''.
(b) Availability of Information From the Disclosure of Financial
Relationship Report (DFRR).--The Secretary of Health and Human Services
shall submit to Congress a report on the full results of the Disclosure
of Physician Financial Relationships surveys required pursuant to
section 5006 of the Deficit Reduction Act of 2005. Such report shall be
submitted to Congress not later than the date that is 6 months after
the date such surveys are collected and shall be made publicly
available on an Internet website of the Department of Health and Human
Services.
Subtitle E--Public Reporting on Health Care-Associated Infections
SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY
SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS.
(a) In General.--Title XI of the Social Security Act is amended by
inserting after section 1138 the following section:
``SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND
AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED
INFECTIONS.
``(a) Reporting Requirement.--
``(1) In general.--The Secretary shall provide that a
hospital (as defined in subsection (g)) or ambulatory surgical
center meeting the requirements of titles XVIII or XIX may
participate in the programs established under such titles
(pursuant to the applicable provisions of law, including
sections 1866(a)(1) and 1832(a)(1)(F)(i)) only if, in
accordance with this section, the hospital or center reports
such information on health care-associated infections that
develop in the hospital or center (and such demographic
information associated with such infections) as the Secretary
specifies.
``(2) Reporting protocols.--Such information shall be
reported in accordance with reporting protocols established by
the Secretary through the Director of the Centers for Disease
Control and Prevention (in this section referred to as the
`CDC') and to the National Healthcare Safety Network of the CDC
or under such another reporting system of such Centers as
determined appropriate by the Secretary in consultation with
such Director.
``(3) Coordination with hit.--The Secretary, through the
Director of the CDC and the Office of the National Coordinator
for Health Information Technology, shall ensure that the
transmission of information under this subsection is
coordinated with systems established under the HITECH Act,
where appropriate.
``(4) Procedures to ensure the validity of information.--
The Secretary shall establish procedures regarding the validity
of the information submitted under this subsection in order to
ensure that such information is appropriately compared across
hospitals and centers. Such procedures shall address failures
to report as well as errors in reporting.
``(5) Implementation.--Not later than 1 year after the date
of enactment of this section, the Secretary, through the
Director of CDC, shall promulgate regulations to carry out this
section.
``(b) Public Posting of Information.--The Secretary shall promptly
post, on the official public Internet site of the Department of Health
and Human Services, the information reported under subsection (a). Such
information shall be set forth in a manner that allows for the
comparison of information on health care-associated infections--
``(1) among hospitals and ambulatory surgical centers; and
``(2) by demographic information.
``(c) Annual Report to Congress.--On an annual basis the Secretary
shall submit to the Congress a report that summarizes each of the
following:
``(1) The number and types of health care-associated
infections reported under subsection (a) in hospitals and
ambulatory surgical centers during such year.
``(2) Factors that contribute to the occurrence of such
infections, including health care worker immunization rates.
``(3) Based on the most recent information available to the
Secretary on the composition of the professional staff of
hospitals and ambulatory surgical centers, the number of
certified infection control professionals on the staff of
hospitals and ambulatory surgical centers.
``(4) The total increases or decreases in health care costs
that resulted from increases or decreases in the rates of
occurrence of each such type of infection during such year.
``(5) Recommendations, in coordination with the Center for
Quality Improvement established under section 931 of the Public
Health Service Act, for best practices to eliminate the rates
of occurrence of each such type of infection in hospitals and
ambulatory surgical centers.
``(d) Non-preemption of State Laws.--Nothing in this section shall
be construed as preempting or otherwise affecting any provision of
State law relating to the disclosure of information on health care-
associated infections or patient safety procedures for a hospital or
ambulatory surgical center.
``(e) Health Care-associated Infection.--For purposes of this
section:
``(1) In general.--The term `health care-associated
infection' means an infection that develops in a patient who
has received care in any institutional setting where health
care is delivered and is related to receiving health care.
``(2) Related to receiving health care.--The term `related
to receiving health care', with respect to an infection, means
that the infection was not incubating or present at the time
health care was provided.
``(f) Application to Critical Access Hospitals.--For purposes of
this section, the term `hospital' includes a critical access hospital,
as defined in section 1861(mm)(1).''.
(b) Effective Date.--With respect to section 1138A of the Social
Security Act (as inserted by subsection (a) of this section), the
requirement under such section that hospitals and ambulatory surgical
centers submit reports takes effect on such date (not later than 2
years after the date of the enactment of this Act) as the Secretary of
Health and Human Services shall specify. In order to meet such
deadline, the Secretary may implement such section through guidance or
other instructions.
(c) GAO Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General of the United States
shall submit to Congress a report on the program established under
section 1138A of the Social Security Act, as inserted by subsection
(a). Such report shall include an analysis of the appropriateness of
the types of information required for submission, compliance with
reporting requirements, the success of the validity procedures
established, and any conflict or overlap between the reporting required
under such section and any other reporting systems mandated by either
the States or the Federal Government.
(d) Report on Additional Data.--Not later than 18 months after the
date of the enactment of this Act, the Secretary of Health and Human
Services shall submit to the Congress a report on the appropriateness
of expanding the requirements under such section to include additional
information (such as health care worker immunization rates), in order
to improve health care quality and patient safety.
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS.
(a) In General.--Section 1886(h) of the Social Security Act (42
U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(F)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(2) in paragraph (4)(H)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(3) in paragraph (7)(E), by inserting ``and paragraph (8)''
after ``this paragraph''; and
(4) by adding at the end the following new paragraph:
``(8) Additional redistribution of unused residency
positions.--
``(A) Reductions in limit based on unused
positions.--
``(i) Programs subject to reduction.--If a
hospital's reference resident level (specified
in clause (ii)) is less than the otherwise
applicable resident limit (as defined in
subparagraph (C)(ii)), effective for portions
of cost reporting periods occurring on or after
July 1, 2011, the otherwise applicable resident
limit shall be reduced by 90 percent of the
difference between such otherwise applicable
resident limit and such reference resident
level.
``(ii) Reference resident level.--
``(I) In general.--Except as
otherwise provided in a subsequent
subclause, the reference resident level
specified in this clause for a hospital
is the highest resident level for any
of the 3 most recent cost reporting
periods (ending before the date of the
enactment of this paragraph) of the
hospital for which a cost report has
been settled (or, if not, submitted
(subject to audit)), as determined by
the Secretary.
``(II) Use of most recent
accounting period to recognize
expansion of existing programs.--If a
hospital submits a timely request to
increase its resident level due to an
expansion, or planned expansion, of an
existing residency training program
that is not reflected on the most
recent settled or submitted cost
report, after audit and subject to the
discretion of the Secretary, subject to
subclause (IV), the reference resident
level for such hospital is the resident
level that includes the additional
residents attributable to such
expansion or establishment, as
determined by the Secretary. The
Secretary is authorized to determine an
alternative reference resident level
for a hospital that submitted to the
Secretary a timely request, before the
start of the 2009-2010 academic year,
for an increase in its reference
resident level due to a planned
expansion.
``(III) Special provider
agreement.--In the case of a hospital
described in paragraph (4)(H)(v), the
reference resident level specified in
this clause is the limitation
applicable under subclause (I) of such
paragraph.
``(IV) Previous redistribution.--
The reference resident level specified
in this clause for a hospital shall be
increased to the extent required to
take into account an increase in
resident positions made available to
the hospital under paragraph (7)(B)
that are not otherwise taken into
account under a previous subclause.
``(iii) Affiliation.--The provisions of
clause (i) shall be applied to hospitals which
are members of the same affiliated group (as
defined by the Secretary under paragraph
(4)(H)(ii)) and to the extent the hospitals can
demonstrate that they are filling any
additional resident slots allocated to other
hospitals through an affiliation agreement, the
Secretary shall adjust the determination of
available slots accordingly, or which the
Secretary otherwise has permitted the resident
positions (under section 402 of the Social
Security Amendments of 1967) to be aggregated
for purposes of applying the resident position
limitations under this subsection.
``(B) Redistribution.--
``(i) In general.--The Secretary shall
increase the otherwise applicable resident
limit for each qualifying hospital that submits
an application under this subparagraph by such
number as the Secretary may approve for
portions of cost reporting periods occurring on
or after July 1, 2011. The estimated aggregate
number of increases in the otherwise applicable
resident limit under this subparagraph may not
exceed the Secretary's estimate of the
aggregate reduction in such limits attributable
to subparagraph (A).
``(ii) Requirements for qualifying
hospitals.--A hospital is not a qualifying
hospital for purposes of this paragraph unless
the following requirements are met:
``(I) Maintenance of primary care
resident level.--The hospital maintains
the number of primary care residents at
a level that is not less than the base
level of primary care residents
increased by the number of additional
primary care resident positions
provided to the hospital under this
subparagraph. For purposes of this
subparagraph, the `base level of
primary care residents' for a hospital
is the level of such residents as of a
base period (specified by the
Secretary), determined without regard
to whether such positions were in
excess of the otherwise applicable
resident limit for such period but
taking into account the application of
subclauses (II) and (III) of
subparagraph (A)(ii).
``(II) Dedicated assignment of
additional resident positions to
primary care.--The hospital assigns all
such additional resident positions for
primary care residents.
``(III) Accreditation.--The
hospital's residency programs in
primary care are fully accredited or,
in the case of a residency training
program not in operation as of the base
year, the hospital is actively applying
for such accreditation for the program
for such additional resident positions
(as determined by the Secretary).
``(iii) Considerations in redistribution.--
In determining for which qualifying hospitals
the increase in the otherwise applicable
resident limit is provided under this
subparagraph, the Secretary shall take into
account the demonstrated likelihood of the
hospital filling the positions within the first
3 cost reporting periods beginning on or after
July 1, 2011, made available under this
subparagraph, as determined by the Secretary.
``(iv) Priority for certain hospitals.--In
determining for which qualifying hospitals the
increase in the otherwise applicable resident
limit is provided under this subparagraph, the
Secretary shall distribute the increase to
qualifying hospitals based on the following
criteria:
``(I) The Secretary shall give
preference to hospitals that had a
reduction in resident training
positions under subparagraph (A).
``(II) The Secretary shall give
preference to hospitals with 3-year
primary care residency training
programs, such as family practice and
general internal medicine.
``(III) The Secretary shall give
preference to hospitals insofar as they
have in effect formal arrangements (as
determined by the Secretary) that place
greater emphasis upon training in
Federally qualified health centers,
rural health clinics, and other
nonprovider settings, and to hospitals
that receive additional payments under
subsection (d)(5)(F) and emphasize
training in an outpatient department.
``(IV) The Secretary shall give
preference to hospitals with a number
of positions (as of July 1, 2009) in
excess of the otherwise applicable
resident limit for such period.
``(V) The Secretary shall give
preference to hospitals that place
greater emphasis upon training in a
health professional shortage area
(designated under section 332 of the
Public Health Service Act) or a health
professional needs area (designated
under section 2211 of such Act).
``(VI) The Secretary shall give
preference to hospitals in States that
have low resident-to-population ratios
(including a greater preference for
those States with lower resident-to-
population ratios).
``(v) Limitation.--In no case shall more
than 20 full-time equivalent additional
residency positions be made available under
this subparagraph with respect to any hospital.
``(vi) Application of per resident amounts
for primary care.--With respect to additional
residency positions in a hospital attributable
to the increase provided under this
subparagraph, the approved FTE resident amounts
are deemed to be equal to the hospital per
resident amounts for primary care and
nonprimary care computed under paragraph (2)(D)
for that hospital.
``(vi) Distribution.--The Secretary shall
distribute the increase in resident training
positions to qualifying hospitals under this
subparagraph not later than July 1, 2011.
``(C) Resident level and limit defined.--In this
paragraph:
``(i) The term `resident level' has the
meaning given such term in paragraph (7)(C)(i).
``(ii) The term `otherwise applicable
resident limit' means, with respect to a
hospital, the limit otherwise applicable under
subparagraphs (F)(i) and (H) of paragraph (4)
on the resident level for the hospital
determined without regard to this paragraph but
taking into account paragraph (7)(A).
``(D) Maintenance of primary care resident level.--
In carrying out this paragraph, the Secretary shall
require hospitals that receive additional resident
positions under subparagraph (B)--
``(i) to maintain records, and periodically
report to the Secretary, on the number of
primary care residents in its residency
training programs; and
``(ii) as a condition of payment for a cost
reporting period under this subsection for such
positions, to maintain the level of such
positions at not less than the sum of--
``(I) the base level of primary
care resident positions (as determined
under subparagraph (B)(ii)(I)) before
receiving such additional positions;
and
``(II) the number of such
additional positions.''.
(b) IME.--
(1) In general.--Section 1886(d)(5)(B)(v) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second
sentence, is amended--
(A) by striking ``subsection (h)(7)'' and inserting
``subsections (h)(7) and (h)(8)''; and
(B) by striking ``it applies'' and inserting ``they
apply''.
(2) Conforming provision.--Section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by
adding at the end the following clause:
``(x) For discharges occurring on or after July 1, 2011, insofar as
an additional payment amount under this subparagraph is attributable to
resident positions distributed to a hospital under subsection
(h)(8)(B), the indirect teaching adjustment factor shall be computed in
the same manner as provided under clause (ii) with respect to such
resident positions.''.
(c) Conforming Amendment.--Section 422(b)(2) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173) is amended by striking ``section 1886(h)(7)'' and all that
follows and inserting ``paragraphs (7) and (8) of subsection (h) of
section 1886 of the Social Security Act''.
SEC. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS.
(a) Direct GME.--Section 1886(h)(4)(E) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) by designating the first sentence as a clause (i) with
the heading ``In general'' and appropriate indentation;
(2) by striking ``shall be counted and that all the time''
and inserting ``shall be counted and that--
``(I) effective for cost reporting
periods beginning before July 1, 2009,
all the time'';
(3) in subclause (I), as inserted by paragraph (1), by
striking the period at the end and inserting ``; and''; and
(A) by inserting after subclause (I), as so
inserted, the following:
``(II) effective for cost reporting
periods beginning on or after July 1,
2009, all the time so spent by a
resident shall be counted towards the
determination of full-time equivalency,
without regard to the setting in which
the activities are performed, if the
hospital incurs the costs of the
stipends and fringe benefits of the
resident during the time the resident
spends in that setting.
Any hospital claiming under this subparagraph
for time spent in a nonprovider setting shall
maintain and make available to the Secretary
records regarding the amount of such time and
such amount in comparison with amounts of such
time in such base year as the Secretary shall
specify.''.
(b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security Act (42
U.S.C. 1395ww(d)(5)(B)(iv)) is amended--
(1) by striking ``(iv) Effective for discharges occurring
on or after October 1, 1997'' and inserting ``(iv)(I) Effective
for discharges occurring on or after October 1, 1997, and
before July 1, 2009''; and
(2) by inserting after subclause (I), as inserted by
paragraph (1), the following new subclause:
``(II) Effective for discharges occurring on or after July
1, 2009, all the time spent by an intern or resident in patient
care activities at an entity in a nonprovider setting shall be
counted towards the determination of full-time equivalency if
the hospital incurs the costs of the stipends and fringe
benefits of the intern or resident during the time the intern
or resident spends in that setting.''.
(c) OIG Study on Impact on Training.--The Inspector General of the
Department of Health and Human Services shall analyze the data
collected by the Secretary of Health and Human Services from the
records made available to the Secretary under section 1886(h)(4)(E) of
the Social Security Act, as amended by subsection (a), in order to
assess the extent to which there is an increase in time spent by
medical residents in training in nonprovider settings as a result of
the amendments made by this section. Not later than 4 years after the
date of the enactment of this Act, the Inspector General shall submit a
report to Congress on such analysis and assessment.
(d) Demonstration Project for Approved Teaching Health Centers.--
(1) In general.--The Secretary of Health and Human Services
shall conduct a demonstration project under which an approved
teaching health center (as defined in paragraph (3)) would be
eligible for payment under subsections (h) and (k) of section
1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts
for its own direct costs of graduate medical education
activities for primary care residents, as well as for the
direct costs of graduate medical education activities of its
contracting hospital for such residents, in a manner similar to
the manner in which such payments would be made to a hospital
if the hospital were to operate such a program.
(2) Conditions.--Under the demonstration project--
(A) an approved teaching health center shall
contract with an accredited teaching hospital to carry
out the inpatient responsibilities of the primary care
residency program of the hospital involved and is
responsible for payment to the hospital for the
hospital's costs of the salary and fringe benefits for
residents in the program;
(B) the number of primary care residents of the
center shall not count against the contracting
hospital's resident limit; and
(C) the contracting hospital shall agree not to
diminish the number of residents in its primary care
residency training program.
(3) Approved teaching health center defined.--In this
subsection, the term ``approved teaching health center'' means
a nonprovider setting, such as a Federally qualified health
center or rural health clinic (as defined in section 1861(aa)
of the Social Security Act), that develops and operates an
accredited primary care residency program for which funding
would be available if it were operated by a hospital.
SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY
ACTIVITIES AND OTHER ACTIVITIES.
(a) Direct GME.--Section 1886(h) of the Social Security Act (42
U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(E), as amended by section 1502(a)--
(A) in clause (i), by striking ``Such rules'' and
inserting ``Subject to clause (ii), such rules''; and
(B) by adding at the end the following new clause:
``(ii) Treatment of certain nonprovider and
didactic activities.--Such rules shall provide
that all time spent by an intern or resident in
an approved medical residency training program
in a nonprovider setting that is primarily
engaged in furnishing patient care (as defined
in paragraph (5)(K)) in nonpatient care
activities, such as didactic conferences and
seminars, but not including research not
associated with the treatment or diagnosis of a
particular patient, as such time and activities
are defined by the Secretary, shall be counted
toward the determination of full-time
equivalency.'';
(2) in paragraph (4), by adding at the end the following
new subparagraph:
``(I) In determining the hospital's number of full-
time equivalent residents for purposes of this
subsection, all the time that is spent by an intern or
resident in an approved medical residency training
program on vacation, sick leave, or other approved
leave, as such time is defined by the Secretary, and
that does not prolong the total time the resident is
participating in the approved program beyond the normal
duration of the program shall be counted toward the
determination of full-time equivalency.''; and
(3) in paragraph (5), by adding at the end the following
new subparagraph:
``(K) Nonprovider setting that is primarily engaged
in furnishing patient care.--The term `nonprovider
setting that is primarily engaged in furnishing patient
care' means a nonprovider setting in which the primary
activity is the care and treatment of patients, as
defined by the Secretary.''.
(b) IME Determinations.--Section 1886(d)(5)(B) of such Act (42
U.S.C. 1395ww(d)(5)(B)), as amended by section 1501(b), is amended by
adding at the end the following new clause:
``(xi)(I) The provisions of subparagraph (I) of subsection (h)(4)
shall apply under this subparagraph in the same manner as they apply
under such subsection.
``(II) In determining the hospital's number of full-time equivalent
residents for purposes of this subparagraph, all the time spent by an
intern or resident in an approved medical residency training program in
nonpatient care activities, such as didactic conferences and seminars,
as such time and activities are defined by the Secretary, that occurs
in the hospital shall be counted toward the determination of full-time
equivalency if the hospital--
``(aa) is recognized as a subsection (d) hospital;
``(bb) is recognized as a subsection (d) Puerto Rico
hospital;
``(cc) is reimbursed under a reimbursement system
authorized under section 1814(b)(3); or
``(dd) is a provider-based hospital outpatient department.
``(III) In determining the hospital's number of full-time
equivalent residents for purposes of this subparagraph, all the time
spent by an intern or resident in an approved medical residency
training program in research activities that are not associated with
the treatment or diagnosis of a particular patient, as such time and
activities are defined by the Secretary, shall not be counted toward
the determination of full-time equivalency.''.
(c) Effective Dates; Application.--
(1) In general.--Except as otherwise provided, the
Secretary of Health and Human Services shall implement the
amendments made by this section in a manner so as to apply to
cost reporting periods beginning on or after January 1, 1983.
(2) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social
Security Act, as added by subsection (a)(1)(B), shall apply to
cost reporting periods beginning on or after July 1, 2008.
(3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social
Security Act, as added by subsection (b), shall apply to cost
reporting periods beginning on or after October 1, 2001. Such
section, as so added, shall not give rise to any inference on
how the law in effect prior to such date should be interpreted.
(4) Application.--The amendments made by this section shall
not be applied in a manner that requires reopening of any
settled hospital cost reports as to which there is not a
jurisdictionally proper appeal pending as of the date of the
enactment of this Act on the issue of payment for indirect
costs of medical education under section 1886(d)(5)(B) of the
Social Security Act or for direct graduate medical education
costs under section 1886(h) of such Act.
SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED
HOSPITALS.
(a) Direct GME.--Section 1886(h)(4)(H) of the Social Security Act
(42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end the
following new clause:
``(vi) Redistribution of residency slots
after a hospital closes.--
``(I) In general.--The Secretary
shall, by regulation, establish a
process consistent with subclauses (II)
and (III) under which, in the case
where a hospital (other than a hospital
described in clause (v)) with an
approved medical residency program in a
State closes on or after the date that
is 2 years before the date of the
enactment of this clause, the Secretary
shall increase the otherwise applicable
resident limit under this paragraph for
other hospitals in the State in
accordance with this clause.
``(II) Process for hospitals in
certain areas.--In determining for
which hospitals the increase in the
otherwise applicable resident limit
described in subclause (I) is provided,
the Secretary shall establish a process
to provide for such increase to one or
more hospitals located in the State.
Such process shall take into
consideration the recommendations
submitted to the Secretary by the
senior health official (as designated
by the chief executive officer of such
State) if such recommendations are
submitted not later than 180 days after
the date of the hospital closure
involved (or, in the case of a hospital
that closed after the date that is 2
years before the date of the enactment
of this clause, 180 days after such
date of enactment).
``(III) Limitation.--The estimated
aggregate number of increases in the
otherwise applicable resident limits
for hospitals under this clause shall
be equal to the estimated number of
resident positions in the approved
medical residency programs that closed
on or after the date described in
subclause (I).''.
(b) No Effect on Temporary FTE Cap Adjustments.--The amendments
made by this section shall not effect any temporary adjustment to a
hospital's FTE cap under section 413.79(h) of title 42, Code of Federal
Regulations (as in effect on the date of enactment of this Act) and
shall not affect the application of section 1886(h)(4)(H)(v) of the
Social Security Act.
(c) Conforming Amendments.--
(1) Section 422(b)(2) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173), as amended by section 1501(c), is amended by striking
``(7) and'' and inserting ``(4)(H)(vi), (7), and''.
(2) Section 1886(h)(7)(E) of the Social Security Act (42
U.S.C. 1395ww(h)(7)(E)) is amended by inserting ``or under
paragraph (4)(H)(vi)'' after ``under this paragraph''.
SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED MEDICAL RESIDENCY
TRAINING.
(a) Specification of Goals for Approved Medical Residency Training
Programs.--Section 1886(h)(1) of the Social Security Act (42 U.S.C.
1395ww(h)(1)) is amended--
(1) by designating the matter beginning with
``Notwithstanding'' as a subparagraph (A) with the heading ``In
general.--'' and with appropriate indentation; and
(2) by adding at the end the following new paragraph:
``(B) Goals and accountability for approved medical
residency training programs.--The goals of medical
residency training programs are to foster a physician
workforce so that physicians are trained to be able to
do the following:
``(i) Work effectively in various health
care delivery settings, such as nonprovider
settings.
``(ii) Coordinate patient care within and
across settings relevant to their specialties.
``(iii) Understand the relevant cost and
value of various diagnostic and treatment
options.
``(iv) Work in inter-professional teams and
multi-disciplinary team-based models in
provider and nonprovider settings to enhance
safety and improve quality of patient care.
``(v) Be knowledgeable in methods of
identifying systematic errors in health care
delivery and in implementing systematic
solutions in case of such errors, including
experience and participation in continuous
quality improvement projects to improve health
outcomes of the population the physicians
serve.
``(vi) Be meaningful EHR users (as
determined under section 1848(o)(2)) in the
delivery of care and in improving the quality
of the health of the community and the
individuals that the hospital serves.''
(b) GAO Study on Evaluation of Training Programs.--
(1) In general.--The Comptroller General of the United
States shall conduct a study to evaluate the extent to which
medical residency training programs--
(A) are meeting the goals described in section
1886(h)(1)(B) of the Social Security Act, as added by
subsection (a), in a range of residency programs,
including primary care and other specialties; and
(B) have the appropriate faculty expertise to teach
the topics required to achieve such goals.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report on such study and shall include in such
report recommendations as to how medical residency training
programs could be further encouraged to meet such goals through
means such as--
(A) development of curriculum requirements; and
(B) assessment of the accreditation processes of
the Accreditation Council for Graduate Medical
Education and the American Osteopathic Association and
effectiveness of those processes in accrediting medical
residency programs that meet the goals referred to in
paragraph (1)(A).
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse
SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO FIGHT FRAUD AND ABUSE.
(a) In General.--Section 1817(k) of the Social Security Act (42
U.S.C. 1395i(k)) is amended--
(1) by adding at the end the following new paragraph:
``(7) Additional funding.--In addition to the funds
otherwise appropriated to the Account from the Trust Fund under
paragraphs (3) and (4) and for purposes described in paragraphs
(3)(C) and (4)(A), there are hereby appropriated an additional
$100,000,000 to such Account from such Trust Fund for each
fiscal year beginning with 2011. The funds appropriated under
this paragraph shall be allocated in the same proportion as the
total funding appropriated with respect to paragraphs (3)(A)
and (4)(A) was allocated with respect to fiscal year 2010, and
shall be available without further appropriation until
expended.''.
(2) in paragraph (4)(A)--
(A) by inserting ``for activities described in
paragraph (3)(C) and'' after ``necessary''; and
(B) by inserting ``until expended'' after
``appropriation''.
(b) Flexibility in Pursuing Fraud and Abuse.--Section 1893(a) of
the Social Security Act (42 U.S.C. 1395ddd(a)) is amended by inserting
``, or otherwise,'' after ``entities''.
Subtitle B--Enhanced Penalties for Fraud and Abuse
SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS ON PROVIDER OR
SUPPLIER ENROLLMENT APPLICATIONS.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)) is amended--
(1) in paragraph (1)(D), by striking all that follows ``in
which the person was excluded'' and inserting ``under Federal
law from the Federal health care program under which the claim
was made, or'';
(2) by striking ``or'' at the end of paragraph (6);
(3) in paragraph (7), by inserting at the end ``or'';
(4) by inserting after paragraph (7) the following new
paragraph:
``(8) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a material fact in
any application, agreement, bid, or contract to participate or
enroll as a provider of services or supplier under a Federal
health care program, including managed care organizations under
title XIX, Medicare Advantage organizations under part C of
title XVIII, prescription drug plan sponsors under part D of
title XVIII, and entities that apply to participate as
providers of services or suppliers in such managed care
organizations and such plans;'';
(5) in the matter following paragraph (8), as inserted by
paragraph (4), by striking ``or in cases under paragraph (7),
$50,000 for each such act)'' and inserting ``in cases under
paragraph (7), $50,000 for each such act, or in cases under
paragraph (8), $50,000 for each false statement, omission, or
misrepresentation of a material fact)''; and
(6) in the second sentence, by striking ``for a lawful
purpose)'' and inserting ``for a lawful purpose, or in cases
under paragraph (8), an assessment of not more than 3 times the
amount claimed as the result of the false statement, omission,
or misrepresentation of material fact claimed by a provider of
services or supplier whose application to participate contained
such false statement, omission, or misrepresentation)''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to acts committed on or after January 1, 2010.
SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF FALSE STATEMENTS
MATERIAL TO A FALSE CLAIM.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)), as amended by section 1611, is further amended--
(1) in paragraph (7), by striking ``or'' at the end;
(2) in paragraph (8), by inserting ``or'' at the end; and
(3) by inserting after paragraph (8), the following new
paragraph:
``(9) knowingly makes, uses, or causes to be made or used,
a false record or statement material to a false or fraudulent
claim for payment for items and services furnished under a
Federal health care program;''; and
(4) in the matter following paragraph (9), as inserted by
paragraph (3)--
(A) by striking ``or in cases under paragraph (8)''
and inserting ``in cases under paragraph (8)''; and
(B) by striking ``a material fact)'' and inserting
``a material fact, in cases under paragraph (9),
$50,000 for each false record or statement)''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to acts committed on or after January 1, 2010.
SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPECTIONS.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)), as amended by sections 1611 and 1612, is further
amended--
(1) in paragraph (8), by striking ``or'' at the end;
(2) in paragraph (9), by inserting ``or'' at the end;
(3) by inserting after paragraph (9) the following new
paragraph:
``(10) fails to grant timely access, upon reasonable
request (as defined by the Secretary in regulations), to the
Inspector General of the Department of Health and Human
Services, for the purpose of audits, investigations,
evaluations, or other statutory functions of the Inspector
General of the Department of Health and Human Services;''; and
(4) in the matter following paragraph (10), as inserted by
paragraph (3)--
(A) by striking ``or'' after ``$50,000 for each
such act,''; and
(B) by inserting ``, or in cases under paragraph
(10), $15,000 for each day of the failure described in
such paragraph'' after ``false record or statement''.
(b) Ensuring Timely Inspections Relating to Contracts With MA
Organizations.--Section 1857(d)(2) of such Act (42 U.S.C. 1395w-
27(d)(2)) is amended--
(1) in subparagraph (A), by inserting ``timely'' before
``inspect''; and
(2) in subparagraph (B), by inserting ``timely'' before
``audit and inspect''.
(c) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS.
(a) Medicare.--Part A of title XVIII of the Social Security Act is
amended by inserting after section 1819 the following new section:
``SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE CARE.
``(a) In General.--If the Secretary determines on the basis of a
survey or otherwise, that a hospice program that is certified for
participation under this title has demonstrated a substandard quality
of care and failed to meet such other requirements as the Secretary may
find necessary in the interest of the health and safety of the
individuals who are provided care and services by the agency or
organization involved and determines--
``(1) that the deficiencies involved immediately jeopardize
the health and safety of the individuals to whom the program
furnishes items and services, the Secretary shall take
immediate action to remove the jeopardy and correct the
deficiencies through the remedy specified in subsection
(b)(2)(A)(iii) or terminate the certification of the program,
and may provide, in addition, for 1 or more of the other
remedies described in subsection (b)(2)(A); or
``(2) that the deficiencies involved do not immediately
jeopardize the health and safety of the individuals to whom the
program furnishes items and services, the Secretary may--
``(A) impose intermediate sanctions developed
pursuant to subsection (b), in lieu of terminating the
certification of the program; and
``(B) if, after such a period of intermediate
sanctions, the program is still not in compliance with
such requirements, the Secretary shall terminate the
certification of the program.
If the Secretary determines that a hospice program that is
certified for participation under this title is in compliance
with such requirements but, as of a previous period, was not in
compliance with such requirements, the Secretary may provide
for a civil money penalty under subsection (b)(2)(A)(i) for the
days in which it finds that the program was not in compliance
with such requirements.
``(b) Intermediate Sanctions.--
``(1) Development and implementation.--The Secretary shall
develop and implement, by not later than July 1, 2012--
``(A) a range of intermediate sanctions to apply to
hospice programs under the conditions described in
subsection (a), and
``(B) appropriate procedures for appealing
determinations relating to the imposition of such
sanctions.
``(2) Specified sanctions.--
``(A) In general.--The intermediate sanctions
developed under paragraph (1) may include--
``(i) civil money penalties in an amount
not to exceed $10,000 for each day of
noncompliance or, in the case of a per instance
penalty applied by the Secretary, not to exceed
$25,000,
``(ii) denial of all or part of the
payments to which a hospice program would
otherwise be entitled under this title with
respect to items and services furnished by a
hospice program on or after the date on which
the Secretary determines that intermediate
sanctions should be imposed pursuant to
subsection (a)(2),
``(iii) the appointment of temporary
management to oversee the operation of the
hospice program and to protect and assure the
health and safety of the individuals under the
care of the program while improvements are
made,
``(iv) corrective action plans, and
``(v) in-service training for staff.
The provisions of section 1128A (other than subsections
(a) and (b)) shall apply to a civil money penalty under
clause (i) in the same manner as such provisions apply
to a penalty or proceeding under section 1128A(a). The
temporary management under clause (iii) shall not be
terminated until the Secretary has determined that the
program has the management capability to ensure
continued compliance with all requirements referred to
in that clause.
``(B) Clarification.--The sanctions specified in
subparagraph (A) are in addition to sanctions otherwise
available under State or Federal law and shall not be
construed as limiting other remedies, including any
remedy available to an individual at common law.
``(C) Commencement of payment.--A denial of payment
under subparagraph (A)(ii) shall terminate when the
Secretary determines that the hospice program no longer
demonstrates a substandard quality of care and meets
such other requirements as the Secretary may find
necessary in the interest of the health and safety of
the individuals who are provided care and services by
the agency or organization involved.
``(3) Secretarial authority.--The Secretary shall develop
and implement, by not later than July 1, 2011, specific
procedures with respect to the conditions under which each of
the intermediate sanctions developed under paragraph (1) is to
be applied, including the amount of any fines and the severity
of each of these sanctions. Such procedures shall be designed
so as to minimize the time between identification of
deficiencies and imposition of these sanctions and shall
provide for the imposition of incrementally more severe fines
for repeated or uncorrected deficiencies.''.
(b) Application to Medicaid.--Section 1905(o) of the Social
Security Act (42 U.S.C. 1396d(o)) is amended by adding at the end the
following new paragraph:
``(4) The provisions of section 1819A shall apply to a hospice
program providing hospice care under this title in the same manner as
such provisions apply to a hospice program providing hospice care under
title XVIII.''.
(c) Application to CHIP.--Title XXI of the Social Security Act is
amended by adding at the end the following new section:
``SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE.
``The provisions of section 1819A shall apply to a hospice program
providing hospice care under this title in the same manner such
provisions apply to a hospice program providing hospice care under
title XVIII.''.
SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EXCLUDED FROM PROGRAM
PARTICIPATION.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)), as amended by the previous sections, is further
amended--
(1) by striking ``or'' at the end of paragraph (9);
(2) by inserting ``or'' at the end of paragraph (10);
(3) by inserting after paragraph (10) the following new
paragraph:
``(11) orders or prescribes an item or service, including
without limitation home health care, diagnostic and clinical
lab tests, prescription drugs, durable medical equipment,
ambulance services, physical or occupational therapy, or any
other item or service, during a period when the person has been
excluded from participation in a Federal health care program,
and the person knows or should know that a claim for such item
or service will be presented to such a program;''; and
(4) in the matter following paragraph (11), as inserted by
paragraph (2), by striking ``$15,000 for each day of the
failure described in such paragraph'' and inserting ``$15,000
for each day of the failure described in such paragraph, or in
cases under paragraph (11), $50,000 for each order or
prescription for an item or service by an excluded
individual''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF FALSE INFORMATION BY
MEDICARE ADVANTAGE AND PART D PLANS.
(a) In General.--Section 1857(g)(2)(A) of the Social Security Act
(42 U.S.C. 1395w-27(g)(2)(A)) is amended by inserting ``except with
respect to a determination under subparagraph (E), an assessment of not
more than 3 times the amount claimed by such plan or plan sponsor based
upon the misrepresentation or falsified information involved,'' after
``for each such determination,''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVANTAGE AND PART D
MARKETING VIOLATIONS.
(a) In General.--Section 1857(g)(1) of the Social Security Act (42
U.S.C. 1395w-27(g)(1)), as amended by section 1221(b), is amended--
(1) in subparagraph (G), by striking ``or'' at the end;
(2) by inserting after subparagraph (H) the following new
subparagraphs:
``(I) except as provided under subparagraph (C) or
(D) of section 1860D-1(b)(1), enrolls an individual in
any plan under this part without the prior consent of
the individual or the designee of the individual;
``(J) transfers an individual enrolled under this
part from one plan to another without the prior consent
of the individual or the designee of the individual or
solely for the purpose of earning a commission;
``(K) fails to comply with marketing restrictions
described in subsections (h) and (j) of section 1851 or
applicable implementing regulations or guidance; or
``(L) employs or contracts with any individual or
entity who engages in the conduct described in
subparagraphs (A) through (K) of this paragraph;''; and
(3) by adding at the end the following new sentence: ``The
Secretary may provide, in addition to any other remedies
authorized by law, for any of the remedies described in
paragraph (2), if the Secretary determines that any employee or
agent of such organization, or any provider or supplier who
contracts with such organization, has engaged in any conduct
described in subparagraphs (A) through (L) of this paragraph.''
(b) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF PROGRAM AUDITS.
(a) In General.--Section 1128(b)(2) of the Social Security Act (42
U.S.C. 1320a-7(b)(2)) is amended--
(1) in the heading, by inserting ``or audit'' after
``investigation''; and
(2) by striking ``investigation into'' and all that follows
through the period and inserting ``investigation or audit
related to--''
``(i) any offense described in paragraph
(1) or in subsection (a); or
``(ii) the use of funds received, directly
or indirectly, from any Federal health care
program (as defined in section 1128B(f)).''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM
PARTICIPATION IN MEDICARE AND STATE HEALTH CARE PROGRAMS.
(a) In General.--Section 1128(c) of the Social Security Act, as
previously amended by this division, is further amended--
(1) in the heading, by striking ``and Period'' and
inserting ``, Period, and Effect''; and
(2) by adding at the end the following new paragraph:
``(4)(A) For purposes of this Act, subject to subparagraph
(C), the effect of exclusion is that no payment may be made by
any Federal health care program (as defined in section
1128B(f)) with respect to any item or service furnished--
``(i) by an excluded individual or entity; or
``(ii) at the medical direction or on the
prescription of a physician or other authorized
individual when the person submitting a claim for such
item or service knew or had reason to know of the
exclusion of such individual.
``(B) For purposes of this section and sections 1128A and
1128B, subject to subparagraph (C), an item or service has been
furnished by an individual or entity if the individual or
entity directly or indirectly provided, ordered, manufactured,
distributed, prescribed, or otherwise supplied the item or
service regardless of how the item or service was paid for by a
Federal health care program or to whom such payment was made.
``(C)(i) Payment may be made under a Federal health care
program for emergency items or services (not including items or
services furnished in an emergency room of a hospital)
furnished by an excluded individual or entity, or at the
medical direction or on the prescription of an excluded
physician or other authorized individual during the period of
such individual's exclusion.
``(ii) In the case that an individual eligible for benefits
under title XVIII or XIX submits a claim for payment for items
or services furnished by an excluded individual or entity, and
such individual eligible for such benefits did not know or have
reason to know that such excluded individual or entity was so
excluded, then, notwithstanding such exclusion, payment shall
be made for such items or services. In such case the Secretary
shall notify such individual eligible for such benefits of the
exclusion of the individual or entity furnishing the items or
services. Payment shall not be made for items or services
furnished by an excluded individual or entity to an individual
eligible for such benefits after a reasonable time (as
determined by the Secretary in regulations) after the Secretary
has notified the individual eligible for such benefits of the
exclusion of the individual or entity furnishing the items or
services.
``(iii) In the case that a claim for payment for items or
services furnished by an excluded individual or entity is
submitted by an individual or entity other than an individual
eligible for benefits under title XVIII or XIX or the excluded
individual or entity, and the Secretary determines that the
individual or entity that submitted the claim took reasonable
steps to learn of the exclusion and reasonably relied upon
inaccurate or misleading information from the relevant Federal
health care program or its contractor, the Secretary may waive
repayment of the amount paid in violation of the exclusion to
the individual or entity that submitted the claim for the items
or services furnished by the excluded individual or entity. If
a Federal health care program contractor provided inaccurate or
misleading information that resulted in the waiver of an
overpayment under this clause, the Secretary shall take
appropriate action to recover the improperly paid amount from
the contractor.''.
Subtitle C--Enhanced Program and Provider Protections
SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.
(a) In General.--Title XI of the Social Security Act (42 U.S.C.
1301 et seq.) is amended by inserting after section 1128F the following
new section:
``SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PROTECTIONS IN THE
MEDICARE, MEDICAID, AND CHIP PROGRAMS.
``(a) Certain Authorized Screening, Enhanced Oversight Periods, and
Enrollment Moratoria.--
``(1) In general.--For periods beginning after January 1,
2011, in the case that the Secretary determines there is a
significant risk of fraudulent activity (as determined by the
Secretary based on relevant complaints, reports, referrals by
law enforcement or other sources, data analysis, trending
information, or claims submissions by providers of services and
suppliers) with respect to a category of provider of services
or supplier of items or services, including a category within a
geographic area, under title XVIII, XIX, or XXI, the Secretary
may impose any of the following requirements with respect to a
provider of services or a supplier (whether such provider or
supplier is initially enrolling in the program or is renewing
such enrollment):
``(A) Screening under paragraph (2).
``(B) Enhanced oversight periods under paragraph
(3).
``(C) Enrollment moratoria under paragraph (4).
In applying this subsection for purposes of title XIX and XXI
the Secretary may require a State to carry out the provisions
of this subsection as a requirement of the State plan under
title XIX or the child health plan under title XXI. Actions
taken and determinations made under this subsection shall not
be subject to review by a judicial tribunal.
``(2) Screening.--For purposes of paragraph (1), the
Secretary shall establish procedures under which screening is
conducted with respect to providers of services and suppliers
described in such paragraph. Such screening may include--
``(A) licensing board checks;
``(B) screening against the list of individuals and
entities excluded from the program under title XVIII,
XIX, or XXI;
``(C) the excluded provider list system;
``(D) background checks; and
``(E) unannounced pre-enrollment or other site
visits.
``(3) Enhanced oversight period.--For purposes of paragraph
(1), the Secretary shall establish procedures to provide for a
period of not less than 30 days and not more than 365 days
during which providers of services and suppliers described in
such paragraph, as the Secretary determines appropriate, would
be subject to enhanced oversight, such as required or
unannounced (or required and unannounced) site visits or
inspections, prepayment review, enhanced review of claims, and
such other actions as specified by the Secretary, under the
programs under titles XVIII, XIX, and XXI. Under such
procedures, the Secretary may extend such period for more than
365 days if the Secretary determines that after the initial
period such additional period of oversight is necessary.
``(4) Moratorium on enrollment of providers and
suppliers.--For purposes of paragraph (1), the Secretary, based
upon a finding of a risk of serious ongoing fraud within a
program under title XVIII, XIX, or XXI, may impose a moratorium
on the enrollment of providers of services and suppliers within
a category of providers of services and suppliers (including a
category within a specific geographic area) under such title.
Such a moratorium may only be imposed if the Secretary makes a
determination that the moratorium would not adversely impact
access of individuals to care under such program.
``(5) Clarification.--Nothing in this subsection shall be
interpreted to preclude or limit the ability of a State to
engage in provider screening or enhanced provider oversight
activities beyond those required by the Secretary.''.
(b) Conforming Amendments.--
(1) Medicaid.--Section 1902(a) of the Social Security Act
(42 U.S.C. 42 U.S.C. 1396a(a)) is amended--
(A) in paragraph (23), by inserting before the
semicolon at the end the following: ``or by a person to
whom or entity to which a moratorium under section
1128G(a)(4) is applied during the period of such
moratorium'';
(B) in paragraph (72); by striking at the end
``and'';
(C) in paragraph (73), by striking the period at
the end and inserting ``and''; and
(D) by adding after paragraph (73) the following
new paragraph:
``(74) provide that the State will enforce any
determination made by the Secretary under subsection (a) of
section 1128G (relating to a significant risk of fraudulent
activity with respect to a category of provider or supplier
described in such subsection (a) through use of the appropriate
procedures described in such subsection (a)), and that the
State will carry out any activities as required by the
Secretary for purposes of such subsection (a).''.
(2) CHIP.--Section 2102 of such Act (42 U.S.C. 1397bb) is
amended by adding at the end the following new subsection:
``(d) Program Integrity.--A State child health plan shall include a
description of the procedures to be used by the State--
``(1) to enforce any determination made by the Secretary
under subsection (a) of section 1128G (relating to a
significant risk of fraudulent activity with respect to a
category of provider or supplier described in such subsection
through use of the appropriate procedures described in such
subsection); and
``(2) to carry out any activities as required by the
Secretary for purposes of such subsection.''.
(3) Medicare.--Section 1866(j) of such Act (42 U.S.C.
1395cc(j)) is amended by adding at the end the following new
paragraph:
``(3) Program integrity.--The provisions of section
1128G(a) apply to enrollments and renewals of enrollments of
providers of services and suppliers under this title.''.
SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP PROGRAM DISCLOSURE
REQUIREMENTS RELATING TO PREVIOUS AFFILIATIONS.
(a) In General.--Section 1128G of the Social Security Act, as
inserted by section 1631, is amended by adding at the end the following
new subsection:
``(b) Enhanced Program Disclosure Requirements.--
``(1) Disclosure.--A provider of services or supplier who
submits on or after July 1, 2011, an application for enrollment
and renewing enrollment in a program under title XVIII, XIX, or
XXI shall disclose (in a form and manner determined by the
Secretary) any current affiliation or affiliation within the
previous 10-year period with a provider of services or supplier
that has uncollected debt or with a person or entity that has
been suspended or excluded under such program, subject to a
payment suspension, or has had its billing privileges revoked.
``(2) Enhanced safeguards.--If the Secretary determines
that such previous affiliation of such provider or supplier
poses a risk of fraud, waste, or abuse, the Secretary may apply
such enhanced safeguards as the Secretary determines necessary
to reduce such risk associated with such provider or supplier
enrolling or participating in the program under title XVIII,
XIX, or XXI. Such safeguards may include enhanced oversight,
such as enhanced screening of claims, required or unannounced
(or required and unannounced) site visits or inspections,
additional information reporting requirements, and conditioning
such enrollment on the provision of a surety bond.
``(3) Authority to deny participation.--If the Secretary
determines that there has been at least one such affiliation
and that such affiliation or affiliations, as applicable, of
such provider or supplier poses a serious risk of fraud, waste,
or abuse, the Secretary may deny the application of such
provider or supplier.''.
(b) Conforming Amendments.--
(1) Medicaid.--Paragraph (74) of section 1902(a) of such
Act (42 U.S.C. 1396a(a)), as added by section 1631(b)(1), is
amended--
(A) by inserting ``or subsection (b) of such
section (relating to disclosure requirements)'' before
``, and that the State''; and
(B) by inserting before the period the following:
``and apply any enhanced safeguards, with respect to a
provider or supplier described in such subsection (b),
as the Secretary determines necessary under such
subsection (b)''.
(2) CHIP.--Subsection (d) of section 2102 of such Act (42
U.S.C. 1397bb), as added by section 1631(b)(2), is amended--
(A) in paragraph (1), by striking at the end
``and'';
(B) in paragraph (2) by striking the period at the
end and inserting ``; and'' and
(C) by adding at the end the following new
paragraph:
``(3) to enforce any determination made by the Secretary
under subsection (b) of section 1128G (relating to disclosure
requirements) and to apply any enhanced safeguards, with
respect to a provider or supplier described in such subsection,
as the Secretary determines necessary under such subsection.''.
SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER FOR CERTAIN
EVALUATION AND MANAGEMENT SERVICES.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by section 4101 of the HITECH Act (Public Law 111-5), is
amended by adding at the end the following new subsection:
``(p) Payment Modifier for Certain Evaluation and Management
Services.--The Secretary shall establish a payment modifier under the
fee schedule under this section for evaluation and management services
(as specified in section 1842(b)(16)(B)(ii)) that result in the
ordering of additional services (such as lab tests), the prescription
of drugs, the furnishing or ordering of durable medical equipment in
order to enable better monitoring of claims for payment for such
additional services under this title, or the ordering, furnishing, or
prescribing of other items and services determined by the Secretary to
pose a high risk of waste, fraud, and abuse. The Secretary may require
providers of services or suppliers to report such modifier in claims
submitted for payment.''.
SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICARE INTEGRITY
PROGRAM.
(a) In General.--Section 1893(c) of the Social Security Act (42
U.S.C. 1395ddd(c)) is amended--
(1) in paragraph (3), by striking at the end ``and'';
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following new
paragraph:
``(4) for the contract year beginning in 2011 and each
subsequent contract year, the entity provides assurances to the
satisfaction of the Secretary that the entity will conduct
periodic evaluations of the effectiveness of the activities
carried out by such entity under the Program and will submit to
the Secretary an annual report on such activities; and''.
(b) Reference to Medicaid Integrity Program.--For a similar
provision with respect to the Medicaid Integrity Program, see section
1752.
SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE
WASTE, FRAUD, AND ABUSE.
(a) In General.--Section 1874 of the Social Security Act (42 U.S.C.
42 U.S.C. 1395kk) is amended by adding at the end the following new
subsection:
``(d) Compliance Programs for Providers of Services and
Suppliers.--
``(1) In general.--The Secretary may disenroll a provider
of services or a supplier (other than a physician or a skilled
nursing facility) under this title (or may impose any civil
monetary penalty or other intermediate sanction under paragraph
(4)) if such provider of services or supplier fails to, subject
to paragraph (5), establish a compliance program that contains
the core elements established under paragraph (2).
``(2) Establishment of core elements.--The Secretary, in
consultation with the Inspector General of the Department of
Health and Human Services, shall establish core elements for a
compliance program under paragraph (1). Such elements may
include written policies, procedures, and standards of conduct,
a designated compliance officer and a compliance committee;
effective training and education pertaining to fraud, waste,
and abuse for the organization's employees and contractors; a
confidential or anonymous mechanism, such as a hotline, to
receive compliance questions and reports of fraud, waste, or
abuse; disciplinary guidelines for enforcement of standards;
internal monitoring and auditing procedures, including
monitoring and auditing of contractors; procedures for ensuring
prompt responses to detected offenses and development of
corrective action initiatives, including responses to potential
offenses; and procedures to return all identified overpayments
to the programs under this title, title XIX, and title XXI.
``(3) Timeline for implementation.--The Secretary shall
determine a timeline for the establishment of the core elements
under paragraph (2) and the date on which a provider of
services and suppliers (other than physicians) shall be
required to have established such a program for purposes of
this subsection.
``(4) CMS enforcement authority.--The Administrator for the
Centers of Medicare & Medicaid Services shall have the
authority to determine whether a provider of services or
supplier described in subparagraph (3) has met the requirement
of this subsection and to impose a civil monetary penalty not
to exceed $50,000 for each violation. The Secretary may also
impose other intermediate sanctions, including corrective
action plans and additional monitoring in the case of a
violation of this subsection.
``(5) Pilot program.--The Secretary may conduct a pilot
program on the application of this subsection with respect to a
category of providers of services or suppliers (other than
physicians) that the Secretary determines to be a category
which is at high risk for waste, fraud, and abuse before
implementing the requirements of this subsection to all
providers of services and suppliers described in paragraph
(3).''.
(b) Reference to Similar Medicaid Provision.--For a similar
provision with respect to the Medicaid program under title XIX of the
Social Security Act, see section 1753.
SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO
NOT MORE THAN 12 MONTHS.
(a) Purpose.--In general, the 36-month period currently allowed for
claims filing under parts A, B, C, and, D of title XVIII of the Social
Security Act presents opportunities for fraud schemes in which
processing patterns of the Centers for Medicare & Medicaid Services can
be observed and exploited. Narrowing the window for claims processing
will not overburden providers and will reduce fraud and abuse.
(b) Reducing Maximum Period for Submission.--
(1) Part a.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)) is amended--
(A) in paragraph (1), by strikeing ``period of 3
calendar years'' and all that follows and inserting
``period of 1 calendar year from which such services
are furnished; and''; and
(B) by adding at the end the following new
sentence: ``In applying paragraph (1), the Secretary
may specify exceptions to the 1 calendar year period
specified in such paragraph.''.
(2) Part b.--Section 1835(a) of such Act (42 U.S.C.
1395n(a)) is amended--
(A) in paragraph (1), by strikeing ``period of 3
calendar years'' and all that follows and inserting
``period of 1 calendar year from which such services
are furnished; and''; and
(B) by adding at the end the following new
sentence: ``In applying paragraph (1), the Secretary
may specify exceptions to the 1 calendar year period
specified in such paragraph.''.
(3) Parts c and d.--Section 1857(d) of such Act is amended
by adding at the end the following new paragraph:
``(7) Period for submission of claims.--The contract shall
require an MA organization or PDP sponsor to require any
provider of services under contract with, in partnership with,
or affiliated with such organization or sponsor to ensure that,
with respect to items and services furnished by such provider
to an enrollee of such organization, written request, signed by
such enrollee, except in cases in which the Secretary finds it
impracticable for the enrollee to do so, is filed for payment
for such items and services in such form, in such manner, and
by such person or persons as the Secretary may by regulation
prescribe, no later than the close of the 1 calendar year
period after such items and services are furnished. In applying
the previous sentence, the Secretary may specify exceptions to
the 1 calendar year period specified.''.
(c) Effective Date.--The amendments made by subsection (b) shall be
effective for items and services furnished on or after January 1, 2011.
SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL EQUIPMENT OR HOME
HEALTH SERVICES REQUIRED TO BE MEDICARE ENROLLED
PHYSICIANS OR ELIGIBLE PROFESSIONALS.
(a) DME.--Section 1834(a)(11)(B) of the Social Security Act (42
U.S.C. 1395m(a)(11)(B)) is amended by striking ``physician'' and
inserting ``physician enrolled under section 1866(j) or an eligible
professional under section 1848(k)(3)(B)''.
(b) Home Health Services.--
(1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C.
1395(a)(2)) is amended in the matter preceding subparagraph (A)
by inserting ``in the case of services described in
subparagraph (C), a physician enrolled under section 1866(j) or
an eligible professional under section 1848(k)(3)(B),'' before
``or, in the case of services''.
(2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C.
1395n(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``, or in the case of services described in
subparagraph (A), a physician enrolled under section 1866(j) or
an eligible professional under section 1848(k)(3)(B),'' after
``a physician''.
(c) Discretion To Expand Application.--The Secretary may extend the
requirement applied by the amendments made by subsections (a) and (b)
to durable medical equipment and home health services (relating to
requiring certifications and written orders to be made by enrolled
physicians and health professions) to other categories of items or
services under this title, including covered part D drugs as defined in
section 1860D-2(e), if the Secretary determines that such application
would help to reduce the risk of waste, fraud, and abuse with respect
to such other categories under title XVIII of the Social Security Act.
(d) Effective Date.--The amendments made by this section shall
apply to written orders and certifications made on or after July 1,
2010.
SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON
REFERRALS TO PROGRAMS AT HIGH RISK OF WASTE AND ABUSE.
(a) Physicians and Other Suppliers.--Section 1842(h) of the Social
Security Act, as amended by section 1635, is further amended by adding
at the end the following new paragraph:
``(10) The Secretary may disenroll, for a period of not more than
one year for each act, a physician or supplier under section 1866(j) if
such physician or supplier fails to maintain and, upon request of the
Secretary, provide access to documentation relating to written orders
or requests for payment for durable medical equipment, certifications
for home health services, or referrals for other items or services
written or ordered by such physician or supplier under this title, as
specified by the Secretary.''.
(b) Providers of Services.--Section 1866(a)(1) of such Act (42
U.S.C. 1395cc), as amended by section 1635, is further amended--
(1) in subparagraph (V), by striking at the end ``and'';
(2) in subparagraph (W), by striking the period at the end
and adding ``; and''; and
(3) by adding at the end the following new subparagraph:
``(X) maintain and, upon request of the Secretary,
provide access to documentation relating to written
orders or requests for payment for durable medical
equipment, certifications for home health services, or
referrals for other items or services written or
ordered by the provider under this title, as specified
by the Secretary.''.
(c) OIG Permissive Exclusion Authority.--Section 1128(b)(11) of the
Social Security Act (42 U.S.C. 1320a-7(b)(11)) is amended by inserting
``, ordering, referring for furnishing, or certifying the need for''
after ``furnishing''.
(d) Effective Date.--The amendments made by this section shall
apply to orders, certifications, and referrals made on or after January
1, 2010.
SEC. 1639. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE
PHYSICIANS MAY CERTIFY ELIGIBILITY FOR HOME HEALTH
SERVICES OR DURABLE MEDICAL EQUIPMENT UNDER MEDICARE.
(a) Condition of Payment for Home Health Services.--
(1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
(A) by striking ``and such services'' and inserting
``such services''; and
(B) by inserting after ``care of a physician'' the
following: ``, and, in the case of a certification or
recertification made by a physician after January 1,
2010, prior to making such certification the physician
must document that the physician has had a face-to-face
encounter (including through use of telehealth and
other than with respect to encounters that are incident
to services involved) with the individual during the 6-
month period preceding such certification, or other
reasonable timeframe as determined by the Secretary''.
(2) Part b.--Section 1835(a)(2)(A) of the Social Security
Act is amended--
(A) by striking ``and'' before ``(iii)''; and
(B) by inserting after ``care of a physician'' the
following: ``, and (iv) in the case of a certification
or recertification after January 1, 2010, prior to
making such certification the physician must document
that the physician has had a face-to-face encounter
(including through use of telehealth and other than
with respect to encounters that are incident to
services involved) with the individual during the 6-
month period preceding such certification or
recertification, or other reasonable timeframe as
determined by the Secretary''.
(b) Condition of Payment for Durable Medical Equipment.--Section
1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B))
is amended by adding at the end the following: ``and shall require that
such an order be written pursuant to the physician documenting that the
physician has had a face-to-face encounter (including through use of
telehealth and other than with respect to encounters that are incident
to services involved) with the individual involved during the 6-month
period preceding such written order, or other reasonable timeframe as
determined by the Secretary''.
(c) Application to Other Areas Under Medicare.--The Secretary may
apply the face-to-face encounter requirement described in the
amendments made by subsections (a) and (b) to other items and services
for which payment is provided under title XVIII of the Social Security
Act based upon a finding that such an decision would reduce the risk of
waste, fraud, or abuse.
(d) Application to Medicaid and CHIP.--The requirements pursuant to
the amendments made by subsections (a) and (b) shall apply in the case
of physicians making certifications for home health services under
title XIX or XXI of the Social Security Act, in the same manner and to
the same extent as such requirements apply in the case of physicians
making such certifications under title XVIII of such Act.
SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AUTHORITY TO PROGRAM
EXCLUSION INVESTIGATIONS.
(a) In General.--Section 1128(f) of the Social Security Act (42
U.S.C. 1320a-7(f)) is amended by adding at the end the following new
paragraph:
``(4) The provisions of subsections (d) and (e) of section 205
shall apply with respect to this section to the same extent as they are
applicable with respect to title II. The Secretary may delegate the
authority granted by section 205(d) (as made applicable to this
section) to the Inspector General of the Department of Health and Human
Services or the Administrator of the Centers for Medicare & Medicaid
Services for purposes of any investigation under this section.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to investigations beginning on or after January 1, 2010.
SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND MEDICAID OVERPAYMENTS.
Section 1128G of the Social Security Act, as inserted by section
1631 and amended by section 1632, is further amended by adding at the
end the following new subsection:
``(c) Reports on and Repayment of Overpayments Identified Through
Internal Audits and Reviews.--
``(1) Reporting and returning overpayments.--If a person
knows of an overpayment, the person must--
``(A) report and return the overpayment to the
Secretary, the State, an intermediary, a carrier, or a
contractor, as appropriate, at the correct address, and
``(B) notify the Secretary, the State,
intermediary, carrier, or contractor to whom the
overpayment was returned in writing of the reason for
the overpayment.
``(2) Timing.--An overpayment must be reported and returned
under paragraph (1)(A) by not later than the date that is 60
days after the date the person knows of the overpayment.
Any known overpayment retained later than the applicable date
specified in this paragraph creates an obligation as defined in
section 3729(b)(3) of title 31 of the United States Code.
``(3) Clarification.--Repayment of any overpayments (or
refunding by withholding of future payments) by a provider of
services or supplier does not otherwise limit the provider or
supplier's potential liability for administrative obligations
such as applicable interests, fines, and specialties or civil
or criminal sanctions involving the same claim if it is
determined later that the reason for the overpayment was
related to fraud by the provider or supplier or the employees
or agents of such provider or supplier.
``(4) Definitions.--In this subsection:
``(A) Knows.--The term `knows' has the meaning
given the terms `knowing' and `knowingly' in section
3729(b) of title 31 of the United States Code.
``(B) Overpayment.--The term ``overpayment'' means
any finally determined funds that a person receives or
retains under title XVIII, XIX, or XXI to which the
person, after applicable reconciliation, is not
entitled under such title.
``(C) Person.--The term `person' means a provider
of services, supplier, Medicaid managed care
organization (as defined in section 1903(m)(1)(A)),
Medicare Advantage organization (as defined in section
1859(a)(1)), or PDP sponsor (as defined in section
1860D-41(a)(13)), but excluding a beneficiary.''.
SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR OIG EXCLUSIONS
TO BENEFICIARIES OF ANY FEDERAL HEALTH CARE PROGRAM.
Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 1320a-
7(c)(3)(B)) is amended by striking ``individuals entitled to benefits
under part A of title XVIII or enrolled under part B of such title, or
both'' and inserting ``beneficiaries (as defined in section
1128A(i)(5)) of that program''.
SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS FACILITIES.
Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is
amended by adding at the end the following new paragraph:
``(15) For purposes of evaluating or auditing payments made to
renal dialysis facilities for items and services under this section
under paragraph (1), each such renal dialysis facility, upon the
request of the Secretary, shall provide to the Secretary access to
information relating to any ownership or compensation arrangement
between such facility and the medical director of such facility or
between such facility and any physician.''.
SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES
REQUIRED TO REGISTER UNDER MEDICARE.
(a) Medicare.--Section 1866(j)(1) of the Social Security Act (42
U.S.C. 1395cc(j)(1)) is amended by adding at the end the following new
subparagraph:
``(D) Billing agents and clearinghouses required to
be register under medicare.--Any agent, clearinghouse,
or other alternate payee that submits claims on behalf
of a health care provider must be registered with the
Secretary in a form and manner specified by the
Secretary.''.
(b) Medicaid.--For a similar provision with respect to the Medicaid
program under title XIX of the Social Security Act, see section 1759.
(c) Effective Date.--The amendment made by subsection (a) shall
apply to claims submitted on or after January 1, 2012.
SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO FALSE CLAIMS ACT
AMENDMENTS.
Section 1128A of the Social Security Act, as amended by sections
1611, 1612, 1613, and 1615, is further amended--
(1) in subsection (a)--
(A) in paragraph (1), by striking ``to an officer,
employee, or agent of the United States, or of any
department or agency thereof, or of any State agency
(as defined in subsection (i)(1))'';
(B) in paragraph (4)--
(i) by striking ``participating in a
program under title XVIII or a State health
care program'' and inserting ``participating in
a Federal health care program (as defined in
section 1128B(f))''; and
(ii) in subparagraph (A), by striking
``title XVIII or a State health care program''
and inserting ``a Federal health care program
(as defined in section 1128B(f))'';
(C) by striking ``or'' at the end of paragraph
(10);
(D) by inserting after paragraph (11) the following
new paragraphs:
``(12) conspires to commit a violation of this section; or
``(13) knowingly makes, uses, or causes to be made or used,
a false record or statement material to an obligation to pay or
transmit money or property to a Federal health care program, or
knowingly conceals or knowingly and improperly avoids or
decreases an obligation to pay or transmit money or property to
a Federal health care program;''; and
(E) in the matter following paragraph (13), as
inserted by subparagraph (D), by striking ``or in cases
under paragraph (11), $50,000 for each such violation''
and inserting ``in cases under paragraph (11), $50,000
for each such violation, in cases under paragraph (12),
$50,000 for any violation described in this section
committed in furtherance of the conspiracy involved; or
in cases under paragraph (13), $50,000 for each false
record or statement, or concealment, avoidance, or
decrease''; and
(F) in the second sentence, by striking ``such
false statement or misrepresentation)'' and inserting
``such false statement or misrepresentation, in cases
under paragraph (12), an assessment of not more than 3
times the total amount that would otherwise apply for
any violation described in this section committed in
furtherance of the conspiracy involved, or in cases
under paragraph (13), an assessment of not more than 3
times the total amount of the obligation to which the
false record or statment was material or that was
avoided or decreased)''.
(2) in subsection (c)(1), by striking ``six years'' and
inserting ``10 years''; and
(3) in subsection (i)--
(A) by amending paragraph (2) to read as follows:
``(2) The term ``claim'' means any application, request, or
demand, whether under contract, or otherwise, for money or
property for items and services under a Federal health care
program (as defined in section 1128B(f)), whether or not the
United States or a State agency has title to the money or
property, that--
``(A) is presented or caused to be presented to an
officer, employee, or agent of the United States, or of
any department or agency thereof, or of any State
agency (as defined in subsection (i)(1)); or
``(B) is made to a contractor, grantee, or other
recipient if the money or property is to be spent or
used on the Federal health care program's behalf or to
advance a Federal health care program interest, and if
the Federal health care program--
``(i) provides or has provided any portion
of the money or property requested or demanded;
or
``(ii) will reimburse such contractor,
grantee, or other recipient for any portion of
the money or property which is requested or
demanded.'';
(B) by amending paragraph (3) to read as follows:
``(3) The term `item or service' means, without limitation,
any medical, social, management, administrative, or other item
or service used in connection with or directly or indirectly
related to a Federal health care program.'';
(C) in paragraph (6)--
(i) in subparagraph (C), by striking at the
end ``or'';
(ii) in the first subparagraph (D), by
striking at the end the period and inserting
``; or''; and
(iii) by redesignating the second
subparagraph (D) as a subparagraph (E);
(D) by amending paragraph (7) to read as follows:
``(7) The terms `knowing', `knowingly', and `should know'
mean that a person, with respect to information--
``(A) has actual knowledge of the information;
``(B) acts in deliberate ignorance of the truth or
falsity of the information; or
``(C) acts in reckless disregard of the truth or
falsity of the information;
and require no proof of specific intent to defraud.''; and
(E) by adding at the end the following new
paragraphs:
``(8) The term `obligation' means an established duty,
whether or not fixed, arising from an express or implied
contractual, grantor-grantee, or licensor-licensee
relationship, from a fee-based or similar relationship, from
statute or regulation, or from the retention of any
overpayment.
``(9) The term `material' means having a natural tendency
to influence, or be capable of influencing, the payment or
receipt of money or property.''.
Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and
Abuse
SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDENTIFY FRAUD, WASTE,
AND ABUSE.
Section 1128G of the Social Security Act, as added by section 1631
and amended by sections 1632 and 1641, is further amended by adding at
the end the following new subsection;
``(d) Access to Information Necessary To Identify Fraud, Waste, and
Abuse.--For purposes of law enforcement activity, and to the extent
consistent with applicable disclosure, privacy, and security laws,
including the Health Insurance Portability and Accountability Act of
1996 and the Privacy Act of 1974, and subject to any information
systems security requirements enacted by law or otherwise required by
the Secretary, the Attorney General shall have access, facilitation by
the Inspector General of the Department of Health and Human Services,
to claims and payment data relating to titles XVIII and XIX, in
consultation with the Centers for Medicare & Medicaid Services or the
owner of such data.''.
SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE INTEGRITY
AND PROTECTION DATA BANK AND THE NATIONAL PRACTITIONER
DATA BANK.
(a) In General.--To eliminate duplication between the Healthcare
Integrity and Protection Data Bank (HIPDB) established under section
1128E of the Social Security Act and the National Practitioner Data
Bank (NPBD) established under the Health Care Quality Improvement Act
of 1986, section 1128E of the Social Security Act (42 U.S.C. 1320a-7e)
is amended--
(1) in subsection (a), by striking ``Not later than'' and
inserting ``Subject to subsection (h), not later than'';
(2) in the first sentence of subsection (d)(2), by striking
``(other than with respect to requests by Federal agencies)'';
and
(3) by adding at the end the following new subsection:
``(h) Sunset of the Healthcare Integrity and Protection Data Bank;
Transition Process.--Effective upon the enactment of this subsection,
the Secretary shall implement a process to eliminate duplication
between the Healthcare Integrity and Protection Data Bank (in this
subsection referred to as the `HIPDB' established pursuant to
subsection (a) and the National Practitioner Data Bank (in this
subsection referred to as the `NPDB') as implemented under the Health
Care Quality Improvement Act of 1986 and section 1921 of this Act,
including systems testing necessary to ensure that information formerly
collected in the HIPDB will be accessible through the NPDB, and other
activities necessary to eliminate duplication between the two data
banks. Upon the completion of such process, notwithstanding any other
provision of law, the Secretary shall cease the operation of the HIPDB
and shall collect information required to be reported under the
preceding provisions of this section in the NPDB. Except as otherwise
provided in this subsection, the provisions of subsections (a) through
(g) shall continue to apply with respect to the reporting of (or
failure to report), access to, and other treatment of the information
specified in this section.''.
(b) Elimination of the Responsibility of the HHS Office of the
Inspector General.--Section 1128C(a)(1) of the Social Security Act (42
U.S.C. 1320a-7c(a)(1)) is amended--
(1) in subparagraph (C), by adding at the end ``and'';
(2) in subparagraph (D), by striking at the end ``, and''
and inserting a period; and
(3) by striking subparagraph (E).
(c) Special Provision for Access to the National Practitioner Data
Bank by the Department of Veterans Affairs.--
(1) In general.--Notwithstanding any other provision of
law, during the one year period that begins on the effective
date specified in subsection (e)(1), the information described
in paragraph (2) shall be available from the National
Practitioner Data Bank (described in section 1921 of the Social
Security Act) to the Secretary of Veterans Affairs without
charge.
(2) Information described.--For purposes of paragraph (1),
the information described in this paragraph is the information
that would, but for the amendments made by this section, have
been available to the Secretary of Veterans Affairs from the
Healthcare Integrity and Protection Data Bank.
(d) Funding.--Notwithstanding any provisions of this Act, sections
1128E(d)(2) and 1817(k)(3) of the Social Security Act, or any other
provision of law, there shall be available for carrying out the
transition process under section 1128E(h) of the Social Security Act
over the period required to complete such process, and for operation of
the National Practitioner Data Bank until such process is completed,
without fiscal year limitation--
(1) any fees collected pursuant to section 1128E(d)(2) of
such Act; and
(2) such additional amounts as necessary, from
appropriations available to the Secretary and to the Office of
the Inspector General of the Department of Health and Human
Services under clauses (i) and (ii), respectively, of section
1817(k)(3)(A) of such Act, for costs of such activities during
the first 12 months following the date of the enactment of this
Act.
(e) Effective Date.--The amendments made--
(1) by subsection (a)(2) shall take effect on the first day
after the Secretary of Health and Human Services certifies that
the process implemented pursuant to section 1128E(h) of the
Social Security Act (as added by subsection (a)(3)) is
complete; and
(2) by subsection (b) shall take effect on the earlier of
the date specified in paragraph (1) or the first day of the
second succeeding fiscal year after the fiscal year during
which this Act is enacted.
SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECURITY STANDARDS.
The provisions of sections 262(a) and 264 of the Health Insurance
Portability and Accountability Act of 1996 (and standards promulgated
pursuant to such sections) and the Privacy Act of 1974 shall apply with
respect to the provisions of this subtitle and amendments made by this
subtitle.
TITLE VII--MEDICAID AND CHIP
Subtitle A--Medicaid and Health Reform
SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME BELOW 133\1/3\
PERCENT OF THE FEDERAL POVERTY LEVEL.
(a) Eligibility for Non-traditional Individuals With Income Below
133 Percent of the Federal Poverty Level.--
(1) In general.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396b(a)(10)(A)(i) is amended--
(A) by striking ``or'' at the end of subclause
(VI);
(B) by adding ``or'' at the end of subclause (VII);
and
(C) by adding at the end the following new
subclause:
``(VIII) who are under 65 years of
age, who are not described in a
previous subclause of this clause, and
who are in families whose income
(determined using methodologies and
procedures specified by the Secretary
in consultation with the Health Choices
Commissioner) does not exceed 133\1/3\
percent of the income official poverty
line (as defined by the Office of
Management and Budget, and revised
annually in accordance with section
673(2) of the Omnibus Budget
Reconciliation Act of 1981) applicable
to a family of the size involved;''.
(2) 100% fmap for non-traditional medicaid eligible
individuals.--Section 1905 of such Act (42 U.S.C. 1396d) is
amended--
(A) in the third sentence of subsection (b) by
inserting before the period at the end the following:
``and with respect to amounts described in subsection
(y)''; and
(B) by adding at the end the following new
subsection:
``(y) Additional Expenditures Subject to 100% FMAP.--For purposes
of section 1905(b), the amounts described in this subsection are the
following:
``(1) Amounts expended for medical assistance for
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).''.
(3) Construction.--Nothing in this subsection shall be
construed as not providing for coverage under subclause (VIII)
of section 1902(a)(10)(A)(i) of the Social Security Act, as
added by paragraph (1) of, and an increased FMAP under the
amendment made by paragraph (2) for, an individual who has been
provided medical assistance under title XIX of the Act under a
demonstration waiver approved under section 1115 of such Act or
with State funds.
(4) Conforming amendment.--Section 1903(f)(4) of the Social
Security Act (42 U.S.C. 1396b(f)(4)) is amended by inserting
``1902(a)(10)(A)(i)(VIII),'' after ``1902(a)(10)(A)(i)(VII),''.
(b) Eligibility for Traditional Medicaid Eligible Individuals With
Income Not Exceeding 133\1/3\ Percent of the Federal Poverty Level.--
(1) In general.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396b(a)(10)(A)(i)), as amended by
subsection (a), is amended--
(A) by striking ``or'' at the end of subclause
(VII);
(B) by adding ``or'' at the end of subclause
(VIII); and
(C) by adding at the end the following new
subclause:
``(IX) who are under 65 years of
age, who would be eligible for medical
assistance under the State plan under
one of subclauses (I) through (VII)
(based on the income standards,
methodologies, and procedures in effect
as of June 16, 2009) but for income and
who are in families whose income does
not exceed 133\1/3\ percent of the
income official poverty line (as
defined by the Office of Management and
Budget, and revised annually in
accordance with section 673(2) of the
Omnibus Budget Reconciliation Act of
1981) applicable to a family of the
size involved;''.
(2) 100% fmap for certain traditional medicaid eligible
individuals.--Section 1905(y) of such Act (42 U.S.C. 1396d(b)),
as added by subsection (a)(2)(B), is amended by inserting ``or
(IX)'' after ``(VIII)''.
(3) Construction.--Nothing in this subsection shall be
construed as not providing for coverage under subclause (IX) of
section 1902(a)(10)(A)(i) of the Social Security Act, as added
by paragraph (1) of, and an increased FMAP under the amendment
made by paragraph (2) for, an individual who has been provided
medical assistance under title XIX of the Act under a
demonstration waiver approved under section 1115 of such Act or
with State funds.
(4) Conforming amendment.--Section 1903(f)(4) of the Social
Security Act (42 U.S.C. 1396b(f)(4)), as amended by subsection
(a)(4), is amended by inserting ``1902(a)(10)(A)(i)(IX),''
after ``1902(a)(10)(A)(i)(VIII),''.
(c) 100% Matching Rate for Temporary Coverage of Certain
Newborns.--Section 1905(y) of such Act, as added by subsection
(a)(2)(B), is amended--
(1) in paragraph (1), by inserting before the period at the
end the following: ``, and who is not provided medical
assistance under section 1943(b)(2) of this title or section
205(d)(1)(B) of the America's Affordable Health Choices Act of
2009''; and
(2) by adding at the end the following:
``(2) Amounts expended for medical assistance for children
described in section 203(d)(1)(A) of the America's Affordable
Health Choices Act of 2009 during the time period specified in
such section.''.
(d) Network Adequacy.--Section 1932(a)(2) of the Social Security
Act (42 U.S.C. 1396u-2(a)(2)) is amended by adding at the end the
following new subparagraph:
``(D) Enrollment of non-traditional medicaid
eligibles.--A State may not require under paragraph (1)
the enrollment in a managed care entity of an
individual described in section 1902(a)(10)(A)(i)(VIII)
unless the State demonstrates, to the satisfaction of
the Secretary, that the entity, through its provider
network and other arrangements, has the capacity to
meet the health, mental health, and substance abuse
needs of such individuals.''.
(e) Effective Date.--The amendments made by this section shall take
effect on the first day of Y1, and shall apply with respect to items
and services furnished on or after such date.
SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CERTAIN MEDICAID ELIGIBLE
INDIVIDUALS.
(a) In General.--Title XIX of the Social Security Act is amended by
adding at the end the following new section:
``requirements and special rules for certain medicaid eligible
individuals
``Sec. 1943. (a) Coordination With NHI Exchange Through Memorandum
of Understanding.--
``(1) In general.--The State shall enter into a Medicaid
memorandum of understanding described in section 204(e)(4) of
the America's Affordable Health Choices Act of 2009 with the
Health Choices Commissioner, acting in consultation with the
Secretary, with respect to coordinating the implementation of
the provisions of division A of such Act with the State plan
under this title in order to ensure the enrollment of Medicaid
eligible individuals in acceptable coverage. Nothing in this
section shall be construed as permitting such memorandum to
modify or vitiate any requirement of a State plan under this
title.
``(2) Enrollment of exchange-referred individuals.--
``(A) Non-traditional individuals.--Pursuant to
such memorandum the State shall accept without further
determination the enrollment under this title of an
individual determined by the Commissioner to be a non-
traditional Medicaid eligible individual. The State
shall not do any redeterminations of eligibility for
such individuals unless the periodicity of such
redeterminations is consistent with the periodicity for
redeterminations by the Commissioner of eligibility for
affordability credits under subtitle C of title II of
division A of the America's Affordable Health Choices
Act of 2009, as specified under such memorandum.
``(B) Traditional individuals.--
``(i) Regular enrollment option.--Pursuant
to such memorandum, insofar as the memorandum
has selected the option described in section
205(e)(3)(A) of the America's Affordable Health
Choices Act of 2009, the State shall accept
without further determination the enrollment
under this title of an individual determined by
the Commissioner to be a traditional Medicaid
eligible individual. The State may do
redeterminations of eligibility of such
individual consistent with such section and the
memorandum.
``(ii) Presumptive eligibility option.--
Pursuant to such memorandum, insofar as the
memorandum has selected the option described in
section 205(e)(3)(B) of the America's
Affordable Health Choices Act of 2009, the
State shall provide for making medical
assistance available during the presumptive
eligibility period and shall, upon application
of the individual for medical assistance under
this title, promptly make a determination (and
subsequent redeterminations) of eligibility in
the same manner as if the individual had
applied directly to the State for such
assistance except that the State shall use the
income-related information used by the
Commissioner and provided to the State under
the memorandum in making the presumptive
eligibility determination to the maximum extent
feasible.
``(3) Determinations of eligibility for affordability
credits.--If the Commissioner determines that a State Medicaid
agency has the capacity to make determinations of eligibility
for affordability credits under subtitle C of title II of
division A of the America's Affordable Health Choices Act of
2009, under such memorandum--
``(A) the State Medicaid agency shall conduct such
determinations for any Exchange-eligible individual who
requests such a determination;
``(B) in the case that a State Medicaid agency
determines that an Exchange-eligible individual is not
eligible for affordability credits, the agency shall
forward the information on the basis of which such
determination was made to the Commissioner; and
``(C) the Commissioner shall reimburse the State
Medicaid agency for the costs of conducting such
determinations.
``(b) Treatment of Certain Newborns.--
``(1) In general.--In the case of a child who is deemed
under section 205(d)(1) of the America's Affordable Health
Choices Act of 2009 to be a non-traditional Medicaid eligible
individual and enrolled under this title pursuant to such
section, the State shall provide for a determination, by not
later than the end of the period referred to in subparagraph
(A) of such section, of the child's eligibility for medical
assistance under this title.
``(2) Extended treatment as traditional medicaid eligible
individual.--In accordance with subparagraph (B) of section
205(d)(1) of the America's Affordable Health Choices Act of
2009, in the case of a child described in subparagraph (A) of
such section who at the end of the period referred to in such
subparagraph is not otherwise covered under acceptable
coverage, the child shall be deemed (until such time as the
child obtains such coverage or the State otherwise makes a
determination of the child's eligibility for medical assistance
under its plan under this title pursuant to paragraph (1)) to
be a traditional Medicaid eligible individual described in
section 1902(l)(1)(B).
``(c) Definitions .--In this section:
``(1) Medicaid eligible individuals.--In this section, the
terms `Medicaid eligible individual', `traditional Medicaid
eligible individual', and `non-traditional Medicaid eligible
individual' have the meanings given such terms in section
205(e)(5) of the America's Affordable Health Choices Act of
2009.
``(2) Memorandum.--The term `memorandum' means a Medicaid
memorandum of understanding under section 205(e)(4) of the
America's Affordable Health Choices Act of 2009.
``(3) Y1.--The term `Y1' has the meaning given such term in
section 100(c) of the America's Affordable Health Choices Act
of 2009.''.
(b) Conforming Amendments to Error Rate.--
(1) Section 1903(u)(1)(D) of the Social Security Act (42
U.S.C. 1396b(u)(1)(D)) is amended by adding at the end the
following new clause:
``(vi) In determining the amount of erroneous excess payments,
there shall not be included any erroneous payments made that are
attributable to an error in an eligibility determination under subtitle
C of title II of division A of the America's Affordable Health Choices
Act of 2009.''.
(2) Section 2105(c)(11) of such Act (42 U.S.C.
1397ee(c)(11)) is amended by adding at the end the following
new sentence: ``Clause (vi) of section 1903(u)(1)(D) shall
apply with respect to the application of such requirements
under this title and title XIX.''.
SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF EFFORT.
(a) CHIP Maintenance of Effort.--Section 1902 of the Social
Security Act (42 U.S.C. 1396a) is amended--
(1) in subsection (a), as amended by section
1631(b)(1)(D)--
(A) by striking ``and'' at the end of paragraph
(72);
(B) by striking the period at the end of paragraph
(73) and inserting ``; and''; and
(C) by inserting after paragraph (74) the following
new paragraph:
``(75) provide for maintenance of effort under the State
child health plan under title XXI in accordance with subsection
(gg).''; and
(2) by adding at the end the following new subsection:
``(gg) CHIP Maintenance of Effort Requirement.--
``(1) In general.--Subject to paragraph (2), as a condition
of its State plan under this title under subsection (a)(75) and
receipt of any Federal financial assistance under section
1903(a) for calendar quarters beginning after the date of the
enactment of this subsection and before CHIP MOE termination
date specified in paragraph (3), a State shall not have in
effect eligibility standards, methodologies, or procedures
under its State child health plan under title XXI (including
any waiver under such title or under section 1115 that is
permitted to continue effect) that are more restrictive than
the eligibility standards, methodologies, or procedures,
respectively, under such plan (or waiver) as in effect on June
16, 2009.
``(2) Limitation.--Paragraph (1) shall not be construed as
preventing a State from imposing a limitation described in
section 2110(b)(5)(C)(i)(II) for a fiscal year in order to
limit expenditures under its State child health plan under
title XXI to those for which Federal financial participation is
available under section 2105 for the fiscal year.
``(3) CHIP moe termination date.--In paragraph (1), the
`CHIP MOE termination date' for a State is the date that is the
first day of Y1 (as defined in section 100(c) of the America's
Affordable Health Choices Act of 2009) or, if later, the first
day after such date that both of the following determinations
have been made:
``(A) The Health Choices Commissioner has
determined that the Health Insurance Exchange has the
capacity to support the participation of CHIP enrollees
who are Exchange-eligible individuals (as defined in
section 202(b) of the America's Affordable Health
Choices Act of 2009),
``(B) The Secretary has determined that such
Exchange, the State, and employers have procedures in
effect to ensure the timely transition without
interruption of coverage of CHIP enrollees from
assistance under title XXI to acceptable coverage (as
defined for purposes of such Act).
In this paragraph, the term `CHIP enrollee' means a targeted
low-income child or (if the State has elected the option under
section 2112, a targeted low-income pregnant woman) who is or
otherwise would be (but for acceptable coverage) eligible for
child health assistance or pregnancy-related assistance,
respectively, under the State child health plan referred to in
paragraph (1).''.
(b) Medicaid Maintenance of Effort; Simplifying and Coordinating
Eligibility Rules Between Exchange and Medicaid.--
(1) In general.--Section 1903 of such Act (42 U.S.C. 1396b)
is amended by adding at the end the following new subsection:
``(aa) Maintenance of Medicaid Effort; Simplifying and Coordinating
Eligibility Rules Between Health Insurance Exchange and Medicaid.--
``(1) Maintenance of effort.--A State is not eligible for
payment under subsection (a) for a calendar quarter beginning
after the date of the enactment of this subsection if
eligibility standards, methodologies, or procedures under its
plan under this title (including any waiver under this title or
under section 1115 that is permitted to continue effect) that
are more restrictive than the eligibility standards,
methodologies, or procedures, respectively, under such plan (or
waiver) as in effect on June 16, 2009. The Secretary shall
extend such a waiver (including the availability of Federal
financial participation under such waiver) for such period as
may be required for a State to meet the requirement of the
previous sentence.
``(2) Removal of asset test for certain eligibility
categories.--
``(A) In general.--A State is not eligible for
payment under subsection (a) for a calendar quarter
beginning on or after the first day of Y1 (as defined
in section 100(c) of the America's Affordable Health
Choices Act of 2009), if the State applies any asset or
resource test in determining (or redetermining)
eligibility of any individual on or after such first
day under any of the following:
``(i) Subclause (I), (III), (IV), or (VI)
of section 1902(a)(10)(A)(i).
``(ii) Subclause (II), (IX), (XIV) or
(XVII) of section 1902(a)(10)(A)(ii).
``(iii) Section 1931(b).
``(B) Overriding contrary provisions; references.--
The provisions of this title that prevent the waiver of
an asset or resource test described in subparagraph (A)
are hereby waived.
``(C) References.--Any reference to a provision
described in a provision in subparagraph (A) shall be
deemed to be a reference to such provision as modified
through the application of subparagraphs (A) and
(B).''.
(2) Conforming amendments.--(A) Section 1902(a)(10)(A) of
such Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the matter
before clause (i), by inserting ``subject to section
1903(aa)(2),'' after ``(A)''.
(B) Section 1931(b)(2) of such Act (42 U.S.C. 1396u-
1(b)(1)) is amended by inserting ``subject to section
1903(aa)(2)'' after ``and (3)''.
(c) Standards for Benchmark Packages.--Section 1937(b) of such Act
(42 U.S.C. 1396u-7(b)) is amended--
(1) in paragraph (1), by inserting ``subject to paragraph
(5)''; and
(2) by adding at the end the following new paragraph:
``(5) Minimum standards.--Effective January 1, 2013, any
benchmark benefit package (or benchmark equivalent coverage
under paragraph (2)) must meet the minimum benefits and cost-
sharing standards of a basic plan offered through the Health
Insurance Exchange.''.
SEC. 1704. REDUCTION IN MEDICAID DSH.
(a) Report.--
(1) In general.--Not later than January 1, 2016, the
Secretary of Health and Human Services (in this title referred
to as the ``Secretary'') shall submit to Congress a report
concerning the extent to which, based upon the impact of the
health care reforms carried out under division A in reducing
the number of uninsured individuals, there is a continued role
for Medicaid DSH. In preparing the report, the Secretary shall
consult with community-based health care networks serving low-
income beneficiaries.
(2) Matters to be included.--The report shall include the
following:
(A) Recommendations.--Recommendations regarding--
(i) the appropriate targeting of Medicaid
DSH within States; and
(ii) the distribution of Medicaid DSH among
the States.
(B) Specification of dsh health reform
methodology.--The DSH Health Reform methodology
described in paragraph (2) of subsection (b) for
purposes of implementing the requirements of such
subsection.
(3) Coordination with medicare dsh report.--The Secretary
shall coordinate the report under this subsection with the
report on Medicare DSH under section 1112.
(4) Medicaid dsh.--In this section, the term ``Medicaid
DSH'' means adjustments in payments under section 1923 of the
Social Security Act for inpatient hospital services furnished
by disproportionate share hospitals.
(b) Medicaid DSH Reductions.--
(1) In general.--The Secretary shall reduce Medicaid DSH so
as to reduce total Federal payments to all States for such
purpose by $1,500,000,000 in fiscal year 2017, $2,500,000,000
in fiscal year 2018, and $6,000,000,000 in fiscal year 2019.
(2) DSH health reform methodology.--The Secretary shall
carry out paragraph (1) through use of a DSH Health Reform
methodology issued by the Secretary that imposes the largest
percentage reductions on the States that--
(A) have the lowest percentages of uninsured
individuals (determined on the basis of audited
hospital cost reports) during the most recent year for
which such data are available; or
(B) do not target their DSH payments on--
(i) hospitals with high volumes of Medicaid
inpatients (as defined in section 1923(b)(1)(A)
of the Social Security Act (42 U.S.C. 1396r-
4(b)(1)(A)); and
(ii) hospitals that have high levels of
uncompensated care (excluding bad debt).
(3) DSH allotment publications.--
(A) In general.--Not later than the publication
deadline specified in subparagraph (B), the Secretary
shall publish in the Federal Register a notice
specifying the DSH allotment to each State under
1923(f) of the Social Security Act for the respective
fiscal year specified in such subparagraph, consistent
with the application of the DSH Health Reform
methodology described in paragraph (2).
(B) Publicataion deadline.--The publication
deadline specified in this subparagraph is--
(i) January 1, 2016, with respect to DSH
allotments described in subparagraph (A) for
fiscal year 2017;
(ii) January 1, 2017, with respect to DSH
allotments described in subparagraph (A) for
fiscal year 2018; and
(iii) January 1, 2018, with respect to DSH
allotments described in subparagraph (A) for
fiscal year 2019.
(c) Conforming Amendments.--
(1) Section 1923(f) of the Social Security Act (42 U.S.C.
1396r-4(f)) is amended--
(A) by redesignating paragraph (7) as paragraph
(8); and
(B) by inserting after paragraph (6) the following
new paragraph:
``(7) Special rule for fiscal years 2017, 2018, and 2019.--
``(A) Fiscal year 2017.--Notwithstanding paragraph
(2), the total DSH allotments for all States for--
``(i) fiscal year 2017, shall be the total
DSH allotments that would otherwise be
determined under this subsection for such
fiscal year decreased by $1,500,000,000;
``(ii) fiscal year 2018, shall be the total
DSH allotments that would otherwise be
determined under this subsection for such
fiscal year decreased by $2,500,000,000; and
``(iii) fiscal year 2019, shall be the
total DSH allotments that would otherwise be
determined under this subsection for such
fiscal year decreased by $6,000,000,000.''.
(2) Section 1923(b)(4) of such Act (42 U.S.C. 1396r-
4(b)(4)) is amended by adding before the period the following:
``or to affect the authority of the Secretary to issue and
implement the DSH Health Reform methodology under section
1704(b)(2) of the America's Health Choices Act of 2009''.
(d) Disproportionate Share Hospitals (DSH) and Essential Access
Hospital (EAH) Non-Discrimination.--
(1) In general.--Section 1923(d) of the Social Security Act
(42 U.S.C. 1396r-4) is amended by adding at the end the
following new paragraph:
``(4) No hospital may be defined or deemed as a
disproportionate share hospital, or as an essential access
hospital (for purposes of subsection (f)(6)(A)(iv), under a
State plan under this title or subsection (b) of this section
(including any waiver under section 1115) unless the hospital--
``(A) provides services to beneficiaries under this
title without discrimination on the ground of race,
color, national origin, creed, source of payment,
status as a beneficiary under this title, or any other
ground unrelated to such beneficiary's need for the
services or the availability of the needed services in
the hospital; and
``(B) makes arrangements for, and accepts,
reimbursement under this title for services provided to
eligible beneficiaries under this title.''.
(2) Effective date.--The amendment made by subsection (a)
shall be apply to expenditures made on or after July 1, 2010.
SEC. 1705. EXPANDED OUTSTATIONING.
(a) In General.--Section 1902(a)(55) of the Social Security Act (42
U.S.C. 1396a(a)(55)) is amended by striking ``under subsection
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or
(a)(10)(A)(ii)(IX)'' and inserting ``(including receipt and processing
of applications of individuals for affordability credits under subtitle
C of title II of division A of the America's Affordable Health Choices
Act of 2009 pursuant to a Medicaid memorandum of understanding under
section 1943(a)(1))''.
(b) Effective Date.--
(1) Except as provided in paragraph (2), the amendment made
by subsection (a) shall apply to services furnished on or after
July 1, 2010, without regard to whether or not final
regulations to carry out such amendment have been promulgated
by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Secretary
of Health and Human Services determines requires State
legislation (other than legislation appropriating funds) in
order for the plan to meet the additional requirement imposed
by the amendment made by this section, the State plan shall not
be regarded as failing to comply with the requirements of such
title solely on the basis of its failure to meet this
additional requirement before the first day of the first
calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of
the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be a
separate regular session of the State legislature.
Subtitle B--Prevention
SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERVICES.
(a) Coverage.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by section 1701(a)(2)(B), is amended--
(1) in subsection (a)(4)--
(A) by striking ``and'' before ``(C)''; and
(B) by inserting before the semicolon at the end
the following: ``and (D) preventive services described
in subsection (z)''; and
(2) by adding at the end the following new subsection:
``(z) Preventive Services.--The preventive services described in
this subsection are services not otherwise described in subsection (a)
or (r) that the Secretary determines are--
``(1)(A) recommended with a grade of A or B by the Task
Force for Clinical Preventive Services; or
``(B) vaccines recommended for use as appropriate by the
Director of the Centers for Disease Control and Prevention; and
``(2) appropriate for individuals entitled to medical
assistance under this title.''.
(b) Conforming Amendment.--Section 1928 of such Act (42 U.S.C.
1396s) is amended--
(1) in subsection (c)(2)(B)(i), by striking ``the advisory
committee referred to in subsection (e)'' and inserting ``the
Director of the Centers for Disease Control and Prevention'';
(2) in subsection (e), by striking ``Advisory Committee''
and all that follows and inserting ``Director of the Centers
for Disease Control and Prevention.''; and
(3) by striking subsection (g).
(c) Effective Date.--
(1) Except as provided in paragraph (2), the amendments
made by this section shall apply to services furnished on or
after July 1, 2010, without regard to whether or not final
regulations to carry out such amendments have been promulgated
by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Secretary
of Health and Human Services determines requires State
legislation (other than legislation appropriating funds) in
order for the plan to meet the additional requirements imposed
by the amendments made by this section, the State plan shall
not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet these
additional requirements before the first day of the first
calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of
the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be a
separate regular session of the State legislature.
SEC. 1712. TOBACCO CESSATION.
(a) Dropping Tobacco Cessation Exclusion From Covered Outpatient
Drugs.--Section 1927(d)(2) of the Social Security Act (42 U.S.C. 1396r-
8(d)(2)) is amended--
(1) by striking subparagraph (E);
(2) in subparagraph (G), by inserting before the period at
the end the following: ``, except agents approved by the Food
and Drug Administration for purposes of promoting, and when
used to promote, tobacco cessation''; and
(3) by redesignating subparagraphs (F) through (K) as
subparagraphs (E) through (J), respectively.
(b) Effective Date.--The amendments made by this section shall
apply to drugs and services furnished on or after January 1, 2010.
SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITATION SERVICES.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by sections 1701(a)(2) and 1711(a), is amended--
(1) in subsection (a)--
(A) in paragraph (27), by striking ``and'' at the
end;
(B) by redesignating paragraph (28) as paragraph
(29); and
(C) by inserting after paragraph (27) the following
new paragraph:
``(28) nurse home visitation services (as defined in
subsection (aa)); and''; and
(2) by adding at the end the following new subsection:
``(aa) The term `nurse home visitation services' means home visits
by trained nurses to families with a first-time pregnant woman, or a
child (under 2 years of age), who is eligible for medical assistance
under this title, but only, to the extent determined by the Secretary
based upon evidence, that such services are effective in one or more of
the following:
``(1) Improving maternal or child health and pregnancy
outcomes or increasing birth intervals between pregnancies.
``(2) Reducing the incidence of child abuse, neglect, and
injury, improving family stability (including reduction in the
incidence of intimate partner violence), or reducing maternal
and child involvement in the criminal justice system.
``(3) Increasing economic self-sufficiency, employment
advancement, school-readiness, and educational achievement, or
reducing dependence on public assistance.''.
(b) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2010.
(c) Construction.--Nothing in the amendments made by this section
shall be construed as affecting the ability of a State under title XIX
or XXI of the Social Security Act to provide nurse home visitation
services as part of another class of items and services falling within
the definition of medical assistance or child health assistance under
the respective title, or as an administrative expenditure for which
payment is made under section 1903(a) or 2105(a) of such Act,
respectively, on or after the date of the enactment of this Act.
SEC. 1714. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERVICES.
(a) Coverage as Optional Categorically Needy Group.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
(A) in subclause (XVIII), by striking ``or'' at the
end;
(B) in subclause (XIX), by adding ``or'' at the
end; and
(C) by adding at the end the following new
subclause:
``(XX) who are described in subsection (hh) (relating to
individuals who meet certain income standards);''.
(2) Group described.--Section 1902 of such Act (42 U.S.C.
1396a), as amended by section 1703, is amended by adding at the
end the following new subsection:
``(hh)(1) Individuals described in this subsection are
individuals--
``(A) whose income does not exceed an income
eligibility level established by the State that does
not exceed the highest income eligibility level
established under the State plan under this title (or
under its State child health plan under title XXI) for
pregnant women; and
``(B) who are not pregnant.
``(2) At the option of a State, individuals described in
this subsection may include individuals who, had individuals
applied on or before January 1, 2007, would have been made
eligible pursuant to the standards and processes imposed by
that State for benefits described in clause (XV) of the matter
following subparagraph (G) of section subsection (a)(10)
pursuant to a waiver granted under section 1115.
``(3) At the option of a State, for purposes of subsection
(a)(17)(B), in determining eligibility for services under this
subsection, the State may consider only the income of the
applicant or recipient.''.
(3) Limitation on benefits.--Section 1902(a)(10) of such
Act (42 U.S.C. 1396a(a)(10)) is amended in the matter following
subparagraph (G)--
(A) by striking ``and (XIV)'' and inserting
``(XIV)''; and
(B) by inserting ``, and (XV) the medical
assistance made available to an individual described in
subsection (hh) shall be limited to family planning
services and supplies described in section
1905(a)(4)(C) including medical diagnosis and treatment
services that are provided pursuant to a family
planning service in a family planning setting'' after
``cervical cancer''.
(4) Conforming amendments.--Section 1905(a) of such Act (42
U.S.C. 1396d(a)), as amended by section 1731(c), is amended in
the matter preceding paragraph (1)--
(A) in clause (xiii), by striking ``or'' at the
end;
(B) in clause (xiv), by adding ``or'' at the end;
and
(C) by inserting after clause (xiv) the following:
``(xv) individuals described in section
1902(hh),''.
(b) Presumptive Eligibility.--
(1) In general.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended by inserting after section
1920B the following:
``presumptive eligibility for family planning services
``Sec. 1920C. (a) State Option.--State plan approved under section
1902 may provide for making medical assistance available to an
individual described in section 1902(hh) (relating to individuals who
meet certain income eligibility standard) during a presumptive
eligibility period. In the case of an individual described in section
1902(hh), such medical assistance shall be limited to family planning
services and supplies described in 1905(a)(4)(C) and, at the State's
option, medical diagnosis and treatment services that are provided in
conjunction with a family planning service in a family planning
setting.
``(b) Definitions.--For purposes of this section:
``(1) Presumptive eligibility period.--The term
`presumptive eligibility period' means, with respect to an
individual described in subsection (a), the period that--
``(A) begins with the date on which a qualified
entity determines, on the basis of preliminary
information, that the individual is described in
section 1902(hh); and
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is
made with respect to the eligibility of such
individual for services under the State plan;
or
``(ii) in the case of such an individual
who does not file an application by the last
day of the month following the month during
which the entity makes the determination
referred to in subparagraph (A), such last day.
``(2) Qualified entity.--
``(A) In general.--Subject to subparagraph (B), the
term `qualified entity' means any entity that--
``(i) is eligible for payments under a
State plan approved under this title; and
``(ii) is determined by the State agency to
be capable of making determinations of the type
described in paragraph (1)(A).
``(B) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a State from
limiting the classes of entities that may become
qualified entities in order to prevent fraud and abuse.
``(c) Administration.--
``(1) In general.--The State agency shall provide qualified
entities with--
``(A) such forms as are necessary for an
application to be made by an individual described in
subsection (a) for medical assistance under the State
plan; and
``(B) information on how to assist such individuals
in completing and filing such forms.
``(2) Notification requirements.--A qualified entity that
determines under subsection (b)(1)(A) that an individual
described in subsection (a) is presumptively eligible for
medical assistance under a State plan shall--
``(A) notify the State agency of the determination
within 5 working days after the date on which
determination is made; and
``(B) inform such individual at the time the
determination is made that an application for medical
assistance is required to be made by not later than the
last day of the month following the month during which
the determination is made.
``(3) Application for medical assistance.--In the case of
an individual described in subsection (a) who is determined by
a qualified entity to be presumptively eligible for medical
assistance under a State plan, the individual shall apply for
medical assistance by not later than the last day of the month
following the month during which the determination is made.
``(d) Payment.--Notwithstanding any other provision of law, medical
assistance that--
``(1) is furnished to an individual described in subsection
(a)--
``(A) during a presumptive eligibility period;
``(B) by a entity that is eligible for payments
under the State plan; and
``(2) is included in the care and services covered by the
State plan,
shall be treated as medical assistance provided by such plan for
purposes of clause (4) of the first sentence of section 1905(b).''.
(2) Conforming amendments.--
(A) Section 1902(a)(47) of the Social Security Act
(42 U.S.C. 1396a(a)(47)) is amended by inserting before
the semicolon at the end the following: ``and provide
for making medical assistance available to individuals
described in subsection (a) of section 1920C during a
presumptive eligibility period in accordance with such
section''.
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C.
1396b(u)(1)(D)(v)) is amended--
(i) by striking ``or for'' and inserting
``for''; and
(ii) by inserting before the period the
following: ``, or for medical assistance
provided to an individual described in
subsection (a) of section 1920C during a
presumptive eligibility period under such
section''.
(c) Clarification of Coverage of Family Planning Services and
Supplies.--Section 1937(b) of the Social Security Act (42 U.S.C. 1396u-
7(b)) is amended by adding at the end the following:
``(5) Coverage of family planning services and supplies.--
Notwithstanding the previous provisions of this section, a
State may not provide for medical assistance through enrollment
of an individual with benchmark coverage or benchmark-
equivalent coverage under this section unless such coverage
includes for any individual described in section 1905(a)(4)(C),
medical assistance for family planning services and supplies in
accordance with such section.''.
(d) Effective Date.--The amendments made by this section take
effect on the date of the enactment of this Act and shall apply to
items and services furnished on or after such date.
Subtitle C--Access
SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS.
(a) In General.--
(1) Fee-for-service payments.--Section 1902(a)(13) of the
Social Security Act (42 U.S.C. 1396b(a)(13)) is amended--
(A) by striking ``and'' at the end of subparagraph
(A);
(B) by adding ``and'' at the end of subparagraph
(B); and
(C) by adding at the end the following new
subparagraph:
``(C) payment for primary care services (as defined
in section 1848(j)(5)(A), but applied without regard to
clause (ii) thereof) furnished by physicians (or for
services furnished by other health care professionals
that would be primary care services under such section
if furnished by a physician) at a rate not less than 80
percent of the payment rate applicable to such services
and physicians or professionals (as the case may be)
under part B of title XVIII for services furnished in
2010, 90 percent of such rate for services and
physicians (or professionals) furnished in 2011, and
100 percent of such payment rate for services and
physicians (or professionals) furnished in 2012 or a
subsequent year;''.
(2) Under medicaid managed care plans.--Section 1923(f) of
such Act (42 U.S.C. 1396u-2(f)) is amended--
(A) in the heading, by adding at the end the
following: ``; Adequacy of Payment for Primary Care
Services''; and
(B) by inserting before the period at the end the
following: ``and, in the case of primary care services
described in section 1902(a)(13)(C), consistent with
the minimum payment rates specified in such section
(regardless of the manner in which such payments are
made, including in the form of capitation or partial
capitation)''.
(b) Increase in Payment Using 100% FMAP.--Section 1905(y), as added
by section 1701(a)(2)(B) and as amended by section 1701(c)(2), is
amended by adding at the end the following:
``(3)(A) The portion of the amounts expended for medical
assistance for services described in section 1902(a)(13)(C)
furnished on or after January 1, 2010, that is attributable to
the amount by which the minimum payment rate required under
such section (or, by application, section 1932(f)) exceeds the
payment rate applicable to such services under the State plan
as of June 16, 2009.
``(B) Subparagraphs (A) shall not be construed as
preventing the payment of Federal financial participation based
on the Federal medical assistance percentage for amounts in
excess of those specified under such subparagraphs.''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2010.
SEC. 1722. MEDICAL HOME PILOT PROGRAM.
(a) In General.--The Secretary of Health and Human Services shall
establish under this section a medical home pilot program under which a
State may apply to the Secretary for approval of a medical home pilot
project described in subsection (b) (in this section referred to as a
``pilot project'') for the application of the medical home concept
under title XIX of the Social Security Act. The pilot program shall
operate for a period of up to 5 years.
(b) Pilot Project Described.--
(1) In general.--A pilot project is a project that applies
one or more of the medical home models described in section
1866E(a)(3) of the Social Security Act (as inserted by section
1302(a)) or such other model as the Secretary may approve, to
high need beneficiaries (including medically fragile children
and high-risk pregnant women) who are eligible for medical
assistance under title XIX of the Social Security Act. The
Secretary shall provide for appropriate coordination of the
pilot program under this section with the medical home pilot
program under section 1866E of such Act.
(2) Limitation.--A pilot project shall be for a duration of
not more than 5 years.
(c) Additional Incentives.--In the case of a pilot project, the
Secretary may--
(1) waive the requirements of section 1902(a)(1) of the
Social Security Act (relating to statewideness) and section
1902(a)(10)(B) of such Act (relating to comparability); and
(2) increase to up to 90 percent (for the first 2 years of
the pilot program) or 75 percent (for the next 3 years) the
matching percentage for administrative expenditures (such as
those for community care workers).
(d) Medically Fragile Children.--In the case of a model involving
medically fragile children, the model shall ensure that the patient-
centered medical home services received by each child, in addition to
fulfilling the requirements under 1866E(b)(1) of the Social Security
Act, provide for continuous involvement and education of the parent or
caregiver and for assistance to the child in obtaining necessary
transitional care if a child's enrollment ceases for any reason.
(e) Evaluation; Report.--
(1) Evaluation.--The Secretary, using the criteria
described in section 1866E(g)(1) of the Social Security Act (as
inserted by section 1123), shall conduct an evaluation of the
pilot program under this section.
(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the Secretary
shall submit to Congress and make available to the public a
report on the findings of the evaluation under such paragraph.
(f) Funding.--The additional Federal financial participation
resulting from the implementation of the pilot program under this
section may not exceed in the aggregate $1,235,000,000 over the 5-year
period of the program.
SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES.
(a) In General.--Section 1903(a)(2)(E) of the Social Security Act
(42 U.S.C. 1396b(a)(2)), as added by section 201(b)(2)(A) of the
Children's Health Insurance Program Reauthorization Act of 2009 (Public
Law 111-3), is amended by inserting ``and other individuals'' after
``children of families''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to payment for translation or interpretation services furnished
on or after January 1, 2010.
SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by section 1713(a), is amended--
(1) in subsection (a)--
(A) by redesignating paragraph (29) as paragraph
(30);
(B) in paragraph (28), by striking at the end
``and''; and
(C) by inserting after paragraph (28) the following
new paragraph:
``(29) freestanding birth center services (as defined in
subsection (l)(3)(A)) and other ambulatory services that are
offered by a freestanding birth center (as defined in
subsection (l)(3)(B)) and that are otherwise included in the
plan; and''; and
(2) in subsection (l), by adding at the end the following
new paragraph:
``(3)(A) The term `freestanding birth center services' means
services furnished to an individual at a freestanding birth center (as
defined in subparagraph (B)), including by a licensed birth attendant
(as defined in subparagraph (C)) at such center.
``(B) The term `freestanding birth center' means a health
facility--
``(i) that is not a hospital; and
``(ii) where childbirth is planned to occur away from the
pregnant woman's residence.
``(C) The term `licensed birth attendant' means an individual who
is licensed or registered by the State involved to provide health care
at childbirth and who provides such care within the scope of practice
under which the individual is legally authorized to perform such care
under State law (or the State regulatory mechanism provided by State
law), regardless of whether the individual is under the supervision of,
or associated with, a physician or other health care provider. Nothing
in this subparagraph shall be construed as changing State law
requirements applicable to a licensed birth attendant.''.
(b) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after the date of the
enactment of this Act.
SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER THE VACCINES FOR
CHILDREN PROGRAM.
Section 1928(b)(2)(A)(iii)(I) of the Social Security Act (42 U.S.C.
1396s(b)(2)(A)(iii)(I)) is amended--
(1) by striking ``or a rural health clinic'' and inserting
``, a rural health clinic''; and
(2) by inserting ``or a public health clinic,'' after
```1905(l)(1)),''.
Subtitle D--Coverage
SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-INFECTED
INDIVIDUALS.
(a) In General.--Section 1902 of the Social Security Act (42 U.S.C.
1396a), as amended by section 1714(a)(1), is amended--
(1) in subsection (a)(10)(A)(ii)--
(A) by striking ``or'' at the end of subclause
(XIX);
(B) by adding ``or'' at the end of subclause (XX);
and
(C) by adding at the end the following:
``(XXI) who are described in subsection (ii) (relating to
HIV-infected individuals);''; and
(2) by adding at the end, as amended by sections 1703 and
1714(a), the following:
``(ii) individuals described in this subsection are individuals not
described in subsection (a)(10)(A)(i)--
``(1) who have HIV infection;
``(2) whose income (as determined under the State plan
under this title with respect to disabled individuals) does not
exceed the maximum amount of income a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain
medical assistance under the plan; and
``(3) whose resources (as determined under the State plan
under this title with respect to disabled individuals) do not
exceed the maximum amount of resources a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain
medical assistance under the plan.''.
(b) Enhanced Match.--The first sentence of section 1905(b) of such
Act (42 U.S.C. 1396d(b)) is amended by striking ``section
1902(a)(10)(A)(ii)(XVIII)'' and inserting ``subclause (XVIII) or (XX)
of section 1902(a)(10)(A)(ii)''.
(c) Conforming Amendments.--Section 1905(a) of such Act (42 U.S.C.
1396d(a)) is amended, in the matter preceding paragraph (1)--
(1) by striking ``or'' at the end of clause (xii);
(2) by adding ``or'' at the end of clause (xiii); and
(3) by inserting after clause (xiii) the following:
``(xiv) individuals described in section
1902(ii),''.
(d) Exemption From Funding Limitation for Territories.--Section
1108(g) of the Social Security Act (42 U.S.C. 1308(g)) is amended by
adding at the end the following:
``(5) Disregarding medical assistance for optional low-
income hiv-infected individuals.--The limitations under
subsection (f) and the previous provisions of this subsection
shall not apply to amounts expended for medical assistance for
individuals described in section 1902(ii) who are only eligible
for such assistance on the basis of section
1902(a)(10)(A)(ii)(XX).''.
(e) Effective Date; Sunset.--The amendments made by this section
shall apply to expenditures for calendar quarters beginning on or after
the date of the enactment of this Act, and before January 1, 2013,
without regard to whether or not final regulations to carry out such
amendments have been promulgated by such date.
SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSISTANCE (TMA).
Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act (42
U.S.C. 1396a(e)(1)(B), 1396r-6(f)), as amended by section 5004(a)(1) of
the American Recovery and Reinvestment Act of 2009 (Public Law 111-5),
are each amended by striking ``December 31, 2010'' and inserting
``December 31, 2012''.
SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER CERTAIN
CHIP PROGRAMS.
(a) In General.--Section 2102(b) of the Social Security Act (42
U.S.C. 1397bb(b)) is amended by adding at the end the following new
paragraph:
``(6) Requirement for 12-month continuous eligibility.--In
the case of a State child health plan that provides child
health assistance under this title through a means other than
described in section 2101(a)(2), the plan shall provide for
implementation under this title of the 12-month continuous
eligibility option described in section 1902(e)(12) for
targeted low-income children whose family income is below 200
percent of the poverty line.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to determinations (and redeterminations) of eligibility made on
or after January 1, 2010.
Subtitle E--Financing
SEC. 1741. PAYMENTS TO PHARMACISTS.
(a) Pharmacy Reimbursement Limits.--
(1) In general.--Section 1927(e) of the Social Security Act
(42 U.S.C. 1396r-8(e)) is amended--
(A) by striking paragraph (5) and inserting the
following:
``(5) Use of amp in upper payment limits.--The Secretary
shall calculate the Federal upper reimbursement limit
established under paragraph (4) as 130 percent of the weighted
average (determined on the basis of manufacturer utilization)
of monthly average manufacturer prices.''.
(2) Definition of amp.--Section 1927(k)(1)(B) of such Act
(42 U.S.C. 1396r-8(k)(1)(B)) is amended--
(B) in the heading, by striking ``extended to
wholesalers'' and inserting ``and other payments''; and
(C) by striking ``regard to'' and all that follows
through the period and inserting the following:
``regard to--
``(i) customary prompt pay discounts
extended to wholesalers;
``(ii) bona fide service fees paid by
manufacturers;
``(iii) reimbursement by manufacturers for
recalled, damaged, expired, or otherwise
unsalable returned goods, including
reimbursement for the cost of the goods and any
reimbursement of costs associated with return
goods handling and processing, reverse
logistics, and drug destruction;
``(iv) sales directly to, or rebates,
discounts, or other price concessions provided
to, pharmacy benefit managers, managed care
organizations, health maintenance
organizations, insurers, mail order pharmacies
that are not open to all members of the public,
or long term care providers, provided that
these rebates, discounts, or price concessions
are not passed through to retail pharmacies;
``(v) sales directly to, or rebates,
discounts, or other price concessions provided
to, hospitals, clinics, and physicians, unless
the drug is an inhalation, infusion, or
injectable drug, or unless the Secretary
determines, as allowed for in Agency
administrative procedures, that it is necessary
to include such sales, rebates, discounts, and
price concessions in order to obtain an
accurate AMP for the drug. Such a determination
shall not be subject to judicial review; or
``(vi) rebates, discounts, and other price
concessions required to be provided under
agreements under subsections (f) and (g) of
section 1860D-2(f).''.
(3) Manufacturer reporting requirements.--Section
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
(A) in subparagraph (A), by adding at the end the
following new clause:
``(iv) not later than 30 days after the
last day of each month of a rebate period under
the agreement, on the manufacturer's total
number of units that are used to calculate the
monthly average manufacturer price for each
covered outpatient drug.''.
(4) Authority to promulgate regulation.--The Secretary of
Health and Human Services may promulgate regulations to clarify
the requirements for upper payment limits and for the
determination of the average manufacturer price in an expedited
manner. Such regulations may become effective on an interim
final basis, pending opportunity for public comment.
(5) Pharmacy reimbursements through december 31, 2010.--The
specific upper limit under section 447.332 of title 42, Code of
Federal Regulations (as in effect on December 31, 2006)
applicable to payments made by a State for multiple source
drugs under a State Medicaid plan shall continue to apply
through December 31, 2010, for purposes of the availability of
Federal financial participation for such payments.
(b) Disclosure of Price Information to the Public.--Section
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
(1) in subparagraph (A)--
(A) in clause (i), in the matter preceding
subclause (I), by inserting ``month of a'' after
``each''; and
(B) in the last sentence, by striking ``and
shall,'' and all that follows through the period; and
(2) in subparagraph (D)(v), by inserting ``weighted''
before ``average manufacturer prices''.
SEC. 1742. PRESCRIPTION DRUG REBATES.
(a) Additional Rebate for New Formulations of Existing Drugs.--
(1) In general.--Section 1927(c)(2) of the Social Security
Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end
the following new subparagraph:
``(C) Treatment of new formulations.--In the case
of a drug that is a line extension of a single source
drug or an innovator multiple source drug that is an
oral solid dosage form, the rebate obligation with
respect to such drug under this section shall be the
amount computed under this section for such new drug
or, if greater, the product of--
``(i) the average manufacturer price of the
line extension of a single source drug or an
innovator multiple source drug that is an oral
solid dosage form;
``(ii) the highest additional rebate
(calculated as a percentage of average
manufacturer price) under this section for any
strength of the original single source drug or
innovator multiple source drug; and
``(iii) the total number of units of each
dosage form and strength of the line extension
product paid for under the State plan in the
rebate period (as reported by the State).
In this subparagraph, the term `line extension' means,
with respect to a drug, an extended release formulation
of the drug.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to drugs dispensed after December 31, 2009.
(b) Increase Minimum Rebate Percentage for Single Source Drugs.--
Section 1927(c)(1)(B)(i) of the Social Security Act (42 U.S.C. 1396r-
8(c)(1)(B)(i)) is amended--
(1) in subclause (IV), by striking ``and'' at the end;
(2) in subclause (V)--
(A) by inserting ``and before January 1, 2010''
after ``December 31, 1995,''; and
(B) by striking the period at the end and inserting
``; and''; and
(3) by adding at the end the following new subclause:
``(VI) after December 31, 2009, is
22.1 percent.''.
SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DISCOUNTS TO ENROLLEES OF
MEDICAID MANAGED CARE ORGANIZATIONS.
(a) In General.--Section 1903(m)(2)(A) of the Social Security Act
(42 U.S.C. 1396b(m)(2)(A)) is amended--
(1) in clause (xi), by striking ``and'' at the end;
(2) in clause (xii), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following:
``(xiii) such contract provides that the entity shall
report to the State such information, on such timely and
periodic basis as specified by the Secretary, as the State may
require in order to include, in the information submitted by
the State to a manufacturer under section 1927(b)(2)(A),
information on covered outpatient drugs dispensed to
individuals eligible for medical assistance who are enrolled
with the entity and for which the entity is responsible for
coverage of such drugs under this subsection.''.
(b) Conforming Amendments.--Section 1927 of such Act (42 U.S.C.
1396r-8) is amended----
(1) in the first sentence of subsection (b)(1)(A), by
inserting before the period at the end the following: ``,
including such drugs dispensed to individuals enrolled with a
medicaid managed care organization if the organization is
responsible for coverage of such drugs'';
(2) in subsection (b)(2), by adding at the end the
following new subparagraph:
``(C) Reporting on mmco drugs.--On a quarterly
basis, each State shall report to the Secretary the
total amount of rebates in dollars received from
pharmacy manufacturers for drugs provided to
individuals enrolled with Medicaid managed care
organizations that contract under section 1903(m).'';
and
(3) in subsection (j)--
(A) in the heading by striking ``Exemption'' and
inserting ``Special Rules''; and
(B) in paragraph (1), by striking ``not''.
(c) Effective Date.--The amendments made by this section take
effect on July 1, 2010, and shall apply to drugs dispensed on or after
such date, without regard to whether or not final regulations to carry
out such amendments have been promulgated by such date.
SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDUCATION.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by sections 1701(a)(2), 1711(a), and 1713(a), is
amended by adding at the end the following new subsection:
``(bb) Payment for Graduate Medical Education.--
``(1) In general.--The term `medical assistance' includes
payment for costs of graduate medical education consistent with
this subsection, whether provided in or outside of a hospital.
``(2) Submission of information.--For purposes of paragraph
(1) and section 1902(a)(13)(A)(v), payment for such costs is
not consistent with this subsection unless--
``(A) the State submits to the Secretary, in a
timely manner and on an annual basis specified by the
Secretary, information on total payments for graduate
medical education and how such payments are being used
for graduate medical education, including--
``(i) the institutions and programs
eligible for receiving the funding;
``(ii) the manner in which such payments
are calculated;
``(iii) the types and fields of education
being supported;
``(iv) the workforce or other goals to
which the funding is being applied;
``(v) State progress in meeting such goals;
and
``(vi) such other information as the
Secretary determines will assist in carrying
out paragraphs (3) and (4); and
``(B) such expenditures are made consistent with
such goals and requirements as are established under
paragraph (4).
``(3) Review of information.--The Secretary shall make the
information submitted under paragraph (2) available to the
Advisory Committee on Health Workforce Evaluation and
Assessment (established under section 2261 of the Public Health
Service Act). The Secretary and the Advisory Committee shall
independently review the information submitted under paragraph
(2), taking into account State and local workforce needs.
``(4) Specification of goals and requirements.--The
Secretary shall specify by rule, initially published by not
later than December 31, 2011--
``(A) program goals for the use of funds described
in paragraph (1), taking into account recommendations
of the such Advisory Committee and the goals for
approved medical residency training programs described
in section 1886(h)(1)(B); and
``(B) requirements for use of such funds consistent
with such goals.
Such rule may be effective on an interim basis pending revision
after an opportunity for public comment.''.
(b) Conforming Amendment.--Section 1902(a)(13)(A) of such Act (42
U.S.C. 1396a(a)(13)(A)) is amended--
(1) by striking ``and'' at the end of clause (iii);
(2) by striking ``; and'' and inserting ``, and''; and
(3) by adding at the end the following new clause:
``(v) in the case of hospitals and at the
option of a State, such rates may include, to
the extent consistent with section 1905(bb),
payment for graduate medical education; and''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act. Nothing in this
section shall be construed as affecting payments made before such date
under a State plan under title XIX of the Social Security Act for
graduate medical education.
Subtitle F--Waste, Fraud, and Abuse
SEC. 1751. HEALTH-CARE ACQUIRED CONDITIONS.
(a) Medicaid Non-Payment for Certain Health Care-Acquired
Conditions.--Section 1903(i) of the Social Security Act (42 U.S.C.
1396b(i)) is amended--
(1) by striking ``or'' at the end of paragraph (23);
(2) by striking the period at the end of paragraph (24) and
inserting ``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) with respect to amounts expended for services
related to the presence of a condition that could be identified
by a secondary diagnostic code described in section
1886(d)(4)(D)(iv) and for any health care acquired condition
determined as a non-covered service under title XVIII.''.
(b) Application to CHIP.--Section 2107(e)(1)(G) of such Act (42
U.S.C. 1397gg(e)(1)(G)) is amended by striking ``and (17)'' and
inserting ``(17), and (25)''.
(c) Permission To Include Additional Health Care-Acquired
Conditions.--Nothing in this section shall prevent a State from
including additional health care-acquired conditions for non-payment in
its Medicaid program under title XIX of the Social Security Act.
(d) Effective Date.--The amendments made by this section shall
apply to discharges occurring on or after January 1, 2010.
SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICAID INTEGRITY
PROGRAM.
Section 1936(c)(2)) of the Social Security Act (42 U.S.C. 1396u-
7(c)(2)) is amended--
(1) by redesignating subparagraph (D) as subparagraph (E);
and
(2) by inserting after subparagraph (C) the following new
subparagraph:
``(D) For the contract year beginning in 2011 and
each subsequent contract year, the entity provides
assurances to the satisfaction of the Secretary that
the entity will conduct periodic evaluations of the
effectiveness of the activities carried out by such
entity under the Program and will submit to the
Secretary an annual report on such activities.''.
SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE
WASTE, FRAUD, AND ABUSE.
Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 1396a(a)), as
amended by sections 1631(b)(1) and 1703, is further amended--
(1) in paragraph (74), by striking at the end ``and'';
(2) in paragraph (75), by striking at the end the period
and inserting ``; and''; and
(3) by inserting after paragraph (75) the following new
paragraph:
``(76) provide that any provider or supplier (other than a
physician or nursing facility) providing services under such
plan shall, subject to paragraph (5) of section 1874(d),
establish a compliance program described in paragraph (1) of
such section in accordance with such section.''.
SEC. 1754. OVERPAYMENTS.
(a) In General.--Section 1903(d)(2)(C) of the Social Security Act
(42 U.S.C. 1396b(d)(2)(C)) is amended by inserting ``(or 1 year in the
case of overpayments due to fraud)'' after ``60 days''.
(b) Effective Date.--In the case overpayments discovered on or
after the date of the enactment of this Act.
SEC. 1755. MANAGED CARE ORGANIZATIONS.
(a) Minimum Medical Loss Ratio.--
(1) Medicaid.--Section 1903(m)(2)(A) of the Social Security
Act (42 U.S.C. 1396b(m)(2)(A)), as amended by section
1743(a)(3), is amended--
(A) by striking ``and'' at the end of clause (xii);
(B) by striking the period at the end of clause
(xiii) and inserting ``; and''; and
(C) by adding at the end the following new clause:
``(xiv) such contract has a medical loss ratio, as
determined in accordance with a methodology specified by the
Secretary that is a percentage (not less than 85 percent) as
specified by the Secretary.''.
(2) CHIP.--Section 2107(e)(1) of such Act (42 U.S.C.
1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (H) through (L)
as subparagraphs (I) through (M); and
(B) by inserting after subparagraph (G) the
following new subparagraph:
``(H) Section 1903(m)(2)(A)(xiv) (relating to
application of minimum loss ratios), with respect to
comparable contracts under this title.''.
(3) Effective date.--The amendments made by this subsection
shall apply to contracts entered into or renewed on or after
July 1, 2010.
(b) Patient Encounter Data.--
(1) In general.--Section 1903(m)(2)(A)(xi) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by
inserting ``and for the provision of such data to the State at
a frequency and level of detail to be specified by the
Secretary'' after ``patients''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to contract years beginning on or
after January 1, 2010.
SEC. 1756. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID AND
CHIP IF TERMINATED UNDER MEDICARE OR OTHER STATE PLAN OR
CHILD HEALTH PLAN.
(a) State Plan Requirement.--Section 1902(a)(39) of the Social
Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is amended by inserting
after ``1128A,'' the following: ``terminate the participation of any
individual or entity in such program if (subject to such exceptions are
are permitted with respect to exclusion under sections 1128(b)(3)(C)
and 1128(d)(3)(B)) participation of such individual or entity is
terminated under title XVIII, any other State plan under this title, or
any child health plan under title XXI,''.
(b) Application to CHIP.--Section 2107(e)(1)(A) of such Act (42
U.S.C. 1397gg(e)(1)(A)) is amended by inserting before the period at
the end the following: ``and section 1902(a)(39) (relating to exclusion
and termination of participation)''.
(c) Effective Date.--
(1) Except as provided in paragraph (2), the amendments
made by this section shall apply to services furnished on or
after JJanuary 1, 2011, without regard to whether or not final
regulations to carry out such amendments have been promulgated
by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act or a child health
plan under title XXI of such Act which the Secretary of Health
and Human Services determines requires State legislation (other
than legislation appropriating funds) in order for the plan to
meet the additional requirement imposed by the amendments made
by this section, the State plan or child health plan shall not
be regarded as failing to comply with the requirements of such
title solely on the basis of its failure to meet this
additional requirement before the first day of the first
calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of
the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be a
separate regular session of the State legislature.
SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICIPATION RELATING TO
CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS.
(a) State Plan Requirement.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)), as amended by sections 1631(b)(1), 1703, and
1753, is further amended--
(1) in paragraph (75), by striking at the end ``and'';
(2) in paragraph (76), by striking at the end the period
and inserting ``; and''; and
(3) by inserting after paragraph (76) the following new
paragraph:
``(77) provide that the State agency described in paragraph
(9) exclude, with respect to a period, any individual or entity
from participation in the program under the State plan if such
individual or entity owns, controls, or manages an entity that
(or if such entity is owned, controlled, or managed by an
individual or entity that)--
``(A) has unpaid overpayments under this title
during such period determined by the Secretary or the
State agency to be delinquent;
``(B) is suspended or excluded from participation
under or whose participation is terminated under this
title during such period; or
``(C) is affiliated with an individual or entity
that has been suspended or excluded from participation
under this title or whose participation is terminated
under this title during such period.''.
(b) Child Health Plan Requirement.--Section 2107(e)(1)(A) of such
Act (42 U.S.C. 1397gg(e)(1)(A)), as amended by section 1756(b), is
amended by striking ``section 1902(a)(39)'' and inserting ``sections
1902(a)(39) and 1902(a)(77)''.
(c) Effective Date.--
(1) Except as provided in paragraph (2), the amendments
made by this section shall apply to services furnished on or
after January 1, 2011, without regard to whether or not final
regulations to carry out such amendments have been promulgated
by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act or a child health
plan under title XXI of such Act which the Secretary of Health
and Human Services determines requires State legislation (other
than legislation appropriating funds) in order for the plan to
meet the additional requirement imposed by the amendments made
by this section, the State plan or child health plan shall not
be regarded as failing to comply with the requirements of such
title solely on the basis of its failure to meet this
additional requirement before the first day of the first
calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of
the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be a
separate regular session of the State legislature.
SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER
MMIS TO DETECT FRAUD AND ABUSE.
Section 1903(r)(1)(F) of the Social Security Act (42 U.S.C.
1396b(r)(1)(F)) is amended by inserting after ``necessary'' the
following: ``and including, for data submitted to the Secretary on or
after July 1, 2010, data elements from the automated data system that
the Secretary determines to be necessary for detection of waste, fraud,
and abuse''.
SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES
REQUIRED TO REGISTER UNDER MEDICAID.
(a) In General.--Section 1902(a) of the Social Security Act (42
U.S.C. 42 U.S.C. 1396a(a)), as amended by sections 1631(b), 1703, 1753,
and 1757, is further amended--
(1) in paragraph (76); by striking at the end ``and'';
(2) in paragraph (77), by striking the period at the end
and inserting ``and''; and
(3) by inserting after paragraph (77) the following new
paragraph:
``(78) provide that any agent, clearinghouse, or other
alternate payee that submits claims on behalf of a health care
provider must register with the State and the Secretary in a
form and manner specified by the Secretary under section
1866(j)(1)(D).''.
(b) Denial of Payment.--Section 1903(i) of such Act (42 U.S.C.
1396b(i)), as amended by section 1753, is amended--
(1) by striking ``or'' at the end of paragraph (24);
(2) by striking the period at the end of paragraph (25) and
inserting ``; or''; and
(3) by inserting after paragraph (25) the following new
paragraph:
``(26) with respect to any amount paid to a billing agent,
clearinghouse, or other alternate payee that is not registered
with the State and the Secretary as required under section
1902(a)(78).''.
(c) Effective Date.--
(1) Except as provided in paragraph (2), the amendments
made by this section shall apply to claims submitted on or
after January 1, 2012, without regard to whether or not final
regulations to carry out such amendments have been promulgated
by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Secretary
of Health and Human Services determines requires State
legislation (other than legislation appropriating funds) in
order for the plan to meet the additional requirement imposed
by the amendments made by this section, the State plan or child
health plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure
to meet this additional requirement before the first day of the
first calendar quarter beginning after the close of the first
regular session of the State legislature that begins after the
date of the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be a
separate regular session of the State legislature.
SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RELATED MISCONDUCT.
(a) In General.--Section 1903(i) of the Social Security Act (42
U.S.C. 1396b(i)), as previously amended is amended--
(1) by striking ``or'' at the end of paragraph (25);
(2) by striking the period at the end of paragraph (26) and
inserting a semicolon; and
(3) by inserting after paragraph (26) the following new
paragraphs:
``(27) with respect to any amount expended--
``(A) on litigation in which a court imposes
sanctions on the State, its employees, or its counsel
for litigation-related misconduct; or
``(B) to reimburse (or otherwise compensate) a
managed care entity for payment of legal expenses
associated with any action in which a court imposes
sanctions on the managed care entity for litigation-
related misconduct.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to amounts expended on or after January 1, 2010.
Subtitle G--Puerto Rico and the Territories
SEC. 1771. PUERTO RICO AND TERRITORIES.
(a) Increase in Cap.--
(1) In general.--Section 1108(g) of the Social Security Act
(42 U.S.C. 1308(g)) is amended--
(A) in paragraph (4) by striking ``and (3)'' and by
inserting ``(3), (6), and (7)''; and
(B) by inserting after paragraph (5), as added by
section 1731(d), the following new paragraph:
``(6) Fiscal years 2011 through 2019.--The amounts
otherwise determined under this subsection for Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa for fiscal year 2011 and each succeeding fiscal
year through fiscal year 2019 shall be increased by the
percentage specified under section 1771(c) of the America's
Affordable Health Choices Act of 2009 for purposes of this
paragraph of the amounts otherwise determined under this
section (without regard to this paragraph).
``(7) Fiscal year 2020 and subsequent fiscal years.--The
amounts otherwise determined under this subsection for Puerto
Rico, the Virgin Islands, Guam, the Northern Mariana Islands,
and American Samoa for fiscal year 2020 and each succeeding
fiscal year shall be the amount provided in paragraph (6) or
this paragraph for the preceding fiscal year for the respective
territory increased by the percentage increase referred to in
paragraph (1)(B), rounded to the nearest $10,000 (or $100,000
in the case of Puerto Rico).''.
(2) Coordination with arra.--Section 5001(d) of the
American Recovery and Reinvestment Act of 2009 shall not apply
during any period for which section 1108(g)(6) of the Social
Security Act, as added by paragraph (1), applies.
(b) Increase in FMAP.--
(1) In general.--Section 1905(b)(2) of the Social Security
Act (42 U.S.C. 1396d(b)(2)) is amended by striking ``50 per
centum'' and inserting ``for fiscal years 2011 through 2019,
the percentage specified under section 1771(c) of the America's
Affordable Health Choices Act of 2009 for purposes of this
clause for such fiscal year and for subsequent fiscal years the
percentage so specified for fiscal year 2019''.
(2) Effective date.--The amendment made by subsection (a)
shall apply to items and services furnished on or after October
1, 2010.
(c) Specification of Percentages.--The Secretary of Health and
Human Services shall specify, before January 1, 2011, the percentages
to be applied under section 1108(g)(6) of the Social Security Act, as
added by subsection (a)(1), and under section 1905(b)(2) of such Act,
as amended by subsection (b)(1), in a manner so that for the period
beginning with 2011 and ending with 2019 the total estimated additional
Federal expenditures resulting from the application of such percentages
will be equal to $10,350,000,000.
Subtitle H--Miscellaneous
SEC. 1781. TECHNICAL CORRECTIONS.
(a) Technical Correction to Section 1144 of the Social Security
Act.--The first sentence of section 1144(c)(3) of the Social Security
Act (42 U.S.C. 1320b--14(c)(3)) is amended--
(1) by striking ``transmittal''; and
(2) by inserting before the period the following: ``as
specified in section 1935(a)(4)''.
(b) Clarifying Amendment to Section 1935 of the Social Security
Act.--Section 1935(a)(4) of the Social Security Act (42 U.S.C. 1396u--
5(a)(4)), as amended by section 113(b) of Public Law 110-275, is
amended--
(1) by striking the second sentence;
(2) by redesignating the first sentence as a subparagraph
(A) with appropriate indentation and with the following
heading: ``In general'';
(3) by adding at the end the following subparagraphs:
``(B) Furnishing medical assistance with reasonable
promptness.--For the purpose of a State's obligation
under section 1902(a)(8) to furnish medical assistance
with reasonable promptness, the date of the electronic
transmission of low-income subsidy program data, as
described in section 1144(c), from the Commissioner of
Social Security to the State Medicaid Agency, shall
constitute the date of filing of such application for
benefits under the Medicare Savings Program.
``(C) Determining availability of medical
assistance.--For the purpose of determining when
medical assistance will be made available, the State
shall consider the date of the individual's application
for the low income subsidy program to constitute the
date of filing for benefits under the Medicare Savings
Program.''.
(c) Effective Date Relating to Medicaid Agency Consideration of
Low-income Subsidy Application and Data Transmittal.--The amendments
made by subsections (a) and (b) shall be effective as if included in
the enactment of section 113(b) of Public Law 110-275.
(d) Technical Correction to Section 605 of CHIPRA.--Section 605 of
the Children's Health Insurance Program Reauthorization Act of 2009
(Public Law 111-3) is amended by striking ``legal residents'' and
inserting ``lawfully residing in the United States''.
(e) Technical Correction to Section 1905 of the Social Security
Act.--Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a))
is amended by inserting ``or the care and services themselves, or
both'' before ``(if provided in or after''.
(f) Clarifying Amendment to Section 1115 of the Social Security
Act.--Section 1115(a) of the Social Security Act (42 U.S.C. 1315(a)) is
amended by adding at the end the following: ``If an experimental,
pilot, or demonstration project that relates to title XIX is approved
pursuant to any part of this subsection, such project shall be treated
as part of the State plan, all medical assistance provided on behalf of
any individuals affected by such project shall be medical assistance
provided under the State plan, and all provisions of this Act not
explicitly waived in approving such project shall remain fully
applicable to all individuals receiving benefits under the State
plan.''.
SEC. 1782. EXTENSION OF QI PROGRAM.
(a) In General.--Section 1902(a)(10)(E)(iv) of the Social Security
Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is amended--
(1) by striking ``sections 1933 and'' and by inserting
``section''; and
(2) by striking ``December 2010'' and inserting ``December
2012''.
(b) Elimination of Funding Limitation.--
(1) In general.--Section 1933 of such Act (42 U.S.C. 1396u-
3) is amended--
(A) in subsection (a), by striking ``who are
selected to receive such assistance under subsection
(b)'';
(B) by striking subsections (b), (c), (e), and (g);
(C) in subsection (d), by striking ``furnished in a
State'' and all that follows and inserting ``the
Federal medical assistance percentage shall be equal to
100 percent.''; and
(D) by redesignating subsections (d) and (f) as
subsections (b) and (c), respectively.
(2) Conforming amendment.--Section 1905(b) of such Act (42
U.S.C. 1396d(b)) is amended by striking ``1933(d)'' and
inserting ``1933(b)''.
(3) Effective date.--The amendments made by paragraph (1)
shall take effect on January 1, 2011.
TITLE VIII--REVENUE-RELATED PROVISIONS
SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF INDIVIDUALS
LIKELY TO BE INELIGIBLE FOR THE LOW-INCOME ASSISTANCE
UNDER THE MEDICARE PRESCRIPTION DRUG PROGRAM TO ASSIST
SOCIAL SECURITY ADMINISTRATION'S OUTREACH TO ELIGIBLE
INDIVIDUALS.
(a) In General.--Paragraph (19) of section 6103(l) of the Internal
Revenue Code of 1986 is amended to read as follows:
``(19) Disclosures to facilitate identification of
individuals likely to be ineligible for low-income subsidies
under medicare prescription drug program to assist social
security administration's outreach to eligible individuals.--
``(A) In general.--Upon written request from the
Commissioner of Social Security, the following return
information (including such information disclosed to
the Social Security Administration under paragraph (1)
or (5)) shall be disclosed to officers and employees of
the Social Security Administration, with respect to any
taxpayer identified by the Commissioner of Social
Security--
``(i) return information for the applicable
year from returns with respect to wages (as
defined in section 3121(a) or 3401(a)) and
payments of retirement income (as described in
paragraph (1) of this subsection),
``(ii) unearned income information and
income information of the taxpayer from
partnerships, trusts, estates, and subchapter S
corporations for the applicable year,
``(iii) if the individual filed an income
tax return for the applicable year, the filing
status, number of dependents, income from
farming, and income from self-employment, on
such return,
``(iv) if the individual is a married
individual filing a separate return for the
applicable year, the social security number (if
reasonably available) of the spouse on such
return,
``(v) if the individual files a joint
return for the applicable year, the social
security number, unearned income information,
and income information from partnerships,
trusts, estates, and subchapter S corporations
of the individual's spouse on such return, and
``(vi) such other return information
relating to the individual (or the individual's
spouse in the case of a joint return) as is
prescribed by the Secretary by regulation as
might indicate that the individual is likely to
be ineligible for a low-income prescription
drug subsidy under section 1860D-14 of the
Social Security Act.
``(B) Applicable year.--For the purposes of this
paragraph, the term `applicable year' means the most
recent taxable year for which information is available
in the Internal Revenue Service's taxpayer information
records.
``(C) Restriction on individuals for whom
disclosure may be requested.--The Commissioner of
Social Security shall request information under this
paragraph only with respect to--
``(i) individuals the Social Security
Administration has identified, using all other
reasonably available information, as likely to
be eligible for a low-income prescription drug
subsidy under section 1860D-14 of the Social
Security Act and who have not applied for such
subsidy, and
``(ii) any individual the Social Security
Administration has identified as a spouse of an
individual described in clause (i).
``(D) Restriction on use of disclosed
information.--Return information disclosed under this
paragraph may be used only by officers and employees of
the Social Security Administration solely for purposes
of identifying individuals likely to be ineligible for
a low-income prescription drug subsidy under section
1860D-14 of the Social Security Act for use in outreach
efforts under section 1144 of the Social Security
Act.''.
(b) Safeguards.--Paragraph (4) of section 6103(p) of such Code is
amended--
(1) by striking ``(l)(19)'' each place it appears, and
(2) by striking ``or (17)'' each place it appears and
inserting ``(17), or (19)''.
(c) Conforming Amendment.--Paragraph (3) of section 6103(a) of such
Code is amended by striking ``(19),''.
(d) Effective Date.--The amendments made by this section shall
apply to disclosures made after the date which is 12 months after the
date of the enactment of this Act.
SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND; FINANCING FOR
TRUST FUND.
(a) Establishment of Trust Fund.--
(1) In general.--Subchapter A of chapter 98 of the Internal
Revenue Code of 1986 (relating to trust fund code) is amended
by adding at the end the following new section:
``SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND.
``(a) Creation of Trust Fund.--There is established in the Treasury
of the United States a trust fund to be known as the `Health Care
Comparative Effectiveness Research Trust Fund' (hereinafter in this
section referred to as the `CERTF'), consisting of such amounts as may
be appropriated or credited to such Trust Fund as provided in this
section and section 9602(b).
``(b) Transfers to Fund.--There are hereby appropriated to the
Trust Fund the following:
``(1) For fiscal year 2010, $90,000,000.
``(2) For fiscal year 2011, $100,000,000.
``(3) For fiscal year 2012, $110,000,000.
``(4) For each fiscal year beginning with fiscal year
2013--
``(A) an amount equivalent to the net revenues
received in the Treasury from the fees imposed under
subchapter B of chapter 34 (relating to fees on health
insurance and self-insured plans) for such fiscal year;
and
``(B) subject to subsection (c)(2), amounts
determined by the Secretary of Health and Human
Services to be equivalent to the fair share per capita
amount computed under subsection (c)(1) for the fiscal
year multiplied by the average number of individuals
entitled to benefits under part A, or enrolled under
part B, of title XVIII of the Social Security Act
during such fiscal year.
The amounts appropriated under paragraphs (1), (2), (3), and (4)(B)
shall be transferred from the Federal Hospital Insurance Trust Fund and
from the Federal Supplementary Medical Insurance Trust Fund
(established under section 1841 of such Act), and from the Medicare
Prescription Drug Account within such Trust Fund, in proportion (as
estimated by the Secretary) to the total expenditures during such
fiscal year that are made under title XVIII of such Act from the
respective trust fund or account.
``(c) Fair Share Per Capita Amount.--
``(1) Computation.--
``(A) In general.--Subject to subparagraph (B), the
fair share per capita amount under this paragraph for a
fiscal year (beginning with fiscal year 2013) is an
amount computed by the Secretary of Health and Human
Services for such fiscal year that, when applied under
this section and subchapter B of chapter 34 of the
Internal Revenue Code of 1986, will result in revenues
to the CERTF of $375,000,000 for the fiscal year.
``(B) Alternative computation.--
``(i) In general.--If the Secretary is
unable to compute the fair share per capita
amount under subparagraph (A) for a fiscal
year, the fair share per capita amount under
this paragraph for the fiscal year shall be the
default amount determined under clause (ii) for
the fiscal year.
``(ii) Default amount.--The default amount
under this clause for--
``(I) fiscal year 2013 is equal to
$2; or
``(II) a subsequent year is equal
to the default amount under this clause
for the preceding fiscal year increased
by the annual percentage increase in
the medical care component of the
consumer price index (United States
city average) for the 12-month period
ending with April of the preceding
fiscal year.
Any amount determined under subclause (II)
shall be rounded to the nearest penny.
``(2) Limitation on medicare funding.--In no case shall the
amount transferred under subsection (b)(4)(B) for any fiscal
year exceed $90,000,000.
``(d) Expenditures From Fund.--
``(1) In general.--Subject to paragraph (2), amounts in the
CERTF are available, without the need for further
appropriations and without fiscal year limitation, to the
Secretary of Health and Human Services for carrying out section
1181 of the Social Security Act.
``(2) Allocation for commission.--Not less than the
following amounts in the CERTF for a fiscal year shall be
available to carry out the activities of the Comparative
Effectiveness Research Commission established under section
1181(b) of the Social Security Act for such fiscal year:
``(A) For fiscal year 2010, $7,000,000.
``(B) For fiscal year 2011, $9,000,000.
``(C) For each fiscal year beginning with 2012,
$10,000,000.
Nothing in this paragraph shall be construed as preventing
additional amounts in the CERTF from being made available to
the Comparative Effectiveness Research Commission for such
activities.
``(e) Net Revenues.--For purposes of this section, the term `net
revenues' means the amount estimated by the Secretary based on the
excess of--
``(1) the fees received in the Treasury under subchapter B
of chapter 34, over
``(2) the decrease in the tax imposed by chapter 1
resulting from the fees imposed by such subchapter.''.
(2) Clerical amendment.--The table of sections for such
subchapter A is amended by adding at the end thereof the
following new item:
``Sec. 9511. Health Care Comparative Effectiveness Research Trust
Fund.''.
(b) Financing for Fund From Fees on Insured and Self-Insured Health
Plans.--
(1) General rule.--Chapter 34 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subchapter:
``Subchapter B--Insured and Self-Insured Health Plans
``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.
``SEC. 4375. HEALTH INSURANCE.
``(a) Imposition of Fee.--There is hereby imposed on each specified
health insurance policy for each policy year a fee equal to the fair
share per capita amount determined under section 9511(c)(1) multiplied
by the average number of lives covered under the policy.
``(b) Liability for Fee.--The fee imposed by subsection (a) shall
be paid by the issuer of the policy.
``(c) Specified Health Insurance Policy.--For purposes of this
section:
``(1) In general.--Except as otherwise provided in this
section, the term `specified health insurance policy' means any
accident or health insurance policy issued with respect to
individuals residing in the United States.
``(2) Exemption for certain policies.--The term `specified
health insurance policy' does not include any insurance if
substantially all of its coverage is of excepted benefits
described in section 9832(c).
``(3) Treatment of prepaid health coverage arrangements.--
``(A) In general.--In the case of any arrangement
described in subparagraph (B)--
``(i) such arrangement shall be treated as
a specified health insurance policy, and
``(ii) the person referred to in such
subparagraph shall be treated as the issuer.
``(B) Description of arrangements.--An arrangement
is described in this subparagraph if under such
arrangement fixed payments or premiums are received as
consideration for any person's agreement to provide or
arrange for the provision of accident or health
coverage to residents of the United States, regardless
of how such coverage is provided or arranged to be
provided.
``SEC. 4376. SELF-INSURED HEALTH PLANS.
``(a) Imposition of Fee.--In the case of any applicable self-
insured health plan for each plan year, there is hereby imposed a fee
equal to the fair share per capita amount determined under section
9511(c)(1) multiplied by the average number of lives covered under the
plan.
``(b) Liability for Fee.--
``(1) In general.--The fee imposed by subsection (a) shall
be paid by the plan sponsor.
``(2) Plan sponsor.--For purposes of paragraph (1) the term
`plan sponsor' means--
``(A) the employer in the case of a plan
established or maintained by a single employer,
``(B) the employee organization in the case of a
plan established or maintained by an employee
organization,
``(C) in the case of--
``(i) a plan established or maintained by 2
or more employers or jointly by 1 or more
employers and 1 or more employee organizations,
``(ii) a multiple employer welfare
arrangement, or
``(iii) a voluntary employees' beneficiary
association described in section 501(c)(9),
the association, committee, joint board of trustees, or
other similar group of representatives of the parties
who establish or maintain the plan, or
``(D) the cooperative or association described in
subsection (c)(2)(F) in the case of a plan established
or maintained by such a cooperative or association.
``(c) Applicable Self-Insured Health Plan.--For purposes of this
section, the term `applicable self-insured health plan' means any plan
for providing accident or health coverage if--
``(1) any portion of such coverage is provided other than
through an insurance policy, and
``(2) such plan is established or maintained--
``(A) by one or more employers for the benefit of
their employees or former employees,
``(B) by one or more employee organizations for the
benefit of their members or former members,
``(C) jointly by 1 or more employers and 1 or more
employee organizations for the benefit of employees or
former employees,
``(D) by a voluntary employees' beneficiary
association described in section 501(c)(9),
``(E) by any organization described in section
501(c)(6), or
``(F) in the case of a plan not described in the
preceding subparagraphs, by a multiple employer welfare
arrangement (as defined in section 3(40) of Employee
Retirement Income Security Act of 1974), a rural
electric cooperative (as defined in section
3(40)(B)(iv) of such Act), or a rural telephone
cooperative association (as defined in section
3(40)(B)(v) of such Act).
``SEC. 4377. DEFINITIONS AND SPECIAL RULES.
``(a) Definitions.--For purposes of this subchapter--
``(1) Accident and health coverage.--The term `accident and
health coverage' means any coverage which, if provided by an
insurance policy, would cause such policy to be a specified
health insurance policy (as defined in section 4375(c)).
``(2) Insurance policy.--The term `insurance policy' means
any policy or other instrument whereby a contract of insurance
is issued, renewed, or extended.
``(3) United states.--The term `United States' includes any
possession of the United States.
``(b) Treatment of Governmental Entities.--
``(1) In general.--For purposes of this subchapter--
``(A) the term `person' includes any governmental
entity, and
``(B) notwithstanding any other law or rule of law,
governmental entities shall not be exempt from the fees
imposed by this subchapter except as provided in
paragraph (2).
``(2) Treatment of exempt governmental programs.--In the
case of an exempt governmental program, no fee shall be imposed
under section 4375 or section 4376 on any covered life under
such program.
``(3) Exempt governmental program defined.--For purposes of
this subchapter, the term `exempt governmental program' means--
``(A) any insurance program established under title
XVIII of the Social Security Act,
``(B) the medical assistance program established by
title XIX or XXI of the Social Security Act,
``(C) any program established by Federal law for
providing medical care (other than through insurance
policies) to individuals (or the spouses and dependents
thereof) by reason of such individuals being--
``(i) members of the Armed Forces of the
United States, or
``(ii) veterans, and
``(D) any program established by Federal law for
providing medical care (other than through insurance
policies) to members of Indian tribes (as defined in
section 4(d) of the Indian Health Care Improvement
Act).
``(c) Treatment as Tax.--For purposes of subtitle F, the fees
imposed by this subchapter shall be treated as if they were taxes.
``(d) No Cover Over to Possessions.--Notwithstanding any other
provision of law, no amount collected under this subchapter shall be
covered over to any possession of the United States.''.
(2) Clerical amendments.--
(A) Chapter 34 of such Code is amended by striking
the chapter heading and inserting the following:
``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES
``subchapter a. policies issued by foreign insurers
``subchapter b. insured and self-insured health plans
``Subchapter A--Policies Issued By Foreign Insurers''.
(B) The table of chapters for subtitle D of such
Code is amended by striking the item relating to
chapter 34 and inserting the following new item:
``Chapter 34--Taxes on Certain Insurance Policies''.
(3) Effective date.--The amendments made by this subsection
shall apply with respect to policies and plans for portions of
policy or plan years beginning on or after October 1, 2012.
TITLE IX--MISCELLANEOUS PROVISIONS
SEC. 1901. REPEAL OF TRIGGER PROVISION.
Subtitle A of title VIII of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-173) is
repealed and the provisions of law amended by such subtitle are
restored as if such subtitle had never been enacted.
SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA) PROGRAM.
Section 1860C-1 of the Social Security Act (42 U.S.C. 1395w-29), as
added by section 241(a) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (Public Law 108-173), is repealed.
SEC. 1903. EXTENSION OF GAINSHARING DEMONSTRATION.
(a) In General.--Subsection (d)(3) of section 5007 of the Deficit
Reduction Act of 2005 (Public Law 109-171) is amended by inserting
``(or September 30, 2011, in the case of a demonstration project in
operation as of October 1, 2008)'' after ``December 31, 2009''.
(b) Funding.--
(1) In general.--Subsection (f)(1) of such section is
amended by inserting ``and for fiscal year 2010, $1,600,000,''
after ``$6,000,000,''.
(2) Availability.--Subsection (f)(2) of such section is
amended by striking ``2010'' and inserting ``2014 or until
expended''.
(c) Reports.--
(1) Quality improvement and savings.--Subsection (e)(3) of
such section is amended by striking ``December 1, 2008'' and
inserting ``March 31, 2011''.
(2) Final report.--Subsection (e)(4) of such section is
amended by striking ``May 1, 2010'' and inserting ``March 31,
2013''.
SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITATION PROGRAMS FOR
FAMILIES WITH YOUNG CHILDREN AND FAMILIES EXPECTING
CHILDREN.
Part B of title IV of the Social Security Act (42 U.S.C. 621-629i)
is amended by adding at the end the following:
``Subpart 3--Support for Quality Home Visitation Programs
``SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN
AND FAMILIES EXPECTING CHILDREN.
``(a) Purpose.--The purpose of this section is to improve the well-
being, health, and development of children by enabling the
establishment and expansion of high quality programs providing
voluntary home visitation for families with young children and families
expecting children.
``(b) Grant Application.--A State that desires to receive a grant
under this section shall submit to the Secretary for approval, at such
time and in such manner as the Secretary may require, an application
for the grant that includes the following:
``(1) Description of home visitation programs.--A
description of the high quality programs of home visitation for
families with young children and families expecting children
that will be supported by a grant made to the State under this
section, the outcomes the programs are intended to achieve, and
the evidence supporting the effectiveness of the programs.
``(2) Results of needs assessment.--The results of a
statewide needs assessment that describes--
``(A) the number, quality, and capacity of home
visitation programs for families with young children
and families expecting children in the State;
``(B) the number and types of families who are
receiving services under the programs;
``(C) the sources and amount of funding provided to
the programs;
``(D) the gaps in home visitation in the State,
including identification of communities that are in
high need of the services; and
``(E) training and technical assistance activities
designed to achieve or support the goals of the
programs.
``(3) Assurances.--Assurances from the State that--
``(A) in supporting home visitation programs using
funds provided under this section, the State shall
identify and prioritize serving communities that are in
high need of such services, especially communities with
a high proportion of low-income families or a high
incidence of child maltreatment;
``(B) the State will reserve 5 percent of the grant
funds for training and technical assistance to the home
visitation programs using such funds;
``(C) in supporting home visitation programs using
funds provided under this section, the State will
promote coordination and collaboration with other home
visitation programs (including programs funded under
title XIX) and with other child and family services,
health services, income supports, and other related
assistance;
``(D) home visitation programs supported using such
funds will, when appropriate, provide referrals to
other programs serving children and families; and
``(E) the State will comply with subsection (i),
and cooperate with any evaluation conducted under
subsection (j).
``(4) Other information.--Such other information as the
Secretary may require.
``(c) Allotments.--
``(1) Indian tribes.--From the amount reserved under
subsection (l)(2) for a fiscal year, the Secretary shall allot
to each Indian tribe that meets the requirement of subsection
(d), if applicable, for the fiscal year the amount that bears
the same ratio to the amount so reserved as the number of
children in the Indian tribe whose families have income that
does not exceed 200 percent of the poverty line bears to the
total number of children in such Indian tribes whose families
have income that does not exceed 200 percent of the poverty
line.
``(2) States and territories.--From the amount appropriated
under subsection (m) for a fiscal year that remains after
making the reservations required by subsection (l), the
Secretary shall allot to each State that is not an Indian tribe
and that meets the requirement of subsection (d), if
applicable, for the fiscal year the amount that bears the same
ratio to the remainder of the amount so appropriated as the
number of children in the State whose families have income that
does not exceed 200 percent of the poverty line bears to the
total number of children in such States whose families have
income that does not exceed 200 percent of the poverty line.
``(3) Reallotments.--The amount of any allotment to a State
under a paragraph of this subsection for any fiscal year that
the State certifies to the Secretary will not be expended by
the State pursuant to this section shall be available for
reallotment using the allotment methodology specified in that
paragraph. Any amount so reallotted to a State is deemed part
of the allotment of the State under this subsection.
``(d) Maintenance of Effort.--Beginning with fiscal year 2011, a
State meets the requirement of this subsection for a fiscal year if the
Secretary finds that the aggregate expenditures by the State from State
and local sources for programs of home visitation for families with
young children and families expecting children for the then preceding
fiscal year was not less than 100 percent of such aggregate
expenditures for the then 2nd preceding fiscal year.
``(e) Payment of Grant.--
``(1) In general.--The Secretary shall make a grant to each
State that meets the requirements of subsections (b) and (d),
if applicable, for a fiscal year for which funds are
appropriated under subsection (m), in an amount equal to the
reimbursable percentage of the eligible expenditures of the
State for the fiscal year, but not more than the amount
allotted to the State under subsection (c) for the fiscal year.
``(2) Reimbursable percentage defined.--In paragraph (1),
the term `reimbursable percentage' means, with respect to a
fiscal year--
``(A) 85 percent, in the case of fiscal year 2010;
``(B) 80 percent, in the case of fiscal year 2011;
or
``(C) 75 percent, in the case of fiscal year 2012
and any succeeding fiscal year.
``(f) Eligible Expenditures.--
``(1) In general.--In this section, the term `eligible
expenditures'--
``(A) means expenditures to provide voluntary home
visitation for as many families with young children
(under the age of school entry) and families expecting
children as practicable, through the implementation or
expansion of high quality home visitation programs
that--
``(i) adhere to clear evidence-based models
of home visitation that have demonstrated
positive effects on important program-
determined child and parenting outcomes, such
as reducing abuse and neglect and improving
child health and development;
``(ii) employ well-trained and competent
staff, maintain high quality supervision,
provide for ongoing training and professional
development, and show strong organizational
capacity to implement such a program;
``(iii) establish appropriate linkages and
referrals to other community resources and
supports;
``(iv) monitor fidelity of program
implementation to ensure that services are
delivered according to the specified model; and
``(v) provide parents with--
``(I) knowledge of age-appropriate
child development in cognitive,
language, social, emotional, and motor
domains (including knowledge of second
language acquisition, in the case of
English language learners);
``(II) knowledge of realistic
expectations of age-appropriate child
behaviors;
``(III) knowledge of health and
wellness issues for children and
parents;
``(IV) modeling, consulting, and
coaching on parenting practices;
``(V) skills to interact with their
child to enhance age-appropriate
development;
``(VI) skills to recognize and seek
help for issues related to health,
developmental delays, and social,
emotional, and behavioral skills; and
``(VII) activities designed to help
parents become full partners in the
education of their children;
``(B) includes expenditures for training, technical
assistance, and evaluations related to the programs;
and
``(C) does not include any expenditure with respect
to which a State has submitted a claim for payment
under any other provision of Federal law.
``(2) Priority funding for programs with strongest
evidence.--
``(A) In general.--The expenditures, described in
paragraph (1), of a State for a fiscal year that are
attributable to the cost of programs that do not adhere
to a model of home visitation with the strongest
evidence of effectiveness shall not be considered
eligible expenditures for the fiscal year to the extent
that the total of the expenditures exceeds the
applicable percentage for the fiscal year of the
allotment of the State under subsection (c) for the
fiscal year.
``(B) Applicable percentage defined.--In
subparagraph (A), the term `applicable percentage'
means, with respect to a fiscal year--
``(i) 60 percent for fiscal year 2010;
``(ii) 55 percent for fiscal year 2011;
``(iii) 50 percent for fiscal year 2012;
``(iv) 45 percent for fiscal year 2013; or
``(v) 40 percent for fiscal year 2014.
``(g) No Use of Other Federal Funds for State Match.--A State to
which a grant is made under this section may not expend any Federal
funds to meet the State share of the cost of an eligible expenditure
for which the State receives a payment under this section.
``(h) Waiver Authority.--
``(1) In general.--The Secretary may waive or modify the
application of any provision of this section, other than
subsection (b) or (f), to an Indian tribe if the failure to do
so would impose an undue burden on the Indian tribe.
``(2) Special rule.--An Indian tribe is deemed to meet the
requirement of subsection (d) for purposes of subsections (c)
and (e) if--
``(A) the Secretary waives the requirement; or
``(B) the Secretary modifies the requirement, and
the Indian tribe meets the modified requirement.
``(i) State Reports.--Each State to which a grant is made under
this section shall submit to the Secretary an annual report on the
progress made by the State in addressing the purposes of this section.
Each such report shall include a description of--
``(1) the services delivered by the programs that received
funds from the grant;
``(2) the characteristics of each such program, including
information on the service model used by the program and the
performance of the program;
``(3) the characteristics of the providers of services
through the program, including staff qualifications, work
experience, and demographic characteristics;
``(4) the characteristics of the recipients of services
provided through the program, including the number of the
recipients, the demographic characteristics of the recipients,
and family retention;
``(5) the annual cost of implementing the program,
including the cost per family served under the program;
``(6) the outcomes experienced by recipients of services
through the program;
``(7) the training and technical assistance provided to aid
implementation of the program, and how the training and
technical assistance contributed to the outcomes achieved
through the program;
``(8) the indicators and methods used to monitor whether
the program is being implemented as designed; and
``(9) other information as determined necessary by the
Secretary.
``(j) Evaluation.--
``(1) In general.--The Secretary shall, by grant or
contract, provide for the conduct of an independent evaluation
of the effectiveness of home visitation programs receiving
funds provided under this section, which shall examine the
following:
``(A) The effect of home visitation programs on
child and parent outcomes, including child
maltreatment, child health and development, school
readiness, and links to community services.
``(B) The effectiveness of home visitation programs
on different populations, including the extent to which
the ability of programs to improve outcomes varies
across programs and populations.
``(2) Reports to the congress.--
``(A) Interim report.--Within 3 years after the
date of the enactment of this section, the Secretary
shall submit to the Congress an interim report on the
evaluation conducted pursuant to paragraph (1).
``(B) Final report.--Within 5 years after the date
of the enactment of this section, the Secretary shall
submit to the Congress a final report on the evaluation
conducted pursuant to paragraph (1).
``(k) Annual Reports to the Congress.--The Secretary shall submit
annually to the Congress a report on the activities carried out using
funds made available under this section, which shall include a
description of the following:
``(1) The high need communities targeted by States for
programs carried out under this section.
``(2) The service delivery models used in the programs
receiving funds provided under this section.
``(3) The characteristics of the programs, including--
``(A) the qualifications and demographic
characteristics of program staff; and
``(B) recipient characteristics including the
number of families served, the demographic
characteristics of the families served, and family
retention and duration of services.
``(4) The outcomes reported by the programs.
``(5) The research-based instruction, materials, and
activities being used in the activities funded under the grant.
``(6) The training and technical activities, including on-
going professional development, provided to the programs.
``(7) The annual costs of implementing the programs,
including the cost per family served under the programs.
``(8) The indicators and methods used by States to monitor
whether the programs are being been implemented as designed.
``(l) Reservations of Funds.--From the amounts appropriated for a
fiscal year under subsection (m), the Secretary shall reserve--
``(1) an amount equal to 5 percent of the amounts to pay
the cost of the evaluation provided for in subsection (j), and
the provision to States of training and technical assistance,
including the dissemination of best practices in early
childhood home visitation; and
``(2) after making the reservation required by paragraph
(1), an amount equal to 3 percent of the amount so
appropriated, to pay for grants to Indian tribes under this
section.
``(m) Appropriations.--Out of any money in the Treasury of the
United States not otherwise appropriated, there is appropriated to the
Secretary to carry out this section--
``(1) $50,000,000 for fiscal year 2010;
``(2) $100,000,000 for fiscal year 2011;
``(3) $150,000,000 for fiscal year 2012;
``(4) $200,000,000 for fiscal year 2013; and
``(5) $250,000,000 for fiscal year 2014.
``(n) Indian Tribes Treated as States.--In this section, paragraphs
(4), (5), and (6) of section 431(a) shall apply.''.
SEC. 1905. IMPROVED COORDINATION AND PROTECTION FOR DUAL ELIGIBLES.
Title XI of the Social Security Act is amended by inserting after
section 1150 the following new section:
``improved coordination and protection for dual eligibles
``Sec. 1150A. (a) In General.--The Secretary shall provide,
through an identifiable office or program within the Centers for
Medicare & Medicaid Services, for a focused effort to provide for
improved coordination between Medicare and Medicaid and protection in
the case of dual eligibles (as defined in subsection (e)). The office
or program shall--
``(1) review Medicare and Medicaid policies related to
enrollment, benefits, service delivery, payment, and grievance
and appeals processes under parts A and B of title XVIII, under
the Medicare Advantage program under part C of such title, and
under title XIX;
``(2) identify areas of such policies where better
coordination and protection could improve care and costs; and
``(3) issue guidance to States regarding improving such
coordination and protection.
``(b) Elements.--The improved coordination and protection under
this section shall include efforts--
``(1) to simplify access of dual eligibles to benefits and
services under Medicare and Medicaid;
``(2) to improve care continuity for dual eligibles and
ensure safe and effective care transitions;
``(3) to harmonize regulatory conflicts between Medicare
and Medicaid rules with regard to dual eligibles; and
``(4) to improve total cost and quality performance under
Medicare and Medicaid for dual eligibles.
``(c) Responsibilities.--In carrying out this section, the
Secretary shall provide for the following:
``(1) An examination of Medicare and Medicaid payment
systems to develop strategies to foster more integrated and
higher quality care.
``(2) Development of methods to facilitate access to post-
acute and community-based services and to identify actions that
could lead to better coordination of community-based care.
``(3) A study of enrollment of dual eligibles in the
Medicare Savings Program (as defined in section 1144(c)(7)),
under Medicaid, and in the low-income subsidy program under
section 1860D-14 to identify methods to more efficiently and
effectively reach and enroll dual eligibles.
``(4) An assessment of communication strategies for dual
eligibles to determine whether additional informational
materials or outreach is needed, including an assessment of the
Medicare website, 1-800-MEDICARE, and the Medicare handbook.
``(5) Research and evaluation of areas where service
utilization, quality, and access to cost sharing protection
could be improved and an assessment of factors related to
enrollee satisfaction with services and care delivery.
``(6) Collection (and making available to the public) of
data and a database that describe the eligibility, benefit and
cost-sharing assistance available to dual eligibles by State.
``(7) Monitoring total combined Medicare and Medicaid
program costs in serving dual eligibles and making
recommendations for optimizing total quality and cost
performance across both programs.
``(8) Coordination of activities relating to Medicare
Advantage plans under 1859(b)(6)(B)(ii) and Medicaid.
``(d) Periodic Reports.--Not later than 1 year after the date of
the enactment of this section and every 3 years thereafter the
Secretary shall submit to Congress a report on progress in activities
conducted under this section.
``(e) Definitions.--In this section:
``(1) Dual eligible.--The term `dual eligible' means an
individual who is dually eligible for benefits under title
XVIII, and medical assistance under title XIX, including such
individuals who are eligible for benefits under the Medicare
Savings Program (as defined in section 1144(c)(7)).
``(2) Medicare; medicaid.--The terms `Medicare' and
`Medicaid' mean the programs under titles XVIII and XIX,
respectively.''.
DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
SEC. 2001. TABLE OF CONTENTS; REFERENCES.
(a) Table of Contents.--The table of contents of this division is
as follows:
Sec. 2001. Table of contents; references.
Sec. 2002. Public Health Investment Fund.
TITLE I--COMMUNITY HEALTH CENTERS
Sec. 2101. Increased funding.
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
Part 1--National Health Service Corps
Sec. 2201. National Health Service Corps.
Sec. 2202. Authorizations of appropriations.
Part 2--Promotion of Primary Care and Dentistry
Sec. 2211. Frontline health providers.
``subpart xi--health professional needs areas
``Sec. 340H. In general.
``Sec. 340I. Loan repayments.
``Sec. 340J. Report.
``Sec. 340K. Allocation.
Sec. 2212. Primary care student loan funds.
Sec. 2213. Training in family medicine, general internal medicine,
general pediatrics, geriatrics, and
physician assistantship.
Sec. 2214. Training of medical residents in community-based settings.
Sec. 2215. Training for general, pediatric, and public health dentists
and dental hygienists.
Sec. 2216. Authorization of appropriations.
Subtitle B--Nursing Workforce
Sec. 2221. Amendments to Public Health Service Act.
Subtitle C--Public Health Workforce
Sec. 2231. Public Health Workforce Corps.
``subpart xii--public health workforce
``Sec. 340L. Public Health Workforce Corps.
``Sec. 340M. Public Health Workforce Scholarship Program.
``Sec. 340N. Public Health Workforce Loan Repayment Program.
Sec. 2232. Enhancing the public health workforce.
Sec. 2233. Public health training centers.
Sec. 2234. Preventive medicine and public health training grant
program.
Sec. 2235. Authorization of appropriations.
Subtitle D--Adapting Workforce to Evolving Health System Needs
Part 1--Health Professions Training for Diversity
Sec. 2241. Scholarships for disadvantaged students, loan repayments and
fellowships regarding faculty positions,
and educational assistance in the health
professions regarding individuals from
disadvantaged backgrounds.
Sec. 2242. Nursing workforce diversity grants.
Sec. 2243. Coordination of diversity and cultural competency programs.
Part 2--Interdisciplinary Training Programs
Sec. 2251. Cultural and linguistic competency training for health care
professionals.
Sec. 2252. Innovations in interdisciplinary care training.
Part 3--Advisory Committee on Health Workforce Evaluation and
Assessment
Sec. 2261. Health workforce evaluation and assessment.
Part 4--Health Workforce Assessment
Sec. 2271. Health workforce assessment.
Part 5--Authorization of Appropriations
Sec. 2281. Authorization of appropriations.
TITLE III--PREVENTION AND WELLNESS
Sec. 2301. Prevention and wellness.
``TITLE XXXI--PREVENTION AND WELLNESS
``Subtitle A--Prevention and Wellness Trust
``Sec. 3111. Prevention and Wellness Trust.
``Subtitle B--National Prevention and Wellness Strategy
``Sec. 3121. National Prevention and Wellness Strategy.
``Subtitle C--Prevention Task Forces
``Sec. 3131. Task Force on Clinical Preventive Services.
``Sec. 3132. Task Force on Community Preventive Services.
``Subtitle D--Prevention and Wellness Research
``Sec. 3141. Prevention and wellness research activity
coordination.
``Sec. 3142. Community prevention and wellness research grants.
``Subtitle E--Delivery of Community Prevention and Wellness Services
``Sec. 3151. Community prevention and wellness services grants.
``Subtitle F--Core Public Health Infrastructure
``Sec. 3161. Core public health infrastructure for State,
local, and tribal health departments.
``Sec. 3162. Core public health infrastructure and activities
for CDC.
``Subtitle G--General Provisions
``Sec. 3171. Definitions.
TITLE IV--QUALITY AND SURVEILLANCE
Sec. 2401. Implementation of best practices in the delivery of health
care.
Sec. 2402. Assistant Secretary for Health Information.
Sec. 2403. Authorization of appropriations.
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals
Sec. 2501. Expanded participation in 340B program.
Sec. 2502. Extension of discounts to inpatient drugs.
Sec. 2503. Effective date.
Subtitle B--School-Based Health Clinics
Sec. 2511. School-based health clinics.
Subtitle C--National Medical Device Registry
Sec. 2521. National medical device registry.
Subtitle D--Grants for Comprehensive Programs To Provide Education to
Nurses and Create a Pipeline to Nursing
Sec. 2531. Establishment of grant program.
Subtitle E--States Failing To Adhere to Certain Employment Obligations
Sec. 2541. Limitation on Federal funds.
(b) References.--Except as otherwise specified, whenever in this
division an amendment is expressed in terms of an amendment to a
section or other provision, the reference shall be considered to be
made to a section or other provision of the Public Health Service Act
(42 U.S.C. 201 et seq.).
SEC. 2002. PUBLIC HEALTH INVESTMENT FUND.
(a) Establishment of Funds.--
(1) In general.--There is established a fund to be known as
the ``Public Health Investment Fund'' (referred to in this
section as the ``Fund'').
(2) Funding.--
(A) There shall be deposited into the Fund--
(i) for fiscal year 2010, $4,600,000,000;
(ii) for fiscal year 2011, $5,600,000,000;
(iii) for fiscal year 2012, $6,900,000,000;
(iv) for fiscal year 2013, $7,800,000,000;
(v) for fiscal year 2014, $9,000,000,000;
(vi) for fiscal year 2015, $9,400,000,000;
(vii) for fiscal year 2016,
$10,100,000,000;
(viii) for fiscal year 2017,
$10,800,000,000;
(ix) for fiscal year 2018, $11,800,000,000;
and
(x) for fiscal year 2019, $12,700,000,000.
(B) Amounts deposited into the Fund shall be
derived from general revenues of the Treasury.
(b) Authorization of Appropriations From the Fund.--
(1) New funding.--
(A) In general.--Amounts in the Fund are authorized
to be appropriated by the Committees on Appropriations
of the House of Representatives and the Senate for
carrying out activities under designated public health
provisions.
(B) Designated provisions.--For purposes of this
paragraph, the term ``designated public health
provisions'' means the provisions for which amounts are
authorized to be appropriated under section 330(s),
338(c), 338H-1, 799C, 872, or 3111 of the Public Health
Service Act, as added by this division.
(2) Baseline funding.--
(A) In general.--Amounts in the Fund are authorized
to be appropriated (as described in paragraph (1)) for
a fiscal year only if (excluding any amounts in or
appropriated from the Fund)--
(i) the amounts specified in subparagraph
(B) for the fiscal year involved are equal to
or greater than the amounts specified in
subparagraph (B) for fiscal year 2008; and
(ii) the amounts appropriated, out of the
general fund of the Treasury, to the Prevention
and Wellness Trust under section 3111 of the
Public Health Service Act, as added by this
division, for the fiscal year involved are
equal to or greater than the funds--
(I) appropriated under the heading
``Prevention and Wellness Fund'' in
title VIII of division A of the
American Recovery and Reinvestment Act
of 2009 (Public Law 111-5); and
(II) allocated by the second
proviso under such heading for
evidence-based clinical and community-
based prevention and wellness
strategies.
(B) Amounts specified.--The amounts specified in
this subparagraph, with respect to a fiscal year, are
the amounts appropriated for the following:
(i) Community health centers (including
funds appropriated under the authority of
section 330 of the Public Health Service Act
(42 U.S.C. 254b)).
(ii) The National Health Service Corps
Program (including funds appropriated under the
authority of section 338 of such Act (42 U.S.C.
254k)).
(iii) The National Health Service Corps
Scholarship and Loan Repayment Programs
(including funds appropriated under the
authority of section 338H of such Act (42
U.S.C. 254q)).
(iv) Primary care loan funds (including
funds appropriated for schools of medicine or
osteopathic medicine under the authority of
section 735(f) of such Act (42 U.S.C.
292y(f))).
(v) Primary care education programs
(including funds appropriated under the
authority of sections 736, 740, 741, and 747 of
such Act (42 U.S.C. 293, 293d, and 293k)).
(vi) Sections 761 and 770 of such Act (42
U.S.C. 294n and 295e).
(vii) Nursing workforce development
(including funds appropriated under the
authority of title VIII of such Act (42 U.S.C.
296 et seq.)).
(viii) The National Center for Health
Statistics (including funds appropriated under
the authority of sections 304, 306, 307, and
308 of such Act (42 U.S.C. 242b, 242k, 242l,
and 242m)).
(ix) The Agency for Healthcare Research and
Quality (including funds appropriated under the
authority of title IX of such Act (42 U.S.C.
299 et seq.)).
(3) Budgetary implications.--Amounts appropriated under
this section, and outlays flowing from such appropriations,
shall not be taken into account for purposes of any budget
enforcement procedures including allocations under section
302(a) and (b) of the Balanced Budget and Emergency Deficit
Control Act and budget resolutions for fiscal years during
which appropriations are made from the Fund.
TITLE I--COMMUNITY HEALTH CENTERS
SEC. 2101. INCREASED FUNDING.
Section 330 of the Public Health Service Act (42 U.S.C. 254b) is
amended--
(1) in subsection (r)(1)--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``; and''; and
(C) by inserting at the end the following:
``(F) Such sums as may be necessary for each of
fiscal years 2013 and 2019.''; and
(2) by inserting after subsection (r) the following:
``(s) Additional Funding.--For the purpose of carrying out this
section, in addition to any other amounts authorized to be appropriated
for such purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) For fiscal year 2010, $1,000,000,000.
``(2) For fiscal year 2011, $1,500,000,000.
``(3) For fiscal year 2012, $2,500,000,000.
``(4) For fiscal year 2013, $3,000,000,000.
``(5) For fiscal year 2014, $4,000,000,000.
``(6) For fiscal year 2015, $4,400,000,000.
``(7) For fiscal year 2016, $4,800,000,000.
``(8) For fiscal year 2017, $5,300,000,000.
``(9) For fiscal year 2018, $5,900,000,000.
``(10) For fiscal year 2019, $6,400,000,000.''.
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
PART 1--NATIONAL HEALTH SERVICE CORPS
SEC. 2201. NATIONAL HEALTH SERVICE CORPS.
(a) Fulfillment of Obligated Service Requirement Through Half-Time
Service.--
(1) Waivers.--Subsection (i) of section 331 (42 U.S.C.
254d) is amended--
(A) in paragraph (1), by striking ``In carrying out
subpart III'' and all that follows through the period
and inserting ``In carrying out subpart III, the
Secretary may, in accordance with this subsection,
issue waivers to individuals who have entered into a
contract for obligated service under the Scholarship
Program or the Loan Repayment Program under which the
individuals are authorized to satisfy the requirement
of obligated service through providing clinical
practice that is half-time.'';
(B) in paragraph (2)--
(i) in subparagraphs (A)(ii) and (B), by
striking ``less than full time'' each place it
appears and inserting ``half time'';
(ii) in subparagraphs (C) and (F), by
striking ``less than full-time service'' each
place it appears and inserting ``half-time
service''; and
(iii) by amending subparagraphs (D) and (E)
to read as follows:
``(D) the entity and the Corps member agree in writing that
the Corps member will perform half-time clinical practice;
``(E) the Corps member agrees in writing to fulfill all of
the service obligations under section 338C through half-time
clinical practice and either--
``(i) double the period of obligated service; or
``(ii) in the case of contracts entered into under
section 338B, accept a minimum service obligation of 2
years with an award amount equal to 50 percent of the
amount that would otherwise be payable for full-time
service; and''; and
(C) in paragraph (3), by striking ``In evaluating a
demonstration project described in paragraph (1)'' and
inserting ``In evaluating waivers issued under
paragraph (1)''.
(2) Definitions.--Subsection (j) of section 331 (42 U.S.C.
254d) is amended by adding at the end the following:
``(5) The terms `full time' and `full-time' mean a minimum
of 40 hours per week in a clinical practice, for a minimum of
45 weeks per year.
``(6) The terms `half time' and `half-time' mean a minimum
of 20 hours per week (not to exceed 39 hours per week) in a
clinical practice, for a minimum of 45 weeks per year.''.
(b) Reappointment to National Advisory Council.--Section 337(b)(1)
(42 U.S.C. 254j(b)(1)) is amended by striking ``Members may not be
reappointed to the Council.''.
(c) Loan Repayment Amount.--Section 338B(g)(2)(A) is amended (42
U.S.C. 254l-1(g)(2)(A)) 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,''.
(d) Treatment of Teaching as Obligated Service.--Subsection (a) of
section 338C (42 U.S.C. 254m) is amended by adding at the end the
following: ``The Secretary may treat teaching as clinical practice for
up to 20 percent of such period of obligated service.''.
SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS.
(a) National Health Service Corps Program.--Section 338 (42 U.S.C.
254k) is amended--
(1) in subsection (a), by striking ``2012'' and inserting
``2019''; and
(2) by adding at the end the following:
``(c) For the purpose of carrying out this subpart, in addition to
any other amounts authorized to be appropriated for such purpose, there
are authorized to be appropriated, out of any monies in the Public
Health Investment Fund, the following:
``(1) $63,000,000 for fiscal year 2010.
``(2) $66,000,000 for fiscal year 2011.
``(3) $70,000,000 for fiscal year 2012.
``(4) $73,000,000 for fiscal year 2013.
``(5) $77,000,000 for fiscal year 2014.
``(6) $81,000,000 for fiscal year 2015.
``(7) $85,000,000 for fiscal year 2016.
``(8) $89,000,000 for fiscal year 2017.
``(9) $94,000,000 for fiscal year 2018.
``(10) $98,000,000 for fiscal year 2019.''.
(b) Scholarship and Loan Repayment Programs.--Subpart III of part D
of title III of the Public Health Service Act (42 U.S.C. 254l et seq.)
is amended--
(1) in section 338H(a)--
(A) in paragraph (4), by striking ``and'' at the
end;
(B) in paragraph (5), by striking the period at the
end and inserting ``; and''; and
(C) by adding at the end the following:
``(6) for fiscal years 2013 and 2019, such sums as may be
necessary.''; and
(2) by inserting after section 338H the following:
``SEC. 338H-1. ADDITIONAL FUNDING.
``For the purpose of carrying out this subpart, in addition to any
other amounts authorized to be appropriated for such purpose, there are
authorized to be appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) $254,000,000 for fiscal year 2010.
``(2) $266,000,000 for fiscal year 2011.
``(3) $278,000,000 for fiscal year 2012.
``(4) $292,000,000 for fiscal year 2013.
``(5) $306,000,000 for fiscal year 2014.
``(6) $321,000,000 for fiscal year 2015.
``(7) $337,000,000 for fiscal year 2016.
``(8) $354,000,000 for fiscal year 2017.
``(9) $372,000,000 for fiscal year 2018.
``(10) $391,000,000 for fiscal year 2019.''.
PART 2--PROMOTION OF PRIMARY CARE AND DENTISTRY
SEC. 2211. FRONTLINE HEALTH PROVIDERS.
Part D of title III (42 U.S.C. 254b et seq.) is amended by adding
at the end the following:
``Subpart XI--Health Professional Needs Areas
``SEC. 340H. IN GENERAL.
``(a) Program.--The Secretary, acting through the Administrator of
the Health Resources and Services Administration, shall establish a
program, to be known as the Frontline Health Providers Loan Repayment
Program, to address unmet health care needs in health professional
needs areas through loan repayments under section 340I.
``(b) Designation of Health Professional Needs Areas.--
``(1) In general.--In this subpart, the term `health
professional needs area' means an area, population, or facility
that is designated by the Secretary in accordance with
paragraph (2).
``(2) Designation.--To be designated by the Secretary as a
health professional needs area under this subpart:
``(A) In the case of an area, the area must be a
rational area for the delivery of health services.
``(B) The area, population, or facility must have,
in one or more health disciplines, specialties, or
subspecialties for the population served, as determined
by the Secretary--
``(i) insufficient capacity of health
professionals; or
``(ii) high needs for health services.
``(C) With respect to the delivery of primary
health services, the area, population, or facility must
not include a health professional shortage area (as
designated under section 332), except that the area,
population, or facility may include such a health
professional shortage area to which no member of the
National Health Service Corps is currently assigned.
``(c) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1) hold a degree in a course of study or program
(approved by the Secretary) from a school defined in section
799B(1)(A) (other than a school of public health);
``(2) hold a degree in a course of study or program
(approved by the Secretary) from a school or program defined in
subparagraph (C), (D), or (E)(4) of section 799B(1), as
designated by the Secretary;
``(3) be enrolled as a full-time student--
``(A) in a school or program defined in
subparagraph (C), (D), or (E)(4) of section 799B(1), as
designated by the Secretary, or a school described in
paragraph (1); and
``(B) in the final year of a course of study or
program, offered by such school or program and approved
by the Secretary, leading to a degree in a discipline
referred to in subparagraph (A) (other than a graduate
degree in public health), (C), (D), or (E)(4) of
section 799B(1);
``(4) be a practitioner described in section 1842(b)(18)(C)
or 1848(k)(3)(B)(iii) or (iv) of the Social Security Act; or
``(5) be a practitioner in the field of respiratory
therapy, medical technology, or radiologic technology.
``(d) Definition.--In this subpart, the term `primary health
services' has the meaning given to such term in section 331(a)(3)(D).
``SEC. 340I. LOAN REPAYMENTS.
``(a) Loan Repayments.--The Secretary, acting through the
Administrator of the Health Resources and Services Administration,
shall enter into contracts with individuals under which--
``(1) the individual agrees--
``(A) to serve as a full-time primary health
services provider or as a full-time or part-time
provider of other health services for a period of time
equal to 2 years or such longer period as the
individual may agree to;
``(B) to serve in a health professional needs area
in a health discipline, specialty, or a subspecialty
for which the area, population, or facility is
designated as a health professional needs area under
section 340H; and
``(C) in the case of an individual described in
subsection 340H(c)(3) who is in the final year of study
and who has accepted employment as primary health
services provider or provider of other health services
in accordance with subparagraphs (A) and (B), to
complete the education or training and maintain an
acceptable level of academic standing (as determined by
the educational institution offering the course of
study or training); and
``(2) the Secretary agrees to pay, for each year of such
service, an amount on the principal and interest of the
undergraduate or graduate educational loans (or both) of the
individual that is not more than 50 percent of the average
award made under the National Health Service Corps Loan
Repayment Program under subpart III in that year.
``(b) Practice Setting.--A contract entered into under this section
shall allow the individual receiving the loan repayment to satisfy the
service requirement described in subsection (a)(1) through employment
in a solo or group practice, a clinic, an accredited public or private
nonprofit hospital, or any other health care entity, as deemed
appropriate by the Secretary.
``(c) Application of Certain Provisions.--The provisions of subpart
III of part D shall, except as inconsistent with this section, apply to
the loan repayment program under this subpart in the same manner and to
the same extent as such provisions apply to the National Health Service
Corps Loan Repayment Program established under section 338B.
``(d) Insufficient Number of Applicants.--If there are an
insufficient number of applicants for loan repayments under this
section to obligate all appropriated funds, the Secretary shall
transfer the unobligated funds to the National Health Service Corps for
the purpose of--
``(1) recruitment of sufficient applicants for the National
Health Service Corps for the following year; or
``(2) making additional loan repayments under section 338B
if there is an excess number of qualified applicants for loan
repayments under such section.
``SEC. 340J. REPORT.
``The Secretary shall submit to the Congress an annual report on
the program carried out under this subpart.
``SEC. 340K. ALLOCATION.
``Of the amount of funds obligated under this subpart each fiscal
year for loan repayments--
``(1) 90 percent shall be for physicians and other health
professionals providing primary health services; and
``(2) 10 percent shall be for health professionals not
described in paragraph (1).''.
SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS.
(a) Loan Provisions.--Section 722 (42 U.S.C. 292r) is amended by
striking subsection (e) and inserting the following:
``(e) Rate of Interest.--Such loans shall bear interest, on the
unpaid balance of the loan, computed only for periods for which the
loan is repayable, at the rate of 2 percentage points less than the
applicable rate of interest described in section 427A(l)(1) of the
Higher Education Act of 1965 per year.''.
(b) Medical Schools and Primary Health Care.--Subsection (a) of
section 723 (42 U.S.C. 292s) is amended--
(1) in paragraph (1), by striking subparagraph (B) and
inserting the following:
``(B) to practice in such care for 10 years
(including residency training in primary health care)
or through the date on which the loan is repaid in
full, whichever occurs first.''; and
(2) by striking paragraph (3) and inserting the following:
``(3) Noncompliance by student.--If an individual fails to
comply with an agreement entered into pursuant to paragraph
(1), such agreement shall provide that the total interest to be
paid on the loan, over the course of the loan period, shall
equal the total amount of interest that would have been
incurred by the individual if, from the outset of the loan, the
loan was repayable at the rate of interest described in section
427A(l)(1) of the Higher Education Act of 1965 per year instead
of the rate of interest described in section 722(e).''.
(c) Student Loan Guidelines.--
(1) In general.--Section 735 (42 U.S.C. 292y) is amended--
(A) by redesignating subsection (f) as subsection
(g); and
(B) by inserting after subsection (e) the
following:
``(f) Determination of Financial Need.--The Secretary--
``(1) may require, or authorize a school or other entity to
require, the submission of financial information to determine
the financial resources available to any individual seeking
assistance under this subpart; and
``(2) shall take into account the extent to which such
individual is financially independent in determining whether to
require or authorize the submission of such information
regarding such individual's family members.''.
(2) Revised guidelines.--The Secretary of Health and Human
Services shall--
(A) strike the second sentence of section 57.206(b)
of title 42, Code of Federal Regulations; and
(B) make such other revisions to guidelines and
regulations in effect as of the date of the enactment
of this Act as may be necessary for consistency with
the amendments made by paragraph (1).
SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE,
GENERAL PEDIATRICS, GERIATRICS, AND PHYSICIAN
ASSISTANTSHIP.
Section 747 (42 U.S.C. 293k) is amended--
(1) by amending the section heading to read as follows:
``primary care training and enhancement'';
(2) by redesignating subsection (e) as subsection (f); and
(3) by striking subsections (a) through (d) and inserting
the following:
``(a) Program.--The Secretary shall establish a primary care
training and capacity building program consisting of awarding grants
and contracts under subsections (b) and (c).
``(b) Support and Development of Primary Care Training Programs.--
``(1) In general.--The Secretary shall make grants to, or
enter into contracts with, eligible entities--
``(A) to plan, develop, operate, or participate in
an accredited professional training program, including
an accredited residency or internship program, in the
field of family medicine, general internal medicine,
general pediatrics, or geriatrics for medical students,
interns, residents, or practicing physicians;
``(B) to provide financial assistance in the form
of traineeships and fellowships to medical students,
interns, residents, or practicing physicians, who are
participants in any such program, and who plan to
specialize or work in family medicine, general internal
medicine, general pediatrics, or geriatrics;
``(C) to plan, develop, operate, or participate in
an accredited program for the training of physicians
who plan to teach in family medicine, general internal
medicine, general pediatrics, or geriatrics training
programs including in community-based settings;
``(D) to provide financial assistance in the form
of traineeships and fellowships to practicing
physicians who are participants in any such programs
and who plan to teach in a family medicine, general
internal medicine, general pediatrics, or geriatrics
training program; and
``(E) to plan, develop, operate, or participate in
an accredited program for physician assistant
education, and for the training of individuals who plan
to teach in programs to provide such training.
``(2) Eligibility.--To be eligible for a grant or contract
under paragraph (1), an entity shall be--
``(A) an accredited school of medicine or
osteopathic medicine, public or nonprofit private
hospital, or physician assistant training program;
``(B) a public or private nonprofit entity; or
``(C) a consortium of 2 or more entities described
in subparagraphs (A) and (B).
``(c) Capacity Building in Primary Care.--
``(1) In general.--The Secretary shall make grants to or
enter into contracts with eligible entities to establish,
maintain, or improve--
``(A) academic administrative units (including
departments, divisions, or other appropriate units) in
the specialties of family medicine, general internal
medicine, general pediatrics, or geriatrics; or
``(B) programs that improve clinical teaching in
such specialties.
``(2) Eligibility.--To be eligible for a grant or contract
under paragraph (1), an entity shall be an accredited school of
medicine or osteopathic medicine.
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of the following:
``(1) Training the greatest percentage, or significantly
improving the percentage, of health care professionals who
provide primary care.
``(2) Training individuals who are from underrepresented
minority groups or disadvantaged backgrounds.
``(3) A high rate of placing graduates in practice settings
having the principal focus of serving in underserved areas or
populations experiencing health disparities (including serving
patients eligible for medical assistance under title XIX of the
Social Security Act or for child health assistance under title
XXI of such Act or those with special health care needs).
``(4) Supporting teaching programs that address the health
care needs of vulnerable populations.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(f) Definition.--In this section, the term `health disparities'
has the meaning given the term in section 3171.''.
SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED SETTINGS.
Title VII (42 U.S.C. 292 et seq.) is amended--
(1) by redesignating section 748 as 749A; and
(2) by inserting after section 747 the following:
``SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED SETTINGS.
``(a) Program.--The Secretary shall establish a program for the
training of medical residents in community-based settings consisting of
awarding grants or contracts under this section.
``(b) Development and Operation of Community-Based Programs.--The
Secretary shall make grants to, or enter into contracts with, eligible
entities--
``(1) to plan and develop a new primary care residency
training program, which may include--
``(A) planning and developing curricula;
``(B) recruiting and training residents and
faculty; and
``(C) other activities designated to result in
accreditation of such a program; or
``(2) to operate or participate in an established primary
care residency training program, which may include--
``(A) planning and developing curricula;
``(B) recruitment and training of residents; and
``(C) retention of faculty.
``(c) Eligible Entity.--To be eligible to receive a grant or
contract under subsection (b), an entity shall--
``(1) be designated as a recipient of payment for the
direct costs of medical education under section 1886(k) of the
Social Security Act;
``(2) be designated as an approved teaching health center
under section 1502(d) of the America's Affordable Health
Choices Act of 2009 and continuing to participate in the
demonstration project under such section; or
``(3) be an applicant for designation described in
paragraph (1) or (2) and have demonstrated to the Secretary
appropriate involvement of an accredited teaching hospital to
carry out the inpatient responsibilities associated with a
primary care residency training program.
``(d) Preferences.--In awarding grants and contracts under
paragraph (1) or (2) of subsection (b), the Secretary shall give
preference to entities that--
``(1) support teaching programs that address the health
care needs of vulnerable populations; or
``(2) are a Federally qualified health center (as defined
in section 1861(aa)(4) of the Social Security Act) or a rural
health clinic (as defined in section 1861(aa)(2) of such Act).
``(e) Additional Preferences for Established Programs.--In awarding
grants and contracts under subsection (b)(2), the Secretary shall give
preference to entities that have a demonstrated record of training--
``(1) a high or significantly improved percentage of health
care professionals who provide primary care;
``(2) individuals who are from underrepresented minority
groups or disadvantaged backgrounds; or
``(3) individuals who practice in settings having the
principal focus of serving underserved areas or populations
experiencing health disparities (including serving patients
eligible for medical assistance under title XIX of the Social
Security Act or for child health assistance under title XXI of
such Act or those with special health care needs).
``(f) Period of Awards.--
``(1) In general.--The period of a grant or contract under
this section--
``(A) shall not exceed 2 years for awards under
subsection (b)(1); and
``(B) shall not exceed 5 years for awards under
subsection (b)(2).
``(2) Special rules.--
``(A) An award of a grant or contract under
subsection (b)(1) shall not be renewed.
``(B) The period of a grant or contract awarded to
an entity under subsection (b)(2) shall not overlap
with the period of any grant or contact awarded to the
same entity under subsection (b)(1).
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(h) Definitions.--In this section:
``(1) Primary care residency training program.--The term
`primary care residency training program' means an approved
medical residency training program described in section
1886(h)(5)(A) of the Social Security Act that is--
``(A) in the case of entities seeking awards under
subsection (b)(1), actively applying to be accredited
by the Accreditation Council for Graduate Medical
Education; or
``(B) in the case of entities seeking awards under
subsection (b)(2), so accredited.
``(2) Health disparities.--The term `health disparities'
has the meaning given the term in section 3171.''.
SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTS
AND DENTAL HYGIENISTS.
Title VII (42 U.S.C. 292 et seq.) is amended--
(1) in section 791(a)(1), by striking ``747 and 750'' and
inserting ``747, 749, and 750''; and
(2) by inserting after section 748, as added, the
following:
``SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTS
AND DENTAL HYGIENISTS.
``(a) Program.--The Secretary shall establish a dental medicine
training program consisting of awarding grants and contracts under this
section.
``(b) Support and Development of Dental Training Programs.--The
Secretary shall make grants to, or enter into contracts with, eligible
entities--
``(1) to plan, develop, operate, or participate in an
accredited professional training program for oral health
professionals;
``(2) to provide financial assistance to oral health
professionals who are in need thereof, who are participants in
any such program, and who plan to work in general, pediatric,
or public heath dentistry, or dental hygiene;
``(3) to plan, develop, operate, or participate in a
program for the training of oral health professionals who plan
to teach in general, pediatric, or public health dentistry, or
dental hygiene;
``(4) to provide financial assistance in the form of
traineeships and fellowships to oral health professionals who
plan to teach in general, pediatric, or public health dentistry
or dental hygiene;
``(5) to establish, maintain, or improve--
``(A) academic administrative units (including
departments, divisions, or other appropriate units) in
the specialties of general, pediatric, or public health
dentistry; or
``(B) programs that improve clinical teaching in
such specialties;
``(6) to plan, develop, operate, or participate in
predoctoral and postdoctoral training in general, pediatric, or
public health dentistry programs, or training for dental
hygienists;
``(7) to plan, develop, operate, or participate in a loan
repayment program for full-time faculty in a program of
general, pediatric, or public health dentistry; and
``(8) to provide technical assistance to pediatric dental
training programs in developing and implementing instruction
regarding the oral health status, dental care needs, and risk-
based clinical disease management of all pediatric populations
with an emphasis on underserved children.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (a), an entity shall be--
``(1) an accredited school of dentistry, training program
in dental hygiene, or public or nonprofit private hospital;
``(2) a training program in dental hygiene at an accredited
institution of higher education;
``(3) a public or private nonprofit entity; or
``(4) a consortium of--
``(A) 2 or more of the entities described in
paragraphs (1) through (3); and
``(B) an accredited school of public health.
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of the following:
``(1) Training the greatest percentage, or significantly
improving the percentage, of oral health professionals who
practice general, pediatric, or public health dentistry.
``(2) Training individuals who are from underrepresented
minority groups or disadvantaged backgrounds.
``(3) A high rate of placing graduates in practice settings
having the principal focus of serving in underserved areas or
populations experiencing health disparities (including serving
patients eligible for medical assistance under title XIX of the
Social Security Act or for child health assistance under title
XXI of such Act or those with special health care needs).
``(4) Supporting teaching programs that address the dental
needs of vulnerable populations.
``(5) Providing instruction regarding the oral health
status, dental care needs, and risk-based clinical disease
management of all pediatric populations with an emphasis on
underserved children.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(f) Definition.--In this section:
``(1) The term `health disparities' has the meaning given
the term in section 3171.
``(2) The term `oral health professional' means an
individual training or practicing--
``(A) in general dentistry, pediatric dentistry,
public health dentistry, or dental hygiene; or
``(B) another dental medicine specialty, as deemed
appropriate by the Secretary.''.
SEC. 2216. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Part F of title VII (42 U.S.C. 295j et seq.) is
amended by adding at the end the following:
``SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.
``(a) Promotion of Primary Care and Dentistry.--For the purpose of
carrying out subpart XI of part D of title III and sections 723, 747,
748, and 749, in addition to any other amounts authorized to be
appropriated for such purpose, there is authorized to be appropriated,
out of any monies in the Public Health Investment Fund, the following:
``(1) $240,000,000 for fiscal year 2010.
``(2) $253,000,000 for fiscal year 2011.
``(3) $265,000,000 for fiscal year 2012.
``(4) $278,000,000 for fiscal year 2013.
``(5) $292,000,000 for fiscal year 2014.
``(6) $307,000,000 for fiscal year 2015.
``(7) $322,000,000 for fiscal year 2016.
``(8) $338,000,000 for fiscal year 2017.
``(9) $355,000,000 for fiscal year 2018.
``(10) $373,000,000 for fiscal year 2019.''.
(b) Existing Authorizations of Appropriations.--
(1) Section 735.--Paragraph (1) of section 735(g), as so
redesignated, is amended by inserting ``and such sums as may be
necessary for subsequent years through fiscal year 2019''
before the period at the end.
(2) Section 747.--Subsection (f), as so redesignated, of
section 747 (42 U.S.C. 293k) is amended by striking ``2002''
and inserting ``2019''.
Subtitle B--Nursing Workforce
SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT.
(a) Definitions.--Section 801 (42 U.S.C. 296 et seq.) is amended--
(1) in paragraph (1), by inserting ``nurse-managed health
centers'' after ``nursing centers,''; and
(2) by adding at the end the following:
``(16) Nurse-managed health center.--The term `nurse-
managed health center' means a nurse-practice arrangement,
managed by advanced practice nurses, that provides primary care
or wellness services to underserved or vulnerable populations
and is associated with an accredited school of nursing,
Federally qualified health center, or independent nonprofit
health or social services agency.''.
(a) Grants for Health Professions Education.--Title VIII (42 U.S.C.
296 et seq.) is amended by striking section 807.
(b) Advanced Education Nursing Grants.--Section 811(f) (42 U.S.C.
296j(f)) is amended--
(1) by striking paragraph (2);
(2) by redesignating paragraph (3) as paragraph (2); and
(3) in paragraph (2), as so redesignated, by striking
``that agrees'' and all that follows through the end and
inserting: ``that agrees to expend the award--
``(A) to train advanced education nurses who will
practice in health professional shortage areas
designated under section 332; or
``(B) to increase diversity among advanced
education nurses.''.
(c) Nurse Education, Practice, and Retention Grants.--Section 831
(42 U.S.C. 296p) is amended--
(1) in subsection (b), by amending paragraph (3) to read as
follows:
``(3) providing coordinated care, quality care, and other
skills needed to practice nursing;''; and
(2) by striking subsection (e) and redesignating
subsections (f) through (h) as subsections (e) through (g),
respectively.
(d) Student Loans.--Subsection (a) of section 836 (42 U.S.C. 297b)
is amended--
(1) by striking ``$2,500'' and inserting ``$3,300'';
(2) by striking ``$4,000'' and inserting ``$5,200'';
(3) by striking ``$13,000'' and inserting ``$17,000''; and
(4) by adding at the end the following: ``Beginning with
fiscal year 2012, the dollar amounts specified in this
subsection shall be adjusted by an amount determined by the
Secretary on an annual basis to reflect inflation.''.
(e) Loan Repayment.--Section 846 (42 U.S.C. 297n) is amended--
(1) in subsection (a), by amending paragraph (3) to read as
follows:
``(3) who enters into an agreement with the Secretary to
serve for a period of not less than 2 years--
``(A) as a nurse at a health care facility with a
critical shortage of nurses; or
``(B) as a faculty member at an accredited school
of nursing;''; and
(2) in subsection (g)(1), by striking ``to provide health
services'' each place it appears and inserting ``to provide
health services or serve as a faculty member''.
(f) Nurse Faculty Loan Program.--Paragraph (2) of section 846A(c)
(42 U.S.C. 297n-1(c)) is amended by striking ``$30,000'' and all that
follows through the semicolon and inserting ``$35,000, plus, beginning
with fiscal year 2012, an amount determined by the Secretary on an
annual basis to reflect inflation;''.
(g) Public Service Announcements.--Title VIII (42 U.S.C. 296 et
seq.) is amended by striking part H.
(h) Technical and Conforming Amendments.--Title VIII (42 U.S.C. 296
et seq.) is amended--
(1) by redesignating section 810 (relating to prohibition
against discrimination by schools on the basis of sex) as
section 809 and moving such section so that it follows section
808;
(2) in sections 835, 836, 838, 840, and 842, by striking
the term ``this subpart'' each place it appears and inserting
``this part'';
(3) in section 836(h), by striking the last sentence;
(4) in section 836, by redesignating subsection (l) as
subsection (k);
(5) in section 839, by striking ``839'' and all that
follows through ``(a)'' and inserting ``839. (a)'';
(6) in section 835(b), by striking ``841'' each place it
appears and inserting ``871'';
(7) by redesignating section 841 as section 871, moving
part F to the end of the title, and redesignating such part as
part H;
(8) in part G--
(A) by redesignating section 845 as section 851;
and
(B) by redesignating part G as part F; and
(9) in part I--
(A) by redesignating section 855 as section 861;
and
(B) by redesignating part I as part G.
(i) Funding.--
(1) In general.--Part H, as redesignated, of title VIII is
amended by adding at the end the following:
``SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.
``For the purpose of carrying out this title, in addition to any
other amounts authorized to be appropriated for such purpose, there are
authorized to be appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) $115,000,000 for fiscal year 2010.
``(2) $122,000,000 for fiscal year 2011.
``(3) $127,000,000 for fiscal year 2012.
``(4) $134,000,000 for fiscal year 2013.
``(5) $140,000,000 for fiscal year 2014.
``(6) $147,000,000 for fiscal year 2015.
``(7) $154,000,000 for fiscal year 2016.
``(8) $162,000,000 for fiscal year 2017.
``(9) $170,000,000 for fiscal year 2018.
``(10) $179,000,000 for fiscal year 2019.''.
(2) Existing authorizations of appropriations.--
(A) Sections 831, 846, 846a, and 861.--Sections
831(g) (as so redesignated), 846(i)(1) (42 U.S.C.
297n(i)(1)), 846A(f) (42 U.S.C. 297n-1(f)), and 861(e)
(as so redesignated) are amended by striking ``2007''
each place it appears and inserting ``2019''.
(B) Section 871.--Section 871, as so redesignated,
is amended to read as follows:
``SEC. 871. FUNDING.
``For the purpose of carrying out parts B, C, and D (subject to
section 845(g)), there are authorized to be appropriated such sums as
may be necessary for each fiscal year through fiscal year 2019.''.
Subtitle C--Public Health Workforce
SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS.
Part D of title III (42 U.S.C. 254b et seq.), as amended by section
2211, is amended by adding at the end the following:
``Subpart XII--Public Health Workforce
``SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS.
``(a) Establishment.--There is established, within the Service, the
Public Health Workforce Corps (in this subpart referred to as the
`Corps'), for the purpose of ensuring an adequate supply of public
health professionals throughout the Nation. The Corps shall consist
of--
``(1) such officers of the Regular and Reserve Corps of the
Service as the Secretary may designate; and
``(2) such civilian employees of the United States as the
Secretary may appoint.
``(b) Administration.--Except as provided in subsection (c), the
Secretary shall carry out this subpart acting through the Administrator
of the Health Resources and Services Administration.
``(c) Placement and Assignment.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention, shall
develop a methodology for placing and assigning Corps participants as
public health professionals. Such methodology may allow for placing and
assigning such participants in State, local, and tribal health
departments and Federally qualified health centers (as defined in
section 1861(aa)(4) of the Social Security Act).
``(d) Application of Certain Provisions.--The provisions of subpart
II shall, except as inconsistent with this subpart, apply to the Public
Health Workforce Corps in the same manner and to the same extent as
such provisions apply to the National Health Service Corps established
under section 331.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the programs carried out under this subpart.
``SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP PROGRAM.
``(a) Establishment.--The Secretary shall establish the Public
Health Workforce Scholarship Program (referred to in this section as
the `Program') for the purpose described in section 340L(a).
``(b) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1)(A) be accepted for enrollment, or be enrolled, as a
full-time or part-time student in a course of study or program
(approved by the Secretary) at an accredited graduate school or
program of public health; or
``(B) have demonstrated expertise in public health and be
accepted for enrollment, or be enrolled, as a full-time or
part-time student in a course of study or program (approved by
the Secretary) at--
``(i) an accredited graduate school or program of
nursing; health administration, management, or policy;
preventive medicine; laboratory science; veterinary
medicine; or dental medicine; or
``(ii) another accredited graduate school or
program, as deemed appropriate by Secretary;
``(2) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Service or be eligible for selection for civilian service in
the Corps; and
``(3) sign and submit to the Secretary a written contract
(described in subsection (c)) to serve full-time as a public
health professional, upon the completion of the course of study
or program involved, for the period of obligated service
described in subsection (c)(2)(E).
``(c) Contract.--The written contract between the Secretary and an
individual under subsection (b)(3) shall contain--
``(1) an agreement on the part of the Secretary that the
Secretary will--
``(A) provide the individual with a scholarship for
a period of years (not to exceed 4 academic years)
during which the individual shall pursue an approved
course of study or program to prepare the individual to
serve in the public health workforce; and
``(B) accept (subject to the availability of
appropriated funds) the individual into the Corps;
``(2) an agreement on the part of the individual that the
individual will--
``(A) accept provision of such scholarship to the
individual;
``(B) maintain full-time or part-time enrollment in
the approved course of study or program described in
subsection (b)(1) until the individual completes that
course of study or program;
``(C) while enrolled in the approved course of
study or program, maintain an acceptable level of
academic standing (as determined by the educational
institution offering such course of study or program);
``(D) if applicable, complete a residency or
internship; and
``(E) serve full-time as a public health
professional for a period of time equal to the greater
of--
``(i) 1 year for each academic year for
which the individual was provided a scholarship
under the Program; or
``(ii) 2 years; and
``(3) an agreement by both parties as to the nature and
extent of the scholarship assistance, which may include--
``(A) payment of reasonable educational expenses of
the individual, including tuition, fees, books,
equipment, and laboratory expenses; and
``(B) payment of a stipend of not more than $1,269
(plus, beginning with fiscal year 2011, an amount
determined by the Secretary on an annual basis to
reflect inflation) per month for each month of the
academic year involved, with the dollar amount of such
a stipend determined by the Secretary taking into
consideration whether the individual is enrolled full-
time or part-time.
``(d) Application of Certain Provisions.--The provisions of subpart
III shall, except as inconsistent with this subpart, apply to the
scholarship program under this section in the same manner and to the
same extent as such provisions apply to the National Health Service
Corps Scholarship Program established under section 338A.
``SEC. 340N. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.
``(a) Establishment.--The Secretary shall establish the Public
Health Workforce Loan Repayment Program (referred to in this section as
the `Program') for the purpose described in section 340L(a).
``(b) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1)(A) have a graduate degree from an accredited school
or program of public health;
``(B) have demonstrated expertise in public health and have
a graduate degree in a course of study or program (approved by
the Secretary) from--
``(i) an accredited school or program of nursing;
health administration, management, or policy;
preventive medicine; laboratory science; veterinary
medicine; or dental medicine; or
``(ii) another accredited school or program
approved by the Secretary; or
``(C) be enrolled as a full-time or part-time student in
the final year of a course of study or program (approved by the
Secretary) offered by a school or program described in
subparagraph (A) or (B), leading to a graduate degree;
``(2) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Service or be eligible for selection for civilian service in
the Corps;
``(3) if applicable, complete a residency or internship;
and
``(4) sign and submit to the Secretary a written contract
(described in subsection (c)) to serve full-time as a public
health professional for the period of obligated service
described in subsection (c)(2).
``(c) Contract.--The written contract between the Secretary and an
individual under subsection (b)(4) shall contain--
``(1) an agreement by the Secretary to repay on behalf of
the individual loans incurred by the individual in the pursuit
of the relevant public health workforce educational degree in
accordance with the terms of the contract;
``(2) an agreement by the individual to serve full-time as
a public health professional for a period of time equal to 2
years or such longer period as the individual may agree to; and
``(3) in the case of an individual described in subsection
(b)(1)(C) who is in the final year of study and who has
accepted employment as a public health professional, in
accordance with subsection 340L(c), an agreement on the part of
the individual to complete the education or training, maintain
an acceptable level of academic standing (as determined by the
educational institution offering the course of study or
training), and serve the period of obligated service described
in paragraph (2).
``(d) Payments.--
``(1) In general.--A loan repayment provided for an
individual under a written contract under the Program shall
consist of payment, in accordance with paragraph (2), on behalf
of the individual of the principal, interest, and related
expenses on government and commercial loans received by the
individual regarding the undergraduate or graduate education of
the individual (or both), which loans were made for reasonable
educational expenses, including tuition, fees, books,
equipment, and laboratory expenses, incurred by the individual.
``(2) Payments for years served.--
``(A) In general.--For each year of obligated
service that an individual contracts to serve under
subsection (c), the Secretary may pay up to $35,000
(plus, beginning with fiscal year 2012, an amount
determined by the Secretary on an annual basis to
reflect inflation) on behalf of the individual for
loans described in paragraph (1).
``(B) Repayment schedule.--Any arrangement made by
the Secretary for the making of loan repayments in
accordance with this subsection shall provide that any
repayments for a year of obligated service shall be
made no later than the end of the fiscal year in which
the individual completes such year of service.
``(e) Application of Certain Provisions.--The provisions of subpart
III shall, except as inconsistent with this subpart, apply to the loan
repayment program under this section in the same manner and to the same
extent as such provisions apply to the National Health Service Corps
Loan Repayment Program established under section 338B.''.
SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE.
Section 765 (42 U.S.C. 295) is amended to read as follows:
``SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE.
``(a) Program.--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 establish a public health workforce training and enhancement
program consisting of awarding grants and contracts under subsection
(b).
``(b) Grants and Contracts.--The Secretary shall award grants and
contracts to eligible entities--
``(1) to plan, develop, operate, or participate in, an
accredited professional training program in the field of public
health (including such a program in nursing; health
administration, management, or policy; preventive medicine;
laboratory science; veterinary medicine; or dental medicine)
for members of the public health workforce including mid-career
professionals;
``(2) to provide financial assistance in the form of
traineeships and fellowships to students who are participants
in any such program and who plan to specialize or work in the
field of public health;
``(3) to plan, develop, operate, or participate in a
program for the training of public health professionals who
plan to teach in any program described in paragraph (1); and
``(4) to provide financial assistance in the form of
traineeships and fellowships to public health professionals who
are participants in any program described in paragraph (1) and
who plan to teach in the field of public health, including
nursing; health administration, management, or policy;
preventive medicine; laboratory science; veterinary medicine;
or dental medicine.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (a), an entity shall be--
``(1) an accredited health professions school, including an
accredited graduate school or program of public health;
nursing; health administration, management, or policy;
preventive medicine; laboratory science; veterinary medicine;
or dental medicine;
``(2) a State, local, or tribal health department;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of the following:
``(1) Training the greatest percentage, or significantly
improving the percentage, of public health professionals who
serve in underserved communities.
``(2) Training individuals who are from underrepresented
minority groups or disadvantaged backgrounds.
``(3) Training individuals in public health specialties
experiencing a significant shortage of public health
professionals (as determined by the Secretary).
``(4) Training the greatest percentage, or significantly
improving the percentage, of public health professionals
serving in the Federal Government or a State, local, or tribal
government.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2233. PUBLIC HEALTH TRAINING CENTERS.
Section 766 (42 U.S.C. 295a) is amended--
(1) in subsection (b)(1), by striking ``in furtherance of
the goals established by the Secretary for the year 2000'' and
inserting ``in furtherance of the goals established by the
Secretary in the national prevention and wellness strategy
under section 3121''; and
(2) by adding at the end the following:
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT
PROGRAM.
Section 768 (42 U.S.C. 295c) is amended to read as follows:
``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT
PROGRAM.
``(a) Grants.--The Secretary, acting through the Administrator of
the Health Resources and Services Administration and in consultation
with the Director of the Centers for Disease Control and Prevention,
shall award grants to, or enter into contracts with, eligible entities
to provide training to graduate medical residents in preventive
medicine specialties.
``(b) Eligibility.--To be eligible for a grant or contract under
subsection (a), an entity shall be--
``(1) an accredited school of public health or school of
medicine or osteopathic medicine;
``(2) an accredited public or private hospital;
``(3) a State, local, or tribal health department; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(c) Use of Funds.--Amounts received under a grant or contract
under this section shall be used to--
``(1) plan, develop (including the development of
curricula), operate, or participate in an accredited residency
or internship program in preventive medicine or public health;
``(2) defray the costs of practicum experiences, as
required in such a program; and
``(3) establish, maintain, or improve--
``(A) academic administrative units (including
departments, divisions, or other appropriate units) in
preventive medicine and public health; or
``(B) programs that improve clinical teaching in
preventive medicine and public health.
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2235. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Section 799C, as added by section 2216 of this
Act, is amended by adding at the end the following:
``(b) Public Health Workforce.--For the purpose of carrying out
subpart XII of part D of title III and sections 765, 766, and 768, in
addition to any other amounts authorized to be appropriated for such
purpose, there are authorized to be appropriated, out of any monies in
the Public Health Investment Fund, the following:
``(1) $51,000,000 for fiscal year 2010.
``(2) $54,000,000 for fiscal year 2011.
``(3) $57,000,000 for fiscal year 2012.
``(4) $59,000,000 for fiscal year 2013.
``(5) $62,000,000 for fiscal year 2014.
``(6) $65,000,000 for fiscal year 2015.
``(7) $68,000,000 for fiscal year 2016.
``(8) $72,000,000 for fiscal year 2017.
``(9) $75,000,000 for fiscal year 2018.
``(10) $79,000,000 for fiscal year 2019.''.
(b) Existing Authorization of Appropriations.--Subpart (a) of
section 770 (42 U.S.C. 295e) is amended by striking ``2002'' and
inserting ``2019''.
Subtitle D--Adapting Workforce to Evolving Health System Needs
PART 1--HEALTH PROFESSIONS TRAINING FOR DIVERSITY
SEC. 2241. SCHOLARSHIPS FOR DISADVANTAGED STUDENTS, LOAN REPAYMENTS AND
FELLOWSHIPS REGARDING FACULTY POSITIONS, AND EDUCATIONAL
ASSISTANCE IN THE HEALTH PROFESSIONS REGARDING
INDIVIDUALS FROM DISADVANTAGED BACKGROUNDS.
Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) is amended by
striking ``not more than $20,000'' and all that follows through the end
of the paragraph and inserting: ``not more than $35,000 (plus,
beginning with fiscal year 2012, an amount determined by the Secretary
on an annual basis to reflect inflation) of the principal and interest
of the educational loans of such individuals.''
SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS.
Subsection (b) of section 821 (42 U.S.C. 296m) is amended--
(1) in the heading, by striking ``Guidance'' and inserting
``Consultation''; and
(2) by striking ``shall take into consideration'' and all
that follows through ``consult with nursing associations'' and
inserting ``shall, as appropriate, consult with nursing
associations''.
SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY PROGRAMS.
Title VII (42 U.S.C. 292 et seq.) is amended by inserting after
section 739 the following:
``SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY
PROGRAMS.
``The Secretary shall, to the extent practicable, coordinate the
activities carried out under this part and section 821 in order to
enhance the effectiveness of such activities and avoid duplication of
effort.''.
PART 2--INTERDISCIPLINARY TRAINING PROGRAMS
SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY TRAINING FOR HEALTH CARE
PROFESSIONALS.
Section 741 (42 U.S.C. 293e) is amended--
(1) in the section heading, by striking ``Grants for Health
Professions Education'' and inserting ``Cultural and Linguistic
Competency Training for Health Care Professionals'';
(2) by redesignating subsection (b) as subsection (h); and
(3) by striking subsection (a) and inserting the following:
``(a) Program.--The Secretary shall establish a cultural and
linguistic competency training program for health care professionals,
including nurse professionals, consisting of awarding grants and
contracts under subsection (b).
``(b) Cultural and Linguistic Competency Training.--The Secretary
shall award grants and contracts to eligible entities--
``(1) to test, develop, and evaluate models of cultural and
linguistic competency training (including continuing education)
for health professionals; and
``(2) to implement cultural and linguistic competency
training programs for health professionals developed under
paragraph (1) or otherwise.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall be--
``(1) an accredited health professions school or program;
``(2) an academic health center;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants and contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of the following:
``(1) Addressing, or partnering with an entity with
experience addressing, the cultural and linguistic competency
needs of the population to be served through the grant or
contract.
``(2) Addressing health disparities.
``(3) Placing health professionals in regions experiencing
significant changes in the cultural and linguistic demographics
of populations, including communities along the United States-
Mexico border.
``(4) Carrying out activities described in subsection (b)
with respect to more than one health profession discipline,
specialty, or subspecialty.
``(e) Consultation.--The Secretary shall carry out this section in
consultation with the heads of appropriate health agencies and offices
in the Department of Health and Human Services, including the Office of
Minority Health.
``(f) Definition.--In this section, the term `health disparities'
has the meaning given to the term in section 3171.
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.
Part D of title VII (42 U.S.C. 294 et seq.) is amended by adding at
the end the following:
``SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.
``(a) Program.--The Secretary shall establish an innovations in
interdisciplinary care training program consisting of awarding grants
and contracts under subsection (b).
``(b) Training Programs.--The Secretary shall award grants to, or
enter into contracts with, eligible entities--
``(1) to test, develop, and evaluate health professional
training programs (including continuing education) designed to
promote--
``(A) the delivery of health services through
interdisciplinary and team-based models, which may
include patient-centered medical home models,
medication therapy management models, and models
integrating physical, mental, or oral health services;
and
``(B) coordination of the delivery of health care
within and across settings, including health care
institutions, community-based settings, and the
patient's home; and
``(2) to implement such training programs developed under
paragraph (1) or otherwise.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall be--
``(1) an accredited health professions school or program;
``(2) an academic health center;
``(3) a public or private nonprofit entity (including an
area health education center or a geriatric education center);
or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preferences.--In awarding grants and contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of the following:
``(1) Training the greatest percentage, or significantly
increasing the percentage, of health professionals who serve in
underserved communities.
``(2) Broad interdisciplinary team-based collaborations.
``(3) Addressing health disparities.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(f) Definitions.--In this section:
``(1) The term `health disparities' has the meaning given
the term in section 3171.
``(2) The term `interdisciplinary' means collaboration
across health professions and specialties, which may include
public health, nursing, allied health, and appropriate medical
specialties.''.
PART 3--ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND
ASSESSMENT
SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.
Subpart 1 of part E of title VII (42 U.S.C. 294n et seq.) is
amended by adding at the end the following:
``SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.
``(a) Advisory Committee.--The Secretary, acting through the
Assistant Secretary for Health, shall establish a permanent advisory
committee to be known as the Advisory Committee on Health Workforce
Evaluation and Assessment (referred to in this section as the `Advisory
Committee').
``(b) Responsibilities.--The Advisory Committee shall--
``(1) not later than 1 year after the date of the
establishment of the Advisory Committee, submit recommendations
to the Secretary on--
``(A) classifications of the health workforce to
ensure consistency of data collection on the health
workforce; and
``(B) based on such classifications, standardized
methodologies and procedures to enumerate the health
workforce;
``(2) not later than 2 years after the date of the
establishment of the Advisory Committee, submit recommendations
to the Secretary on--
``(A) the supply, diversity, and geographic
distribution of the health workforce;
``(B) the retention of the health workforce to
ensure quality and adequacy of such workforce; and
``(C) policies to carry out the recommendations
made pursuant to subparagraphs (A) and (B); and
``(3) not later than 4 years after the date of the
establishment of the Advisory Committee, and every 2 years
thereafter, submit updated recommendations to the Secretary
under paragraphs (1) and (2).
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the operations of
the Advisory Committee, including coordinating and supporting the
dissemination of the recommendations of the Advisory Committee.
``(d) Membership.--
``(1) Number; appointment.--The Secretary shall appoint 15
members to serve on the Advisory Committee.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint
members of the Advisory Committee for a term of 3 years
and may reappoint such members, but the Secretary may
not appoint any member to serve more than a total of 6
years.
``(B) Staggered terms.--Notwithstanding
subparagraph (A), of the members first appointed to the
Advisory Committee under paragraph (1)--
``(i) 5 shall be appointed for a term of 1
year;
``(ii) 5 shall be appointed for a term of 2
years; and
``(iii) 5 shall be appointed for a term of
3 years.
``(3) Qualifications.--Members of the Advisory Committee
shall be appointed from among individuals who possess expertise
in at least one of the following areas:
``(A) Conducting and interpreting health workforce
market analysis, including health care labor workforce
analysis.
``(B) Conducting and interpreting health finance
and economics research.
``(C) Delivering and administering health care
services.
``(D) Delivering and administering health workforce
education and training.
``(4) Representation.--In appointing members of the
Advisory Committee, the Secretary shall--
``(A) include no less than one representative of
each of--
``(i) health professionals within the
health workforce;
``(ii) health care patients and consumers;
``(iii) employers;
``(iv) labor unions; and
``(v) third-party health payors; and
``(B) ensure that--
``(i) all areas of expertise described in
paragraph (3) are represented;
``(ii) the members of the Advisory
Committee include members who, collectively,
have significant experience working with--
``(I) populations in urban and
federally designated rural and
nonmetropolitan areas; and
``(II) populations who are
underrepresented in the health
professions, including underrepresented
minority groups; and
``(iii) individuals who are directly
involved in health professions education or
practice do not constitute a majority of the
members of the Advisory Committee.
``(5) Disclosure and conflicts of interest.--Members of the
Advisory Committee shall not be considered employees of the
Federal Government by reason of service on the Advisory
Committee, except members of the Advisory Committee shall be
considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of 1978
(5 U.S.C. App.) and section 208 of title 18, United States
Code, for the purposes of disclosure and management of
conflicts of interest under those sections.
``(6) No pay; receipt of travel expenses.--Members of the
Advisory Committee shall not receive any pay for service on the
Committee, but may receive travel expenses, including a per
diem, in accordance with applicable provisions of subchapter I
of chapter 57 of title 5, United States Code.
``(e) Consultation.--In carrying out this section, the Secretary
shall consult with the Secretary of Education and the Secretary of
Labor.
``(f) Collaboration.--The Advisory Committee shall collaborate with
the advisory bodies at the Health Resources and Services
Administration, the National Advisory Council (as authorized in section
337), the Advisory Committee on Training in Primary Care Medicine and
Dentistry (as authorized in section 749A), the Advisory Committee on
Interdisciplinary, Community-Based Linkages (as authorized in section
756), the Advisory Council on Graduate Medical Education (as authorized
in section 762), and the National Advisory Council on Nurse Education
and Practice (as authorized in section 851).
``(g) FACA.--The Federal Advisory Committee Act (5 U.S.C. App.)
except for section 14 of such Act shall apply to the Advisory Committee
under this section only to the extent that the provisions of such Act
do not conflict with the requirements of this section.
``(h) Report.--The Secretary shall submit to the Congress an annual
report on the activities of the Advisory Committee.
``(i) Definition.--In this section, the term `health workforce'
includes all health care providers with direct patient care and support
responsibilities, including physicians, nurses, physician assistants,
pharmacists, oral health professionals (as defined in section 749(f)),
allied health professionals, mental and behavioral professionals, and
public health professionals (including veterinarians engaged in public
health practice).''.
PART 4--HEALTH WORKFORCE ASSESSMENT
SEC. 2271. HEALTH WORKFORCE ASSESSMENT.
(a) In General.--Section 761 (42 U.S.C. 294n) is amended--
(1) by redesignating subsection (c) as subsection (e); and
(2) by striking subsections (a) and (b) and inserting the
following:
``(a) In General.--The Secretary shall, based upon the
classifications and standardized methodologies and procedures developed
by the Advisory Committee on Health Workforce Evaluation and Assessment
under section 764(b)--
``(1) collect data on the health workforce (as defined in
section 764(i)), disaggregated by field, discipline, and
specialty, with respect to--
``(A) the supply (including retention) of health
professionals relative to the demand for such
professionals;
``(B) the diversity of health professionals
(including with respect to race, ethnic background, and
gender); and
``(C) the geographic distribution of health
professionals; and
``(2) collect such data on individuals participating in the
programs authorized by subtitles A, B, and C and part 1 of
subtitle D of title II of division C of the America's
Affordable Health Choices Act of 2009.
``(b) Grants and Contracts for Health Workforce Analysis.--
``(1) In general.--The Secretary may award grants or
contracts to eligible entities to carry out subsection (a).
``(2) Eligibility.--To be eligible for a grant or contract
under this subsection, an entity shall be--
``(A) an accredited health professions school or
program;
``(B) an academic health center;
``(C) a State, local, or tribal government;
``(D) a public or private entity; or
``(E) a consortium of 2 or more entities described
in subparagraphs (A) through (D).
``(c) Collaboration and Data Sharing.--The Secretary shall
collaborate with Federal departments and agencies, health professions
organizations (including health professions education organizations),
and professional medical societies for the purpose of carrying out
subsection (a).
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the data collected under subsection (a).''.
(b) Period Before Completion of National Strategy.--Pending
completion of the classifications and standardized methodologies and
procedures developed by the Advisory Committee on Health Workforce
Evaluation and Assessment under section 764(b) of the Public Health
Service Act, as added by section 2261, the Secretary of Health and
Human Services, acting through the Administrator of the Health
Resources and Services Administration and in consultation with such
Advisory Committee, may make a judgment about the classifications,
methodologies, and procedures to be used for collection of data under
section 761(a) of the Public Health Service Act, as amended by this
section.
PART 5--AUTHORIZATION OF APPROPRIATIONS
SEC. 2281. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Section 799C, as added by section 2216 of this
Act, is amended by adding at the end the following:
``(c) Health Professions Training for Diversity.--For the purpose
of carrying out sections 736, 737, 738, 739, and 739A, in addition to
any other amounts authorized to be appropriated for such purpose, there
are authorized to be appropriated, out of any monies in the Public
Health Investment Fund, the following:
``(1) $90,000,000 for fiscal year 2010.
``(2) $97,000,000 for fiscal year 2011.
``(3) $100,000,000 for fiscal year 2012.
``(4) $104,000,000 for fiscal year 2013.
``(5) $110,000,000 for fiscal year 2014.
``(6) $116,000,000 for fiscal year 2015.
``(7) $121,000,000 for fiscal year 2016.
``(8) $127,000,000 for fiscal year 2017.
``(9) $133,000,000 for fiscal year 2018.
``(10) $140,000,000 for fiscal year 2019.
``(d) Interdisciplinary Training Programs, Advisory Committee on
Health Workforce Evaluation and Assessment, and Health Workforce
Assessment.--For the purpose of carrying out sections 741, 759, 761,
and 764, in addition to any other amounts authorized to be appropriated
for such purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) $91,000,000 for fiscal year 2010.
``(2) $97,000,000 for fiscal year 2011.
``(3) $101,000,000 for fiscal year 2012.
``(4) $105,000,000 for fiscal year 2013.
``(5) $111,000,000 for fiscal year 2014.
``(6) $117,000,000 for fiscal year 2015.
``(7) $122,000,000 for fiscal year 2016.
``(8) $129,000,000 for fiscal year 2017.
``(9) $135,000,000 for fiscal year 2018.
``(10) $141,000,000 for fiscal year 2019.''.
(b) Existing Authorizations of Appropriations.--
(1) Section 736.--Paragraph (1) of section 736(h) (42
U.S.C. 293(h)) is amended by striking ``2002'' and inserting
``2019''.
(2) Sections 737, 738, and 739.--Subsections (a), (b), and
(c) of section 740 are amended by striking ``2002'' each place
it appears and inserting ``2019''.
(3) Section 741.--Subsection (h), as so redesignated, of
section 741 is amended--
(A) by striking ``and'' after ``fiscal year
2003,''; and
(B) by inserting ``, and such sums as may be
necessary for subsequent fiscal years through the end
of fiscal year 2019'' before the period at the end.
(4) Section 761.--Subsection (e)(1), as so redesignated, of
section 761 is amended by striking ``2002'' and inserting
``2019''.
TITLE III--PREVENTION AND WELLNESS
SEC. 2301. PREVENTION AND WELLNESS.
(a) In General.--The Public Health Service Act (42 U.S.C. 201 et
seq.) is amended by adding at the end the following:
``TITLE XXXI--PREVENTION AND WELLNESS
``Subtitle A--Prevention and Wellness Trust
``SEC. 3111. PREVENTION AND WELLNESS TRUST.
``(a) Deposits Into Trust.--There is established a Prevention and
Wellness Trust. There are authorized to be appropriated to the Trust--
``(1) amounts described in section 2002(b)(2)(ii) of the
America's Affordable Health Choices Act of 2009 for each fiscal
year; and
``(2) in addition, out of any monies in the Public Health
Investment Fund--
``(A) for fiscal year 2010, $2,400,000,000;
``(B) for fiscal year 2011, $2,800,000,000;
``(C) for fiscal year 2012, $3,100,000,000;
``(D) for fiscal year 2013, $3,400,000,000;
``(E) for fiscal year 2014, $3,500,000,000;
``(F) for fiscal year 2015, $3,600,000,000;
``(G) for fiscal year 2016, $3,700,000,000;
``(H) for fiscal year 2017, $3,900,000,000;
``(I) for fiscal year 2018, $4,300,000,000; and
``(J) for fiscal year 2019, $4,600,000,000.
``(b) Availability of Funds.--Amounts in the Prevention and
Wellness Trust shall be available, as provided in advance in
appropriation Acts, for carrying out this title.
``(c) Allocation.--Of the amounts authorized to be appropriated in
subsection (a)(2), there are authorized to be appropriated--
``(1) for carrying out subtitle C (Prevention Task Forces),
$35,000,000 for each of fiscal years 2010 through 2019;
``(2) for carrying out subtitle D (Prevention and Wellness
Research)--
``(A) for fiscal year 2010, $100,000,000;
``(B) for fiscal year 2011, $150,000,000;
``(C) for fiscal year 2012, $200,000,000;
``(D) for fiscal year 2013, $250,000,000;
``(E) for fiscal year 2014, $300,000,000;
``(F) for fiscal year 2015, $315,000,000;
``(G) for fiscal year 2016, $331,000,000;
``(H) for fiscal year 2017, $347,000,000;
``(I) for fiscal year 2018, $364,000,000; and
``(J) for fiscal year 2019, $383,000,000.
``(3) for carrying out subtitle E (Delivery of Community
Preventive and Wellness Services)--
``(A) for fiscal year 2010, $1,100,000,000;
``(B) for fiscal year 2011, $1,300,000,000;
``(C) for fiscal year 2012, $1,400,000,000;
``(D) for fiscal year 2013, $1,600,000,000;
``(E) for fiscal year 2014, $1,700,000,000;
``(F) for fiscal year 2015, $1,800,000,000;
``(G) for fiscal year 2016, $1,900,000,000;
``(H) for fiscal year 2017, $2,000,000,000;
``(I) for fiscal year 2018, $2,100,000,000; and
``(J) for fiscal year 2019, $2,300,000,000.
``(4) for carrying out section 3161 (Core Public Health
Infrastructure and Activities for State and Local Health
Departments)--
``(A) for fiscal year 2010, $800,000,000;
``(B) for fiscal year 2011, $1,000,000,000;
``(C) for fiscal year 2012, $1,100,000,000;
``(D) for fiscal year 2013, $1,200,000,000;
``(E) for fiscal year 2014, $1,300,000,000;
``(F) for fiscal year 2015, $1,400,000,000;
``(G) for fiscal year 2016, $1,500,000,000;
``(H) for fiscal year 2017, $1,600,000,000;
``(I) for fiscal year 2018, $1,800,000,000; and
``(J) for fiscal year 2019, $1,900,000,000; and
``(5) for carrying out section 3162 (Core Public Health
Infrastructure and Activities for CDC), $400,000,000 for each
of fiscal years 2010 through 2019.
``Subtitle B--National Prevention and Wellness Strategy
``SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRATEGY.
``(a) In General.--The Secretary shall submit to the Congress
within one year after the date of the enactment of this section, and at
least every 2 years thereafter, a national strategy that is designed to
improve the Nation's health through evidence-based clinical and
community prevention and wellness activities (in this section referred
to as `prevention and wellness activities'), including core public
health infrastructure improvement activities.
``(b) Contents.--The strategy under subsection (a) shall include
each of the following:
``(1) Identification of specific national goals and
objectives in prevention and wellness activities that take into
account appropriate public health measures and standards,
including departmental measures and standards (including
Healthy People and National Public Health Performance
Standards).
``(2) Establishment of national priorities for prevention
and wellness, taking into account unmet prevention and wellness
needs.
``(3) Establishment of national priorities for research on
prevention and wellness, taking into account unanswered
research questions on prevention and wellness.
``(4) Identification of health disparities in prevention
and wellness.
``(5) A plan for addressing and implementing paragraphs (1)
through (4).
``(c) Consultation.--In developing or revising the strategy under
subsection (a), the Secretary shall consult with the following:
``(1) The heads of appropriate health agencies and offices
in the Department, including the Office of the Surgeon General
of the Public Health Service, the Office of Minority Health,
and the Office on Women's Health.
``(2) As appropriate, the heads of other Federal
departments and agencies whose programs have a significant
impact upon health (as determined by the Secretary).
``(3) As appropriate, nonprofit and for-profit entities.
``(4) The Association of State and Territorial Health
Officials and the National Association of County and City
Health Officials.
``Subtitle C--Prevention Task Forces
``SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERVICES.
``(a) In General.--The Secretary, acting through the Director of
the Agency for Healthcare Research and Quality, shall establish a
permanent task force to be known as the Task Force on Clinical
Preventive Services (in this section referred to as the `Task Force').
``(b) Responsibilities.--The Task Force shall--
``(1) identify clinical preventive services for review;
``(2) review the scientific evidence related to the
benefits, effectiveness, appropriateness, and costs of clinical
preventive services identified under paragraph (1) for the
purpose of developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(3) as appropriate, take into account health disparities
in developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(4) identify gaps in clinical preventive services
research and evaluation and recommend priority areas for such
research and evaluation;
``(5) as appropriate, consult with the clinical prevention
stakeholders board in accordance with subsection (f);
``(6) as appropriate, consult with the Task Force on
Community Preventive Services established under section 3132;
and
``(7) as appropriate, in carrying out this section,
consider the national strategy under section 3121.
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the operations of
the Task Force, including coordinating and supporting the dissemination
of the recommendations of the Task Force.
``(d) Membership.--
``(1) Number; appointment.--The Task Force shall be
composed of 30 members, appointed by the Secretary.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint
members of the Task Force for a term of 6 years and may
reappoint such members, but the Secretary may not
appoint any member to serve more than a total of 12
years.
``(B) Staggered terms.--Notwithstanding
subparagraph (A), of the members first appointed to
serve on the Task Force after the enactment of this
title--
``(i) 10 shall be appointed for a term of 2
years;
``(ii) 10 shall be appointed for a term of
4 years; and
``(iii) 10 shall be appointed for a term of
6 years.
``(3) Qualifications.--Members of the Task Force shall be
appointed from among individuals who possess expertise in at
least one of the following areas:
``(A) Health promotion and disease prevention.
``(B) Evaluation of research and systematic
evidence reviews.
``(C) Application of systematic evidence reviews to
clinical decisionmaking or health policy.
``(D) Clinical primary care in child and adolescent
health.
``(E) Clinical primary care in adult health,
including women's health.
``(F) Clinical primary care in geriatrics.
``(G) Clinical counseling and behavioral services
for primary care patients.
``(4) Representation.--In appointing members of the Task
Force, the Secretary shall ensure that--
``(A) all areas of expertise described in paragraph
(3) are represented; and
``(B) the members of the Task Force include
practitioners who, collectively, have significant
experience treating racially and ethnically diverse
populations.
``(e) Subgroups.--As appropriate to maximize efficiency, the Task
Force may delegate authority for conducting reviews and making
recommendations to subgroups consisting of Task Force members, subject
to final approval by the Task Force.
``(f) Clinical Prevention Stakeholders Board.--
``(1) In general.--The Task Force shall convene a clinical
prevention stakeholders board composed of representatives of
appropriate public and private entities with an interest in
clinical preventive services to advise the Task Force on
developing, updating, publishing, and disseminating evidence-
based recommendations on the use of clinical preventive
services.
``(2) Membership.--The members of the clinical prevention
stakeholders board shall include representatives of the
following:
``(A) Health care consumers and patient groups.
``(B) Providers of clinical preventive services,
including community-based providers.
``(C) Federal departments and agencies, including--
``(i) appropriate health agencies and
offices in the Department, including the Office
of the Surgeon General of the Public Health
Service, the Office of Minority Health, and the
Office on Women's Health; and
``(ii) as appropriate, other Federal
departments and agencies whose programs have a
significant impact upon health (as determined
by the Secretary).
``(D) Private health care payors.
``(3) Responsibilities.--In accordance with subsection
(b)(5), the clinical prevention stakeholders board shall--
``(A) recommend clinical preventive services for
review by the Task Force;
``(B) suggest scientific evidence for consideration
by the Task Force related to reviews undertaken by the
Task Force;
``(C) provide feedback regarding draft
recommendations by the Task Force; and
``(D) assist with efforts regarding dissemination
of recommendations by the Director of the Agency for
Healthcare Research and Quality.
``(g) Disclosure and Conflicts of Interest.--Members of the Task
Force or the clinical prevention stakeholders board shall not be
considered employees of the Federal Government by reason of service on
the Task Force, except members of the Task Force shall be considered to
be special Government employees within the meaning of section 107 of
the Ethics in Government Act of 1978 (5 U.S.C. App.) and section 208 of
title 18, United States Code, for the purposes of disclosure and
management of conflicts of interest under those sections.
``(h) No Pay; Receipt of Travel Expenses.--Members of the Task
Force or the clinical prevention stakeholders board shall not receive
any pay for service on the Task Force, but may receive travel expenses,
including a per diem, in accordance with applicable provisions of
subchapter I of chapter 57 of title 5, United States Code.
``(i) Application of FACA.--The Federal Advisory Committee Act (5
U.S.C. App.) except for section 14 of such Act shall apply to the Task
Force to the extent that the provisions of such Act do not conflict
with the provisions of this title.
``(j) Report.--The Secretary shall submit to the Congress an annual
report on the Task Force, including with respect to gaps identified and
recommendations made under subsection (b)(4).
``SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE SERVICES.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall establish a
permanent task force to be known as the Task Force on Community
Preventive Services (in this section referred to as the `Task Force').
``(b) Responsibilities.--The Task Force shall--
``(1) identify community preventive services for review;
``(2) review the scientific evidence related to the
benefits, effectiveness, appropriateness, and costs of
community preventive services identified under paragraph (1)
for the purpose of developing, updating, publishing, and
disseminating evidence-based recommendations on the use of such
services;
``(3) as appropriate, take into account health disparities
in developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(4) identify gaps in community preventive services
research and evaluation and recommend priority areas for such
research and evaluation;
``(5) as appropriate, consult with the community prevention
stakeholders board in accordance with subsection (f);
``(6) as appropriate, consult with the Task Force on
Clinical Preventive Services established under section 3131;
and
``(7) as appropriate, in carrying out this section,
consider the national strategy under section 3121.
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the operations of
the Task Force, including coordinating and supporting the dissemination
of the recommendations of the Task Force.
``(d) Membership.--
``(1) Number; appointment.--The Task Force shall be
composed of 30 members, appointed by the Secretary.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint
members of the Task Force for a term of 6 years and may
reappoint such members, but the Secretary may not
appoint any member to serve more than a total of 12
years.
``(B) Staggered terms.--Notwithstanding
subparagraph (A), of the members first appointed to
serve on the Task Force after the enactment of this
section--
``(i) 10 shall be appointed for a term of 2
years;
``(ii) 10 shall be appointed for a term of
4 years; and
``(iii) 10 shall be appointed for a term of
6 years.
``(3) Qualifications.--Members of the Task Force shall be
appointed from among individuals who possess expertise in at
least one of the following areas:
``(A) Public health.
``(B) Evaluation of research and systematic
evidence reviews.
``(C) Disciplines relevant to community preventive
services, including health promotion; disease
prevention; chronic disease; worksite health;
qualitative and quantitative analysis; and health
economics, policy, law, and statistics.
``(4) Representation.--In appointing members of the Task
Force, the Secretary--
``(A) shall ensure that all areas of expertise
described in paragraph (3) are represented;
``(B) shall ensure that such members include
sufficient representatives of each of--
``(i) State health officers;
``(ii) local health officers;
``(iii) health care practitioners; and
``(iv) public health practitioners; and
``(C) shall appoint individuals who, collectively,
have significant experience working with racially and
ethnically diverse populations.
``(e) Subgroups.--As appropriate to maximize efficiency, the Task
Force may delegate authority for conducting reviews and making
recommendations to subgroups consisting of Task Force members, subject
to final approval by the Task Force.
``(f) Community Prevention Stakeholders Board.--
``(1) In general.--The Task Force shall convene a community
prevention stakeholders board composed of representatives of
appropriate public and private entities with an interest in
community preventive services to advise the Task Force on
developing, updating, publishing, and disseminating evidence-
based recommendations on the use of community preventive
services.
``(2) Membership.--The members of the community prevention
stakeholders board shall include representatives of the
following:
``(A) Health care consumers and patient groups.
``(B) Providers of community preventive services,
including community-based providers.
``(C) Federal departments and agencies, including--
``(i) appropriate health agencies and
offices in the Department, including the Office
of the Surgeon General of the Public Health
Service, the Office of Minority Health, and the
Office on Women's Health; and
``(ii) as appropriate, other Federal
departments and agencies whose programs have a
significant impact upon health (as determined
by the Secretary).
``(D) Private health care payors.
``(3) Responsibilities.--In accordance with subsection
(b)(5), the community prevention stakeholders board shall--
``(A) recommend community preventive services for
review by the Task Force;
``(B) suggest scientific evidence for consideration
by the Task Force related to reviews undertaken by the
Task Force;
``(C) provide feedback regarding draft
recommendations by the Task Force; and
``(D) assist with efforts regarding dissemination
of recommendations by the Director of the Centers for
Disease Control and Prevention.
``(g) Disclosure and Conflicts of Interest.--Members of the Task
Force or the community prevention stakeholders board shall not be
considered employees of the Federal Government by reason of service on
the Task Force, except members of the Task Force shall be considered to
be special Government employees within the meaning of section 107 of
the Ethics in Government Act of 1978 (5 U.S.C. App.) and section 208 of
title 18, United States Code, for the purposes of disclosure and
management of conflicts of interest under those sections.
``(h) No Pay; Receipt of Travel Expenses.--Members of the Task
Force or the community prevention stakeholders board shall not receive
any pay for service on the Task Force, but may receive travel expenses,
including a per diem, in accordance with applicable provisions of
subchapter I of chapter 57 of title 5, United States Code.
``(i) Application of FACA.--The Federal Advisory Committee Act (5
U.S.C. App.) except for section 14 of such Act shall apply to the Task
Force to the extent that the provisions of such Act do not conflict
with the provisions of this title.
``(j) Report.--The Secretary shall submit to the Congress an annual
report on the Task Force, including with respect to gaps identified and
recommendations made under subsection (b)(4).
``Subtitle D--Prevention and Wellness Research
``SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIVITY COORDINATION.
``In conducting or supporting research on prevention and wellness,
the Director of the Centers for Disease Control and Prevention, the
Director of the National Institutes of Health, and the heads of other
agencies within the Department of Health and Human Services conducting
or supporting such research, shall take into consideration the national
strategy under section 3121 and the recommendations of the Task Force
on Clinical Preventive Services under section 3131 and the Task Force
on Community Preventive Services under section 3132.
``SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RESEARCH GRANTS.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall conduct, or award
grants to eligible entities to conduct, research in priority areas
identified by the Secretary in the national strategy under section 3121
or by the Task Force on Community Preventive Services as required by
section 3132.
``(b) Eligibility.--To be eligible for a grant under this section,
an entity shall be--
``(1) a State, local, or tribal department of health;
``(2) a public or private nonprofit entity; or
``(3) a consortium of 2 or more entities described in
paragraphs (1) and (2).
``(c) Report.--The Secretary shall submit to the Congress an annual
report on the program of research under this section.
``Subtitle E--Delivery of Community Prevention and Wellness Services
``SEC. 3151. COMMUNITY PREVENTION AND WELLNESS SERVICES GRANTS.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall establish a
program for the delivery of community preventive and wellness services
consisting of awarding grants to eligible entities--
``(1) to provide evidence-based, community preventive and
wellness services in priority areas identified by the Secretary
in the national strategy under section 3121; or
``(2) to plan such services.
``(b) Eligibility.--
``(1) Definition.--To be eligible for a grant under this
section, an entity shall be--
``(A) a State, local, or tribal department of
health;
``(B) a public or private entity; or
``(C) a consortium of--
``(i) 2 or more entities described in
subparagraph (A) or (B); and
``(ii) a community partnership representing
a Health Empowerment Zone.
``(2) Health empowerment zone.--In this subsection, the
term `Health Empowerment Zone' means an area--
``(A) in which multiple community preventive and
wellness services are implemented in order to address
one or more health disparities, including those
identified by the Secretary in the national strategy
under section 3121; and
``(B) which is represented by a community
partnership that demonstrates community support and
coordination with State, local, or tribal health
departments and includes--
``(i) a broad cross section of
stakeholders;
``(ii) residents of the community; and
``(iii) representatives of entities that
have a history of working within and serving
the community.
``(c) Preferences.--In awarding grants under this section, the
Secretary shall give preference to entities that--
``(1) will address one or more goals or objectives
identified by the Secretary in the national strategy under
section 3121;
``(2) will address significant health disparities,
including those identified by the Secretary in the national
strategy under section 3121;
``(3) will address unmet community prevention needs and
avoids duplication of effort;
``(4) have been demonstrated to be effective in communities
comparable to the proposed target community;
``(5) will contribute to the evidence base for community
preventive and wellness services;
``(6) demonstrate that the community preventive services to
be funded will be sustainable; and
``(7) demonstrate coordination or collaboration across
governmental and nongovernmental partners.
``(d) Health Disparities.--Of the funds awarded under this section
for a fiscal year, the Secretary shall award not less than 50 percent
for planning or implementing community preventive and wellness services
whose primary purpose is to achieve a measurable reduction in one or
more health disparities, including those identified by the Secretary in
the national strategy under section 3121.
``(e) Emphasis on Recommended Services.--For fiscal year 2013 and
subsequent fiscal years, the Secretary shall award grants under this
section only for planning or implementing services recommended by the
Task Force on Community Preventive Services under section 3122 or
deemed effective based on a review of comparable rigor (as determined
by the Director of the Centers for Disease Control and Prevention).
``(f) Prohibited Uses of Funds.--An entity that receives a grant
under this section may not use funds provided through the grant--
``(1) to build or acquire real property or for
construction; or
``(2) for services or planning to the extent that payment
has been made, or can reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits
program (including titles XIX and XXI of the Social
Security Act); or
``(C) by an entity which provides health services
on a prepaid basis.
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program of grants awarded under this section.
``(h) Definitions.--In this section, the term `evidence-based'
means that methodologically sound research has demonstrated a
beneficial health effect, in the judgment of the Director of the
Centers for Disease Control and Prevention.
``Subtitle F--Core Public Health Infrastructure
``SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR STATE, LOCAL, AND
TRIBAL HEALTH DEPARTMENTS.
``(a) Program.--The Secretary, acting through the Director of the
Centers for Disease Control and Prevention shall establish a core
public health infrastructure program consisting of awarding grants
under subsection (b).
``(b) Grants.--
``(1) Award.--For the purpose of addressing core public
health infrastructure needs, the Secretary--
``(A) shall award a grant to each State health
department; and
``(B) may award grants on a competitive basis to
State, local, or tribal health departments.
``(2) Allocation.--Of the total amount of funds awarded as
grants under this subsection for a fiscal year--
``(A) not less than 50 percent shall be for grants
to State health departments under paragraph (1)(A); and
``(B) not less than 30 percent shall be for grants
to State, local, or tribal health departments under
paragraph (1)(B).
``(c) Use of Funds.--The Secretary may award a grant to an entity
under subsection (b)(1) only if the entity agrees to use the grant to
address core public health infrastructure needs, including those
identified in the accreditation process under subsection (g).
``(d) Formula Grants to State Health Departments.--In making grants
under subsection (b)(1)(A), the Secretary shall award funds to each
State health department in accordance with--
``(1) a formula based on population size; burden of
preventable disease and disability; and core public health
infrastructure gaps, including those identified in the
accreditation process under subsection (g); and
``(2) application requirements established by the
Secretary, including a requirement that the State submit a plan
that demonstrates to the satisfaction of the Secretary that the
State's health department will--
``(A) address its highest priority core public
health infrastructure needs; and
``(B) as appropriate, allocate funds to local
health departments within the State.
``(e) Competitive Grants to State, Local, and Tribal Health
Departments.--In making grants under subsection (b)(1)(B), the
Secretary shall give priority to applicants demonstrating core public
health infrastructure needs identified in the accreditation process
under subsection (g).
``(f) Maintenance of Effort.--The Secretary may award a grant to an
entity under subsection (b) only if the entity demonstrates to the
satisfaction of the Secretary that--
``(1) funds received through the grant will be expended
only to supplement, and not supplant, non-Federal and Federal
funds otherwise available to the entity for the purpose of
addressing core public health infrastructure needs; and
``(2) with respect to activities for which the grant is
awarded, the entity will maintain expenditures of non-Federal
amounts for such activities at a level 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
the grant.
``(g) Establishment of a Public Health Accreditation Program.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall--
``(A) develop, and periodically review and update,
standards for voluntary accreditation of State, local,
or tribal health departments and public health
laboratories for the purpose of advancing the quality
and performance of such departments and laboratories;
and
``(B) implement a program to accredit such health
departments and laboratories in accordance with such
standards.
``(2) Cooperative agreement.--The Secretary may enter into
a cooperative agreement with a private nonprofit entity to
carry out paragraph (1).
``(h) Report.--The Secretary shall submit to the Congress an annual
report on progress being made to accredit entities under subsection
(g), including--
``(1) a strategy, including goals and objectives, for
accrediting entities under subsection (g) and achieving the
purpose described in subsection (g)(1); and
``(2) identification of gaps in research related to core
public health infrastructure and recommendations of priority
areas for such research.
``SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND ACTIVITIES FOR CDC.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall expand and
improve the core public health infrastructure and activities of the
Centers for Disease Control and Prevention to address unmet and
emerging public health needs.
``(b) Report.--The Secretary shall submit to the Congress an annual
report on the activities funded through this section.
``Subtitle G--General Provisions
``SEC. 3171. DEFINITIONS.
``In this title:
``(1) The term `core public health infrastructure' includes
workforce capacity and competency; laboratory systems; health
information, health information systems, and health information
analysis; communications; financing; other relevant components
of organizational capacity; and other related activities.
``(2) The terms `Department' and `departmental' refer to
the Department of Health and Human Services.
``(3) The term `health disparities' includes health and
health care disparities and means population-specific
differences in the presence of disease, health outcomes, or
access to health care. For purposes of the preceding sentence,
a population may be delineated by race, ethnicity, geographic
setting, or other population or subpopulation determined
appropriate by the Secretary.
``(4) The term `tribal' refers to an Indian tribe, a Tribal
organization, or an Urban Indian organization, as such terms
are defined in section 4 of the Indian Health Care Improvement
Act.''.
(b) Transition Provisions Applicable to Task Forces.--
(1) Functions, personnel, assets, liabilities, and
administrative actions.--All functions, personnel, assets, and
liabilities of, and administrative actions applicable to, the
Preventive Services Task Force convened under section 915(a) of
the Public Health Service Act and the Task Force on Community
Preventive Services (as such section and Task Forces were in
existence on the day before the date of the enactment of this
Act) shall be transferred to the Task Force on Clinical
Preventive Services and the Task Force on Community Preventive
Services, respectively, established under sections 3121 and
3122 of the Public Health Service Act, as added by subsection
(a).
(2) Recommendations.--All recommendations of the Preventive
Services Task Force and the Task Force on Community Preventive
Services, as in existence on the day before the date of the
enactment of this Act, shall be considered to be
recommendations of the Task Force on Clinical Preventive
Services and the Task Force on Community Preventive Services,
respectively, established under sections 3121 and 3122 of the
Public Health Service Act, as added by subsection (a).
(3) Members already serving.--
(A) Initial members.--The Secretary of Health and
Human Services may select those individuals already
serving on the Preventive Services Task Force and the
Task Force on Community Preventive Services, as in
existence on the day before the date of the enactment
of this Act, to be among the first members appointed to
the Task Force on Clinical Preventive Services and the
Task Force on Community Preventive Services,
respectively, under sections 3121 and 3122 of the
Public Health Service Act, as added by subsection (a).
(B) Calculation of total service.--In calculating
the total years of service of a member of a task force
for purposes of section 3131(d)(2)(A) or 3132(d)(2)(A)
of the Public Health Service Act, as added by
subsection (a), the Secretary of Health and Human
Services shall not include any period of service by the
member on the Preventive Services Task Force or the
Task Force on Community Preventive Services,
respectively, as in existence on the day before the
date of the enactment of this Act.
(c) Period Before Completion of National Strategy.--Pending
completion of the national strategy under section 3121 of the Public
Health Service Act, as added by subsection (a), the Secretary of Health
and Human Services, acting through the relevant agency head, may make a
judgment about how the strategy will address an issue and rely on such
judgment in carrying out any provision of subtitle C, D, E, or F of
title XXXI of such Act, as added by subsection (a), that requires the
Secretary--
(1) to take into consideration such strategy;
(2) to conduct or support research or provide services in
priority areas identified in such strategy; or
(3) to take any other action in reliance on such strategy.
(d) Conforming Amendments.--
(1) Paragraph (61) of section 3(b) of the Indian Health
Care Improvement Act (25 U.S.C. 1602) is amended by striking
``United States Preventive Services Task Force'' and inserting
``Task Force on Clinical Preventive Services''.
(2) Section 126 of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (Appendix F of
Public Law 106-554) is amended by striking ``United States
Preventive Services Task Force'' each place it appears and
inserting ``Task Force on Clinical Preventive Services''.
(3) Paragraph (7) of section 317D of the Public Health
Service Act (42 U.S.C. 247b-5) is amended by striking ``United
States Preventive Services Task Force'' each place it appears
and inserting ``Task Force on Clinical Preventive Services''.
(4) Section 915 of the Public Health Service Act (42 U.S.C.
299b-4) is amended by striking subsection (a).
(5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and
(ddd)(1)(B) of section 1861 of the Social Security Act (42
U.S.C. 1395x) are amended by striking ``United States
Preventive Services Task Force'' each place it appears and
inserting ``Task Force on Clinical Preventive Services''.
TITLE IV--QUALITY AND SURVEILLANCE
SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH
CARE.
(a) In General.--Title IX of the Public Health Service Act (42
U.S.C. 299 et seq.) is amended--
(1) by redesignating part D as part E;
(2) by redesignating sections 931 through 938 as sections
941 through 948, respectively;
(3) in section 938(1), by striking ``931'' and inserting
``941''; and
(4) by inserting after part C the following:
``PART D--IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH
CARE
``SEC. 931. CENTER FOR QUALITY IMPROVEMENT.
``(a) In General.--There is established the Center for Quality
Improvement (referred to in this part as the `Center'), to be headed by
the Director.
``(b) Prioritization.--
``(1) In general.--The Director shall prioritize areas for
the identification, development, evaluation, and implementation
of best practices (including innovative methodologies and
strategies) for quality improvement activities in the delivery
of health care services (in this section referred to as `best
practices').
``(2) Considerations.--In prioritizing areas under
paragraph (1), the Director shall consider--
``(A) the priorities established under section 1191
of the Social Security Act; and
``(B) the key health indicators identified by the
Assistant Secretary for Health Information under
section 1709.
``(c) Other Responsibilities.--The Director, acting directly or by
awarding a grant or contract to an eligible entity, shall--
``(1) identify existing best practices under subsection
(e);
``(2) develop new best practices under subsection (f);
``(3) evaluate best practices under subsection (g);
``(4) implement best practices under subsection (h);
``(5) ensure that best practices are identified, developed,
evaluated, and implemented under this section consistent with
standards adopted by the Secretary under section 3004 for
health information technology used in the collection and
reporting of quality information (including for purposes of the
demonstration of meaningful use of certified electronic health
record (EHR) technology by physicians and hospitals under the
Medicare program (under sections 1848(o)(2) and 1886(n)(3),
respectively, of the Social Security Act)); and
``(6) provide for dissemination of information and
reporting under subsections (i) and (j).
``(d) Eligibility.--To be eligible for a grant or contract under
subsection (c), an entity shall--
``(1) be a nonprofit entity;
``(2) agree to work with a variety of institutional health
care providers, physicians, nurses, and other health care
practitioners; and
``(3) if the entity is not the organization holding a
contract under section 1153 of the Social Security Act for the
area to be served, agree to cooperate with and avoid
duplication of the activities of such organization.
``(e) Identifying Existing Best Practices.--The Secretary shall
identify best practices that are--
``(1) currently utilized by health care providers
(including hospitals, physician and other clinician practices,
community cooperatives, and other health care entities) that
deliver consistently high-quality, efficient health care
services; and
``(2) easily adapted for use by other health care providers
and for use across a variety of health care settings.
``(f) Developing New Best Practices.--The Secretary shall develop
best practices that are--
``(1) based on a review of existing scientific evidence;
``(2) sufficiently detailed for implementation and
incorporation into the workflow of health care providers; and
``(3) designed to be easily adapted for use by health care
providers across a variety of health care settings.
``(g) Evaluation of Best Practices.--The Director shall evaluate
best practices identified or developed under this section. Such
evaluation--
``(1) shall include determinations of which best
practices--
``(A) most reliably and effectively achieve
significant progress in improving the quality of
patient care; and
``(B) are easily adapted for use by health care
providers across a variety of health care settings;
``(2) shall include regular review, updating, and
improvement of such best practices; and
``(3) may include in-depth case studies or empirical
assessments of health care providers (including hospitals,
physician and other clinician practices, community
cooperatives, and other health care entities) and simulations
of such best practices for determinations under paragraph (1).
``(h) Implementation of Best Practices.--
``(1) In general.--The Director shall enter into voluntary
arrangements with health care providers (including hospitals
and other health facilities and health practitioners) in a
State or region to implement best practices identified or
developed under this section. Such implementation--
``(A) may include forming collaborative multi-
institutional teams; and
``(B) shall include an evaluation of the best
practices being implemented, including the measurement
of patient outcomes before, during, and after
implementation of such best practices.
``(2) Preferences.--In carrying out this subsection, the
Director shall give priority to health care providers
implementing best practices that--
``(A) have the greatest impact on patient outcomes
and satisfaction;
``(B) are the most easily adapted for use by health
care providers across a variety of health care
settings;
``(C) promote coordination of health care
practitioners across the continuum of care; and
``(D) engage patients and their families in
improving patient care and outcomes.
``(i) Public Dissemination of Information.--The Director shall
provide for the public dissemination of information with respect to
best practices and activities under this section. Such information
shall be made available in appropriate formats and languages to reflect
the varying needs of consumers and diverse levels of health literacy.
``(j) Report.--
``(1) In general.--The Director shall submit an annual
report to the Congress and the Secretary on activities under
this section.
``(2) Content.--Each report under paragraph (1) shall
include--
``(A) information on activities conducted pursuant
to grants and contracts awarded;
``(B) summary data on patient outcomes before,
during, and after implementation of best practices; and
``(C) recommendations on the adaptability of best
practices for use by health providers.''.
(b) Initial Quality Improvement Activities and Initiatives To Be
Implemented.--Until the Director of the Agency for Healthcare Research
and Quality has established initial priorities under section 931(b) of
the Public Health Service Act, as added by subsection (a), the Director
shall, for purposes of such section, prioritize the following:
(1) Health care-associated infections.--Reducing health
care-associated infections, including infections in nursing
homes and outpatient settings.
(2) Surgery.--Increasing hospital and outpatient
perioperative patient safety, including reducing surgical-site
infections and surgical errors (such as wrong-site surgery and
retained foreign bodies).
(3) Emergency room.--Improving care in hospital emergency
rooms, including through the use of principles of efficiency of
design and delivery to improve patient flow.
(4) Obstetrics.--Improving the provision of obstetrical and
neonatal care, including the identification of interventions
that are effective in reducing the risk of preterm and
premature labor and the implementation of best practices for
labor and delivery care.
SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMATION.
(a) Establishment.--Title XVII (42 U.S.C. 300u et seq.) is
amended--
(1) by redesignating sections 1709 and 1710 as sections
1710 and 1711, respectively; and
(2) by inserting after section 1708 the following:
``SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMATION.
``(a) In General.--There is established within the Department an
Assistant Secretary for Health Information (in this section referred to
as the `Assistant Secretary'), to be appointed by the Secretary.
``(b) Responsibilities.--The Assistant Secretary shall--
``(1) ensure the collection, collation, reporting, and
publishing of information (including full and complete
statistics) on key health indicators regarding the Nation's
health and the performance of the Nation's health care;
``(2) facilitate and coordinate the collection, collation,
reporting, and publishing of information regarding the Nation's
health and the performance of the Nation's health care (other
than information described in paragraph (1));
``(3)(A) develop standards for the collection of data
regarding the Nation's health and the performance of the
Nation's health care; and
``(B) in carrying out subparagraph (A)--
``(i) ensure appropriate specificity and
standardization for data collection at the national,
regional, State, and local levels;
``(ii) include standards, as appropriate, for the
collection of accurate data on health and health care
by race, ethnicity, primary language, sex, sexual
orientation, gender identity, disability, socioeconomic
status, rural, urban, or other geographic setting, and
any other population or subpopulation determined
appropriate by the Secretary;
``(iii) ensure, with respect to data on race and
ethnicity, consistency with the 1997 Office of
Management and Budget Standards for Maintaining,
Collecting and Presenting Federal Data on Race and
Ethnicity (or any successor standards); and
``(iv) in consultation with the Director of the
Office of Minority Health, and the Director of the
Office of Civil Rights, of the Department, develop
standards for the collection of data on health and
health care with respect to data on primary language;
``(4) provide support to Federal departments and agencies
whose programs have a significant impact upon health (as
determined by the Secretary) for the collection and collation
of information described in paragraphs (1) and (2);
``(5) ensure the sharing of information described in
paragraphs (1) and (2) among the agencies of the Department;
``(6) facilitate the sharing of information described in
paragraphs (1) and (2) by Federal departments and agencies
whose programs have a significant impact upon health (as
determined by the Secretary);
``(7) identify gaps in information described in paragraphs
(1) and (2) and the appropriate agency or entity to address
such gaps;
``(8) facilitate and coordinate identification and
monitoring by the agencies of the Department of health
disparities to inform program and policy efforts to reduce such
disparities, including facilitating and funding analyses
conducted in cooperation with the Social Security
Administration, the Bureau of the Census, and other appropriate
agencies and entities;
``(9) consistent with privacy, proprietary, and other
appropriate safeguards, facilitate public accessibility of
datasets (such as de-identified Medicare datasets or publicly
available data on key health indicators) by means of the
Internet; and
``(10) award grants or contracts for the collection and
collation of information described in paragraphs (1) and (2)
(including through statewide surveys that provide standardized
information).
``(c) Key Health Indicators.--
``(1) In general.--In carrying out subsection (b)(1), the
Assistant Secretary shall--
``(A) identify, and reassess at least once every 3
years, key health indicators described in such
subsection;
``(B) publish statistics on such key health
indicators for the public--
``(i) not less than annually; and
``(ii) on a supplemental basis whenever
warranted by--
``(I) the rate of change for a key
health indicator; or
``(II) the need to inform policy
regarding the Nation's health and the
performance of the Nation's health
care; and
``(C) ensure consistency with the national strategy
developed by the Secretary under section 3121 and
consideration of the indicators specified in the
reports under sections 308, 903(a)(6), and 913(b)(2).
``(2) Release of key health indicators.--The regulations,
rules, processes, and procedures of the Office of Management
and Budget governing the review, release, and dissemination of
key health indicators shall be the same as the regulations,
rules, processes, and procedures of the Office of Management
and Budget governing the review, release, and dissemination of
Principal Federal Economic Indicators (or equivalent
statistical data) by the Bureau of Labor Statistics.
``(d) Coordination.--In carrying out this section, the Assistant
Secretary shall coordinate with--
``(1) public and private entities that collect and
disseminate information on health and health care, including
foundations; and
``(2) the head of the Office of the National Coordinator
for Health Information Technology to ensure optimal use of
health information technology.
``(e) Request for Information From Other Departments and
Agencies.--Consistent with applicable law, the Assistant Secretary may
secure directly from any Federal department or agency information
necessary to enable the Assistant Secretary to carry out this section.
``(f) Report.--
``(1) Submission.--The Assistant Secretary shall submit to
the Secretary and the Congress an annual report containing--
``(A) a description of national, regional, or State
changes in health or health care, as reflected by the
key health indicators identified under subsection
(c)(1);
``(B) a description of gaps in the collection,
collation, reporting, and publishing of information
regarding the Nation's health and the performance of
the Nation's health care;
``(C) recommendations for addressing such gaps and
identification of the appropriate agency within the
Department or other entity to address such gaps;
``(D) a description of analyses of health
disparities, including the results of completed
analyses, the status of ongoing longitudinal studies,
and proposed or planned research; and
``(E) a plan for actions to be taken by the
Assistant Secretary to address gaps described in
subparagraph (B).
``(2) Consideration.--In preparing a report under paragraph
(1), the Assistant Secretary shall take into consideration the
findings and conclusions in the reports under sections 308,
903(a)(6), and 913(b)(2).
``(g) Proprietary and Privacy Protections.--Nothing in this section
shall be construed to affect applicable proprietary or privacy
protections.
``(h) Consultation.--In carrying out this section, the Assistant
Secretary shall consult with--
``(1) the heads of appropriate health agencies and offices
in the Department, including the Office of the Surgeon General
of the Public Health Service, the Office of Minority Health,
and the Office on Women's Health; and
``(2) as appropriate, the heads of other Federal
departments and agencies whose programs have a significant
impact upon health (as determined by the Secretary).
``(i) Definition.--In this section:
``(1) The terms `agency' and `agencies' include an
epidemiology center established under section 214 of the Indian
Health Care Improvement Act.
``(2) The term `Department' means the Department of Health
and Human Services.
``(3) The term `health disparities' has the meaning given
to such term in section 3171.''.
(b) Other Coordination Responsibilities.--Title III (42 U.S.C. 241
et seq.) is amended--
(1) in paragraphs (1) and (2) of section 304(c) (42 U.S.C.
242b(c)), by inserting ``, acting through the Assistant
Secretary for Health Information,'' after ``The Secretary''
each place it appears; and
(2) in section 306(j) (42 U.S.C. 242k(j)), by inserting ``,
acting through the Assistant Secretary for Health
Information,'' after ``of this section, the Secretary''.
SEC. 2403. AUTHORIZATION OF APPROPRIATIONS.
Section 799C, as added and amended, is further amended by adding at
the end the following:
``(e) Quality and Surveillance.--For the purpose of carrying out
part D of title IX and section 1709, in addition to any other amounts
authorized to be appropriated for such purpose, there is authorized to
be appropriated, out of any monies in the Public Health Investment
Fund, $300,000,000 for each of fiscal years 2010 through 2014 and
$330,000,000 for each of fiscal years 2015 through 2019.''.
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals
SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM.
(a) Expansion of Covered Entities Receiving Discounted Prices.--
Section 340B(a)(4) (42 U.S.C. 256b(a)(4)) is amended by adding at the
end the following:
``(M) A children's hospital excluded from the
Medicare prospective payment system pursuant to section
1886(d)(1)(B)(iii) of the Social Security Act which
would meet the requirements of subparagraph (L),
including the disproportionate share adjustment
percentage requirement under subparagraph (L)(ii), if
the hospital were a subsection (d) hospital as defined
in section 1886(d)(1)(B) of the Social Security Act.
``(N) An entity that is a critical access hospital
(as determined under section 1820(c)(2) of the Social
Security Act).
``(O) An entity receiving funds under title V of
the Social Security Act (relating to maternal and child
health) for the provision of health services.
``(P) An entity receiving funds under subpart I of
part B of title XIX of the Public Health Service Act
(relating to comprehensive mental health services) for
the provision of community mental health services.
``(Q) An entity receiving funds under subpart II of
such part B (relating to the prevention and treatment
of substance abuse) for the provision of treatment
services for substance abuse.
``(R) An entity that is a Medicare-dependent, small
rural hospital (as defined in section 1886(d)(5)(G)(iv)
of the Social Security Act).
``(S) An entity that is a sole community hospital
(as defined in section 1886(d)(5)(D)(iii) of the Social
Security Act).
``(T) An entity that is classified as a rural
referral center under section 1886(d)(5)(C) of the
Social Security Act.''.
(b) Prohibition on Group Purchasing Arrangements.--Section 340B(a)
(42 U.S.C. 256b(a)) is amended--
(1) in paragraph (4)(L)--
(A) by adding ``and'' at the end of clause (i);
(B) by striking ``; and'' at the end of clause (ii)
and inserting a period; and
(C) by striking clause (iii);
(2) in paragraph (5), by redesignating subparagraphs (C)
and (D) as subparagraphs (D) and (E), respectively, and by
inserting after subparagraph (B) the following:
``(C) Prohibiting use of group purchasing
arrangements.--
``(i) A hospital described in subparagraph
(L), (M), (N), (R), (S), or (T) of paragraph
(4) shall not obtain covered outpatient drugs
through a group purchasing organization or
other group purchasing arrangement, except as
permitted or provided pursuant to clause (ii).
``(ii) The Secretary shall establish
reasonable exceptions to the requirement of
clause (i)--
``(I) with respect to a covered
outpatient drug that is unavailable to
be purchased through the program under
this section due to a drug shortage
problem, manufacturer noncompliance, or
any other reason beyond the hospital's
control;
``(II) to facilitate generic
substitution when a generic covered
outpatient drug is available at a lower
price; and
``(III) to reduce in other ways the
administrative burdens of managing both
inventories of drugs obtained under
this section and not under this
section, if such exception does not
create a duplicate discount problem in
violation of subparagraph (A) or a
diversion problem in violation of
subparagraph (B).''.
SEC. 2502. EXTENSION OF DISCOUNTS TO INPATIENT DRUGS.
(a) In General.--Section 340B (42 U.S.C. 256b) is amended--
(1) in subsection (b)--
(A) by striking ``In this section, the terms'' and
inserting the following: ``In this section:
``(1) In general.--The terms''; and
(B) by adding at the end the following new
paragraph:
``(2) Covered drug.--The term `covered drug'--
``(A) means a covered outpatient drug (as defined
in section 1927(k)(2) of the Social Security Act); and
``(B) includes, notwithstanding the section
1927(k)(3)(A) of such Act, a drug used in connection
with an inpatient or outpatient service provided by a
hospital described in subparagraph (L), (M), (N), (R),
(S), or (T) of subsection (a)(4) that is enrolled to
participate in the drug discount program under this
section.''; and
(2) in paragraphs (5), (7), and (9) of subsection (a), by
striking ``outpatient'' each place it appears.
(b) Medicaid Credits on Inpatient Drugs.--Subsection (c) of section
340B (42 U.S.C. 256b(c)) is amended to read as follows:
``(c) Medicaid Credits on Inpatient Drugs.--
``(1) In general.--For the cost reporting period covered by
the most recently filed Medicare cost report under title XVIII
of the Social Security Act, a hospital described in
subparagraph (L), (M), (N), (R), (S), or (T) of subsection
(a)(4) and enrolled to participate in the drug discount program
under this section shall provide to each State under its plan
under title XIX of such Act--
``(A) a credit on the estimated annual costs to
such hospital of single source and innovator multiple
source drugs provided to Medicaid beneficiaries for
inpatient use; and
``(B) a credit on the estimated annual costs to
such hospital of noninnovator multiple source drugs
provided to Medicaid beneficiaries for inpatient use.
``(2) Amount of credits.--
``(A) Single source and innovator multiple source
drugs.--For purposes of paragraph (1)(A)--
``(i) the credit under such paragraph shall
be equal to the product of--
``(I) the annual value of single
source and innovator multiple source
drugs purchased under this section by
the hospital based on the drugs'
average manufacturer price;
``(II) the estimated percentage of
the hospital's drug purchases
attributable to Medicaid beneficiaries
for inpatient use; and
``(III) the minimum rebate
percentage described in section
1927(c)(1)(B) of the Social Security
Act;
``(ii) the reference in clause (i)(I) to
the annual value of single source and innovator
multiple source drugs purchased under this
section by the hospital based on the drugs'
average manufacturer price shall be equal to
the sum of--
``(I) the annual quantity of each
single source and innovator multiple
source drug purchased during the cost
reporting period, multiplied by
``(II) the average manufacturer
price for that drug;
``(iii) the reference in clause (i)(II) to
the estimated percentage of the hospital's drug
purchases attributable to Medicaid
beneficiaries for inpatient use; shall be equal
to--
``(I) the Medicaid inpatient drug
charges as reported on the hospital's
most recently filed Medicare cost
report, divided by
``(II) total drug charges reported
on the cost report; and
``(iv) the terms `single source drug' and
`innovator multiple source drug' have the
meanings given such terms in section 1927(k)(7)
of the Social Security Act.
``(B) Noninnovator multiple source drugs.--For
purposes of paragraph (1)(B)--
``(i) the credit under such paragraph shall
be equal to the product of--
``(I) the annual value of
noninnovator multiple source drugs
purchased under this section by the
hospital based on the drugs' average
manufacturer price;
``(II) the estimated percentage of
the hospital's drug purchases
attributable to Medicaid beneficiaries
for inpatient use; and
``(III) the applicable percentage
as defined in section 1927(c)(3)(B) of
the Social Security Act;
``(ii) the reference in clause (i)(I) to
the annual value of noninnovator multiple
source drugs purchased under this section by
the hospital based on the drugs' average
manufacturer price shall be equal to the sum
of--
``(I) the annual quantity of each
noninnovator multiple source drug
purchased during the cost reporting
period, multiplied by
``(II) the average manufacturer
price for that drug;
``(iii) the reference in clause (i)(II) to
the estimated percentage of the hospital's drug
purchases attributable to Medicaid
beneficiaries for inpatient use shall be equal
to--
``(I) the Medicaid inpatient drug
charges as reported on the hospital's
most recently filed Medicare cost
report, divided by
``(II) total drug charges reported
on the cost report; and
``(iv) the term `noninnovator multiple
source drug' has the meaning given such term in
section 1927(k)(7) of the Social Security Act.
``(3) Calculation of credits.--
``(A) In general.--Each State calculates credits
under paragraph (1) and informs hospitals of amount
under section 1927(a)(5)(D) of the Social Security Act.
``(B) Hospital provision of information.--Not later
than 30 days after the date of the filing of the
hospital's most recently filed Medicare cost report,
the hospital shall provide the State with the
information described in paragraphs (2)(A)(ii) and
(2)(B)(ii). With respect to each drug purchased during
the cost reporting period, the hospital shall provide
the dosage form, strength, package size, date of
purchase and the number of units purchased.
``(4) Payment deadline.--The credits provided by a hospital
under paragraph (1) shall be paid within 60 days after
receiving the information specified in paragraph (3)(A).
``(5) Opt out.--A hospital shall not be required to provide
the Medicaid credit required under paragraph (1) if it can
demonstrate to the State that it will lose reimbursement under
the State plan resulting from the extension of discounts to
inpatient drugs under subsection (b)(2) and that the loss of
reimbursement will exceed the amount of the credit otherwise
owed by the hospital.
``(6) Offset against medical assistance.--Amounts received
by a State under this subsection in any quarter shall be
considered to be a reduction in the amount expended under the
State plan in the quarter for medical assistance for purposes
of section 1903(a)(1) of the Social Security Act.''.
(c) Conforming Amendments.--Section 1927 of the Social Security Act
(42 U.S.C. 1396r-8) is amended--
(1) in subsection (a)(5)(A), by striking ``covered
outpatient drugs'' and inserting ``covered drugs (as defined in
section 340B(b)(2) of the Public Health Service Act)'';
(2) in subsection (a)(5), by striking subparagraph (D) and
inserting the following:
``(D) State responsibility for calculating hospital
credits.--The State shall calculate the credits owed by
the hospital under paragraph (1) of section 340B(c) of
the Public Health Service Act and provide the hospital
with both the amounts and an explanation of how it
calculated the credits. In performing the calculations
specified in paragraphs (2)(A)(ii) and (2)(B)(ii) of
such section, the State shall use the average
manufacturer price applicable to the calendar quarter
in which the drug was purchased by the hospital.''; and
(3) in subsection (k)(1)--
(A) in subparagraph (A), by striking ``subparagraph
(B)'' and inserting ``subparagraphs (B) and (D)''; and
(B) by adding at the end the following:
``(D) Calculation for covered drugs.--With respect
to a covered drug (as defined in section 340B(b)(2) of
the Public Health Service Act), the average
manufacturer price shall be determined in accordance
with subparagraph (A) except that, in the event a
covered drug is not distributed to the retail pharmacy
class of trade, it shall mean the average price paid to
the manufacturer for the drug in the United States by
wholesalers for drugs distributed to the acute care
class of trade, after deducting customary prompt pay
discounts.''.
SEC. 2503. EFFECTIVE DATE.
(a) In General.--The amendments made by this subtitle shall take
effect on July 1, 2010, and shall apply to drugs dispensed on or after
such date.
(b) Effectiveness.--The amendments made by this subtitle shall be
effective, and shall be taken into account in determining whether a
manufacturer is deemed to meet the requirements of section 340B(a) of
the Public Health Service Act (42 U.S.C. 256b(a)) and of section
1927(a)(5) of the Social Security Act (42 U.S.C. 1396r-8(a)(5)),
notwithstanding any other provision of law.
Subtitle B--School-Based Health Clinics
SEC. 2511. SCHOOL-BASED HEALTH CLINICS.
(a) In General.--Part Q of title III (42 U.S.C. 280h et seq.) is
amended by adding at the end the following:
``SEC. 399Z-1. SCHOOL-BASED HEALTH CLINICS.
``(a) Program.--The Secretary shall establish a school-based health
clinic program consisting of awarding grants to eligible entities to
support the operation of school-based health clinics (referred to in
this section as `SBHCs').
``(b) Eligibility.--To be eligible for a grant under this section,
an entity shall--
``(1) be an SBHC (as defined in subsection (l)(4)); and
``(2) submit an application at such time, in such manner,
and containing such information as the Secretary may require,
including at a minimum--
``(A) evidence that the applicant meets all
criteria necessary to be designated as an SBHC;
``(B) evidence of local need for the services to be
provided by the SBHC;
``(C) an assurance that--
``(i) SBHC services will be provided in
accordance with Federal, State, and local laws
governing--
``(I) obtaining parental or
guardian consent; and
``(II) patient privacy and student
records, including section 264 of the
Health Insurance Portability and
Accountability Act of 1996 and section
444 of the General Education Provisions
Act;
``(ii) the SBHC has established and
maintains collaborative relationships with
other health care providers in the catchment
area of the SBHC;
``(iii) the SBHC will provide on-site
access during the academic day when school is
in session and has an established network of
support and access to services with backup
health providers when the school or SBHC is
closed;
``(iv) the SBHC will be integrated into the
school environment and will coordinate health
services with appropriate school personnel and
other community providers co-located at the
school; and
``(v) the SBHC sponsoring facility assumes
all responsibility for the SBHC administration,
operations, and oversight; and
``(D) such other information as the Secretary may
require.
``(c) Use of Funds.--Funds awarded under a grant under this section
may be used for--
``(1) providing training related to the provision of
comprehensive primary health services and additional health
services;
``(2) the management and operation of SBHC programs; and
``(3) the payment of salaries for health professionals and
other appropriate SBHC personnel.
``(d) Consideration of Need.--In determining the amount of a grant
under this section, the Secretary shall take into consideration--
``(1) the financial need of the SBHC;
``(2) State, local, or other sources of funding provided to
the SBHC; and
``(3) other factors as determined appropriate by the
Secretary.
``(e) Preferences.--In awarding grants under this section, the
Secretary shall give preference to SBHCs that have a demonstrated
record of service to the following:
``(1) A high percentage of medically underserved children
and adolescents.
``(2) Communities or populations in which children and
adolescents have difficulty accessing health and mental health
services.
``(3) Communities with high percentages of children and
adolescents who are uninsured, underinsured, or eligible for
medical assistance under Federal or State health benefits
programs (including titles XIX and XXI of the Social Security
Act).
``(f) Matching Requirement.--The Secretary may award a grant to an
SBHC only if the SBHC agrees to provide, from non-Federal sources, an
amount equal to 20 percent of the amount of the grant (which may be
provided in cash or in kind) to carry out the activities supported by
the grant.
``(g) Supplement, Not Supplant.--The Secretary may award a grant to
an SBHC under this section only if the SBHC demonstrates to the
satisfaction of the Secretary that funds received through the grant
will be expended only to supplement, and not supplant, non-Federal and
Federal funds otherwise available to the SBHC for operation of the SBHC
(including each activity described in paragraph (1) or (2) of
subsection (c)).
``(h) Payor of Last Resort.--The Secretary may award a grant to an
SBHC under this section only if the SBHC demonstrates to the
satisfaction of the Secretary that funds received through the grant
will not be expended for any activity to the extent that payment has
been made, or can reasonably be expected to be made--
``(1) under any insurance policy;
``(2) under any Federal or State health benefits program
(including titles XIX and XXI of the Social Security Act); or
``(3) by an entity which provides health services on a
prepaid basis.
``(i) Regulations Regarding Reimbursement for Health Services.--The
Secretary shall issue regulations regarding the reimbursement for
health services provided by SBHCs to individuals eligible to receive
such services through the program under this section, including
reimbursement under any insurance policy or any Federal or State health
benefits program (including titles XIX and XXI of the Social Security
Act).
``(j) Technical Assistance.--The Secretary shall provide (either
directly or by grant or contract) technical and other assistance to
SBHCs to assist such SBHCs to meet the requirements of this section.
Such assistance may include fiscal and program management assistance,
training in fiscal and program management, operational and
administrative support, and the provision of information to the SBHCs
of the variety of resources available under this title and how those
resources can be best used to meet the health needs of the communities
served by the SBHCs.
``(k) Evaluation; Report.--The Secretary shall--
``(1) develop and implement a plan for evaluating SBHCs and
monitoring quality performances under the awards made under
this section; and
``(2) submit to the Congress on an annual basis a report on
the program under this section.
``(l) Definitions.--In this section:
``(1) Comprehensive primary health services.--The term
`comprehensive primary health services' means the core services
offered by SBHCs, which shall include the following:
``(A) Physical.--Comprehensive health assessments,
diagnosis, and treatment of minor, acute, and chronic
medical conditions and referrals to, and follow-up for,
specialty care.
``(B) Mental health.--Mental health assessments,
crisis intervention, counseling, treatment, and
referral to a continuum of services including emergency
psychiatric care, community support programs, inpatient
care, and outpatient programs.
``(C) Optional services.--Additional services,
which may include oral health, social, and age-
appropriate health education services, including
nutritional counseling.
``(2) Medically underserved children and adolescents.--The
term `medically underserved children and adolescents' means a
population of children and adolescents who are residents of an
area designated by the Secretary as an area with a shortage of
personal health services and health infrastructure for such
children and adolescents.
``(3) School-based health clinic.--The term `school-based
health clinic' means a health clinic that--
``(A) is located in, or is adjacent to, a school
facility of a local educational agency;
``(B) is organized through school, community, and
health provider relationships;
``(C) is administered by a sponsoring facility; and
``(D) provides, at a minimum, comprehensive primary
health services during school hours to children and
adolescents by health professionals in accordance with
State and local laws and regulations, established
standards, and community practice.
``(4) Sponsoring facility.--The term `sponsoring facility'
is--
``(A) a hospital;
``(B) a public health department;
``(C) a community health center;
``(D) a nonprofit health care agency;
``(E) a local educational agency; or
``(F) a program administered by the Indian Health
Service or the Bureau of Indian Affairs or operated by
an Indian tribe or a tribal organization under the
Indian Self-Determination and Education Assistance Act,
a Native Hawaiian entity, or an urban Indian program
under title V of the Indian Health Care Improvement
Act.
``(m) Authorization of Appropriations.--For purposes of carrying
out this section, there are authorized to be appropriated $50,000,000
for fiscal year 2010 and such sums as may be necessary for each of the
fiscal years 2011 through 2014.''.
(b) Effective Date.--The Secretary of Health and Human Services
shall begin awarding grants under section 399Z-1 of the Public Health
Service Act, as added by subsection (b), not later than July 1, 2010,
without regard to whether or not final regulations have been issued
under section 399Z-1(h) of such Act.
Subtitle C--National Medical Device Registry
SEC. 2521. NATIONAL MEDICAL DEVICE REGISTRY.
(a) Registry.--
(1) In general.--Section 519 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 360i) is amended--
(A) by redesignating subsection (g) as subsection
(h); and
(B) by inserting after subsection (f) the
following:
``National Medical Device Registry
``(g)(1) The Secretary shall establish a national medical device
registry (in this subsection referred to as the `registry') to
facilitate analysis of postmarket safety and outcomes data on each
device that--
``(A) is or has been used in or on a patient; and
``(B) is--
``(i) a class III device; or
``(ii) a class II device that is implantable, life-
supporting, or life-sustaining.
``(2) In developing the registry, the Secretary shall, in
consultation with the Commissioner of Food and Drugs, the Administrator
of the Centers for Medicare & Medicaid Services, the head of the Office
of the National Coordinator for Health Information Technology, and the
Secretary of Veterans Affairs, determine the best methods for--
``(A) including in the registry, in a manner consistent
with subsection (f), appropriate information to identify each
device described in paragraph (1) by type, model, and serial
number or other unique identifier;
``(B) validating methods for analyzing patient safety and
outcomes data from multiple sources and for linking such data
with the information included in the registry as described in
subparagraph (A), including, to the extent feasible, use of--
``(i) data provided to the Secretary under other
provisions of this chapter; and
``(ii) information from public and private sources
identified under paragraph (3);
``(C) integrating the activities described in this
subsection with--
``(i) activities under paragraph (3) of section
505(k) (relating to active postmarket risk
identification);
``(ii) activities under paragraph (4) of section
505(k) (relating to advanced analysis of drug safety
data); and
``(iii) other postmarket device surveillance
activities of the Secretary authorized by this chapter;
and
``(D) providing public access to the data and analysis
collected or developed through the registry in a manner and
form that protects patient privacy and proprietary information
and is comprehensive, useful, and not misleading to patients,
physicians, and scientists.
``(3)(A) To facilitate analyses of postmarket safety and patient
outcomes for devices described in paragraph (1), the Secretary shall,
in collaboration with public, academic, and private entities, develop
methods to--
``(i) obtain access to disparate sources of patient
safety and outcomes data, including--
``(I) Federal health-related electronic
data (such as data from the Medicare program
under title XVIII of the Social Security Act or
from the health systems of the Department of
Veterans Affairs);
``(II) private sector health-related
electronic data (such as pharmaceutical
purchase data and health insurance claims
data); and
``(III) other data as the Secretary deems
necessary to permit postmarket assessment of
device safety and effectiveness; and
``(ii) link data obtained under clause (i) with
information in the registry.
``(B) In this paragraph, the term `data' refers to information
respecting a device described in paragraph (1), including claims data,
patient survey data, standardized analytic files that allow for the
pooling and analysis of data from disparate data environments,
electronic health records, and any other data deemed appropriate by the
Secretary.
``(4) Not later than 36 months after the date of the enactment of
this subsection, the Secretary shall promulgate regulations for
establishment and operation of the registry under paragraph (1). Such
regulations--
``(A)(i) in the case of devices that are described in
paragraph (1) and sold on or after the date of the enactment of
this subsection, shall require manufacturers of such devices to
submit information to the registry, including, for each such
device, the type, model, and serial number or, if required
under subsection (f), other unique device identifier; and
``(ii) in the case of devices that are described in
paragraph (1) and sold before such date, may require
manufacturers of such devices to submit such information to the
registry, if deemed necessary by the Secretary to protect the
public health;
``(B) shall establish procedures--
``(i) to permit linkage of information submitted
pursuant to subparagraph (A) with patient safety and
outcomes data obtained under paragraph (3); and
``(ii) to permit analyses of linked data;
``(C) may require device manufacturers to submit such other
information as is necessary to facilitate postmarket
assessments of device safety and effectiveness and notification
of device risks;
``(D) shall establish requirements for regular and timely
reports to the Secretary, which shall be included in the
registry, concerning adverse event trends, adverse event
patterns, incidence and prevalence of adverse events, and other
information the Secretary determines appropriate, which may
include data on comparative safety and outcomes trends; and
``(E) shall establish procedures to permit public access to
the information in the registry in a manner and form that
protects patient privacy and proprietary information and is
comprehensive, useful, and not misleading to patients,
physicians, and scientists.
``(5) To carry out this subsection, there are authorized to be
appropriated such sums as may be necessary for fiscal years 2010 and
2011.''.
(2) Effective date.--The Secretary of Health and Human
Services shall establish and begin implementation of the
registry under section 519(g) of the Federal Food, Drug, and
Cosmetic Act, as added by paragraph (1), by not later than the
date that is 36 months after the date of the enactment of this
Act, without regard to whether or not final regulations to
establish and operate the registry have been promulgated by
such date.
(3) Conforming amendment.--Section 303(f)(1)(B)(ii) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C.
333(f)(1)(B)(ii)) is amended by striking ``519(g)'' and
inserting ``519(h)''.
(b) Electronic Exchange and Use in Certified Electronic Health
Records of Unique Device Identifiers.--
(1) Recommendations.--The HIT Policy Committee established
under section 3002 of the Public Health Service Act (42 U.S.C.
300jj-12) shall recommend to the head of the Office of the
National Coordinator for Health Information Technology
standards, implementation specifications, and certification
criteria for the electronic exchange and use in certified
electronic health records of a unique device identifier for
each device described in section 519(g)(1) of the Federal Food,
Drug, and Cosmetic Act, as added by subsection (a).
(2) Standards, implementation criteria, and certification
criteria.--The Secretary of the Health Human Services, acting
through the head of the Office of the National Coordinator for
Health Information Technology, shall adopt standards,
implementation specifications, and certification criteria for
the electronic exchange and use in certified electronic health
records of a unique device identifier for each device described
in paragraph (1), if such an identifier is required by section
519(f) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
360i(f)) for the device.
Subtitle D--Grants for Comprehensive Programs To Provide Education to
Nurses and Create a Pipeline to Nursing
SEC. 2531. ESTABLISHMENT OF GRANT PROGRAM.
(a) Purposes.--It is the purpose of this section to authorize
grants to--
(1) address the projected shortage of nurses by funding
comprehensive programs to create a career ladder to nursing
(including Certified Nurse Assistants, Licensed Practical
Nurses, Licensed Vocational Nurses, and Registered Nurses) for
incumbent ancillary health care workers;
(2) increase the capacity for educating nurses by
increasing both nurse faculty and clinical opportunities
through collaborative programs between staff nurse
organizations, health care providers, and accredited schools of
nursing; and
(3) provide training programs through education and
training organizations jointly administered by health care
providers and health care labor organizations or other
organizations representing staff nurses and frontline health
care workers, working in collaboration with accredited schools
of nursing and academic institutions.
(b) Grants.--Not later than 6 months after the date of the
enactment of this Act, the Secretary of Labor (referred to in this
section as the ``Secretary'') shall establish a partnership grant
program to award grants to eligible entities to carry out comprehensive
programs to provide education to nurses and create a pipeline to
nursing for incumbent ancillary health care workers who wish to advance
their careers, and to otherwise carry out the purposes of this section.
(c) Eligibility.--To be eligible for a grant under this section, an
entity shall be--
(1) a health care entity that is jointly administered by a
health care employer and a labor union representing the health
care employees of the employer and that carries out activities
using labor management training funds as provided for under
section 302(c)(6) of the Labor Management Relations Act, 1947
(29 U.S.C. 186(c)(6));
(2) an entity that operates a training program that is
jointly administered by--
(A) one or more health care providers or
facilities, or a trade association of health care
providers; and
(B) one or more organizations which represent the
interests of direct care health care workers or staff
nurses and in which the direct care health care workers
or staff nurses have direct input as to the leadership
of the organization;
(3) a State training partnership program that consists of
nonprofit organizations that include equal participation from
industry, including public or private employers, and labor
organizations including joint labor-management training
programs, and which may include representatives from local
governments, worker investment agency one-stop career centers,
community-based organizations, community colleges, and
accredited schools of nursing; or
(4) a school of nursing (as defined in section 801 of the
Public Health Service Act (42 U.S.C. 296)).
(d) Additional Requirements for Health Care Employer Described in
Subsection (c).--To be eligible for a grant under this section, a
health care employer described in subsection (c) shall demonstrate that
it--
(1) has an established program within their facility to
encourage the retention of existing nurses;
(2) provides wages and benefits to its nurses that are
competitive for its market or that have been collectively
bargained with a labor organization; and
(3) supports programs funded under this section through 1
or more of the following:
(A) The provision of paid leave time and continued
health coverage to incumbent health care workers to
allow their participation in nursing career ladder
programs, including certified nurse assistants,
licensed practical nurses, licensed vocational nurses,
and registered nurses.
(B) Contributions to a joint labor-management
training fund which administers the program involved.
(C) The provision of paid release time, incentive
compensation, or continued health coverage to staff
nurses who desire to work full- or part-time in a
faculty position.
(D) The provision of paid release time for staff
nurses to enable them to obtain a bachelor of science
in nursing degree, other advanced nursing degrees,
specialty training, or certification program.
(E) The payment of tuition assistance which is
managed by a joint labor-management training fund or
other jointly administered program.
(e) Other Requirements.--
(1) Matching requirement.--
(A) In general.--The Secretary may not make a grant
under this section unless the applicant involved
agrees, with respect to the costs to be incurred by the
applicant in carrying out the program under the grant,
to make available non-Federal contributions (in cash or
in kind under subparagraph (B)) toward such costs in an
amount equal to not less than $1 for each $1 of Federal
funds provided in the grant. Such contributions may be
made directly or through donations from public or
private entities, or may be provided through the cash
equivalent of paid release time provided to incumbent
worker students.
(B) Determination of amount of non-federal
contribution.--Non-Federal contributions required in
subparagraph (A) may be in cash or in kind (including
paid release time), fairly evaluated, including
equipment or services (and excluding indirect or
overhead costs). Amounts provided by the Federal
Government, or services assisted or subsidized to any
significant extent by the Federal Government, may not
be included in determining the amount of such non-
Federal contributions.
(2) Required collaboration.--Entities carrying out or
overseeing programs carried out with assistance provided under
this section shall demonstrate collaboration with accredited
schools of nursing which may include community colleges and
other academic institutions providing associate, bachelor's, or
advanced nursing degree programs or specialty training or
certification programs.
(f) Use of Funds.--Amounts awarded to an entity under a grant under
this section shall be used for the following:
(1) To carry out programs that provide education and
training to establish nursing career ladders to educate
incumbent health care workers to become nurses (including
certified nurse assistants, licensed practical nurses, licensed
vocational nurses, and registered nurses). Such programs shall
include one or more of the following:
(A) Preparing incumbent workers to return to the
classroom through English -as-a-second language
education, GED education, pre-college counseling,
college preparation classes, and support with entry
level college classes that are a prerequisite to
nursing.
(B) Providing tuition assistance with preference
for dedicated cohort classes in community colleges,
universities, accredited schools of nursing with
supportive services including tutoring and counseling.
(C) Providing assistance in preparing for and
meeting all nursing licensure tests and requirements.
(D) Carrying out orientation and mentorship
programs that assist newly graduated nurses in
adjusting to working at the bedside to ensure their
retention postgraduation, and ongoing programs to
support nurse retention.
(E) Providing stipends for release time and
continued health care coverage to enable incumbent
health care workers to participate in these programs.
(2) To carry out programs that assist nurses in obtaining
advanced degrees and completing specialty training or
certification programs and to establish incentives for nurses
to assume nurse faculty positions on a part-time or full-time
basis. Such programs shall include one or more of the
following:
(A) Increasing the pool of nurses with advanced
degrees who are interested in teaching by funding
programs that enable incumbent nurses to return to
school.
(B) Establishing incentives for advanced degree
bedside nurses who wish to teach in nursing programs so
they can obtain a leave from their bedside position to
assume a full- or part-time position as adjunct or
full-time faculty without the loss of salary or
benefits.
(C) Collaboration with accredited schools of
nursing which may include community colleges and other
academic institutions providing associate, bachelor's,
or advanced nursing degree programs, or specialty
training or certification programs, for nurses to carry
out innovative nursing programs which meet the needs of
bedside nursing and health care providers.
(g) Preference.--In awarding grants under this section the
Secretary shall give preference to programs that--
(1) provide for improving nurse retention;
(2) provide for improving the diversity of the new nurse
graduates to reflect changes in the demographics of the patient
population;
(3) provide for improving the quality of nursing education
to improve patient care and safety;
(4) have demonstrated success in upgrading incumbent health
care workers to become nurses or which have established
effective programs or pilots to increase nurse faculty; or
(5) are modeled after or affiliated with such programs
described in paragraph (4).
(h) Evaluation.--
(1) Program evaluations.--An entity that receives a grant
under this section shall annually evaluate, and submit to the
Secretary a report on, the activities carried out under the
grant and the outcomes of such activities. Such outcomes may
include--
(A) an increased number of incumbent workers
entering an accredited school of nursing and in the
pipeline for nursing programs;
(B) an increasing number of graduating nurses and
improved nurse graduation and licensure rates;
(C) improved nurse retention;
(D) an increase in the number of staff nurses at
the health care facility involved;
(E) an increase in the number of nurses with
advanced degrees in nursing;
(F) an increase in the number of nurse faculty;
(G) improved measures of patient quality (which may
include staffing ratios of nurses, patient satisfaction
rates, patient safety measures); and
(H) an increase in the diversity of new nurse
graduates relative to the patient population.
(2) General report.--Not later than 2 years after the date
of the enactment of this Act, and annually thereafter, the
Secretary of Labor shall, using data and information from the
reports received under paragraph (1), submit to the Congress a
report concerning the overall effectiveness of the grant
program carried out under this section.
(i) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary.
Subtitle E--States Failing To Adhere to Certain Employment Obligations
SEC. 2541. LIMITATION ON FEDERAL FUNDS.
A State is eligible for Federal funds under the provisions of the
Public Health Service Act (42 U.S.C. 201 et seq.) only if the State--
(1) agrees to be subject in its capacity as an employer to
each obligation under division A of this Act and the amendments
made by such division applicable to persons in their capacity
as an employer; and
(2) assures that all political subdivisions in the State
will do the same.
<all>