To change the enactment date.

AMENDMENTS SUBMITTED AND PROPOSED

SA 3276. Mr. REID (for himself, Mr. Baucus, Mr. Dodd, and
Mr. Harkin) proposed an amendment to amendment SA 2786
proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and
Mr. Harkin) to the bill H.R. 3590, to amend the Internal
Revenue Code of 1986 to modify the first-time homebuyers
credit in the case of members of the Armed Forces and certain
other Federal employees, and for other purposes.
SA 3277. Mr. REID proposed an amendment to amendment SA
3276 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd,
and Mr. Harkin) to the amendment SA 2786 proposed by Mr. REID
(for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the
bill H.R. 3590, supra.
SA 3278. Mr. REID proposed an amendment to the bill H.R.
3590, supra.
SA 3279. Mr. REID proposed an amendment to amendment SA
3278 proposed by Mr. Reid to the bill H.R. 3590, supra.
SA 3280. Mr. REID proposed an amendment to the bill H.R.
3590, supra.
SA 3281. Mr. REID proposed an amendment to amendment SA
3280 proposed by Mr. Reid to the bill H.R. 3590, supra.
SA 3282. Mr. REID proposed an amendment to amendment SA
3281 proposed by Mr. Reid to the amendment SA 3280 proposed
by Mr. Reid to the bill H.R. 3590, supra.
SA 3283. Mr. COBURN submitted an amendment intended to be
proposed to amendment SA 2786 proposed by Mr. Reid (for
himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the bill
H.R. 3590, supra; which was ordered to lie on the table.
______

SA 3276. Mr. REID (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin)
proposed an amendment to amendment SA 2786 proposed by Mr. Reid (for
himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the bill H.R. 3590,
to amend the Internal Revenue Code of 1986 to modify the first-time
homebuyers credit in the case of members of the Armed Forces and
certain other Federal employees, and for other purposes; which was
ordered to lie on the table; as follows:

On page 2074, strike lines 22 through 25, and insert the
following:
(f) Effective Date.--The amendments made by subsections (a)
through (d) of this section shall apply to amounts paid or
incurred after December 31, 2008, in taxable years beginning
after such date.

TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS

Subtitle A--Provisions Relating to Title I

SEC. 10101. AMENDMENTS TO SUBTITLE A.

(a) Section 2711 of the Public Health Service Act, as added
by section 1001(5) of this Act, is amended to read as
follows:

``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.

``(a) Prohibition.--
``(1) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not establish--
``(A) lifetime limits on the dollar value of benefits for
any participant or beneficiary; or
``(B) except as provided in paragraph (2), annual limits on
the dollar value of benefits for any participant or
beneficiary.
``(2) Annual limits prior to 2014.--With respect to plan
years beginning prior to January 1, 2014, a group health plan
and a health insurance issuer offering group or individual
health insurance coverage may only establish a restricted
annual limit on the dollar value of benefits for any
participant or beneficiary with respect to the scope of
benefits that are essential health benefits under section
1302(b) of the Patient Protection and Affordable Care Act, as
determined by the Secretary. In defining the term `restricted
annual limit' for purposes of the preceding sentence, the
Secretary shall ensure that access to needed services is made
available with a minimal impact on premiums.
``(b) Per Beneficiary Limits.--Subsection (a) shall not be
construed to prevent a group health plan or health insurance
coverage from placing annual or lifetime per beneficiary
limits on specific covered benefits that are not essential
health benefits under section 1302(b) of the Patient
Protection and Affordable Care Act, to the extent that such
limits are otherwise permitted under Federal or State law.''.
(b) Section 2715(a) of the Public Health Service Act, as
added by section 1001(5) of this Act, is amended by striking
``and providing to enrollees'' and inserting ``and providing
to applicants, enrollees, and policyholders or certificate
holders''.
(c) Subpart II of part A of title XXVII of the Public
Health Service Act, as added by section 1001(5), is amended
by inserting after section 2715, the following:

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

``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
comply with the provisions of section 1311(e)(3) of the
Patient Protection and Affordable Care Act, except that a
plan or coverage that is not offered through an Exchange
shall only be required to submit the information required to
the Secretary and the State insurance commissioner, and make
such information available to the public.''.
(d) Section 2716 of the Public Health Service Act, as added
by section 1001(5) of this Act, is amended to read as
follows:

``SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR OF HIGHLY
COMPENSATED INDIVIDUALS.

``(a) In General.--A group health plan (other than a self-
insured plan) shall satisfy the requirements of section
105(h)(2) of the Internal Revenue Code of 1986 (relating to
prohibition on discrimination in favor of highly compensated
individuals).
``(b) Rules and Definitions.--For purposes of this
section--
``(1) Certain rules to apply.--Rules similar to the rules
contained in paragraphs (3), (4), and (8) of section 105(h)
of such Code shall apply.
``(2) Highly compensated individual.--The term `highly
compensated individual' has the meaning given such term by
section 105(h)(5) of such Code.''.
(e) Section 2717 of the Public Health Service Act, as added
by section 1001(5) of this Act, is amended--
(1) by redesignating subsections (c) and (d) as subsections
(d) and (e), respectively; and
(2) by inserting after subsection (b), the following:
``(c) Protection of Second Amendment Gun Rights.--
``(1) Wellness and prevention programs.--A wellness and
health promotion activity implemented under subsection
(a)(1)(D) may not require the disclosure or collection of any
information relating to--
``(A) the presence or storage of a lawfully-possessed
firearm or ammunition in the residence or on the property of
an individual; or
``(B) the lawful use, possession, or storage of a firearm
or ammunition by an individual.
``(2) Limitation on data collection.--None of the
authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made by
that Act shall be construed to authorize or may be used for
the collection of any information relating to--
``(A) the lawful ownership or possession of a firearm or
ammunition;
``(B) the lawful use of a firearm or ammunition; or
``(C) the lawful storage of a firearm or ammunition.
``(3) Limitation on databases or data banks.--None of the
authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made by
that Act shall be construed to authorize or may be used to
maintain records of individual ownership or possession of a
firearm or ammunition.
``(4) Limitation on determination of premium rates or
eligibility for health insurance.--A premium rate may not be
increased, health insurance coverage may not be denied, and a
discount, rebate, or reward offered for participation in a
wellness program may not be reduced or withheld under

[[Page S13491]]

any health benefit plan issued pursuant to or in accordance
with the Patient Protection and Affordable Care Act or an
amendment made by that Act on the basis of, or on reliance
upon--
``(A) the lawful ownership or possession of a firearm or
ammunition; or
``(B) the lawful use or storage of a firearm or ammunition.
``(5) Limitation on data collection requirements for
individuals.--No individual shall be required to disclose any
information under any data collection activity authorized
under the Patient Protection and Affordable Care Act or an
amendment made by that Act relating to--
``(A) the lawful ownership or possession of a firearm or
ammunition; or
``(B) the lawful use, possession, or storage of a firearm
or ammunition.''.
(f) Section 2718 of the Public Health Service Act, as added
by section 1001(5), is amended to read as follows:

``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.

``(a) Clear Accounting for Costs.--A health insurance
issuer offering group or individual health insurance coverage
(including a grandfathered health plan) shall, with respect
to each plan year, submit to the Secretary a report
concerning the ratio of the incurred loss (or incurred
claims) plus the loss adjustment expense (or change in
contract reserves) to earned premiums. Such report shall
include the percentage of total premium revenue, after
accounting for collections or receipts for risk adjustment
and risk corridors and payments of reinsurance, that such
coverage expends--
``(1) on reimbursement for clinical services provided to
enrollees under such coverage;
``(2) for activities that improve health care quality; and
``(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding
Federal and State taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section
available to the public on the Internet website of the
Department of Health and Human Services.
``(b) Ensuring That Consumers Receive Value for Their
Premium Payments.--
``(1) Requirement to provide value for premium payments.--
``(A) Requirement.--Beginning not later than January 1,
2011, a health insurance issuer offering group or individual
health insurance coverage (including a grandfathered health
plan) shall, with respect to each plan year, provide an
annual rebate to each enrollee under such coverage, on a pro
rata basis, if the ratio of the amount of premium revenue
expended by the issuer on costs described in paragraphs (1)
and (2) of subsection (a) to the total amount of premium
revenue (excluding Federal and State taxes and licensing or
regulatory fees and after accounting for payments or receipts
for risk adjustment, risk corridors, and reinsurance under
sections 1341, 1342, and 1343 of the Patient Protection and
Affordable Care Act) for the plan year (except as provided in
subparagraph (B)(ii)), is less than--
``(i) with respect to a health insurance issuer offering
coverage in the large group market, 85 percent, or such
higher percentage as a State may by regulation determine; or
``(ii) with respect to a health insurance issuer offering
coverage in the small group market or in the individual
market, 80 percent, or such higher percentage as a State may
by regulation determine, except that the Secretary may adjust
such percentage with respect to a State if the Secretary
determines that the application of such 80 percent may
destabilize the individual market in such State.
``(B) Rebate amount.--
``(i) Calculation of amount.--The total amount of an annual
rebate required under this paragraph shall be in an amount
equal to the product of--

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

``(ii) Calculation based on average ratio.--Beginning on
January 1, 2014, the determination made under subparagraph
(A) for the year involved shall be based on the averages of
the premiums expended on the costs described in such
subparagraph and total premium revenue for each of the
previous 3 years for the plan.
``(2) Consideration in setting percentages.--In determining
the percentages under paragraph (1), a State shall seek to
ensure adequate participation by health insurance issuers,
competition in the health insurance market in the State, and
value for consumers so that premiums are used for clinical
services and quality improvements.
``(3) Enforcement.--The Secretary shall promulgate
regulations for enforcing the provisions of this section and
may provide for appropriate penalties.
``(c) Definitions.--Not later than December 31, 2010, and
subject to the certification of the Secretary, the National
Association of Insurance Commissioners shall establish
uniform definitions of the activities reported under
subsection (a) and standardized methodologies for calculating
measures of such activities, including definitions of which
activities, and in what regard such activities, constitute
activities described in subsection (a)(2). Such methodologies
shall be designed to take into account the special
circumstances of smaller plans, different types of plans, and
newer plans.
``(d) Adjustments.--The Secretary may adjust the rates
described in subsection (b) if the Secretary determines
appropriate on account of the volatility of the individual
market due to the establishment of State Exchanges.
``(e) Standard Hospital Charges.--Each hospital operating
within the United States shall for each year establish (and
update) and make public (in accordance with guidelines
developed by the Secretary) a list of the hospital's standard
charges for items and services provided by the hospital,
including for diagnosis-related groups established under
section 1886(d)(4) of the Social Security Act.''.
(g) Section 2719 of the Public Health Service Act, as added
by section 1001(4) of this Act, is amended to read as
follows:

``SEC. 2719. APPEALS PROCESS.

``(a) Internal Claims Appeals.--
``(1) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall implement an effective appeals
process for appeals of coverage determinations and claims,
under which the plan or issuer shall, at a minimum--
``(A) have in effect an internal claims appeal process;
``(B) provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and
external appeals processes, and the availability of any
applicable office of health insurance consumer assistance or
ombudsman established under section 2793 to assist such
enrollees with the appeals processes; and
``(C) allow an enrollee to review their file, to present
evidence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process.
``(2) Established processes.--To comply with paragraph
(1)--
``(A) a group health plan and a health insurance issuer
offering group health coverage shall provide an internal
claims and appeals process that initially incorporates the
claims and appeals procedures (including urgent claims) set
forth at section 2560.503-1 of title 29, Code of Federal
Regulations, as published on November 21, 2000 (65 Fed. Reg.
70256), and shall update such process in accordance with any
standards established by the Secretary of Labor for such
plans and issuers; and
``(B) a health insurance issuer offering individual health
coverage, and any other issuer not subject to subparagraph
(A), shall provide an internal claims and appeals process
that initially incorporates the claims and appeals procedures
set forth under applicable law (as in existence on the date
of enactment of this section), and shall update such process
in accordance with any standards established by the Secretary
of Health and Human Services for such issuers.
``(b) External Review.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage--
``(1) shall comply with the applicable State external
review process for such plans and issuers that, at a minimum,
includes the consumer protections set forth in the Uniform
External Review Model Act promulgated by the National
Association of Insurance Commissioners and is binding on such
plans; or
``(2) shall implement an effective external review process
that meets minimum standards established by the Secretary
through guidance and that is similar to the process described
under paragraph (1)--
``(A) if the applicable State has not established an
external review process that meets the requirements of
paragraph (1); or
``(B) if the plan is a self-insured plan that is not
subject to State insurance regulation (including a State law
that establishes an external review process described in
paragraph (1)).
``(c) Secretary Authority.--The Secretary may deem the
external review process of a group health plan or health
insurance issuer, in operation as of the date of enactment of
this section, to be in compliance with the applicable process
established under subsection (b), as determined appropriate
by the Secretary.''.
(h) Subpart II of part A of title XVIII of the Public
Health Service Act, as added by section 1001(5) of this Act,
is amended by inserting after section 2719 the following:

``SEC. 2719A. PATIENT PROTECTIONS.

``(a) Choice of Health Care Professional.--If a group
health plan, or a health insurance issuer offering group or
individual health insurance coverage, requires or provides
for designation by a participant, beneficiary, or enrollee of
a participating primary care provider, then the plan or
issuer shall permit each participant, beneficiary, and
enrollee to designate any participating primary care provider
who is available to accept such individual.
``(b) Coverage of Emergency Services.--
``(1) In general.--If a group health plan, or a health
insurance issuer offering group or individual health
insurance issuer, provides

[[Page S13492]]

or covers any benefits with respect to services in an
emergency department of a hospital, the plan or issuer shall
cover emergency services (as defined in paragraph (2)(B))--
``(A) without the need for any prior authorization
determination;
``(B) whether the health care provider furnishing such
services is a participating provider with respect to such
services;
``(C) in a manner so that, if such services are provided to
a participant, beneficiary, or enrollee--
``(i) by a nonparticipating health care provider with or
without prior authorization; or
``(ii)(I) such services will be provided without imposing
any requirement under the plan for prior authorization of
services or any limitation on coverage where the provider of
services does not have a contractual relationship with the
plan for the providing of services that is more restrictive
than the requirements or limitations that apply to emergency
department services received from providers who do have such
a contractual relationship with the plan; and
``(II) if such services are provided out-of-network, the
cost-sharing requirement (expressed as a copayment amount or
coinsurance rate) is the same requirement that would apply if
such services were provided in-network;
``(D) without regard to any other term or condition of such
coverage (other than exclusion or coordination of benefits,
or an affiliation or waiting period, permitted under section
2701 of this Act, section 701 of the Employee Retirement
Income Security Act of 1974, or section 9801 of the Internal
Revenue Code of 1986, and other than applicable cost-
sharing).
``(2) Definitions.--In this subsection:
``(A) Emergency medical condition.--The term `emergency
medical condition' means a medical condition manifesting
itself by acute symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result
in a condition described in clause (i), (ii), or (iii) of
section 1867(e)(1)(A) of the Social Security Act.
``(B) Emergency services.--The term `emergency services'
means, with respect to an emergency medical condition--
``(i) a medical screening examination (as required under
section 1867 of the Social Security Act) that is within the
capability of the emergency department of a hospital,
including ancillary services routinely available to the
emergency department to evaluate such emergency medical
condition, and
``(ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination
and treatment as are required under section 1867 of such Act
to stabilize the patient.
``(C) Stabilize.--The term `to stabilize', with respect to
an emergency medical condition (as defined in subparagraph
(A)), has the meaning give in section 1867(e)(3) of the
Social Security Act (42 U.S.C. 1395dd(e)(3)).
``(c) Access to Pediatric Care.--
``(1) Pediatric care.--In the case of a person who has a
child who is a participant, beneficiary, or enrollee under a
group health plan, or health insurance coverage offered by a
health insurance issuer in the group or individual market, if
the plan or issuer requires or provides for the designation
of a participating primary care provider for the child, the
plan or issuer shall permit such person to designate a
physician (allopathic or osteopathic) who specializes in
pediatrics as the child's primary care provider if such
provider participates in the network of the plan or issuer.
``(2) Construction.--Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage with
respect to coverage of pediatric care.
``(d) Patient Access to Obstetrical and Gynecological
Care.--
``(1) General rights.--
``(A) Direct access.--A group health plan, or health
insurance issuer offering group or individual health
insurance coverage, described in paragraph (2) may not
require authorization or referral by the plan, issuer, or any
person (including a primary care provider described in
paragraph (2)(B))) in the case of a female participant,
beneficiary, or enrollee who seeks coverage for obstetrical
or gynecological care provided by a participating health care
professional who specializes in obstetrics or gynecology.
Such professional shall agree to otherwise adhere to such
plan's or issuer's policies and procedures, including
procedures regarding referrals and obtaining prior
authorization and providing services pursuant to a treatment
plan (if any) approved by the plan or issuer.
``(B) Obstetrical and gynecological care.--A group health
plan or health insurance issuer described in paragraph (2)
shall treat the provision of obstetrical and gynecological
care, and the ordering of related obstetrical and
gynecological items and services, pursuant to the direct
access described under subparagraph (A), by a participating
health care professional who specializes in obstetrics or
gynecology as the authorization of the primary care provider.
``(2) Application of paragraph.--A group health plan, or
health insurance issuer offering group or individual health
insurance coverage, described in this paragraph is a group
health plan or coverage that--
``(A) provides coverage for obstetric or gynecologic care;
and
``(B) requires the designation by a participant,
beneficiary, or enrollee of a participating primary care
provider.
``(3) Construction.--Nothing in paragraph (1) shall be
construed to--
``(A) waive any exclusions of coverage under the terms and
conditions of the plan or health insurance coverage with
respect to coverage of obstetrical or gynecological care; or
``(B) preclude the group health plan or health insurance
issuer involved from requiring that the obstetrical or
gynecological provider notify the primary care health care
professional or the plan or issuer of treatment decisions.''.
(i) Section 2794 of the Public Health Service Act, as added
by section 1003 of this Act, is amended--
(1) in subsection (c)(1)--
(A) in subparagraph (A), by striking ``and'' at the end;
(B) in subparagraph (B), by striking the period and
inserting ``; and''; and
(C) by adding at the end the following:
``(C) in establishing centers (consistent with subsection
(d)) at academic or other nonprofit institutions to collect
medical reimbursement information from health insurance
issuers, to analyze and organize such information, and to
make such information available to such issuers, health care
providers, health researchers, health care policy makers, and
the general public.''; and
(2) by adding at the end the following:
``(d) Medical Reimbursement Data Centers.--
``(1) Functions.--A center established under subsection
(c)(1)(C) shall--
``(A) develop fee schedules and other database tools that
fairly and accurately reflect market rates for medical
services and the geographic differences in those rates;
``(B) use the best available statistical methods and data
processing technology to develop such fee schedules and other
database tools;
``(C) regularly update such fee schedules and other
database tools to reflect changes in charges for medical
services;
``(D) make health care cost information readily available
to the public through an Internet website that allows
consumers to understand the amounts that health care
providers in their area charge for particular medical
services; and
``(E) regularly publish information concerning the
statistical methodologies used by the center to analyze
health charge data and make such data available to
researchers and policy makers.
``(2) Conflicts of interest.--A center established under
subsection (c)(1)(C) shall adopt by-laws that ensures that
the center (and all members of the governing board of the
center) is independent and free from all conflicts of
interest. Such by-laws shall ensure that the center is not
controlled or influenced by, and does not have any corporate
relation to, any individual or entity that may make or
receive payments for health care services based on the
center's analysis of health care costs.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to permit a center established under
subsection (c)(1)(C) to compel health insurance issuers to
provide data to the center.''.

SEC. 10102. AMENDMENTS TO SUBTITLE B.

(a) Section 1102(a)(2)(B) of this Act is amended--
(1) in the matter preceding clause (i), by striking ``group
health benefits plan'' and inserting ``group benefits plan
providing health benefits''; and
(2) in clause (i)(I), by inserting ``or any agency or
instrumentality of any of the foregoing'' before the closed
parenthetical.
(b) Section 1103(a) of this Act is amended--
(1) in paragraph (1), by inserting ``, or small business
in,'' after ``residents of any''; and
(2) by striking paragraph (2) and inserting the following:
``(2) Connecting to affordable coverage.--An Internet
website established under paragraph (1) shall, to the extent
practicable, provide ways for residents of, and small
businesses in, any State to receive information on at least
the following coverage options:
``(A) Health insurance coverage offered by health insurance
issuers, other than coverage that provides reimbursement only
for the treatment or mitigation of--
``(i) a single disease or condition; or
``(ii) an unreasonably limited set of diseases or
conditions (as determined by the Secretary).
``(B) Medicaid coverage under title XIX of the Social
Security Act.
``(C) Coverage under title XXI of the Social Security Act.
``(D) A State health benefits high risk pool, to the extent
that such high risk pool is offered in such State; and
``(E) Coverage under a high risk pool under section 1101.
``(F) Coverage within the small group market for small
businesses and their employees, including reinsurance for
early retirees under section 1102, tax credits available
under section 45R of the Internal Revenue Code of 1986 (as
added by section 1421), and other information specifically
for small businesses regarding affordable health care
options.''.

SEC. 10103. AMENDMENTS TO SUBTITLE C.

(a) Section 2701(a)(5) of the Public Health Service Act, as
added by section 1201(4) of

[[Page S13493]]

this Act, is amended by inserting ``(other than self-insured
group health plans offered in such market)'' after ``such
market''.
(b) Section 2708 of the Public Health Service Act, as added
by section 1201(4) of this Act, is amended by striking ``or
individual''.
(c) Subpart I of part A of title XXVII of the Public Health
Service Act, as added by section 1201(4) of this Act, is
amended by inserting after section 2708, the following:

``SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING IN
APPROVED CLINICAL TRIALS.

``(a) Coverage.--
``(1) In general.--If a group health plan or a health
insurance issuer offering group or individual health
insurance coverage provides coverage to a qualified
individual, then such plan or issuer--
``(A) may not deny the individual participation in the
clinical trial referred to in subsection (b)(2);
``(B) subject to subsection (c), may not deny (or limit or
impose additional conditions on) the coverage of routine
patient costs for items and services furnished in connection
with participation in the trial; and
``(C) may not discriminate against the individual on the
basis of the individual's participation in such trial.
``(2) Routine patient costs.--
``(A) Inclusion.--For purposes of paragraph (1)(B), subject
to subparagraph (B), routine patient costs include all items
and services consistent with the coverage provided in the
plan (or coverage) that is typically covered for a qualified
individual who is not enrolled in a clinical trial.
``(B) Exclusion.--For purposes of paragraph (1)(B), routine
patient costs does not include--
``(i) the investigational item, device, or service, itself;
``(ii) items and services that are provided solely to
satisfy data collection and analysis needs and that are not
used in the direct clinical management of the patient; or
``(iii) a service that is clearly inconsistent with widely
accepted and established standards of care for a particular
diagnosis.
``(3) Use of in-network providers.--If one or more
participating providers is participating in a clinical trial,
nothing in paragraph (1) shall be construed as preventing a
plan or issuer from requiring that a qualified individual
participate in the trial through such a participating
provider if the provider will accept the individual as a
participant in the trial.
``(4) Use of out-of-network.--Notwithstanding paragraph
(3), paragraph (1) shall apply to a qualified individual
participating in an approved clinical trial that is conducted
outside the State in which the qualified individual resides.
``(b) Qualified Individual Defined.--For purposes of
subsection (a), the term `qualified individual' means an
individual who is a participant or beneficiary in a health
plan or with coverage described in subsection (a)(1) and who
meets the following conditions:
``(1) The individual is eligible to participate in an
approved clinical trial according to the trial protocol with
respect to treatment of cancer or other life-threatening
disease or condition.
``(2) Either--
``(A) the referring health care professional is a
participating health care provider and has concluded that the
individual's participation in such trial would be appropriate
based upon the individual meeting the conditions described in
paragraph (1); or
``(B) the participant or beneficiary provides medical and
scientific information establishing that the individual's
participation in such trial would be appropriate based upon
the individual meeting the conditions described in paragraph
(1).
``(c) Limitations on Coverage.--This section shall not be
construed to require a group health plan, or a health
insurance issuer offering group or individual health
insurance coverage, to provide benefits for routine patient
care services provided outside of the plan's (or coverage's)
health care provider network unless out-of-network benefits
are otherwise provided under the plan (or coverage).
``(d) Approved Clinical Trial Defined.--
``(1) In general.--In this section, the term `approved
clinical trial' means a phase I, phase II, phase III, or
phase IV clinical trial that is conducted in relation to the
prevention, detection, or treatment of cancer or other life-
threatening disease or condition and is described in any of
the following subparagraphs:
``(A) Federally funded trials.--The study or investigation
is approved or funded (which may include funding through in-
kind contributions) by one or more of the following:
``(i) The National Institutes of Health.
``(ii) The Centers for Disease Control and Prevention.
``(iii) The Agency for Health Care Research and Quality.
``(iv) The Centers for Medicare & Medicaid Services.
``(v) cooperative group or center of any of the entities
described in clauses (i) through (iv) or the Department of
Defense or the Department of Veterans Affairs.
``(vi) A qualified non-governmental research entity
identified in the guidelines issued by the National
Institutes of Health for center support grants.
``(vii) Any of the following if the conditions described in
paragraph (2) are met:

``(I) The Department of Veterans Affairs.
``(II) The Department of Defense.
``(III) The Department of Energy.

``(B) The study or investigation is conducted under an
investigational new drug application reviewed by the Food and
Drug Administration.
``(C) The study or investigation is a drug trial that is
exempt from having such an investigational new drug
application.
``(2) Conditions for departments.--The conditions described
in this paragraph, for a study or investigation conducted by
a Department, are that the study or investigation has been
reviewed and approved through a system of peer review that
the Secretary determines--
``(A) to be comparable to the system of peer review of
studies and investigations used by the National Institutes of
Health, and
``(B) assures unbiased review of the highest scientific
standards by qualified individuals who have no interest in
the outcome of the review.
``(e) Life-Threatening Condition Defined.--In this section,
the term `life-threatening condition' means any disease or
condition from which the likelihood of death is probable
unless the course of the disease or condition is interrupted.
``(f) Construction.--Nothing in this section shall be
construed to limit a plan's or issuer's coverage with respect
to clinical trials.
``(g) Application to FEHBP.--Notwithstanding any provision
of chapter 89 of title 5, United States Code, this section
shall apply to health plans offered under the program under
such chapter.
``(h) Preemption.--Notwithstanding any other provision of
this Act, nothing in this section shall preempt State laws
that require a clinical trials policy for State regulated
health insurance plans that is in addition to the policy
required under this section.''.
(d) Section 1251(a) of this Act is amended--
(1) in paragraph (2), by striking ``With'' and inserting
``Except as provided in paragraph (3), with''; and
(2) by adding at the end the following:
``(3) Application of certain provisions.--The provisions of
sections 2715 and 2718 of the Public Health Service Act (as
added by subtitle A) shall apply to grandfathered health
plans for plan years beginning on or after the date of
enactment of this Act.''.
(e) Section 1253 of this Act is amended insert before the
period the following: ``, except that--
``(1) section 1251 shall take effect on the date of
enactment of this Act; and
``(2) the provisions of section 2704 of the Public Health
Service Act (as amended by section 1201), as they apply to
enrollees who are under 19 years of age, shall become
effective for plan years beginning on or after the date that
is 6 months after the date of enactment of this Act.''.
(f) Subtitle C of title I of this Act is amended--
(1) by redesignating section 1253 as section 1255; and
(2) by inserting after section 1252, the following:

``SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS.

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

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

``(a) In General.--The Secretary of Health and Human
Services shall conduct a study of the fully-insured and self-
insured group health plan markets to--
``(1) compare the characteristics of employers (including
industry, size, and other characteristics as determined
appropriate by the Secretary), health plan benefits,
financial solvency, capital reserve levels, and the risks of
becoming insolvent; and
``(2) determine the extent to which new insurance market
reforms are likely to cause adverse selection in the large
group market or to encourage small and midsize employers to
self-insure.
``(b) Collection of Information.--In conducting the study
under subsection (a), the Secretary, in coordination with the
Secretary of Labor, shall collect information and analyze--
``(1) the extent to which self-insured group health plans
can offer less costly coverage and, if so, whether lower
costs are due to more efficient plan administration and lower
overhead or to the denial of claims and the offering very
limited benefit packages;
``(2) claim denial rates, plan benefit fluctuations (to
evaluate the extent that plans scale back health benefits
during economic downturns), and the impact of the limited
recourse options on consumers; and
``(3) any potential conflict of interest as it relates to
the health care needs of self-insured enrollees and self-
insured employer's financial contribution or profit margin,
and the impact of such conflict on administration of the
health plan.

[[Page S13494]]

``(c) Report.--Not later than 1 year after the date of
enactment of this Act, the Secretary shall submit to the
appropriate committees of Congress a report concerning the
results of the study conducted under subsection (a).''.

SEC. 10104. AMENDMENTS TO SUBTITLE D.

(a) Section 1301(a) of this Act is amended by striking
paragraph (2) and inserting the following:
``(2) Inclusion of co-op plans and multi-state qualified
health plans.--Any reference in this title to a qualified
health plan shall be deemed to include a qualified health
plan offered through the CO-OP program under section 1322,
and a multi-State plan under section 1334, unless
specifically provided for otherwise.
``(3) Treatment of qualified direct primary care medical
home plans.--The Secretary of Health and Human Services shall
permit a qualified health plan to provide coverage through a
qualified direct primary care medical home plan that meets
criteria established by the Secretary, so long as the
qualified health plan meets all requirements that are
otherwise applicable and the services covered by the medical
home plan are coordinated with the entity offering the
qualified health plan.
``(4) Variation based on rating area.--A qualified health
plan, including a multi-State qualified health plan, may as
appropriate vary premiums by rating area (as defined in
section 2701(a)(2) of the Public Health Service Act).''.
(b) Section 1302 of this Act is amended--
(1) in subsection (d)(2)(B), by striking ``may issue'' and
inserting ``shall issue''; and
(2) by adding at the end the following:
``(g) Payments to Federally-Qualified Health Centers.--If
any item or service covered by a qualified health plan is
provided by a Federally-qualified health center (as defined
in section 1905(l)(2)(B) of the Social Security Act (42
U.S.C. 1396d(l)(2)(B)) to an enrollee of the plan, the
offeror of the plan shall pay to the center for the item or
service an amount that is not less than the amount of payment
that would have been paid to the center under section
1902(bb) of such Act (42 U.S.C. 1396a(bb)) for such item or
service.''.
(c) Section 1303 of this Act is amended to read as follows:

``SEC. 1303. SPECIAL RULES.

``(a) State Opt-Out of Abortion Coverage.--
``(1) In general.--A State may elect to prohibit abortion
coverage in qualified health plans offered through an
Exchange in such State if such State enacts a law to provide
for such prohibition.
``(2) Termination of opt out.--A State may repeal a law
described in paragraph (1) and provide for the offering of
such services through the Exchange.
``(b) Special Rules Relating to Coverage of Abortion
Services.--
``(1) Voluntary choice of coverage of abortion services.--
``(A) In general.--Notwithstanding any other provision of
this title (or any amendment made by this title)--
``(i) nothing in this title (or any amendment made by this
title), shall be construed to require a qualified health plan
to provide coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of its essential health benefits
for any plan year; and
``(ii) subject to subsection (a), the issuer of a qualified
health plan shall determine whether or not the plan provides
coverage of services described in subparagraph (B)(i) or
(B)(ii) as part of such benefits for the plan year.
``(B) Abortion services.--
``(i) Abortions for which public funding is prohibited.--
The services described in this clause are abortions for which
the expenditure of Federal funds appropriated for the
Department of Health and Human Services is not permitted,
based on the law as in effect as of the date that is 6 months
before the beginning of the plan year involved.
``(ii) Abortions for which public funding is allowed.--The
services described in this clause are abortions for which the
expenditure of Federal funds appropriated for the Department
of Health and Human Services is permitted, based on the law
as in effect as of the date that is 6 months before the
beginning of the plan year involved.
``(2) Prohibition on the use of federal funds.--
``(A) In general.--If a qualified health plan provides
coverage of services described in paragraph (1)(B)(i), the
issuer of the plan shall not use any amount attributable to
any of the following for purposes of paying for such
services:
``(i) The credit under section 36B of the Internal Revenue
Code of 1986 (and the amount (if any) of the advance payment
of the credit under section 1412 of the Patient Protection
and Affordable Care Act).
``(ii) Any cost-sharing reduction under section 1402 of
thePatient Protection and Affordable Care Act (and the amount
(if any) of the advance payment of the reduction under
section 1412 of the Patient Protection and Affordable Care
Act).
``(B) Establishment of allocation accounts.--In the case of
a plan to which subparagraph (A) applies, the issuer of the
plan shall--
``(i) collect from each enrollee in the plan (without
regard to the enrollee's age, sex, or family status) a
separate payment for each of the following:

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

``(ii) shall deposit all such separate payments into
separate allocation accounts as provided in subparagraph (C).
In the case of an enrollee whose premium for coverage under
the plan is paid through employee payroll deposit, the
separate payments required under this subparagraph shall each
be paid by a separate deposit.
``(C) Segregation of funds.--
``(i) In general.--The issuer of a plan to which
subparagraph (A) applies shall establish allocation accounts
described in clause (ii) for enrollees receiving amounts
described in subparagraph (A).
``(ii) Allocation accounts.--The issuer of a plan to which
subparagraph (A) applies shall deposit--

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

``(D) Actuarial value.--
``(i) In general.--The issuer of a qualified health plan
shall estimate the basic per enrollee, per month cost,
determined on an average actuarial basis, for including
coverage under the qualified health plan of the services
described in paragraph (1)(B)(i).
``(ii) Considerations.--In making such estimate, the
issuer--

``(I) may take into account the impact on overall costs of
the inclusion of such coverage, but may not take into account
any cost reduction estimated to result from such services,
including prenatal care, delivery, or postnatal care;
``(II) shall estimate such costs as if such coverage were
included for the entire population covered; and
``(III) may not estimate such a cost at less than $1 per
enrollee, per month.

``(E) Ensuring compliance with segregation requirements.--
``(i) In general.--Subject to clause (ii), State health
insurance commissioners shall ensure that health plans comply
with the segregation requirements in this subsection through
the segregation of plan funds in accordance with applicable
provisions of generally accepted accounting requirements,
circulars on funds management of the Office of Management and
Budget, and guidance on accounting of the Government
Accountability Office.
``(ii) Clarification.--Nothing in clause (i) shall prohibit
the right of an individual or health plan to appeal such
action in courts of competent jurisdiction.
``(3) Rules relating to notice.--
``(A) Notice.--A qualified health plan that provides for
coverage of the services described in paragraph (1)(B)(i)
shall provide a notice to enrollees, only as part of the
summary of benefits and coverage explanation, at the time of
enrollment, of such coverage.
``(B) Rules relating to payments.--The notice described in
subparagraph (A), any advertising used by the issuer with
respect to the plan, any information provided by the
Exchange, and any other information specified by the
Secretary shall provide information only with respect to the
total amount of the combined payments for services described
in paragraph (1)(B)(i) and other services covered by the
plan.
``(4) No discrimination on basis of provision of
abortion.--No qualified health plan offered through an
Exchange may discriminate against any individual health care
provider or health care facility because of its unwillingness
to provide, pay for, provide coverage of, or refer for
abortions
``(c) Application of State and Federal Laws Regarding
Abortion.--
``(1) No preemption of state laws regarding abortion.--
Nothing in this Act shall be construed to preempt or
otherwise have any effect on State laws regarding the
prohibition of (or requirement of) coverage, funding, or
procedural requirements on abortions, including parental
notification or consent for the performance of an abortion on
a minor.
``(2) No effect on federal laws regarding abortion.--
``(A) In general.--Nothing in this Act shall be construed
to have any effect on Federal laws regarding--
``(i) conscience protection;
``(ii) willingness or refusal to provide abortion; and
``(iii) discrimination on the basis of the willingness or
refusal to provide, pay for, cover, or refer for abortion or
to provide or participate in training to provide abortion.
``(3) No effect on federal civil rights law.--Nothing in
this subsection shall alter the rights and obligations of
employees and employers under title VII of the Civil Rights
Act of 1964.
``(d) Application of Emergency Services Laws.--Nothing in
this Act shall be construed to relieve any health care
provider from providing emergency services as required by
State or Federal law, including

[[Page S13495]]

section 1867 of the Social Security Act (popularly known as
`EMTALA').''.
(d) Section 1304 of this Act is amended by adding at the
end the following:
``(e) Educated Health Care Consumers.--The term `educated
health care consumer' means an individual who is
knowledgeable about the health care system, and has
background or experience in making informed decisions
regarding health, medical, and scientific matters.''.
(e) Section 1311(d) of this Act is amended--
(1) in paragraph (3)(B), by striking clause (ii) and
inserting the following:
``(ii) State must assume cost.--A State shall make
payments--

``(I) to an individual enrolled in a qualified health plan
offered in such State; or
``(II) on behalf of an individual described in subclause
(I) directly to the qualified health plan in which such
individual is enrolled;

to defray the cost of any additional benefits described in
clause (i).''; and
(2) in paragraph (6)(A), by inserting ``educated'' before
``health care''.
(f) Section 1311(e) of this Act is amended--
(1) in paragraph (2), by striking ``may'' in the second
sentence and inserting ``shall''; and
(2) by adding at the end the following:
``(3) Transparency in coverage.--
``(A) In general.--The Exchange shall require health plans
seeking certification as qualified health plans to submit to
the Exchange, the Secretary, the State insurance
commissioner, and make available to the public, accurate and
timely disclosure of the following information:
``(i) Claims payment policies and practices.
``(ii) Periodic financial disclosures.
``(iii) Data on enrollment.
``(iv) Data on disenrollment.
``(v) Data on the number of claims that are denied.
``(vi) Data on rating practices.
``(vii) Information on cost-sharing and payments with
respect to any out-of-network coverage.
``(viii) Information on enrollee and participant rights
under this title.
``(ix) Other information as determined appropriate by the
Secretary.
``(B) Use of plain language.--The information required to
be submitted under subparagraph (A) shall be provided in
plain language. The term `plain language' means language that
the intended audience, including individuals with limited
English proficiency, can readily understand and use because
that language is concise, well-organized, and follows other
best practices of plain language writing. The Secretary and
the Secretary of Labor shall jointly develop and issue
guidance on best practices of plain language writing.
``(C) Cost sharing transparency.--The Exchange shall
require health plans seeking certification as qualified
health plans to permit individuals to learn the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the individual's plan or coverage that the
individual would be responsible for paying with respect to
the furnishing of a specific item or service by a
participating provider in a timely manner upon the request of
the individual. At a minimum, such information shall be made
available to such individual through an Internet website and
such other means for individuals without access to the
Internet.
``(D) Group health plans.--The Secretary of Labor shall
update and harmonize the Secretary's rules concerning the
accurate and timely disclosure to participants by group
health plans of plan disclosure, plan terms and conditions,
and periodic financial disclosure with the standards
established by the Secretary under subparagraph (A).''.
(g) Section 1311(g)(1) of this Act is amended--
(1) in subparagraph (C), by striking ``; and'' and
inserting a semicolon;
(2) in subparagraph (D), by striking the period and
inserting ``; and''; and
(3) by adding at the end the following:
``(E) the implementation of activities to reduce health and
health care disparities, including through the use of
language services, community outreach, and cultural
competency trainings.''.
(h) Section 1311(i)(2)((B) of this Act is amended by
striking ``small business development centers'' and inserting
``resource partners of the Small Business Administration''.
(i) Section 1312 of this Act is amended--
(1) in subsection (a)(1), by inserting ``and for which such
individual is eligible'' before the period;
(2) in subsection (e)--
(A) in paragraph (1), by inserting ``and employers'' after
``enroll individuals''; and
(B) by striking the flush sentence at the end; and
(3) in subsection (f)(1)(A)(ii), by striking the
parenthetical.
(j)(1) Subparagraph (B) of section 1313(a)(6) of this Act
is hereby deemed null, void, and of no effect.
(2) Section 3730(e) of title 31, United States Code, is
amended by striking paragraph (4) and inserting the
following:
``(4)(A) The court shall dismiss an action or claim under
this section, unless opposed by the Government, if
substantially the same allegations or transactions as alleged
in the action or claim were publicly disclosed--
``(i) in a Federal criminal, civil, or administrative
hearing in which the Government or its agent is a party;
``(ii) in a congressional, Government Accountability
Office, or other Federal report, hearing, audit, or
investigation; or
``(iii) from the news media,
unless the action is brought by the Attorney General or the
person bringing the action is an original source of the
information.
``(B) For purposes of this paragraph, ``original source''
means an individual who either (i) prior to a public
disclosure under subsection (e)(4)(a), has voluntarily
disclosed to the Government the information on which
allegations or transactions in a claim are based, or (2) who
has knowledge that is independent of and materially adds to
the publicly disclosed allegations or transactions, and who
has voluntarily provided the information to the Government
before filing an action under this section.''.
(k) Section 1313(b) of this Act is amended--
(1) in paragraph (3), by striking ``and'' at the end;
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following:
``(4) a survey of the cost and affordability of health care
insurance provided under the Exchanges for owners and
employees of small business concerns (as defined under
section 3 of the Small Business Act (15 U.S.C. 632)),
including data on enrollees in Exchanges and individuals
purchasing health insurance coverage outside of Exchanges;
and''.
(l) Section 1322(b) of this Act is amended--
(1) by redesignating paragraph (3) as paragraph (4); and
(2) by inserting after paragraph (2), the following:
``(3) Repayment of loans and grants.--Not later than July
1, 2013, and prior to awarding loans and grants under the CO-
OP program, the Secretary shall promulgate regulations with
respect to the repayment of such loans and grants in a manner
that is consistent with State solvency regulations and other
similar State laws that may apply. In promulgating such
regulations, the Secretary shall provide that such loans
shall be repaid within 5 years and such grants shall be
repaid within 15 years, taking into consideration any
appropriate State reserve requirements, solvency regulations,
and requisite surplus note arrangements that must be
constructed in a State to provide for such repayment prior to
awarding such loans and grants.''.
(m) Part III of subtitle D of title I of this Act is
amended by striking section 1323.
(n) Section 1324(a) of this Act is amended by striking ``,
a community health'' and all that follows through ``1333(b)''
and inserting ``, or a multi-State qualified health plan
under section 1334''.
(o) Section 1331 of this Act is amended--
(1) in subsection (d)(3)(A)(i), by striking ``85'' and
inserting ``95''; and
(2) in subsection (e)(1)(B), by inserting before the
semicolon the following: ``, or, in the case of an alien
lawfully present in the United States, whose income is not
greater than 133 percent of the poverty line for the size of
the family involved but who is not eligible for the Medicaid
program under title XIX of the Social Security Act by reason
of such alien status''.
(p) Section 1333 of this Act is amended by striking
subsection (b).
(q) Part IV of subtitle D of title I of this Act is amended
by adding at the end the following:

``SEC. 1334. MULTI-STATE PLANS.

``(a) Oversight by the Office of Personnel Management.--
``(1) In general.--The Director of the Office of Personnel
Management (referred to in this section as the `Director')
shall enter into contracts with health insurance issuers
(which may include a group of health insurance issuers
affiliated either by common ownership and control or by the
common use of a nationally licensed service mark), without
regard to section 5 of title 41, United States Code, or other
statutes requiring competitive bidding, to offer at least 2
multi-State qualified health plans through each Exchange in
each State. Such plans shall provide individual, or in the
case of small employers, group coverage.
``(2) Terms.--Each contract entered into under paragraph
(1) shall be for a uniform term of at least 1 year, but may
be made automatically renewable from term to term in the
absence of notice of termination by either party. In entering
into such contracts, the Director shall ensure that health
benefits coverage is provided in accordance with the types of
coverage provided for under section 2701(a)(1)(A)(i) of the
Public Health Service Act.
``(3) Non-profit entities.--In entering into contracts
under paragraph (1), the Director shall ensure that at least
one contract is entered into with a non-profit entity.
``(4) Administration.--The Director shall implement this
subsection in a manner similar to the manner in which the
Director implements the contracting provisions with respect
to carriers under the Federal employees health benefit
program under chapter 89 of title 5, United States Code,
including (through negotiating with each multi-state plan)--
``(A) a medical loss ratio;
``(B) a profit margin;
``(C) the premiums to be charged; and
``(D) such other terms and conditions of coverage as are in
the interests of enrollees in such plans.
``(5) Authority to protect consumers.--The Director may
prohibit the offering of any multi-State health plan that
does not

[[Page S13496]]

meet the terms and conditions defined by the Director with
respect to the elements described in subparagraphs (A)
through (D) of paragraph (4).
``(6) Assured availability of varied coverage.--In entering
into contracts under this subsection, the Director shall
ensure that with respect to multi-State qualified health
plans offered in an Exchange, there is at least one such plan
that does not provide coverage of services described in
section 1303(b)(1)(B)(i).
``(7) Withdrawal.--Approval of a contract under this
subsection may be withdrawn by the Director only after notice
and opportunity for hearing to the issuer concerned without
regard to subchapter II of chapter 5 and chapter 7 of title
5, United States Code.
``(b) Eligibility.--A health insurance issuer shall be
eligible to enter into a contract under subsection (a)(1) if
such issuer--
``(1) agrees to offer a multi-State qualified health plan
that meets the requirements of subsection (c) in each
Exchange in each State;
``(2) is licensed in each State and is subject to all
requirements of State law not inconsistent with this section,
including the standards and requirements that a State imposes
that do not prevent the application of a requirement of part
A of title XXVII of the Public Health Service Act or a
requirement of this title;
``(3) otherwise complies with the minimum standards
prescribed for carriers offering health benefits plans under
section 8902(e) of title 5, United States Code, to the extent
that such standards do not conflict with a provision of this
title; and
``(4) meets such other requirements as determined
appropriate by the Director, in consultation with the
Secretary.
``(c) Requirements for Multi-State Qualified Health Plan.--
``(1) In general.--A multi-State qualified health plan
meets the requirements of this subsection if, in the
determination of the Director--
``(A) the plan offers a benefits package that is uniform in
each State and consists of the essential benefits described
in section 1302;
``(B) the plan meets all requirements of this title with
respect to a qualified health plan, including requirements
relating to the offering of the bronze, silver, and gold
levels of coverage and catastrophic coverage in each State
Exchange;
``(C) except as provided in paragraph (5), the issuer
provides for determinations of premiums for coverage under
the plan on the basis of the rating requirements of part A of
title XXVII of the Public Health Service Act; and
``(D) the issuer offers the plan in all geographic regions,
and in all States that have adopted adjusted community rating
before the date of enactment of this Act.
``(2) States may offer additional benefits.--Nothing in
paragraph (1)(A) shall preclude a State from requiring that
benefits in addition to the essential health benefits
required under such paragraph be provided to enrollees of a
multi-State qualified health plan offered in such State.
``(3) Credits.--
``(A) In general.--An individual enrolled in a multi-State
qualified health plan under this section shall be eligible
for credits under section 36B of the Internal Revenue Code of
1986 and cost sharing assistance under section 1402 in the
same manner as an individual who is enrolled in a qualified
health plan.
``(B) No additional federal cost.--A requirement by a State
under paragraph (2) that benefits in addition to the
essential health benefits required under paragraph (1)(A) be
provided to enrollees of a multi-State qualified health plan
shall not affect the amount of a premium tax credit provided
under section 36B of the Internal Revenue Code of 1986 with
respect to such plan.
``(4) State must assume cost.--A State shall make
payments--
``(A) to an individual enrolled in a multi-State qualified
health plan offered in such State; or
``(B) on behalf of an individual described in subparagraph
(A) directly to the multi-State qualified health plan in
which such individual is enrolled;
to defray the cost of any additional benefits described in
paragraph (2).
``(5) Application of certain state rating requirements.--
With respect to a multi-State qualified health plan that is
offered in a State with age rating requirements that are
lower than 3:1, the State may require that Exchanges
operating in such State only permit the offering of such
multi-State qualified health plans if such plans comply with
the State's more protective age rating requirements.
``(d) Plans Deemed to Be Certified.--A multi-State
qualified health plan that is offered under a contract under
subsection (a) shall be deemed to be certified by an Exchange
for purposes of section 1311(d)(4)(A).
``(e) Phase-in.--Notwithstanding paragraphs (1) and (2) of
subsection (b), the Director shall enter into a contract with
a health insurance issuer for the offering of a multi-State
qualified health plan under subsection (a) if--
``(1) with respect to the first year for which the issuer
offers such plan, such issuer offers the plan in at least 60
percent of the States;
``(2) with respect to the second such year, such issuer
offers the plan in at least 70 percent of the States;
``(3) with respect to the third such year, such issuer
offers the plan in at least 85 percent of the States; and
``(4) with respect to each subsequent year, such issuer
offers the plan in all States.
``(f) Applicability.--The requirements under chapter 89 of
title 5, United States Code, applicable to health benefits
plans under such chapter shall apply to multi-State qualified
health plans provided for under this section to the extent
that such requirements do not conflict with a provision of
this title.
``(g) Continued Support for FEHBP.--
``(1) Maintenance of effort.--Nothing in this section shall
be construed to permit the Director to allocate fewer
financial or personnel resources to the functions of the
Office of Personnel Management related to the administration
of the Federal Employees Health Benefit Program under chapter
89 of title 5, United States Code.
``(2) Separate risk pool.--Enrollees in multi-State
qualified health plans under this section shall be treated as
a separate risk pool apart from enrollees in the Federal
Employees Health Benefit Program under chapter 89 of title 5,
United States Code.
``(3) Authority to establish separate entities.--The
Director may establish such separate units or offices within
the Office of Personnel Management as the Director determines
to be appropriate to ensure that the administration of multi-
State qualified health plans under this section does not
interfere with the effective administration of the Federal
Employees Health Benefit Program under chapter 89 of title 5,
United States Code.
``(4) Effective oversight.--The Director may appoint such
additional personnel as may be necessary to enable the
Director to carry out activities under this section.
``(5) Assurance of separate program.--In carrying out this
section, the Director shall ensure that the program under
this section is separate from the Federal Employees Health
Benefit Program under chapter 89 of title 5, United States
Code. Premiums paid for coverage under a multi-State
qualified health plan under this section shall not be
considered to be Federal funds for any purposes.
``(6) FEHBP plans not required to participate.--Nothing in
this section shall require that a carrier offering coverage
under the Federal Employees Health Benefit Program under
chapter 89 of title 5, United States Code, also offer a
multi-State qualified health plan under this section.
``(h) Advisory Board.--The Director shall establish an
advisory board to provide recommendations on the activities
described in this section. A significant percentage of the
members of such board shall be comprised of enrollees in a
multi-State qualified health plan, or representatives of such
enrollees.
``(i) Authorization of Appropriations.--There is authorized
to be appropriated, such sums as may be necessary to carry
out this section.''.
(r) Section 1341 of this Act is amended--
(1) in the section heading, by striking ``and small group
markets'' and inserting ``market'';
(2) in subsection (b)(2)(B), by striking ``paragraph
(1)(A)'' and inserting ``paragraph (1)(B)''; and
(3) in subsection (c)(1)(A), by striking ``and small group
markets'' and inserting ``market''.

SEC. 10105. AMENDMENTS TO SUBTITLE E.

(a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code
of 1986, as added by section 1401(a) of this Act, is amended
by striking ``is in excess of'' and inserting ``equals or
exceeds''.
(b) Section 36B(c)(1)(A) of the Internal Revenue Code of
1986, as added by section 1401(a) of this Act, is amended by
inserting ``equals or'' before ``exceeds''.
(c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code
of 1986, as added by section 1401(a) of this Act, is amended
by striking ``subsection (b)(3)(A)(ii)'' and inserting
``subsection (b)(3)(A)(iii)''.
(d) Section 1401(d) of this Act is amended by adding at the
end the following:
``(3) Section 6211(b)(4)(A) of the Internal Revenue Code of
1986 is amended by inserting `36B,' after `36A,'.''.
(e)(1) Subparagraph (B) of section 45R(d)(3) of the
Internal Revenue Code of 1986, as added by section 1421(a) of
this Act, is amended to read as follows:
``(B) Dollar amount.--For purposes of paragraph (1)(B) and
subsection (c)(2)--
``(i) 2010, 2011, 2012, and 2013.--The dollar amount in
effect under this paragraph for taxable years beginning in
2010, 2011, 2012, or 2013 is $25,000.
``(ii) Subsequent years.--In the case of a taxable year
beginning in a calendar year after 2013, the dollar amount in
effect under this paragraph shall be equal to $25,000,
multiplied by the cost-of-living adjustment under section
1(f)(3) for the calendar year, determined by substituting
`calendar year 2012' for `calendar year 1992' in subparagraph
(B) thereof.''.
(2) Subsection (g) of section 45R of the Internal Revenue
Code of 1986, as added by section 1421(a) of this Act, is
amended by striking ``2011'' both places it appears and
inserting ``2010, 2011''.
(3) Section 280C(h) of the Internal Revenue Code of 1986,
as added by section 1421(d)(1) of this Act, is amended by
striking ``2011'' and inserting ``2010, 2011''.
(4) Section 1421(f) of this Act is amended by striking
``2010'' both places it appears and inserting ``2009''.
(5) The amendments made by this subsection shall take
effect as if included in the enactment of section 1421 of
this Act.

[[Page S13497]]

(f) Part I of subtitle E of title I of this Act is amended
by adding at the end of subpart B, the following:

``SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF
FPL.

``(a) In General.--The Secretary shall conduct a study to
examine the feasibility and implication of adjusting the
application of the Federal poverty level under this subtitle
(and the amendments made by this subtitle) for different
geographic areas so as to reflect the variations in cost-of-
living among different areas within the United States. If the
Secretary determines that an adjustment is feasible, the
study should include a methodology to make such an
adjustment. Not later than January 1, 2013, the Secretary
shall submit to Congress a report on such study and shall
include such recommendations as the Secretary determines
appropriate.
``(b) Inclusion of Territories.--
``(1) In general.--The Secretary shall ensure that the
study under subsection (a) covers the territories of the
United States and that special attention is paid to the
disparity that exists among poverty levels and the cost of
living in such territories and to the impact of such
disparity on efforts to expand health coverage and ensure
health care.
``(2) Territories defined.--In this subsection, the term
`territories of the United States' includes the Commonwealth
of Puerto Rico, the United States Virgin Islands, Guam, the
Northern Mariana Islands, and any other territory or
possession of the United States.''.

SEC. 10106. AMENDMENTS TO SUBTITLE F.

(a) Section 1501(a)(2) of this Act is amended to read as
follows:
``(2) Effects on the national economy and interstate
commerce.--The effects described in this paragraph are the
following:
``(A) The requirement regulates activity that is commercial
and economic in nature: economic and financial decisions
about how and when health care is paid for, and when health
insurance is purchased. In the absence of the requirement,
some individuals would make an economic and financial
decision to forego health insurance coverage and attempt to
self-insure, which increases financial risks to households
and medical providers.
``(B) Health insurance and health care services are a
significant part of the national economy. National health
spending is projected to increase from $2,500,000,000,000, or
17.6 percent of the economy, in 2009 to $4,700,000,000,000 in
2019. Private health insurance spending is projected to be
$854,000,000,000 in 2009, and pays for medical supplies,
drugs, and equipment that are shipped in interstate commerce.
Since most health insurance is sold by national or regional
health insurance companies, health insurance is sold in
interstate commerce and claims payments flow through
interstate commerce.
``(C) The requirement, together with the other provisions
of this Act, will add millions of new consumers to the health
insurance market, increasing the supply of, and demand for,
health care services, and will increase the number and share
of Americans who are insured.
``(D) The requirement achieves near-universal coverage by
building upon and strengthening the private employer-based
health insurance system, which covers 176,000,000 Americans
nationwide. In Massachusetts, a similar requirement has
strengthened private employer-based coverage: despite the
economic downturn, the number of workers offered employer-
based coverage has actually increased.
``(E) The economy loses up to $207,000,000,000 a year
because of the poorer health and shorter lifespan of the
uninsured. By significantly reducing the number of the
uninsured, the requirement, together with the other
provisions of this Act, will significantly reduce this
economic cost.
``(F) The cost of providing uncompensated care to the
uninsured was $43,000,000,000 in 2008. To pay for this cost,
health care providers pass on the cost to private insurers,
which pass on the cost to families. This cost-shifting
increases family premiums by on average over $1,000 a year.
By significantly reducing the number of the uninsured, the
requirement, together with the other provisions of this Act,
will lower health insurance premiums.
``(G) 62 percent of all personal bankruptcies are caused in
part by medical expenses. By significantly increasing health
insurance coverage, the requirement, together with the other
provisions of this Act, will improve financial security for
families.
``(H) Under the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act
(42 U.S.C. 201 et seq.), and this Act, the Federal Government
has a significant role in regulating health insurance. The
requirement is an essential part of this larger regulation of
economic activity, and the absence of the requirement would
undercut Federal regulation of the health insurance market.
``(I) Under sections 2704 and 2705 of the Public Health
Service Act (as added by section 1201 of this Act), if there
were no requirement, many individuals would wait to purchase
health insurance until they needed care. By significantly
increasing health insurance coverage, the requirement,
together with the other provisions of this Act, will minimize
this adverse selection and broaden the health insurance risk
pool to include healthy individuals, which will lower health
insurance premiums. The requirement is essential to creating
effective health insurance markets in which improved health
insurance products that are guaranteed issue and do not
exclude coverage of pre-existing conditions can be sold.
``(J) Administrative costs for private health insurance,
which were $90,000,000,000 in 2006, are 26 to 30 percent of
premiums in the current individual and small group markets.
By significantly increasing health insurance coverage and the
size of purchasing pools, which will increase economies of
scale, the requirement, together with the other provisions of
this Act, will significantly reduce administrative costs and
lower health insurance premiums. The requirement is essential
to creating effective health insurance markets that do not
require underwriting and eliminate its associated
administrative costs.''.
(b)(1) Section 5000A(b)(1) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended to
read as follows:
``(1) In general.--If a taxpayer who is an applicable
individual, or an applicable individual for whom the taxpayer
is liable under paragraph (3), fails to meet the requirement
of subsection (a) for 1 or more months, then, except as
provided in subsection (e), there is hereby imposed on the
taxpayer a penalty with respect to such failures in the
amount determined under subsection (c).''.
(2) Paragraphs (1) and (2) of section 5000A(c) of the
Internal Revenue Code of 1986, as so added, are amended to
read as follows:
``(1) In general.--The amount of the penalty imposed by
this section on any taxpayer for any taxable year with
respect to failures described in subsection (b)(1) shall be
equal to the lesser of--
``(A) the sum of the monthly penalty amounts determined
under paragraph (2) for months in the taxable year during
which 1 or more such failures occurred, or
``(B) an amount equal to the national average premium for
qualified health plans which have a bronze level of coverage,
provide coverage for the applicable family size involved, and
are offered through Exchanges for plan years beginning in the
calendar year with or within which the taxable year ends.
``(2) Monthly penalty amounts.--For purposes of paragraph
(1)(A), the monthly penalty amount with respect to any
taxpayer for any month during which any failure described in
subsection (b)(1) occurred is an amount equal to \1/12\ of
the greater of the following amounts:
``(A) Flat dollar amount.--An amount equal to the lesser
of--
``(i) the sum of the applicable dollar amounts for all
individuals with respect to whom such failure occurred during
such month, or
``(ii) 300 percent of the applicable dollar amount
(determined without regard to paragraph (3)(C)) for the
calendar year with or within which the taxable year ends.
``(B) Percentage of income.--An amount equal to the
following percentage of the taxpayer's household income for
the taxable year:
``(i) 0.5 percent for taxable years beginning in 2014.
``(ii) 1.0 percent for taxable years beginning in 2015.
``(iii) 2.0 percent for taxable years beginning after
2015.''.
(3) Section 5000A(c)(3) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended by
striking ``$350'' and inserting ``$495''.
(c) Section 5000A(d)(2)(A) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended to
read as follows:
``(A) Religious conscience exemption.--Such term shall not
include any individual for any month if such individual has
in effect an exemption under section 1311(d)(4)(H) of the
Patient Protection and Affordable Care Act which certifies
that such individual is--
``(i) a member of a recognized religious sect or division
thereof which is described in section 1402(g)(1), and
``(ii) an adherent of established tenets or teachings of
such sect or division as described in such section.''.
(d) Section 5000A(e)(1)(C) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended to
read as follows:
``(C) Special rules for individuals related to employees.--
For purposes of subparagraph (B)(i), if an applicable
individual is eligible for minimum essential coverage through
an employer by reason of a relationship to an employee, the
determination under subparagraph (A) shall be made by
reference to required contribution of the employee.''.
(e) Section 4980H(b) of the Internal Revenue Code of 1986,
as added by section 1513(a) of this Act, is amended to read
as follows:
``(b) Large Employers With Waiting Periods Exceeding 60
Days.--
``(1) In general.--In the case of any applicable large
employer which requires an extended waiting period to enroll
in any minimum essential coverage under an employer-sponsored
plan (as defined in section 5000A(f)(2)), there is hereby
imposed on the employer an assessable payment of $600 for
each full-time employee of the employer to whom the extended
waiting period applies.
``(2) Extended waiting period.--The term `extended waiting
period' means any waiting period (as defined in section
2701(b)(4) of the Public Health Service Act) which exceeds 60
days.''.

[[Page S13498]]

(f)(1) Subparagraph (A) of section 4980H(d)(4) of the
Internal Revenue Code of 1986, as added by section 1513(a) of
this Act, is amended by inserting ``, with respect to any
month,'' after ``means''.
(2) Section 4980H(d)(2) of the Internal Revenue Code of
1986, as added by section 1513(a) of this Act, is amended by
adding at the end the following:
``(D) Application to construction industry employers.--In
the case of any employer the substantial annual gross
receipts of which are attributable to the construction
industry--
``(i) subparagraph (A) shall be applied by substituting
`who employed an average of at least 5 full-time employees on
business days during the preceding calendar year and whose
annual payroll expenses exceed $250,000 for such preceding
calendar year' for `who employed an average of at least 50
full-time employees on business days during the preceding
calendar year', and
``(ii) subparagraph (B) shall be applied by substituting
`5' for `50'.''.
(3) The amendment made by paragraph (2) shall apply to
months beginning after December 31, 2013.
(g) Section 6056(b) of the Internal Revenue Code of 1986,
as added by section 1514(a) of the Act, is amended by adding
at the end the following new flush sentence:
``The Secretary shall have the authority to review the
accuracy of the information provided under this subsection,
including the applicable large employer's share under
paragraph (2)(C)(iv).''.

SEC. 10107. AMENDMENTS TO SUBTITLE G.

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

``SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF
COVERAGE AND ENROLLMENT BY HEALTH INSURANCE
ISSUERS AND GROUP HEALTH PLANS.

``(a) In General.--The Comptroller General of the United
States (referred to in this section as the `Comptroller
General') shall conduct a study of the incidence of denials
of coverage for medical services and denials of applications
to enroll in health insurance plans, as described in
subsection (b), by group health plans and health insurance
issuers.
``(b) Data.--
``(1) In general.--In conducting the study described in
subsection (a), the Comptroller General shall consider
samples of data concerning the following:
``(A)(i) denials of coverage for medical services to a plan
enrollees, by the types of services for which such coverage
was denied; and
``(ii) the reasons such coverage was denied; and
``(B)(i) incidents in which group health plans and health
insurance issuers deny the application of an individual to
enroll in a health insurance plan offered by such group
health plan or issuer; and
``(ii) the reasons such applications are denied.
``(2) Scope of data.--
``(A) Favorably resolved disputes.--The data that the
Comptroller General considers under paragraph (1) shall
include data concerning denials of coverage for medical
services and denials of applications for enrollment in a plan
by a group health plan or health insurance issuer, where such
group health plan or health insurance issuer later approves
such coverage or application.
``(B) All health plans.--The study under this section shall
consider data from varied group health plans and health
insurance plans offered by health insurance issuers,
including qualified health plans and health plans that are
not qualified health plans.
``(c) Report.--Not later than one year after the date of
enactment of this Act, the Comptroller General shall submit
to the Secretaries of Health and Human Services and Labor a
report describing the results of the study conducted under
this section.
``(d) Publication of Report.--The Secretaries of Health and
Human Services and Labor shall make the report described in
subsection (c) available to the public on an Internet
website.

``SEC. 1563. SMALL BUSINESS PROCUREMENT.

``Part 19 of the Federal Acquisition Regulation, section 15
of the Small Business Act (15 U.S.C. 644), and any other
applicable laws or regulations establishing procurement
requirements relating to small business concerns (as defined
in section 3 of the Small Business Act (15 U.S.C. 632)) may
not be waived with respect to any contract awarded under any
program or other authority under this Act or an amendment
made by this Act.''.

SEC. 10108. FREE CHOICE VOUCHERS.

(a) In General.--An offering employer shall provide free
choice vouchers to each qualified employee of such employer.
(b) Offering Employer.--For purposes of this section, the
term ``offering employer'' means any employer who--
(1) offers minimum essential coverage to its employees
consisting of coverage through an eligible employer-sponsored
plan; and
(2) pays any portion of the costs of such plan.
(c) Qualified Employee.--For purposes of this section--
(1) In general.--The term ``qualified employee'' means,
with respect to any plan year of an offering employer, any
employee--
(A) whose required contribution (as determined under
section 5000A(e)(1)(B)) for minimum essential coverage
through an eligible employer-sponsored plan--
(i) exceeds 8 percent of such employee's household income
for the taxable year described in section 1412(b)(1)(B) which
ends with or within in the plan year; and
(ii) does not exceed 9.8 percent of such employee's
household income for such taxable year;
(B) whose household income for such taxable year is not
greater than 400 percent of the poverty line for a family of
the size involved; and
(C) who does not participate in a health plan offered by
the offering employer.
(2) Indexing.--In the case of any calendar year beginning
after 2014, the Secretary shall adjust the 8 percent under
paragraph (1)(A)(i) and 9.8 percent under paragraph
(1)(A)(ii) for the calendar year to reflect the rate of
premium growth between the preceding calendar year and 2013
over the rate of income growth for such period.
(d) Free Choice Voucher.--
(1) Amount.--
(A) In general.--The amount of any free choice voucher
provided under subsection (a) shall be equal to the monthly
portion of the cost of the eligible employer-sponsored plan
which would have been paid by the employer if the employee
were covered under the plan with respect to which the
employer pays the largest portion of the cost of the plan.
Such amount shall be equal to the amount the employer would
pay for an employee with self-only coverage unless such
employee elects family coverage (in which case such amount
shall be the amount the employer would pay for family
coverage).
(B) Determination of cost.--The cost of any health plan
shall be determined under the rules similar to the rules of
section 2204 of the Public Health Service Act, except that
such amount shall be adjusted for age and category of
enrollment in accordance with regulations established by the
Secretary.
(2) Use of vouchers.--An Exchange shall credit the amount
of any free choice voucher provided under subsection (a) to
the monthly premium of any qualified health plan in the
Exchange in which the qualified employee is enrolled and the
offering employer shall pay any amounts so credited to the
Exchange.
(3) Payment of excess amounts.--If the amount of the free
choice voucher exceeds the amount of the premium of the
qualified health plan in which the qualified employee is
enrolled for such month, such excess shall be paid to the
employee.
(e) Other Definitions.--Any term used in this section which
is also used in section 5000A of the Internal Revenue Code of
1986 shall have the meaning given such term under such
section 5000A.
(f) Exclusion From Income for Employee.--
(1) In general.--Part III of subchapter B of chapter 1 of
the Internal Revenue Code of 1986 is amended by inserting
after section 139C the following new section:

``SEC. 139D. FREE CHOICE VOUCHERS.

``Gross income shall not include the amount of any free
choice voucher provided by an employer under section 10108 of
the Patient Protection and Affordable Care Act to the extent
that the amount of such voucher does not exceed the amount
paid for a qualified health plan (as defined in section 1301
of such Act) by the taxpayer.''.
(2) Clerical amendment.--The table of sections for part III
of subchapter B of chapter 1 of such Code is amended by
inserting after the item relating to section 139C the
following new item:

``Sec. 139D. Free choice vouchers.''.
(3) Effective date.--The amendments made by this subsection
shall apply to vouchers provided after December 31, 2013.
(g) Deduction Allowed to Employer.--
(1) In general.--Section 162(a) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new sentence: ``For purposes of paragraph (1), the amount of
a free choice voucher provided under section 10108 of the
Patient Protection and Affordable Care Act shall be treated
as an amount for compensation for personal services actually
rendered.''.
(2) Effective date.--The amendments made by this subsection
shall apply to vouchers provided after December 31, 2013.
(h) Voucher Taken Into Account in Determining Premium
Credit.--
(1) In general.--Subsection (c)(2) of section 36B of the
Internal Revenue Code of 1986, as added by section 1401, is
amended by adding at the end the following new subparagraph:
``(D) Exception for individual receiving free choice
vouchers.--The term `coverage month' shall not include any
month in which such individual has a free choice voucher
provided under section 10108 of the Patient Protection and
Affordable Care Act.''.
(2) Effective date.--The amendment made by this subsection
shall apply to taxable years beginning after December 31,
2013.
(i) Coordination With Employer Responsibilities.--
(1) Shared responsibility penalty.--
(A) In general.--Subsection (c) of section 4980H of the
Internal Revenue Code of 1986, as added by section 1513, is
amended by adding at the end the following new paragraph:

[[Page S13499]]

``(3) Special rules for employers providing free choice
vouchers.--No assessable payment shall be imposed under
paragraph (1) for any month with respect to any employee to
whom the employer provides a free choice voucher under
section 10108 of the Patient Protection and Affordable Care
Act for such month.''.
(B) Effective date.--The amendment made by this paragraph
shall apply to months beginning after December 31, 2013.
(2) Notification requirement.--Section 18B(a)(3) of the
Fair Labor Standards Act of 1938, as added by section 1512,
is amended--
(A) by inserting ``and the employer does not offer a free
choice voucher'' after ``Exchange''; and
(B) by striking ``will lose'' and inserting ``may lose''.
(j) Employer Reporting.--
(1) In general.--Subsection (a) of section 6056 of the
Internal Revenue Code of 1986, as added by section 1514, is
amended by inserting ``and every offering employer'' before
``shall''.
(2) Offering employers.--Subsection (f) of section 6056 of
such Code, as added by section 1514, is amended to read as
follows:
``(f) Definitions.--For purposes of this section--
``(1) Offering employer.--
``(A) In general.--The term `offering employer' means any
offering employer (as defined in section 10108(b) of the
Patient Protection and Affordable Care Act) if the required
contribution (within the meaning of section
5000A(e)(1)(B)(i)) of any employee exceeds 8 percent of the
wages (as defined in section 3121(a)) paid to such employee
by such employer.
``(B) Indexing.--In the case of any calendar year beginning
after 2014, the 8 percent under subparagraph (A) shall be
adjusted for the calendar year to reflect the rate of premium
growth between the preceding calendar year and 2013 over the
rate of income growth for such period.
``(2) Other definitions.--Any term used in this section
which is also used in section 4980H shall have the meaning
given such term by section 4980H.''.
(3) Conforming amendments.--
(A) The heading of section 6056 of such Code, as added by
section 1514, is amended by striking ``large'' and inserting
``certain''.
(B) Section 6056(b)(2)(C) of such Code is amended--
(i) by inserting ``in the case of an applicable large
employer,'' before ``the length'' in clause (i);
(ii) by striking ``and'' at the end of clause (iii);
(iii) by striking ``applicable large employer'' in clause
(iv) and inserting ``employer'';
(iv) by inserting ``and'' at the end of clause (iv); and
(v) by inserting at the end the following new clause:
``(v) in the case of an offering employer, the option for
which the employer pays the largest portion of the cost of
the plan and the portion of the cost paid by the employer in
each of the enrollment categories under such option,''.
(C) Section 6056(d)(2) of such Code is amended by inserting
``or offering employer'' after ``applicable large employer''.
(D) Section 6056(e) of such Code is amended by inserting
``or offering employer'' after ``applicable large employer''.
(E) Section 6724(d)(1)(B)(xxv) of such Code, as added by
section 1514, is amended by striking ``large'' and inserting
``certain''.
(F) Section 6724(d)(2)(HH) of such Code, as added by
section 1514, is amended by striking ``large'' and inserting
``certain''.
(G) The table of sections for subpart D of part III of
subchapter A of chapter 1 of such Code, as amended by section
1514, is amended by striking ``Large employers'' in the item
relating to section 6056 and inserting ``Certain employers''.
(4) Effective date.--The amendments made by this subsection
shall apply to periods beginning after December 31, 2013.

SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND
ADMINISTRATIVE TRANSACTIONS.

(a) Additional Transaction Standards and Operating Rules.--
(1) Development of additional transaction standards and
operating rules.--Section 1173(a) of the Social Security Act
(42 U.S.C. 1320d-2(a)), as amended by section 1104(b)(2), is
amended--
(A) in paragraph (1)(B), by inserting before the period the
following: ``, and subject to the requirements under
paragraph (5)''; and
(B) by adding at the end the following new paragraph:
``(5) Consideration of standardization of activities and
items.--
``(A) In general.--For purposes of carrying out paragraph
(1)(B), the Secretary shall solicit, not later than January
1, 2012, and not less than every 3 years thereafter, input
from entities described in subparagraph (B) on--
``(i) whether there could be greater uniformity in
financial and administrative activities and items, as
determined appropriate by the Secretary; and
``(ii) whether such activities should be considered
financial and administrative transactions (as described in
paragraph (1)(B)) for which the adoption of standards and
operating rules would improve the operation of the health
care system and reduce administrative costs.
``(B) Solicitation of input.--For purposes of subparagraph
(A), the Secretary shall seek input from--
``(i) the National Committee on Vital and Health
Statistics, the Health Information Technology Policy
Committee, and the Health Information Technology Standards
Committee; and
``(ii) standard setting organizations and stakeholders, as
determined appropriate by the Secretary.''.
(b) Activities and Items for Initial Consideration.--For
purposes of section 1173(a)(5) of the Social Security Act, as
added by subsection (a), the Secretary of Health and Human
Services (in this section referred to as the ``Secretary'')
shall, not later than January 1, 2012, seek input on
activities and items relating to the following areas:
(1) Whether the application process, including the use of a
uniform application form, for enrollment of health care
providers by health plans could be made electronic and
standardized.
(2) Whether standards and operating rules described in
section 1173 of the Social Security Act should apply to the
health care transactions of automobile insurance, worker's
compensation, and other programs or persons not described in
section 1172(a) of such Act (42 U.S.C. 1320d-1(a)).
(3) Whether standardized forms could apply to financial
audits required by health plans, Federal and State agencies
(including State auditors, the Office of the Inspector
General of the Department of Health and Human Services, and
the Centers for Medicare & Medicaid Services), and other
relevant entities as determined appropriate by the Secretary.
(4) Whether there could be greater transparency and
consistency of methodologies and processes used to establish
claim edits used by health plans (as described in section
1171(5) of the Social Security Act (42 U.S.C. 1320d(5))).
(5) Whether health plans should be required to publish
their timeliness of payment rules.
(c) ICD Coding Crosswalks.--
(1) ICD-9 to icd-10 crosswalk.--The Secretary shall task
the ICD-9-CM Coordination and Maintenance Committee to
convene a meeting, not later than January 1, 2011, to receive
input from appropriate stakeholders (including health plans,
health care providers, and clinicians) regarding the
crosswalk between the Ninth and Tenth Revisions of the
International Classification of Diseases (ICD-9 and ICD-10,
respectively) that is posted on the website of the Centers
for Medicare & Medicaid Services, and make recommendations
about appropriate revisions to such crosswalk.
(2) Revision of crosswalk.--For purposes of the crosswalk
described in paragraph (1), the Secretary shall make
appropriate revisions and post any such revised crosswalk on
the website of the Centers for Medicare & Medicaid Services.
(3) Use of revised crosswalk.--For purposes of paragraph
(2), any revised crosswalk shall be treated as a code set for
which a standard has been adopted by the Secretary for
purposes of section 1173(c)(1)(B) of the Social Security Act
(42 U.S.C. 1320d-2(c)(1)(B)).
(4) Subsequent crosswalks.--For subsequent revisions of the
International Classification of Diseases that are adopted by
the Secretary as a standard code set under section 1173(c) of
the Social Security Act (42 U.S.C. 1320d-2(c)), the Secretary
shall, after consultation with the appropriate stakeholders,
post on the website of the Centers for Medicare & Medicaid
Services a crosswalk between the previous and subsequent
version of the International Classification of Diseases not
later than the date of implementation of such subsequent
revision.

Subtitle B--Provisions Relating to Title II

PART I--MEDICAID AND CHIP

SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE
II OF THIS ACT.

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

``(IX) who--

``(aa) are under 26 years of age;
``(bb) are not described in or enrolled under any of
subclauses (I) through (VII) of this clause or are described
in any of such subclauses but have income that exceeds the
level of income applicable under the State plan for
eligibility to enroll for medical assistance under such
subclause;
``(cc) were in foster care under the responsibility of the
State on the date of attaining 18 years of age or such higher
age as the State has elected under section 475(8)(B)(iii);
and
``(dd) were enrolled in the State plan under this title or
under a waiver of the plan while in such foster care;''.
(2) Section 1902(a)(10) of the Social Security Act (42
U.S.C. 1396a(a)(10), as amended by section 2001(a)(5)(A), is
amended in the matter following subparagraph (G), by striking
``and (XV)'' and inserting ``(XV)'', and by inserting ``and
(XVI) if an individual is described in subclause (IX) of
subparagraph (A)(i) and is also described in subclause (VIII)
of that subparagraph, the medical assistance shall be made
available to the individual through subclause (IX) instead of
through subclause (VIII)'' before the semicolon.
(3) Section 2004(d) of this Act is amended by striking
``2019'' and inserting ``2014''.
(b) Section 1902(k)(2) of the Social Security Act (42
U.S.C. 1396a(k)(2)), as added by section 2001(a)(4)(A), is
amended by striking

[[Page S13500]]

``January 1, 2011'' and inserting ``April 1, 2010''.
(c) Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by sections 2001(a)(3), 2001(a)(5)(C),
2006, and 4107(a)(2), is amended--
(1) in subsection (a), in the matter preceding paragraph
(1), by inserting in clause (xiv), ``or
1902(a)(10)(A)(i)(IX)'' before the comma;
(2) in subsection (b), in the first sentence, by inserting
``, (z),'' before ``and (aa)'';
(3) in subsection (y)--
(A) in paragraph (1)(B)(ii)(II), in the first sentence, by
inserting ``includes inpatient hospital services,'' after
``100 percent of the poverty line, that''; and
(B) in paragraph (2)(A), by striking ``on the date of
enactment of the Patient Protection and Affordable Care Act''
and inserting ``as of December 1, 2009'';
(4) by inserting after subsection (y) the following:
``(z) Equitable Support for Certain States.--
``(1)(A) During the period that begins on January 1, 2014,
and ends on September 30, 2019, notwithstanding subsection
(b), the Federal medical assistance percentage otherwise
determined under subsection (b) with respect to a fiscal year
occurring during that period shall be increased by 2.2
percentage points for any State described in subparagraph (B)
for amounts expended for medical assistance for individuals
who are not newly eligible (as defined in subsection (y)(2))
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).
``(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that--
``(i) is an expansion State described in subsection
(y)(1)(B)(ii)(II);
``(ii) the Secretary determines will not receive any
payments under this title on the basis of an increased
Federal medical assistance percentage under subsection (y)
for expenditures for medical assistance for newly eligible
individuals (as so defined); and
``(iii) has not been approved by the Secretary to divert a
portion of the DSH allotment for a State to the costs of
providing medical assistance or other health benefits
coverage under a waiver that is in effect on July 2009.
``(2)(A) During the period that begins on January 1, 2014,
and ends on December 31, 2016, notwithstanding subsection
(b), the Federal medical assistance percentage otherwise
determined under subsection (b) with respect to all or any
portion of a fiscal year occurring during that period shall
be increased by .5 percentage point for a State described in
subparagraph (B) for amounts expended for medical assistance
under the State plan under this title or under a waiver of
that plan during that period.
``(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that--
``(i) is described in clauses (i) and (ii) of paragraph
(1)(B); and
``(ii) is the State with the highest percentage of its
population insured during 2008, based on the Current
Population Survey.
``(3) Notwithstanding subsection (b) and paragraphs (1) and
(2) of this subsection, the Federal medical assistance
percentage otherwise determined under subsection (b) with
respect to all or any portion of a fiscal year that begins on
or after January 1, 2017, for the State of Nebraska, with
respect to amounts expended for newly eligible individuals
described in subclause (VIII) of section 1902(a)(10)(A)(i),
shall be determined as provided for under subsection
(y)(1)(A) (notwithstanding the period provided for in such
paragraph).
``(4) The increase in the Federal medical assistance
percentage for a State under paragraphs (1), (2), or (3)
shall apply only for purposes of this title and shall not
apply with respect to--
``(A) disproportionate share hospital payments described in
section 1923;
``(B) payments under title IV;
``(C) payments under title XXI; and
``(D) payments under this title that are based on the
enhanced FMAP described in section 2105(b).'';
(5) in subsection (aa), is amended by striking ``without
regard to this subsection and subsection (y)'' and inserting
``without regard to this subsection, subsection (y),
subsection (z), and section 10202 of the Patient Protection
and Affordable Care Act'' each place it appears;
(6) by adding after subsection (bb), the following:
``(cc) Requirement for Certain States.--Notwithstanding
subsections (y), (z), and (aa), in the case of a State that
requires political subdivisions within the State to
contribute toward the non-Federal share of expenditures
required under the State plan under section 1902(a)(2), the
State shall not be eligible for an increase in its Federal
medical assistance percentage under such subsections if it
requires that political subdivisions pay a greater percentage
of the non-Federal share of such expenditures, or a greater
percentage of the non-Federal share of payments under section
1923, than the respective percentages that would have been
required by the State under the State plan under this title,
State law, or both, as in effect on December 31, 2009, and
without regard to any such increase. Voluntary contributions
by a political subdivision to the non-Federal share of
expenditures under the State plan under this title or to the
non-Federal share of payments under section 1923, shall not
be considered to be required contributions for purposes of
this subsection. The treatment of voluntary contributions,
and the treatment of contributions required by a State under
the State plan under this title, or State law, as provided by
this subsection, shall also apply to the increases in the
Federal medical assistance percentage under section 5001 of
the American Recovery and Reinvestment Act of 2009.''.
(d) Section 1108(g)(4)(B) of the Social Security Act (42
U.S.C. 1308(g)(4)(B)), as added by section 2005(b), is
amended by striking ``income eligibility level in effect for
that population under title XIX or under a waiver'' and
inserting ``the highest income eligibility level in effect
for parents under the commonwealth's or territory's State
plan under title XIX or under a waiver of the plan''.
(e)(1) Section 1923(f) of the Social Security Act (42
U.S.C. 1396r-4(f)), as amended by section 2551, is amended--
(A) in paragraph (6)--
(i) by striking the paragraph heading and inserting the
following: ``Allotment adjustments''; and
(ii) in subparagraph (B), by adding at the end the
following:
``(iii) Allotment for 2d, 3rd, and 4th quarter of fiscal
year 2012, fiscal year 2013, and succeeding fiscal years.--
Notwithstanding the table set forth in paragraph (2) or
paragraph (7):

``(I) 2d, 3rd, and 4th quarter of fiscal year 2012.--The
DSH allotment for Hawaii for the 2d, 3rd, and 4th quarters of
fiscal year 2012 shall be $7,500,000.
``(II) Treatment as a low-dsh state for fiscal year 2013
and succeeding fiscal years.--With respect to fiscal year
2013, and each fiscal year thereafter, the DSH allotment for
Hawaii shall be increased in the same manner as allotments
for low DSH States are increased for such fiscal year under
clause (iii) of paragraph (5)(B).
``(III) Certain hospital payments.--The Secretary may not
impose a limitation on the total amount of payments made to
hospitals under the QUEST section 1115 Demonstration Project
except to the extent that such limitation is necessary to
ensure that a hospital does not receive payments in excess of
the amounts described in subsection (g), or as necessary to
ensure that such payments under the waiver and such payments
pursuant to the allotment provided in this clause do not, in
the aggregate in any year, exceed the amount that the
Secretary determines is equal to the Federal medical
assistance percentage component attributable to
disproportionate share hospital payment adjustments for such
year that is reflected in the budget neutrality provision of
the QUEST Demonstration Project.''; and

(B) in paragraph (7)--
(i) in subparagraph (A), in the matter preceding clause
(i), by striking ``subparagraph (E)'' and inserting
``subparagraphs (E) and (G)'';
(ii) in subparagraph (B)--
(I) in clause (i), by striking subclauses (I) and (II), and
inserting the following:

``(I) if the State is a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 25 percent;
``(II) if the State is a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 17.5 percent;
``(III) if the State is not a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 50 percent; and
``(IV) if the State is not a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 35 percent.'';

(II) in clause (ii), by striking subclauses (I) and (II),
and inserting the following:

``(I) if the State is a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 27.5 percent;
``(II) if the State is a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 20 percent;
``(III) if the State is not a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 55 percent; and

[[Page S13501]]

``(IV) if the State is not a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 40 percent.'';

(III) in subparagraph (E), by striking ``35 percent'' and
inserting ``50 percent''; and
(IV) by adding at the end the following:
``(G) Nonapplication.--The preceding provisions of this
paragraph shall not apply to the DSH allotment determined for
the State of Hawaii for a fiscal year under paragraph (6).''.
(f) Section 2551 of this Act is amended by striking
subsection (b).
(g) Section 2105(d)(3)(B) of the Social Security Act (42
U.S.C. 1397ee(d)(3)(B)), as added by section 2101(b)(1), is
amended by adding at the end the following: ``For purposes of
eligibility for premium assistance for the purchase of a
qualified health plan under section 36B of the Internal
Revenue Code of 1986 and reduced cost-sharing under section
1402 of the Patient Protection and Affordable Care Act,
children described in the preceding sentence shall be deemed
to be ineligible for coverage under the State child health
plan.''.
(h) Clause (i) of subparagraph (C) of section 513(b)(2) of
the Social Security Act, as added by section 2953 of this
Act, is amended to read as follows:
``(i) Healthy relationships, including marriage and family
interactions.''.
(i) Section 1115 of the Social Security Act (42 U.S.C.
1315) is amended by inserting after subsection (c) the
following:
``(d)(1) An application or renewal of any experimental,
pilot, or demonstration project undertaken under subsection
(a) to promote the objectives of title XIX or XXI in a State
that would result in an impact on eligibility, enrollment,
benefits, cost-sharing, or financing with respect to a State
program under title XIX or XXI (in this subsection referred
to as a `demonstration project') shall be considered by the
Secretary in accordance with the regulations required to be
promulgated under paragraph (2).
``(2) Not later than 180 days after the date of enactment
of this subsection, the Secretary shall promulgate
regulations relating to applications for, and renewals of, a
demonstration project that provide for--
``(A) a process for public notice and comment at the State
level, including public hearings, sufficient to ensure a
meaningful level of public input;
``(B) requirements relating to--
``(i) the goals of the program to be implemented or renewed
under the demonstration project;
``(ii) the expected State and Federal costs and coverage
projections of the demonstration project; and
``(iii) the specific plans of the State to ensure that the
demonstration project will be in compliance with title XIX or
XXI;
``(C) a process for providing public notice and comment
after the application is received by the Secretary, that is
sufficient to ensure a meaningful level of public input;
``(D) a process for the submission to the Secretary of
periodic reports by the State concerning the implementation
of the demonstration project; and
``(E) a process for the periodic evaluation by the
Secretary of the demonstration project.
``(3) The Secretary shall annually report to Congress
concerning actions taken by the Secretary with respect to
applications for demonstration projects under this
section.''.
(j) Subtitle F of title III of this Act is amended by
adding at the end the following:

``SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION.

``(a) Study.--
``(1) In general.--The Comptroller General of the United
States shall conduct a study of whether the development,
recognition, or implementation of any guideline or other
standards under a provision described in paragraph (2) would
result in the establishment of a new cause of action or
claim.
``(2) Provisions described.--The provisions described in
this paragraph include the following:
``(A) Section 2701 (adult health quality measures).
``(B) Section 2702 (payment adjustments for health care
acquired conditions).
``(C) Section 3001 (Hospital Value-Based Purchase Program).
``(D) Section 3002 (improvements to the Physician Quality
Reporting Initiative).
``(E) Section 3003 (improvements to the Physician Feedback
Program).
``(F) Section 3007 (value based payment modifier under
physician fee schedule).
``(G) Section 3008 (payment adjustment for conditions
acquired in hospitals).
``(H) Section 3013 (quality measure development).
``(I) Section 3014 (quality measurement).
``(J) Section 3021 (Establishment of Center for Medicare
and Medicaid Innovation).
``(K) Section 3025 (hospital readmission reduction
program).
``(L) Section 3501 (health care delivery system research,
quality improvement).
``(M) Section 4003 (Task Force on Clinical and Preventive
Services).
``(N) Section 4301 (research to optimize deliver of public
health services).
``(b) Report.--Not later than 2 years after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to the appropriate committees of
Congress, a report containing the findings made by the
Comptroller General under the study under subsection (a).''.

SEC. 10202. INCENTIVES FOR STATES TO OFFER HOME AND
COMMUNITY-BASED SERVICES AS A LONG-TERM CARE
ALTERNATIVE TO NURSING HOMES.

(a) State Balancing Incentive Payments Program.--
Notwithstanding section 1905(b) of the Social Security Act
(42 U.S.C. 1396d(b)), in the case of a balancing incentive
payment State, as defined in subsection (b), that meets the
conditions described in subsection (c), during the balancing
incentive period, the Federal medical assistance percentage
determined for the State under section 1905(b) of such Act
and, if applicable, increased under subsection (z) or (aa)
shall be increased by the applicable percentage points
determined under subsection (d) with respect to eligible
medical assistance expenditures described in subsection (e).
(b) Balancing Incentive Payment State.--A balancing
incentive payment State is a State--
(1) in which less than 50 percent of the total expenditures
for medical assistance under the State Medicaid program for a
fiscal year for long-term services and supports (as defined
by the Secretary under subsection (f))(1)) are for non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B);
(2) that submits an application and meets the conditions
described in subsection (c); and
(3) that is selected by the Secretary to participate in the
State balancing incentive payment program established under
this section.
(c) Conditions.--The conditions described in this
subsection are the following:
(1) Application.--The State submits an application to the
Secretary that includes, in addition to such other
information as the Secretary shall require--
(A) a proposed budget that details the State's plan to
expand and diversify medical assistance for non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B) under the State Medicaid
program during the balancing incentive period and achieve the
target spending percentage applicable to the State under
paragraph (2), including through structural changes to how
the State furnishes such assistance, such as through the
establishment of a ``no wrong door - single entry point
system'', optional presumptive eligibility, case management
services, and the use of core standardized assessment
instruments, and that includes a description of the new or
expanded offerings of such services that the State will
provide and the projected costs of such services; and
(B) in the case of a State that proposes to expand the
provision of home and community-based services under its
State Medicaid program through a State plan amendment under
section 1915(i) of the Social Security Act, at the option of
the State, an election to increase the income eligibility for
such services from 150 percent of the poverty line to such
higher percentage as the State may establish for such
purpose, not to exceed 300 percent of the supplemental
security income benefit rate established by section
1611(b)(1) of the Social Security Act (42 U.S.C. 1382(b)(1)).
(2) Target spending percentages.--
(A) In the case of a balancing incentive payment State in
which less than 25 percent of the total expenditures for
long-term services and supports under the State Medicaid
program for fiscal year 2009 are for home and community-based
services, the target spending percentage for the State to
achieve by not later than October 1, 2015, is that 25 percent
of the total expenditures for long-term services and supports
under the State Medicaid program are for home and community-
based services.
(B) In the case of any other balancing incentive payment
State, the target spending percentage for the State to
achieve by not later than October 1, 2015, is that 50 percent
of the total expenditures for long-term services and supports
under the State Medicaid program are for home and community-
based services.
(3) Maintenance of eligibility requirements.--The State
does not apply eligibility standards, methodologies, or
procedures for determining eligibility for medical assistance
for non-institutionally-based long-term services and supports
described in subsection (f)(1)(B) under the State Medicaid
program that are more restrictive than the eligibility
standards, methodologies, or procedures in effect for such
purposes on December 31, 2010.
(4) Use of additional funds.--The State agrees to use the
additional Federal funds paid to the State as a result of
this section only for purposes of providing new or expanded
offerings of non-institutionally-based long-term services and
supports described in subsection (f)(1)(B) under the State
Medicaid program.
(5) Structural changes.--The State agrees to make, not
later than the end of the 6-month period that begins on the
date the State submits an application under this section, the
following changes:
(A) ``No wrong door - single entry point system''.--
Development of a statewide system to enable consumers to
access all long-term services and supports through an agency,
organization, coordinated network, or portal, in accordance
with such standards as the State shall establish and that
shall provide information regarding the availability

[[Page S13502]]

of such services, how to apply for such services, referral
services for services and supports otherwise available in the
community, and determinations of financial and functional
eligibility for such services and supports, or assistance
with assessment processes for financial and functional
eligibility.
(B) Conflict-free case management services.--Conflict-free
case management services to develop a service plan, arrange
for services and supports, support the beneficiary (and, if
appropriate, the beneficiary's caregivers) in directing the
provision of services and supports for the beneficiary, and
conduct ongoing monitoring to assure that services and
supports are delivered to meet the beneficiary's needs and
achieve intended outcomes.
(C) Core standardized assessment instruments.--Development
of core standardized assessment instruments for determining
eligibility for non-institutionally-based long-term services
and supports described in subsection (f)(1)(B), which shall
be used in a uniform manner throughout the State, to
determine a beneficiary's needs for training, support
services, medical care, transportation, and other services,
and develop an individual service plan to address such needs.
(6) Data collection.--The State agrees to collect from
providers of services and through such other means as the
State determines appropriate the following data:
(A) Services data.--Services data from providers of non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B) on a per-beneficiary basis
and in accordance with such standardized coding procedures as
the State shall establish in consultation with the Secretary.
(B) Quality data.--Quality data on a selected set of core
quality measures agreed upon by the Secretary and the State
that are linked to population-specific outcomes measures and
accessible to providers.
(C) Outcomes measures.--Outcomes measures data on a
selected set of core population-specific outcomes measures
agreed upon by the Secretary and the State that are
accessible to providers and include--
(i) measures of beneficiary and family caregiver experience
with providers;
(ii) measures of beneficiary and family caregiver
satisfaction with services; and
(iii) measures for achieving desired outcomes appropriate
to a specific beneficiary, including employment,
participation in community life, health stability, and
prevention of loss in function.
(d) Applicable Percentage Points Increase in FMAP.--The
applicable percentage points increase is--
(1) in the case of a balancing incentive payment State
subject to the target spending percentage described in
subsection (c)(2)(A), 5 percentage points; and
(2) in the case of any other balancing incentive payment
State, 2 percentage points.
(e) Eligible Medical Assistance Expenditures.--
(1) In general.--Subject to paragraph (2), medical
assistance described in this subsection is medical assistance
for non-institutionally-based long-term services and supports
described in subsection (f)(1)(B) that is provided by a
balancing incentive payment State under its State Medicaid
program during the balancing incentive payment period.
(2) Limitation on payments.--In no case may the aggregate
amount of payments made by the Secretary to balancing
incentive payment States under this section during the
balancing incentive period exceed $3,000,000,000.
(f) Definitions.--In this section:
(1) Long-term services and supports defined.--The term
``long-term services and supports'' has the meaning given
that term by Secretary and may include any of the following
(as defined for purposes of State Medicaid programs):
(A) Institutionally-based long-term services and
supports.--Services provided in an institution, including the
following:
(i) Nursing facility services.
(ii) Services in an intermediate care facility for the
mentally retarded described in subsection (a)(15) of section
1905 of such Act.
(B) Non-institutionally-based long-term services and
supports.--Services not provided in an institution, including
the following:
(i) Home and community-based services provided under
subsection (c), (d), or (i) of section 1915 of such Act or
under a waiver under section 1115 of such Act.
(ii) Home health care services.
(iii) Personal care services.
(iv) Services described in subsection (a)(26) of section
1905 of such Act (relating to PACE program services).
(v) Self-directed personal assistance services described in
section 1915(j) of such Act.
(2) Balancing incentive period.--The term ``balancing
incentive period'' means the period that begins on October 1,
2011, and ends on September 30, 2015.
(3) Poverty line.--The term ``poverty line'' has the
meaning given that term in section 2110(c)(5) of the Social
Security Act (42 U.S.C. 1397jj(c)(5)).
(4) State medicaid program.--The term ``State Medicaid
program'' means the State program for medical assistance
provided under a State plan under title XIX of the Social
Security Act and under any waiver approved with respect to
such State plan.

SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL YEAR
2015 AND OTHER CHIP-RELATED PROVISIONS.

(a) Section 1311(c)(1) of this Act is amended by striking
``and'' at the end of subparagraph (G), by striking the
period at the end of subparagraph (H) and inserting ``;
and'', and by adding at the end the following:
``(I) report to the Secretary at least annually and in such
manner as the Secretary shall require, pediatric quality
reporting measures consistent with the pediatric quality
reporting measures established under section 1139A of the
Social Security Act.''.
(b) Effective as if included in the enactment of the
Children's Health Insurance Program Reauthorization Act of
2009 (Public Law 111-3):
(1) Section 1906(e)(2) of the Social Security Act (42
U.S.C. 1396e(e)(2)) is amended by striking ``means'' and all
that follows through the period and inserting ``has the
meaning given that term in section 2105(c)(3)(A).''.
(2)(A) Section 1906A(a) of the Social Security Act (42
U.S.C. 1396e-1(a)), is amended by inserting before the period
the following: ``and the offering of such a subsidy is cost-
effective, as defined for purposes of section
2105(c)(3)(A)''.
(B) This Act shall be applied without regard to
subparagraph (A) of section 2003(a)(1) of this Act and that
subparagraph and the amendment made by that subparagraph are
hereby deemed null, void, and of no effect.
(3) Section 2105(c)(10) of the Social Security Act (42
U.S.C. 1397ee(c)(10)) is amended--
(A) in subparagraph (A), in the first sentence, by
inserting before the period the following: ``if the offering
of such a subsidy is cost-effective, as defined for purposes
of paragraph (3)(A)'';
(B) by striking subparagraph (M); and
(C) by redesignating subparagraph (N) as subparagraph (M).
(4) Section 2105(c)(3)(A) of the Social Security Act (42
U.S.C. 1397ee(c)(3)(A)) is amended--
(A) in the matter preceding clause (i), by striking ``to''
and inserting ``to--''; and
(B) in clause (ii), by striking the period and inserting a
semicolon.
(c) Section 2105 of the Social Security Act (42 U.S.C.
1397ee), as amended by section 2101, is amended--
(1) in subsection (b), in the second sentence, by striking
``2013'' and inserting ``2015''; and
(2) in subsection (d)(3)--
(A) in subparagraph (A)--
(i) in the first sentence, by inserting ``as a condition of
receiving payments under section 1903(a),'' after ``2019,'';
(ii) in clause (i), by striking ``or'' at the end;
(iii) by redesignating clause (ii) as clause (iii); and
(iv) by inserting after clause (i), the following:
``(ii) after September 30, 2015, enrolling children
eligible to be targeted low-income children under the State
child health plan in a qualified health plan that has been
certified by the Secretary under subparagraph (C); or'';
(B) in subparagraph (B), by striking ``provided coverage''
and inserting ``screened for eligibility for medical
assistance under the State plan under title XIX or a waiver
of that plan and, if found eligible, enrolled in such plan or
a waiver. In the case of such children who, as a result of
such screening, are determined to not be eligible for medical
assistance under the State plan or a waiver under title XIX,
the State shall establish procedures to ensure that the
children are enrolled in a qualified health plan that has
been certified by the Secretary under subparagraph (C) and is
offered''; and
(C) by adding at the end the following:
``(C) Certification of comparability of pediatric coverage
offered by qualified health plans.--With respect to each
State, the Secretary, not later than April 1, 2015, shall
review the benefits offered for children and the cost-sharing
imposed with respect to such benefits by qualified health
plans offered through an Exchange established by the State
under section 1311 of the Patient Protection and Affordable
Care Act and shall certify those plans that offer benefits
for children and impose cost-sharing with respect to such
benefits that the Secretary determines are at least
comparable to the benefits offered and cost-sharing
protections provided under the State child health plan.''.
(d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is
amended--
(A) in paragraph (15), by striking ``and'' at the end; and
(B) by striking paragraph (16) and inserting the following:
``(16) for fiscal year 2013, $17,406,000,000;
``(17) for fiscal year 2014, $19,147,000,000; and
``(18) for fiscal year 2015, for purposes of making 2 semi-
annual allotments--
``(A) $2,850,000,000 for the period beginning on October 1,
2014, and ending on March 31, 2015, and
``(B) $2,850,000,000 for the period beginning on April 1,
2015, and ending on September 30, 2015.''.
(2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)),
as amended by section 2102(a)(1), is amended--
(i) in the subsection heading, by striking ``2013'' and
inserting ``2015'';
(ii) in paragraph (2)--
(I) in the paragraph heading, by striking ``2012'' and
inserting ``2014''; and
(II) by adding at the end the following:
``(B) Fiscal years 2013 and 2014.--Subject to paragraphs
(4) and (6), from the amount made available under paragraphs
(16) and (17) of subsection (a) for fiscal years 2013 and

[[Page S13503]]

2014, respectively, the Secretary shall compute a State
allotment for each State (including the District of Columbia
and each commonwealth and territory) for each such fiscal
year as follows:
``(i) Rebasing in fiscal year 2013.--For fiscal year 2013,
the allotment of the State is equal to the Federal payments
to the State that are attributable to (and countable towards)
the total amount of allotments available under this section
to the State in fiscal year 2012 (including payments made to
the State under subsection (n) for fiscal year 2012 as well
as amounts redistributed to the State in fiscal year 2012),
multiplied by the allotment increase factor under paragraph
(5) for fiscal year 2013.
``(ii) Growth factor update for fiscal year 2014.--For
fiscal year 2014, the allotment of the State is equal to the
sum of--

``(I) the amount of the State allotment under clause (i)
for fiscal year 2013; and
``(II) the amount of any payments made to the State under
subsection (n) for fiscal year 2013,

multiplied by the allotment increase factor under paragraph
(5) for fiscal year 2014.'';
(iii) in paragraph (3)--
(I) in the paragraph heading, by striking ``2013'' and
inserting ``2015'';
(II) in subparagraphs (A) and (B), by striking ``paragraph
(16)'' each place it appears and inserting ``paragraph
(18)'';
(III) in subparagraph (C)--

(aa) by striking ``2012'' each place it appears and
inserting ``2014''; and
(bb) by striking ``2013'' and inserting ``2015''; and

(IV) in subparagraph (D)--

(aa) in clause (i)(I), by striking ``subsection
(a)(16)(A)'' and inserting ``subsection (a)(18)(A)''; and
(bb) in clause (ii)(II), by striking ``subsection
(a)(16)(B)'' and inserting ``subsection (a)(18)(B)'';

(iv) in paragraph (4), by striking ``2013'' and inserting
``2015'';
(v) in paragraph (6)--
(I) in subparagraph (A), by striking ``2013'' and inserting
``2015''; and
(II) in the flush language after and below subparagraph
(B)(ii), by striking ``or fiscal year 2012'' and inserting
``, fiscal year 2012, or fiscal year 2014''; and
(vi) in paragraph (8)--
(I) in the paragraph heading, by striking ``2013'' and
inserting ``2015''; and
(II) by striking ``2013'' and inserting ``2015''.
(B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is
amended--
(i) in paragraph (2)--
(I) in subparagraph (A)(ii)--
(aa) by striking ``2012'' and inserting ``2014''; and
(bb) by striking ``2013'' and inserting ``2015'';
(II) in subparagraph (B)--
(aa) by striking ``2012'' and inserting ``2014''; and
(bb) by striking ``2013'' and inserting ``2015''; and
(ii) in paragraph (3)(A), by striking ``or a semi-annual
allotment period for fiscal year 2013'' and inserting
``fiscal year 2013, fiscal year 2014, or a semi-annual
allotment period for fiscal year 2015''.
(C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4))
is amended--
(i) in the paragraph heading, by striking ``2013'' and
inserting ``2015''; and
(ii) in subparagraph (A), by striking ``2013'' and
inserting ``2015''.
(D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is
amended--
(i) in paragraph (2)(B), by inserting ``except as provided
in paragraph (6),'' before ``a child''; and
(ii) by adding at the end the following new paragraph:
``(6) Exceptions to exclusion of children of employees of a
public agency in the state.--
``(A) In general.--A child shall not be considered to be
described in paragraph (2)(B) if--
``(i) the public agency that employs a member of the
child's family to which such paragraph applies satisfies
subparagraph (B); or
``(ii) subparagraph (C) applies to such child.
``(B) Maintenance of effort with respect to per person
agency contribution for family coverage.--For purposes of
subparagraph (A)(i), a public agency satisfies this
subparagraph if the amount of annual agency expenditures made
on behalf of each employee enrolled in health coverage paid
for by the agency that includes dependent coverage for the
most recent State fiscal year is not less than the amount of
such expenditures made by the agency for the 1997 State
fiscal year, increased by the percentage increase in the
medical care expenditure category of the Consumer Price Index
for All-Urban Consumers (all items: U.S. City Average) for
such preceding fiscal year.
``(C) Hardship exception.--For purposes of subparagraph
(A)(ii), this subparagraph applies to a child if the State
determines, on a case-by-case basis, that the annual
aggregate amount of premiums and cost-sharing imposed for
coverage of the family of the child would exceed 5 percent of
such family's income for the year involved.''.
(E) Section 2113 of such Act (42 U.S.C. 1397mm) is
amended--
(i) in subsection (a)(1), by striking ``2013'' and
inserting ``2015''; and
(ii) in subsection (g), by striking ``$100,000,000 for the
period of fiscal years 2009 through 2013'' and inserting
``$140,000,000 for the period of fiscal years 2009 through
2015''.
(F) Section 108 of Public Law 111-3 is amended by striking
``$11,706,000,000'' and all that follows through the second
sentence and inserting ``$15,361,000,000 to accompany the
allotment made for the period beginning on October 1, 2014,
and ending on March 31, 2015, under section 2104(a)(18)(A) of
the Social Security Act (42 U.S.C. 1397dd(a)(18)(A)), to
remain available until expended. Such amount shall be used to
provide allotments to States under paragraph (3) of section
2104(m) of the Social Security Act (42 U.S.C. 1397dd(m)) for
the first 6 months of fiscal year 2015 in the same manner as
allotments are provided under subsection (a)(18)(A) of such
section 2104 and subject to the same terms and conditions as
apply to the allotments provided from such subsection
(a)(18)(A).''.

PART II--SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN

SEC. 10211. DEFINITIONS.

In this part:
(1) Accompaniment.--The term ``accompaniment'' means
assisting, representing, and accompanying a woman in seeking
judicial relief for child support, child custody, restraining
orders, and restitution for harm to persons and property, and
in filing criminal charges, and may include the payment of
court costs and reasonable attorney and witness fees
associated therewith.
(2) Eligible institution of higher education.--The term
``eligible institution of higher education'' means an
institution of higher education (as such term is defined in
section 101 of the Higher Education Act of 1965 (20 U.S.C.
1001)) that has established and operates, or agrees to
establish and operate upon the receipt of a grant under this
part, a pregnant and parenting student services office.
(3) Community service center.--The term ``community service
center'' means a non-profit organization that provides social
services to residents of a specific geographical area via
direct service or by contract with a local governmental
agency.
(4) High school.--The term ``high school'' means any public
or private school that operates grades 10 through 12,
inclusive, grades 9 through 12, inclusive or grades 7 through
12, inclusive.
(5) Intervention services.--The term ``intervention
services'' means, with respect to domestic violence, sexual
violence, sexual assault, or stalking, 24-hour telephone
hotline services for police protection and referral to
shelters.
(6) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(7) State.--The term ``State'' includes the District of
Columbia, any commonwealth, possession, or other territory of
the United States, and any Indian tribe or reservation.
(8) Supportive social services.--The term ``supportive
social services'' means transitional and permanent housing,
vocational counseling, and individual and group counseling
aimed at preventing domestic violence, sexual violence,
sexual assault, or stalking.
(9) Violence.--The term ``violence'' means actual violence
and the risk or threat of violence.

SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE FUND.

(a) In General.--The Secretary, in collaboration and
coordination with the Secretary of Education (as
appropriate), shall establish a Pregnancy Assistance Fund to
be administered by the Secretary, for the purpose of awarding
competitive grants to States to assist pregnant and parenting
teens and women.
(b) Use of Fund.--A State may apply for a grant under
subsection (a) to carry out any activities provided for in
section 10213.
(c) Applications.--To be eligible to receive a grant under
subsection (a), a State shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require, including a
description of the purposes for which the grant is being
requested and the designation of a State agency for receipt
and administration of funding received under this part.

SEC. 10213. PERMISSIBLE USES OF FUND.

(a) In General.--A State shall use amounts received under a
grant under section 10212 for the purposes described in this
section to assist pregnant and parenting teens and women.
(b) Institutions of Higher Education.--
(1) In general.--A State may use amounts received under a
grant under section 10212 to make funding available to
eligible institutions of higher education to enable the
eligible institutions to establish, maintain, or operate
pregnant and parenting student services. Such funding shall
be used to supplement, not supplant, existing funding for
such services.
(2) Application.--An eligible institution of higher
education that desires to receive funding under this
subsection shall submit an application to the designated
State agency at such time, in such manner, and containing
such information as the State agency may require.
(3) Matching requirement.--An eligible institution of
higher education that receives funding under this subsection
shall contribute to the conduct of the pregnant and parenting
student services office supported by the funding an amount
from non-Federal funds equal to 25 percent of the amount of

[[Page S13504]]

the funding provided. The non-Federal share may be in cash or
in-kind, fairly evaluated, including services, facilities,
supplies, or equipment.
(4) Use of funds for assisting pregnant and parenting
college students.--An eligible institution of higher
education that receives funding under this subsection shall
use such funds to establish, maintain or operate pregnant and
parenting student services and may use such funding for the
following programs and activities:
(A) Conduct a needs assessment on campus and within the
local community--
(i) to assess pregnancy and parenting resources, located on
the campus or within the local community, that are available
to meet the needs described in subparagraph (B); and
(ii) to set goals for--

(I) improving such resources for pregnant, parenting, and
prospective parenting students; and
(II) improving access to such resources.

(B) Annually assess the performance of the eligible
institution in meeting the following needs of students
enrolled in the eligible institution who are pregnant or are
parents:
(i) The inclusion of maternity coverage and the
availability of riders for additional family members in
student health care.
(ii) Family housing.
(iii) Child care.
(iv) Flexible or alternative academic scheduling, such as
telecommuting programs, to enable pregnant or parenting
students to continue their education or stay in school.
(v) Education to improve parenting skills for mothers and
fathers and to strengthen marriages.
(vi) Maternity and baby clothing, baby food (including
formula), baby furniture, and similar items to assist parents
and prospective parents in meeting the material needs of
their children.
(vii) Post-partum counseling.
(C) Identify public and private service providers, located
on the campus of the eligible institution or within the local
community, that are qualified to meet the needs described in
subparagraph (B), and establishes programs with qualified
providers to meet such needs.
(D) Assist pregnant and parenting students, fathers or
spouses in locating and obtaining services that meet the
needs described in subparagraph (B).
(E) If appropriate, provide referrals for prenatal care and
delivery, infant or foster care, or adoption, to a student
who requests such information. An office shall make such
referrals only to service providers that serve the following
types of individuals:
(i) Parents.
(ii) Prospective parents awaiting adoption.
(iii) Women who are pregnant and plan on parenting or
placing the child for adoption.
(iv) Parenting or prospective parenting couples.
(5) Reporting.--
(A) Annual report by institutions.--
(i) In general.--For each fiscal year that an eligible
institution of higher education receives funds under this
subsection, the eligible institution shall prepare and submit
to the State, by the date determined by the State, a report
that--

(I) itemizes the pregnant and parenting student services
office's expenditures for the fiscal year;
(II) contains a review and evaluation of the performance of
the office in fulfilling the requirements of this section,
using the specific performance criteria or standards
established under subparagraph (B)(i); and
(III) describes the achievement of the office in meeting
the needs listed in paragraph (4)(B) of the students served
by the eligible institution, and the frequency of use of the
office by such students.

(ii) Performance criteria.--Not later than 180 days before
the date the annual report described in clause (i) is
submitted, the State--

(I) shall identify the specific performance criteria or
standards that shall be used to prepare the report; and
(II) may establish the form or format of the report.

(B) Report by state.--The State shall annually prepare and
submit a report on the findings under this subsection,
including the number of eligible institutions of higher
education that were awarded funds and the number of students
served by each pregnant and parenting student services office
receiving funds under this section, to the Secretary.
(c) Support for Pregnant and Parenting Teens.--A State may
use amounts received under a grant under section 10212 to
make funding available to eligible high schools and community
service centers to establish, maintain or operate pregnant
and parenting services in the same general manner and in
accordance with all conditions and requirements described in
subsection (b), except that paragraph (3) of such subsection
shall not apply for purposes of this subsection.
(d) Improving Services for Pregnant Women Who Are Victims
of Domestic Violence, Sexual Violence, Sexual Assault, and
Stalking.--
(1) In general.--A State may use amounts received under a
grant under section 10212 to make funding available tp its
State Attorney General to assist Statewide offices in
providing--
(A) intervention services, accompaniment, and supportive
social services for eligible pregnant women who are victims
of domestic violence, sexual violence, sexual assault, or
stalking.
(B) technical assistance and training (as described in
subsection (c)) relating to violence against eligible
pregnant women to be made available to the following:
(i) Federal, State, tribal, territorial, and local
governments, law enforcement agencies, and courts.
(ii) Professionals working in legal, social service, and
health care settings.
(iii) Nonprofit organizations.
(iv) Faith-based organizations.
(2) Eligibility.--To be eligible for a grant under
paragraph (1), a State Attorney General shall submit an
application to the designated State agency at such time, in
such manner, and containing such information, as specified by
the State.
(3) Technical assistance and training described.--For
purposes of paragraph (1)(B), technical assistance and
training is--
(A) the identification of eligible pregnant women
experiencing domestic violence, sexual violence, sexual
assault, or stalking;
(B) the assessment of the immediate and short-term safety
of such a pregnant woman, the evaluation of the impact of the
violence or stalking on the pregnant woman's health, and the
assistance of the pregnant woman in developing a plan aimed
at preventing further domestic violence, sexual violence,
sexual assault, or stalking, as appropriate;
(C) the maintenance of complete medical or forensic records
that include the documentation of any examination, treatment
given, and referrals made, recording the location and nature
of the pregnant woman's injuries, and the establishment of
mechanisms to ensure the privacy and confidentiality of those
medical records; and
(D) the identification and referral of the pregnant woman
to appropriate public and private nonprofit entities that
provide intervention services, accompaniment, and supportive
social services.
(4) Eligible pregnant woman.--In this subsection, the term
``eligible pregnant woman'' means any woman who is pregnant
on the date on which such woman becomes a victim of domestic
violence, sexual violence, sexual assault, or stalking or who
was pregnant during the one-year period before such date.
(e) Public Awareness and Education.--A State may use
amounts received under a grant under section 10212 to make
funding available to increase public awareness and education
concerning any services available to pregnant and parenting
teens and women under this part, or any other resources
available to pregnant and parenting women in keeping with the
intent and purposes of this part. The State shall be
responsible for setting guidelines or limits as to how much
of funding may be utilized for public awareness and education
in any funding award.

SEC. 10214. APPROPRIATIONS.

There is authorized to be appropriated, and there are
appropriated, $25,000,000 for each of fiscal years 2010
through 2019, to carry out this part.

PART III--INDIAN HEALTH CARE IMPROVEMENT

SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.

(a) In General.--Except as provided in subsection (b), S.
1790 entitled ``A bill to amend the Indian Health Care
Improvement Act to revise and extend that Act, and for other
purposes.'', as reported by the Committee on Indian Affairs
of the Senate in December 2009, is enacted into law.
(b) Amendments.--
(1) Section 119 of the Indian Health Care Improvement Act
(as amended by section 111 of the bill referred to in
subsection (a)) is amended--
(A) in subsection (d)--
(i) in paragraph (2), by striking ``In establishing'' and
inserting ``Subject to paragraphs (3) and (4), in
establishing''; and
(ii) by adding at the end the following:
``(3) Election of indian tribe or tribal organization.--
``(A) In general.--Subparagraph (B) of paragraph (2) shall
not apply in the case of an election made by an Indian tribe
or tribal organization located in a State (other than Alaska)
in which the use of dental health aide therapist services or
midlevel dental health provider services is authorized under
State law to supply such services in accordance with State
law.
``(B) Action by secretary.--On an election by an Indian
tribe or tribal organization under subparagraph (A), the
Secretary, acting through the Service, shall facilitate
implementation of the services elected.
``(4) Vacancies.--The Secretary shall not fill any vacancy
for a certified dentist in a program operated by the Service
with a dental health aide therapist.''; and
(B) by adding at the end the following:
``(e) Effect of Section.--Nothing in this section shall
restrict the ability of the Service, an Indian tribe, or a
tribal organization to participate in any program or to
provide any service authorized by any other Federal law.''.
(2) The Indian Health Care Improvement Act (as amended by
section 134(b) of the bill referred to in subsection (a)) is
amended by striking section 125 (relating to treatment of
scholarships for certain purposes).
(3) Section 806 of the Indian Health Care Improvement Act
(25 U.S.C. 1676) is amended--
(A) by striking ``Any limitation'' and inserting the
following:
``(a) HHS Appropriations.--Any limitation''; and
(B) by adding at the end the following:

[[Page S13505]]

``(b) Limitations Pursuant to Other Federal Law.--Any
limitation pursuant to other Federal laws on the use of
Federal funds appropriated to the Service shall apply with
respect to the performance or coverage of abortions.''.
(4) The bill referred to in subsection (a) is amended by
striking section 201.

Subtitle C--Provisions Relating to Title III

SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR
AMBULATORY SURGICAL CENTERS.

(a) In General.--Section 3006 is amended by adding at the
end the following new subsection:
``(f) Ambulatory Surgical Centers.--
``(1) In general.--The Secretary shall develop a plan to
implement a value-based purchasing program for payments under
the Medicare program under title XVIII of the Social Security
Act for ambulatory surgical centers (as described in section
1833(i) of the Social Security Act (42 U.S.C. 1395l(i))).
``(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
``(A) The ongoing development, selection, and modification
process for measures (including under section 1890 of the
Social Security Act (42 U.S.C. 1395aaa) and section 1890A of
such Act, as added by section 3014), to the extent feasible
and practicable, of all dimensions of quality and efficiency
in ambulatory surgical centers.
``(B) The reporting, collection, and validation of quality
data.
``(C) The structure of value-based payment adjustments,
including the determination of thresholds or improvements in
quality that would substantiate a payment adjustment, the
size of such payments, and the sources of funding for the
value-based bonus payments.
``(D) Methods for the public disclosure of information on
the performance of ambulatory surgical centers.
``(E) Any other issues determined appropriate by the
Secretary.
``(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
``(A) consult with relevant affected parties; and
``(B) consider experience with such demonstrations that the
Secretary determines are relevant to the value-based
purchasing program described in paragraph (1).
``(4) Report to congress.--Not later than January 1, 2011,
the Secretary shall submit to Congress a report containing
the plan developed under paragraph (1).''.
(b) Technical.--Section 3006(a)(2)(A) is amended by
striking clauses (i) and (ii).

SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY
IMPROVEMENT IN HEALTH CARE.

Section 399HH(a)(2)(B)(iii) of the Public Health Service
Act, as added by section 3011, is amended by inserting
``(taking into consideration the limitations set forth in
subsections (c) and (d) of section 1182 of the Social
Security Act)'' after ``information''.

SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.

(a) Development.--Section 931 of the Public Health Service
Act, as added by section 3013(a), is amended by adding at the
end the following new subsection:
``(f) Development of Outcome Measures.--
``(1) In general.--The Secretary shall develop, and
periodically update (not less than every 3 years), provider-
level outcome measures for hospitals and physicians, as well
as other providers as determined appropriate by the
Secretary.
``(2) Categories of measures.--The measures developed under
this subsection shall include, to the extent determined
appropriate by the Secretary--
``(A) outcome measurement for acute and chronic diseases,
including, to the extent feasible, the 5 most prevalent and
resource-intensive acute and chronic medical conditions; and
``(B) outcome measurement for primary and preventative
care, including, to the extent feasible, measurements that
cover provision of such care for distinct patient populations
(such as healthy children, chronically ill adults, or infirm
elderly individuals).
``(3) Goals.--In developing such measures, the Secretary
shall seek to--
``(A) address issues regarding risk adjustment,
accountability, and sample size;
``(B) include the full scope of services that comprise a
cycle of care; and
``(C) include multiple dimensions.
``(4) Timeframe.--
``(A) Acute and chronic diseases.--Not later than 24 months
after the date of enactment of this Act, the Secretary shall
develop not less than 10 measures described in paragraph
(2)(A).
``(B) Primary and preventive care.--Not later than 36
months after the date of enactment of this Act, the Secretary
shall develop not less than 10 measures described in
paragraph (2)(B).''.
(b) Hospital-Acquired Conditions.--Section 1890A of the
Social Security Act, as amended by section 3013(b), is
amended by adding at the end the following new subsection:
``(f) Hospital Acquired Conditions.--The Secretary shall,
to the extent practicable, publicly report on measures for
hospital-acquired conditions that are currently utilized by
the Centers for Medicare & Medicaid Services for the
adjustment of the amount of payment to hospitals based on
rates of hospital-acquired infections.''.
(c) Clinical Practice Guidelines.--Section 304(b) of the
Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275) is amended by adding at the end the
following new paragraph:
``(4) Identification.--
``(A) In general.--Following receipt of the report
submitted under paragraph (2), and not less than every 3
years thereafter, the Secretary shall contract with the
Institute to employ the results of the study performed under
paragraph (1) and the best methods identified by the
Institute for the purpose of identifying existing and new
clinical practice guidelines that were developed using such
best methods, including guidelines listed in the National
Guideline Clearinghouse.
``(B) Consultation.--In carrying out the identification
process under subparagraph (A), the Secretary shall allow for
consultation with professional societies, voluntary health
care organizations, and expert panels.''.

SEC. 10304. SELECTION OF EFFICIENCY MEASURES.

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

SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.

Section 399II(a) of the Public Health Service Act, as added
by section 3015, is amended to read as follows:
``(a) In General.--
``(1) Establishment of strategic framework.--The Secretary
shall establish and implement an overall strategic framework
to carry out the public reporting of performance information,
as described in section 399JJ. Such strategic framework may
include methods and related timelines for implementing
nationally consistent data collection, data aggregation, and
analysis methods.
``(2) Collection and aggregation of data.--The Secretary
shall collect and aggregate consistent data on quality and
resource use measures from information systems used to
support health care delivery, and may award grants or
contracts for this purpose. The Secretary shall align such
collection and aggregation efforts with the requirements and
assistance regarding the expansion of health information
technology systems, the interoperability of such technology
systems, and related standards that are in effect on the date
of enactment of the Patient Protection and Affordable Care
Act.
``(3) Scope.--The Secretary shall ensure that the data
collection, data aggregation, and analysis systems described
in paragraph (1) involve an increasingly broad range of
patient populations, providers, and geographic areas over
time.''.

SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND
MEDICAID INNOVATION.

Section 1115A of the Social Security Act, as added by
section 3021, is amended--
(1) in subsection (a), by inserting at the end the
following new paragraph:
``(5) Testing within certain geographic areas.--For
purposes of testing payment and service delivery models under
this section, the Secretary may elect to limit testing of a
model to certain geographic areas.'';
(2) in subsection (b)(2)--
(A) in subparagraph (A)--
(i) in the second sentence, by striking ``the preceding
sentence may include'' and inserting ``this subparagraph may
include, but are not limited to,''; and
(ii) by inserting after the first sentence the following
new sentence: ``The Secretary shall focus on models expected
to reduce program costs under the applicable title while
preserving or enhancing the quality of care received by
individuals receiving benefits under such title.'';
(B) in subparagraph (B), by adding at the end the following
new clauses:
``(xix) Utilizing, in particular in entities located in
medically underserved areas and facilities of the Indian
Health Service (whether operated by such Service or by an
Indian tribe or tribal organization (as those terms are
defined in section 4 of the Indian Health Care Improvement
Act)), telehealth services--

``(I) in treating behavioral health issues (such as post-
traumatic stress disorder) and stroke; and
``(II) to improve the capacity of non-medical providers and
non-specialized medical providers to provide health services
for patients with chronic complex conditions.

``(xx) Utilizing a diverse network of providers of services
and suppliers to improve care coordination for applicable
individuals described in subsection (a)(4)(A)(i) with 2 or
more chronic conditions and a history of prior-year
hospitalization through interventions developed under the
Medicare Coordinated Care Demonstration Project under section
4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b-1
note).''; and
(C) in subparagraph (C), by adding at the end the following
new clause:
``(viii) Whether the model demonstrates effective linkage
with other public sector or private sector payers.'';
(3) in subsection (b)(4), by adding at the end the
following new subparagraph:
``(C) Measure selection.--To the extent feasible, the
Secretary shall select measures under this paragraph that
reflect national priorities for quality improvement and
patient-centered care consistent with the measures described
in 1890(b)(7)(B).''; and
(4) in subsection (c)--

[[Page S13506]]

(A) in paragraph (1)(B), by striking ``care and reduce
spending; and'' and inserting ``patient care without
increasing spending;'';
(B) in paragraph (2), by striking ``reduce program spending
under applicable titles.'' and inserting ``reduce (or would
not result in any increase in) net program spending under
applicable titles; and''; and
(C) by adding at the end the following:
``(3) the Secretary determines that such expansion would
not deny or limit the coverage or provision of benefits under
the applicable title for applicable individuals.

In determining which models or demonstration projects to
expand under the preceding sentence, the Secretary shall
focus on models and demonstration projects that improve the
quality of patient care and reduce spending.''.

SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS
PROGRAM.

Section 1899 of the Social Security Act, as added by
section 3022, is amended by adding at the end the following
new subsections:
``(i) Option To Use Other Payment Models.--
``(1) In general.--If the Secretary determines appropriate,
the Secretary may use any of the payment models described in
paragraph (2) or (3) for making payments under the program
rather than the payment model described in subsection (d).
``(2) Partial capitation model.--
``(A) In general.--Subject to subparagraph (B), a model
described in this paragraph is a partial capitation model in
which an ACO is at financial risk for some, but not all, of
the items and services covered under parts A and B, such as
at risk for some or all physicians' services or all items and
services under part B. The Secretary may limit a partial
capitation model to ACOs that are highly integrated systems
of care and to ACOs capable of bearing risk, as determined to
be appropriate by the Secretary.
``(B) No additional program expenditures.--Payments to an
ACO for items and services under this title for beneficiaries
for a year under the partial capitation model shall be
established in a manner that does not result in spending more
for such ACO for such beneficiaries than would otherwise be
expended for such ACO for such beneficiaries for such year if
the model were not implemented, as estimated by the
Secretary.
``(3) Other payment models.--
``(A) In general.--Subject to subparagraph (B), a model
described in this paragraph is any payment model that the
Secretary determines will improve the quality and efficiency
of items and services furnished under this title.
``(B) No additional program expenditures.--Subparagraph (B)
of paragraph (2) shall apply to a payment model under
subparagraph (A) in a similar manner as such subparagraph (B)
applies to the payment model under paragraph (2).
``(j) Involvement in Private Payer and Other Third Party
Arrangements.--The Secretary may give preference to ACOs who
are participating in similar arrangements with other payers.
``(k) Treatment of Physician Group Practice
Demonstration.--During the period beginning on the date of
the enactment of this section and ending on the date the
program is established, the Secretary may enter into an
agreement with an ACO under the demonstration under section
1866A, subject to rebasing and other modifications deemed
appropriate by the Secretary.''.

SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT
BUNDLING.

(a) In General.--Section 1866D of the Social Security Act,
as added by section 3023, is amended--
(1) in paragraph (a)(2)(B), in the matter preceding clause
(i), by striking ``8 conditions'' and inserting ``10
conditions'';
(2) by striking subsection (c)(1)(B) and inserting the
following:
``(B) Expansion.--The Secretary may, at any point after
January 1, 2016, expand the duration and scope of the pilot
program, to the extent determined appropriate by the
Secretary, if--
``(i) the Secretary determines that such expansion is
expected to--

``(I) reduce spending under title XVIII of the Social
Security Act without reducing the quality of care; or
``(II) improve the quality of care and reduce spending;

``(ii) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under such title XVIII; and
``(iii) the Secretary determines that such expansion would
not deny or limit the coverage or provision of benefits under
this title for individuals.''; and
(3) by striking subsection (g) and inserting the following
new subsection:
``(g) Application of Pilot Program to Continuing Care
Hospitals.--
``(1) In general.--In conducting the pilot program, the
Secretary shall apply the provisions of the program so as to
separately pilot test the continuing care hospital model.
``(2) Special rules.--In pilot testing the continuing care
hospital model under paragraph (1), the following rules shall
apply:
``(A) Such model shall be tested without the limitation to
the conditions selected under subsection (a)(2)(B).
``(B) Notwithstanding subsection (a)(2)(D), an episode of
care shall be defined as the full period that a patient stays
in the continuing care hospital plus the first 30 days
following discharge from such hospital.
``(3) Continuing care hospital defined.--In this
subsection, the term `continuing care hospital' means an
entity that has demonstrated the ability to meet patient care
and patient safety standards and that provides under common
management the medical and rehabilitation services provided
in inpatient rehabilitation hospitals and units (as defined
in section 1886(d)(1)(B)(ii)), long term care hospitals (as
defined in section1886(d)(1)(B)(iv)(I)), and skilled nursing
facilities (as defined in section 1819(a)) that are located
in a hospital described in section 1886(d).''.
(b) Technical Amendments.--
(1) Section 3023 is amended by striking ``1886C'' and
inserting ``1866C''.
(2) Title XVIII of the Social Security Act is amended by
redesignating section 1866D, as added by section 3024, as
section 1866E.

SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION
PROGRAM.

Section 1886(q)(1) of the Social Security Act, as added by
section 3025, in the matter preceding subparagraph (A), is
amended by striking ``the Secretary shall reduce the
payments'' and all that follows through ``the product of''
and inserting ``the Secretary shall make payments (in
addition to the payments described in paragraph (2)(A)(ii))
for such a discharge to such hospital under subsection (d)
(or section 1814(b)(3), as the case may be) in an amount
equal to the product of''.

SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.

The provisions of, and the amendment made by, section 3101
are repealed

SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE ADD-ONS.

(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)), as amended by
section 3105(a), is further amended--
(1) in the matter preceding clause (i)--
(A) by striking ``2007, for'' and inserting ``2007, and
for''; and
(B) by striking ``2010, and for such services furnished on
or after April 1, 2010, and before January 1, 2011'' and
inserting ``2011''; and
(2) in each of clauses (i) and (ii)--
(A) by striking ``, and on or after April 1, 2010, and
before January 1, 2011'' each place it appears; and
(B) by striking ``January 1, 2010'' and inserting ``January
1, 2011'' each place it appears.
(b) Air Ambulance.--Section 146(b)(1) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public
Law 110-275), as amended by section 3105(b), is further
amended by striking ``December 31, 2009, and during the
period beginning on April 1, 2010, and ending on January 1,
2011'' and inserting ``December 31, 2010''.
(c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)), as amended
by section 3105(c), is further amended by striking ``2010,
and on or after April 1, 2010, and before January 1, 2011''
and inserting ``2011''.

SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL
SERVICES AND MORATORIUM ON THE ESTABLISHMENT OF
CERTAIN HOSPITALS AND FACILITIES.

(a) Certain Payment Rules.--Section 114(c) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww
note), as amended by section 4302(a) of the American Recovery
and Reinvestment Act (Public Law 111-5) and section 3106(a)
of this Act, is further amended by striking ``4-year period''
each place it appears and inserting ``5-year period''.
(b) Moratorium.--Section 114(d) of such Act (42 U.S.C.
1395ww note), as amended by section 3106(b) of this Act, in
the matter preceding subparagraph (A), is amended by striking
``4-year period'' and inserting ``5-year period''.

SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL
COMMUNITY HOSPITAL DEMONSTRATION PROGRAM.

(a) In General.--Subsection (g) of section 410A of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173; 117 Stat. 2272), as added by
section 3123(a) of this Act, is amended to read as follows:
``(g) Five-Year Extension of Demonstration Program.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall conduct the
demonstration program under this section for an additional 5-
year period (in this section referred to as the `5-year
extension period') that begins on the date immediately
following the last day of the initial 5-year period under
subsection (a)(5).
``(2) Expansion of demonstration states.--Notwithstanding
subsection (a)(2), during the 5-year extension period, the
Secretary shall expand the number of States with low
population densities determined by the Secretary under such
subsection to 20. In determining which States to include in
such expansion, the Secretary shall use the same criteria and
data that the Secretary used to determine the States under
such subsection for purposes of the initial 5-year period.
``(3) Increase in maximum number of hospitals participating
in the demonstration program.--Notwithstanding subsection
(a)(4), during the 5-year extension period, not more than 30
rural community hospitals may participate in the
demonstration program under this section.
``(4) Hospitals in demonstration program on date of
enactment.--In the case of a

[[Page S13507]]

rural community hospital that is participating in the
demonstration program under this section as of the last day
of the initial 5-year period, the Secretary--
``(A) shall provide for the continued participation of such
rural community hospital in the demonstration program during
the 5-year extension period unless the rural community
hospital makes an election, in such form and manner as the
Secretary may specify, to discontinue such participation; and
``(B) in calculating the amount of payment under subsection
(b) to the rural community hospital for covered inpatient
hospital services furnished by the hospital during such 5-
year extension period, shall substitute, under paragraph
(1)(A) of such subsection--
``(i) the reasonable costs of providing such services for
discharges occurring in the first cost reporting period
beginning on or after the first day of the 5-year extension
period, for
``(ii) the reasonable costs of providing such services for
discharges occurring in the first cost reporting period
beginning on or after the implementation of the demonstration
program.''.
(b) Conforming Amendments.--Subsection (a)(5) of section
410A of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat.
2272), as amended by section 3123(b) of this Act, is amended
by striking ``1-year extension'' and inserting ``5-year
extension''.

SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION.

Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12), as amended by section 3125, is amended--
(1) in subparagraph (C)(i), by striking ``1,500
discharges'' and inserting ``1,600 discharges''; and
(2) in subparagraph (D), by striking ``1,500 discharges''
and inserting ``1,600 discharges''.

SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS.

(a) Rebasing.--Section 1895(b)(3)(A)(iii) of the Social
Security Act, as added by section 3131, is amended--
(1) in the clause heading, by striking ``2013'' and
inserting ``2014'';
(2) in subclause (I), by striking ``2013'' and inserting
``2014''; and
(3) in subclause (II), by striking ``2016'' and inserting
``2017''.
(b) Revision of Home Health Study and Report.--Section
3131(d) is amended to read as follows:
``(d) Study and Report on the Development of Home Health
Payment Revisions in Order to Ensure Access to Care and
Payment for Severity of Illness.--
``(1) In general.--The Secretary of Health and Human
Services (in this section referred to as the `Secretary')
shall conduct a study on home health agency costs involved
with providing ongoing access to care to low-income Medicare
beneficiaries or beneficiaries in medically underserved
areas, and in treating beneficiaries with varying levels of
severity of illness. In conducting the study, the Secretary
may analyze items such as the following:
``(A) Methods to potentially revise the home health
prospective payment system under section 1895 of the Social
Security Act (42 U.S.C. 1395fff) to account for costs related
to patient severity of illness or to improving beneficiary
access to care, such as--
``(i) payment adjustments for services that may involve
additional or fewer resources;
``(ii) changes to reflect resources involved with providing
home health services to low-income Medicare beneficiaries or
Medicare beneficiaries residing in medically underserved
areas;
``(iii) ways outlier payments might be revised to reflect
costs of treating Medicare beneficiaries with high levels of
severity of illness; and
``(iv) other issues determined appropriate by the
Secretary.
``(B) Operational issues involved with potential
implementation of potential revisions to the home health
payment system, including impacts for both home health
agencies and administrative and systems issues for the
Centers for Medicare & Medicaid Services, and any possible
payment vulnerabilities associated with implementing
potential revisions.
``(C) Whether additional research might be needed.
``(D) Other items determined appropriate by the Secretary.
``(2) Considerations.--In conducting the study under
paragraph (1), the Secretary may consider whether patient
severity of illness and access to care could be measured by
factors, such as--
``(A) population density and relative patient access to
care;
``(B) variations in service costs for providing care to
individuals who are dually eligible under the Medicare and
Medicaid programs;
``(C) the presence of severe or chronic diseases, which
might be measured by multiple, discontinuous home health
episodes;
``(D) poverty status, such as evidenced by the receipt of
Supplemental Security Income under title XVI of the Social
Security Act; and
``(E) other factors determined appropriate by the
Secretary.
``(3) Report.--Not later than March 1, 2014, the Secretary
shall submit to Congress a report on the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
``(4) Consultations.--In conducting the study under
paragraph (1), the Secretary shall consult with appropriate
stakeholders, such as groups representing home health
agencies and groups representing Medicare beneficiaries.
``(5) Medicare demonstration project based on the results
of the study.--
``(A) In general.--Subject to subparagraph (D), taking into
account the results of the study conducted under paragraph
(1), the Secretary may, as determined appropriate, provide
for a demonstration project to test whether making payment
adjustments for home health services under the Medicare
program would substantially improve access to care for
patients with high severity levels of illness or for low-
income or underserved Medicare beneficiaries.
``(B) Waiving budget neutrality.--The Secretary shall not
reduce the standard prospective payment amount (or amounts)
under section 1895 of the Social Security Act (42 U.S.C.
1395fff) applicable to home health services furnished during
a period to offset any increase in payments during such
period resulting from the application of the payment
adjustments under subparagraph (A).
``(C) No effect on subsequent periods.--A payment
adjustment resulting from the application of subparagraph (A)
for a period--
``(i) shall not apply to payments for home health services
under title XVIII after such period; and
``(ii) shall not be taken into account in calculating the
payment amounts applicable for such services after such
period.
``(D) Duration.--If the Secretary determines it appropriate
to conduct the demonstration project under this subsection,
the Secretary shall conduct the project for a four year
period beginning not later than January 1, 2015.
``(E) Funding.--The Secretary shall provide for the
transfer from the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and
the Federal Supplementary Medical Insurance Trust Fund
established under section 1841 of such Act (42 U.S.C. 1395t),
in such proportion as the Secretary determines appropriate,
of $500,000,000 for the period of fiscal years 2015 through
2018. Such funds shall be made available for the study
described in paragraph (1) and the design, implementation and
evaluation of the demonstration described in this paragraph.
Amounts available under this subparagraph shall be available
until expended.
``(F) Evaluation and report.--If the Secretary determines
it appropriate to conduct the demonstration project under
this subsection, the Secretary shall--
``(i) provide for an evaluation of the project; and
``(ii) submit to Congress, by a date specified by the
Secretary, a report on the project.
``(G) Administration.--Chapter 35 of title 44, United
States Code, shall not apply with respect to this
subsection.''.

SEC. 10316. MEDICARE DSH.

Section 1886(r)(2)(B) of the Social Security Act, as added
by section 3133, is amended--
(1) in clause (i)--
(A) in the matter preceding subclause (I), by striking
``(divided by 100)'';
(B) in subclause (I), by striking ``2012'' and inserting
``2013'';
(C) in subclause (II), by striking the period at the end
and inserting a comma; and
(D) by adding at the end the following flush matter:
``minus 1.5 percentage points.''.
(2) in clause (ii)--
(A) in the matter preceding subclause (I), by striking
``(divided by 100)'';
(B) in subclause (I), by striking ``2012'' and inserting
``2013'';
(C) in subclause (II), by striking the period at the end
and inserting a comma; and
(D) by adding at the end the following flush matter:

``and, for each of 2018 and 2019, minus 1.5 percentage
points.''.

SEC. 10317. REVISIONS TO EXTENSION OF SECTION 508 HOSPITAL
PROVISIONS.

Section 3137(a) is amended to read as follows:
``(a) Extension.--
``(1) In general.--Subsection (a) of section 106 of
division B of the Tax Relief and Health Care Act of 2006 (42
U.S.C. 1395 note), as amended by section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173) and section 124 of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275), is
amended by striking `September 30, 2009' and inserting
`September 30, 2010'.
``(2) Special rule for fiscal year 2010.--
``(A) In general.--Subject to subparagraph (B), for
purposes of implementation of the amendment made by paragraph
(1), including (notwithstanding paragraph (3) of section
117(a) of the Medicare, Medicaid and SCHIP Extension Act of
2007 (Public Law 110-173), as amended by section 124(b) of
the Medicare Improvements for Patients and Providers Act of
2008 (Public Law 110-275)) for purposes of the implementation
of paragraph (2) of such section 117(a), during fiscal year
2010, the Secretary of Health and Human Services (in this
subsection referred to as the `Secretary') shall use the
hospital wage index that was promulgated by the Secretary in
the Federal Register on August 27, 2009 (74 Fed. Reg. 43754),
and any subsequent corrections.

[[Page S13508]]

``(B) Exception.--Beginning on April 1, 2010, in
determining the wage index applicable to hospitals that
qualify for wage index reclassification, the Secretary shall
include the average hourly wage data of hospitals whose
reclassification was extended pursuant to the amendment made
by paragraph (1) only if including such data results in a
higher applicable reclassified wage index.
``(3) Adjustment for certain hospitals in fiscal year
2010.--
``(A) In general.--In the case of a subsection (d) hospital
(as defined in subsection (d)(1)(B) of section 1886 of the
Social Security Act (42 U.S.C. 1395ww)) with respect to
which--
``(i) a reclassification of its wage index for purposes of
such section was extended pursuant to the amendment made by
paragraph (1); and
``(ii) the wage index applicable for such hospital for the
period beginning on October 1, 2009, and ending on March 31,
2010, was lower than for the period beginning on April 1,
2010, and ending on September 30, 2010, by reason of the
application of paragraph (2)(B);
the Secretary shall pay such hospital an additional payment
that reflects the difference between the wage index for such
periods.
``(B) Timeframe for payments.--The Secretary shall make
payments required under subparagraph by not later than
December 31, 2010.''.

SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER
MEDICARE ADVANTAGE.

Section 1853(p)(3)(A) of the Social Security Act, as added
by section 3201(h), is amended by inserting ``in 2009''
before the period at the end.

SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS.

(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B)(xii)
of the Social Security Act, as added by section 3401(a), is
amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of fiscal years 2012 and 2013, by 0.1
percentage point; and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
(b) Long-Term Care Hospitals.--Section 1886(m)(4) of the
Social Security Act, as added by section 3401(c), is
amended--
(1) in subparagraph (A)--
(A) in clause (i)--
(i) by striking ``each of rate years 2010 and 2011'' and
inserting ``rate year 2010''; and
(ii) by striking ``and'' at the end;
(B) by redesignating clause (ii) as clause (iv);
(C) by inserting after clause (i) the following new
clauses:
``(ii) for rate year 2011, 0.50 percentage point;
``(iii) for each of the rate years beginning in 2012 and
2013, 0.1 percentage point; and''; and
(D) in clause (iv), as redesignated by subparagraph (B), by
striking ``2012'' and inserting ``2014''; and
(2) in subparagraph (B), by striking ``(A)(ii)'' and
inserting ``(A)(iv)''.
(c) Inpatient Rehabilitation Facilities.--Section
1886(j)(3)(D)(i) of the Social Security Act, as added by
section 3401(d), is amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:

``(II) for each of fiscal years 2012 and 2013, 0.1
percentage point; and''; and

(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
(d) Home Health Agencies.--Section 1895(b)(3)(B)(vi)(II) of
such Act, as added by section 3401(e), is amended by striking
``and 2012'' and inserting ``, 2012, and 2013''.
(e) Psychiatric Hospitals.--Section 1886(s)(3)(A) of the
Social Security Act, as added by section 3401(f), is
amended--
(1) in clause (i), by striking ``and'' at the end;
(2) by redesignating clause (ii) as clause (iii);
(3) by inserting after clause (ii) the following new
clause:
``(ii) for each of the rate years beginning in 2012 and
2013, 0.1 percentage point; and''; and
(4) in clause (iii), as redesignated by paragraph (2), by
striking ``2012'' and inserting ``2014''.
(f) Hospice Care.--Section 1814(i)(1)(C) of the Social
Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended by
section 3401(g), is amended--
(1) in clause (iv)(II), by striking ``0.5'' and inserting
``0.3''; and
(2) in clause (v), in the matter preceding subclause (I),
by striking ``0.5'' and inserting ``0.3''.
(g) Outpatient Hospitals.--Section 1833(t)(3)(G)(i) of the
Social Security Act, as added by section 3401(i), is
amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:

``(II) for each of 2012 and 2013, 0.1 percentage point;
and''; and

(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.

SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL
IMPROVEMENTS TO, THE INDEPENDENT MEDICARE
ADVISORY BOARD.

(a) In General.--Section 1899A of the Social Security Act,
as added by section 3403, is amended--
(1) in subsection (c)--
(A) in paragraph (1)(B), by adding at the end the following
new sentence: ``In any year (beginning with 2014) that the
Board is not required to submit a proposal under this
section, the Board shall submit to Congress an advisory
report on matters related to the Medicare program.'';
(B) in paragraph (2)(A)--
(i) in clause (iv), by inserting ``or the full premium
subsidy under section 1860D-14(a)'' before the period at the
end of the last sentence; and
(ii) by adding at the end the following new clause:
``(vii) If the Chief Actuary of the Centers for Medicare &
Medicaid Services has made a determination described in
subsection (e)(3)(B)(i)(II) in the determination year, the
proposal shall be designed to help reduce the growth rate
described in paragraph (8) while maintaining or enhancing
beneficiary access to quality care under this title.'';
(C) in paragraph (2)(B)--
(i) in clause (v), by striking ``and'' at the end;
(ii) in clause (vi), by striking the period at the end and
inserting ``; and''; and
(iii) by adding at the end the following new clause:
``(vii) take into account the data and findings contained
in the annual reports under subsection (n) in order to
develop proposals that can most effectively promote the
delivery of efficient, high quality care to Medicare
beneficiaries.'';
(D) in paragraph (3)--
(i) in the heading, by striking ``Transmission of board
proposal to president'' and inserting ``Submission of board
proposal to congress and the president'';
(ii) in subparagraph (A)(i), by striking ``transmit a
proposal under this section to the President'' and insert
``submit a proposal under this section to Congress and the
President''; and
(iii) in subparagraph (A)(ii)--

(I) in subclause (I), by inserting ``or'' at the end;
(II) in subclause (II), by striking ``; or'' and inserting
a period; and
(III) by striking subclause (III);

(E) in paragraph (4)--
(i) by striking ``the Board under paragraph (3)(A)(i) or'';
and
(ii) by striking ``immediately'' and inserting ``within 2
days'';
(F) in paragraph (5)--
(i) by striking ``to but'' and inserting ``but''; and
(ii) by inserting ``Congress and'' after ``submit a
proposal to''; and
(G) in paragraph (6)(B)(i), by striking ``per unduplicated
enrollee'' and inserting ``(calculated as the sum of per
capita spending under each of parts A, B, and D)'';
(2) in subsection (d)--
(A) in paragraph (1)(A)--
(i) by inserting ``the Board or'' after ``a proposal is
submitted by''; and
(ii) by inserting ``subsection (c)(3)(A)(i) or'' after
``the Senate under''; and
(B) in paragraph (2)(A), by inserting ``the Board or''
after ``a proposal is submitted by'';
(3) in subsection (e)--
(A) in paragraph (1), by inserting ``the Board or'' after
``a proposal submitted by''; and
(B) in paragraph (3)--
(i) by striking ``Exception.--The Secretary shall not be
required to implement the recommendations contained in a
proposal submitted in a proposal year by'' and inserting
``Exceptions.--
``(A) In general.--The Secretary shall not implement the
recommendations contained in a proposal submitted in a
proposal year by the Board or'';
(ii) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively, and indenting appropriately; and
(iii) by adding at the end the following new subparagraph:
``(B) Limited additional exception.--
``(i) In general.--Subject to clause (ii), the Secretary
shall not implement the recommendations contained in a
proposal submitted by the Board or the President to Congress
pursuant to this section in a proposal year (beginning with
proposal year 2019) if--

``(I) the Board was required to submit a proposal to
Congress under this section in the year preceding the
proposal year; and
``(II) the Chief Actuary of the Centers for Medicare &
Medicaid Services makes a determination in the determination
year that the growth rate described in subsection (c)(8)
exceeds the growth rate described in subsection (c)(6)(A)(i).

``(ii) Limited additional exception may not be applied in
two consecutive years.--This subparagraph shall not apply if
the recommendations contained in a proposal submitted by the
Board or the President to Congress pursuant to this section
in the year preceding the proposal year were not required to
be implemented by reason of this subparagraph.
``(iii) No affect on requirement to submit proposals or for
congressional consideration of proposals.--Clause (i) and
(ii) shall not affect--

[[Page S13509]]

``(I) the requirement of the Board or the President to
submit a proposal to Congress in a proposal year in
accordance with the provisions of this section; or
``(II) Congressional consideration of a legislative
proposal (described in subsection (c)(3)(B)(iv)) contained
such a proposal in accordance with subsection (d).'';

(4) in subsection (f)(3)(B)--
(A) by striking ``or advisory reports to Congress'' and
inserting ``, advisory reports, or advisory
recommendations''; and
(B) by inserting ``or produce the public report under
subsection (n)'' after ``this section''; and
(5) by adding at the end the following new subsections:
``(n) Annual Public Report.--
``(1) In general.--Not later than July 1, 2014, and
annually thereafter, the Board shall produce a public report
containing standardized information on system-wide health
care costs, patient access to care, utilization, and quality-
of-care that allows for comparison by region, types of
services, types of providers, and both private payers and the
program under this title.
``(2) Requirements.--Each report produced pursuant to
paragraph (1) shall include information with respect to the
following areas:
``(A) The quality and costs of care for the population at
the most local level determined practical by the Board (with
quality and costs compared to national benchmarks and
reflecting rates of change, taking into account quality
measures described in section 1890(b)(7)(B)).
``(B) Beneficiary and consumer access to care, patient and
caregiver experience of care, and the cost-sharing or out-of-
pocket burden on patients.
``(C) Epidemiological shifts and demographic changes.
``(D) The proliferation, effectiveness, and utilization of
health care technologies, including variation in provider
practice patterns and costs.
``(E) Any other areas that the Board determines affect
overall spending and quality of care in the private sector.
``(o) Advisory Recommendations for Non-Federal Health Care
Programs.--
``(1) In general.--Not later than January 15, 2015, and at
least once every two years thereafter, the Board shall submit
to Congress and the President recommendations to slow the
growth in national health expenditures (excluding
expenditures under this title and in other Federal health
care programs) while preserving or enhancing quality of care,
such as recommendations--
``(A) that the Secretary or other Federal agencies can
implement administratively;
``(B) that may require legislation to be enacted by
Congress in order to be implemented;
``(C) that may require legislation to be enacted by State
or local governments in order to be implemented;
``(D) that private sector entities can voluntarily
implement; and
``(E) with respect to other areas determined appropriate by
the Board.
``(2) Coordination.--In making recommendations under
paragraph (1), the Board shall coordinate such
recommendations with recommendations contained in proposals
and advisory reports produced by the Board under subsection
(c).
``(3) Available to public.--The Board shall make
recommendations submitted to Congress and the President under
this subsection available to the public.''.
(b) Name Change.--Any reference in the provisions of, or
amendments made by, section 3403 to the ``Independent
Medicare Advisory Board'' shall be deemed to be a reference
to the ``Independent Payment Advisory Board''.
(c) Rule of Construction.--Nothing in the amendments made
by this section shall preclude the Independent Medicare
Advisory Board, as established under section 1899A of the
Social Security Act (as added by section 3403), from solely
using data from public or private sources to carry out the
amendments made by subsection (a)(4).

SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS.

Section 3502(c)(2)(A) is amended by inserting ``or other
primary care providers'' after ``physicians''.

SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOSPITALS.

(a) In General.--Section 1886(s) of the Social Security
Act, as added by section 3401(f), is amended by adding at the
end the following new paragraph:
``(4) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--Under the system described in paragraph
(1), for rate year 2014 and each subsequent rate year, in the
case of a psychiatric hospital or psychiatric unit that does
not submit data to the Secretary in accordance with
subparagraph (C) with respect to such a rate year, any annual
update to a standard Federal rate for discharges for the
hospital during the rate year, and after application of
paragraph (2), shall be reduced by 2 percentage points.
``(ii) Special rule.--The application of this subparagraph
may result in such annual update being less than 0.0 for a
rate year, and may result in payment rates under the system
described in paragraph (1) for a rate year being less than
such payment rates for the preceding rate year.
``(B) Noncumulative application.--Any reduction under
subparagraph (A) shall apply only with respect to the rate
year involved and the Secretary shall not take into account
such reduction in computing the payment amount under the
system described in paragraph (1) for a subsequent rate year.
``(C) Submission of quality data.--For rate year 2014 and
each subsequent rate year, each psychiatric hospital and
psychiatric unit shall submit to the Secretary data on
quality measures specified under subparagraph (D). Such data
shall be submitted in a form and manner, and at a time,
specified by the Secretary for purposes of this subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii), any measure
specified by the Secretary under this subparagraph must have
been endorsed by the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for
which a feasible and practical measure has not been endorsed
by the entity with a contract under section 1890(a), the
Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by
the Secretary.
``(iii) Time frame.--Not later than October 1, 2012, the
Secretary shall publish the measures selected under this
subparagraph that will be applicable with respect to rate
year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such procedures
shall ensure that a psychiatric hospital and a psychiatric
unit has the opportunity to review the data that is to be
made public with respect to the hospital or unit prior to
such data being made public. The Secretary shall report
quality measures that relate to services furnished in
inpatient settings in psychiatric hospitals and psychiatric
units on the Internet website of the Centers for Medicare &
Medicaid Services.''.
(b) Conforming Amendment.--Section 1890(b)(7)(B)(i)(I) of
the Social Security Act, as added by section 3014, is amended
by inserting ``1886(s)(4)(D),'' after ``1886(o)(2),''.

SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO
ENVIRONMENTAL HEALTH HAZARDS.

(a) In General.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended by inserting after section
1881 the following new section:

``SEC. 1881A. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO
ENVIRONMENTAL HEALTH HAZARDS.

``(a) Deeming of Individuals as Eligible for Medicare
Benefits.--
``(1) In general.--For purposes of eligibility for benefits
under this title, an individual determined under subsection
(c) to be an environmental exposure affected individual
described in subsection (e)(2) shall be deemed to meet the
conditions specified in section 226(a).
``(2) Discretionary deeming.--For purposes of eligibility
for benefits under this title, the Secretary may deem an
individual determined under subsection (c) to be an
environmental exposure affected individual described in
subsection (e)(3) to meet the conditions specified in section
226(a).
``(3) Effective date of coverage.--An Individual who is
deemed eligible for benefits under this title under paragraph
(1) or (2) shall be--
``(A) entitled to benefits under the program under Part A
as of the date of such deeming; and
``(B) eligible to enroll in the program under Part B
beginning with the month in which such deeming occurs.
``(b) Pilot Program for Care of Certain Individuals
Residing in Emergency Declaration Areas.--
``(1) Program; purpose.--
``(A) Primary pilot program.--The Secretary shall establish
a pilot program in accordance with this subsection to provide
innovative approaches to furnishing comprehensive,
coordinated, and cost-effective care under this title to
individuals described in paragraph (2)(A).
``(B) Optional pilot programs.--The Secretary may establish
a separate pilot program, in accordance with this subsection,
with respect to each geographic area subject to an emergency
declaration (other than the declaration of June 17, 2009), in
order to furnish such comprehensive, coordinated and cost-
effective care to individuals described in subparagraph
(2)(B) who reside in each such area.
``(2) Individual described.--For purposes of paragraph (1),
an individual described in this paragraph is an individual
who enrolls in part B, submits to the Secretary an
application to participate in the applicable pilot program
under this subsection, and--
``(A) is an environmental exposure affected individual
described in subsection (e)(2) who resides in or around the
geographic area subject to an emergency declaration made as
of June 17, 2009; or
``(B) is an environmental exposure affected individual
described in subsection (e)(3) who--
``(i) is deemed under subsection (a)(2); and
``(ii) meets such other criteria or conditions for
participation in a pilot program under paragraph (1)(B) as
the Secretary specifies.
``(3) Flexible benefits and services.--A pilot program
under this subsection may

[[Page S13510]]

provide for the furnishing of benefits, items, or services
not otherwise covered or authorized under this title, if the
Secretary determines that furnishing such benefits, items, or
services will further the purposes of such pilot program (as
described in paragraph (1)).
``(4) Innovative reimbursement methodologies.--For purposes
of the pilot program under this subsection, the Secretary--
``(A) shall develop and implement appropriate methodologies
to reimburse providers for furnishing benefits, items, or
services for which payment is not otherwise covered or
authorized under this title, if such benefits, items, or
services are furnished pursuant to paragraph (3); and
``(B) may develop and implement innovative approaches to
reimbursing providers for any benefits, items, or services
furnished under this subsection.
``(5) Limitation.--Consistent with section 1862(b), no
payment shall be made under the pilot program under this
subsection with respect to benefits, items, or services
furnished to an environmental exposure affected individual
(as defined in subsection (e)) to the extent that such
individual is eligible to receive such benefits, items, or
services through any other public or private benefits plan or
legal agreement.
``(6) Waiver authority.--The Secretary may waive such
provisions of this title and title XI as are necessary to
carry out pilot programs under this subsection.
``(7) Funding.--For purposes of carrying out pilot programs
under this subsection, the Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841, in such proportion
as the Secretary determines appropriate, of such sums as the
Secretary determines necessary, to the Centers for Medicare &
Medicaid Services Program Management Account.
``(8) Waiver of budget neutrality.--The Secretary shall not
require that pilot programs under this subsection be budget
neutral with respect to expenditures under this title.
``(c) Determinations.--
``(1) By the commissioner of social security.--For purposes
of this section, the Commissioner of Social Security, in
consultation with the Secretary, and using the cost
allocation method prescribed in section 201(g), shall
determine whether individuals are environmental exposure
affected individuals.
``(2) By the secretary.--The Secretary shall determine
eligibility for pilot programs under subsection (b).
``(d) Emergency Declaration Defined.--For purposes of this
section, the term `emergency declaration' means a declaration
of a public health emergency under section 104(a) of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980.
``(e) Environmental Exposure Affected Individual Defined.--
``(1) In general.--For purposes of this section, the term
`environmental exposure affected individual' means--
``(A) an individual described in paragraph (2); and
``(B) an individual described in paragraph (3).
``(2) Individual described.--
``(A) In general.--An individual described in this
paragraph is any individual who--
``(i) is diagnosed with 1 or more conditions described in
subparagraph (B);
``(ii) as demonstrated in such manner as the Secretary
determines appropriate, has been present for an aggregate
total of 6 months in the geographic area subject to an
emergency declaration specified in subsection (b)(2)(A),
during a period ending--

``(I) not less than 10 years prior to such diagnosis; and
``(II) prior to the implementation of all the remedial and
removal actions specified in the Record of Decision for
Operating Unit 4 and the Record of Decision for Operating
Unit 7;

``(iii) files an application for benefits under this title
(or has an application filed on behalf of the individual),
including pursuant to this section; and
``(iv) is determined under this section to meet the
criteria in this subparagraph.
``(B) Conditions described.--For purposes of subparagraph
(A), the following conditions are described in this
subparagraph:
``(i) Asbestosis, pleural thickening, or pleural plaques as
established by--

``(I) interpretation by a `B Reader' qualified physician of
a plain chest x-ray or interpretation of a computed
tomographic radiograph of the chest by a qualified physician,
as determined by the Secretary; or
``(II) such other diagnostic standards as the Secretary
specifies,

except that this clause shall not apply to pleural thickening
or pleural plaques unless there are symptoms or conditions
requiring medical treatment as a result of these diagnoses.
``(ii) Mesothelioma, or malignancies of the lung, colon,
rectum, larynx, stomach, esophagus, pharynx, or ovary, as
established by--

``(I) pathologic examination of biopsy tissue;
``(II) cytology from bronchioalveolar lavage; or
``(III) such other diagnostic standards as the Secretary
specifies.

``(iii) Any other diagnosis which the Secretary, in
consultation with the Commissioner of Social Security,
determines is an asbestos-related medical condition, as
established by such diagnostic standards as the Secretary
specifies.
``(3) Other individual described.--An individual described
in this paragraph is any individual who--
``(A) is not an individual described in paragraph (2);
``(B) is diagnosed with a medical condition caused by the
exposure of the individual to a public health hazard to which
an emergency declaration applies, based on such medical
conditions, diagnostic standards, and other criteria as the
Secretary specifies;
``(C) as demonstrated in such manner as the Secretary
determines appropriate, has been present for an aggregate
total of 6 months in the geographic area subject to the
emergency declaration involved, during a period determined
appropriate by the Secretary;
``(D) files an application for benefits under this title
(or has an application filed on behalf of the individual),
including pursuant to this section; and
``(E) is determined under this section to meet the criteria
in this paragraph.''.
(b) Program for Early Detection of Certain Medical
Conditions Related to Environmental Health Hazards.--Title XX
of the Social Security Act (42 U.S.C. 1397 et seq.), as
amended by section 5507, is amended by adding at the end the
following:

``SEC. 2009. PROGRAM FOR EARLY DETECTION OF CERTAIN MEDICAL
CONDITIONS RELATED TO ENVIRONMENTAL HEALTH
HAZARDS.

``(a) Program Establishment.--The Secretary shall establish
a program in accordance with this section to make competitive
grants to eligible entities specified in subsection (b) for
the purpose of--
``(1) screening at-risk individuals (as defined in
subsection (c)(1)) for environmental health conditions (as
defined in subsection (c)(3)); and
``(2) developing and disseminating public information and
education concerning--
``(A) the availability of screening under the program under
this section;
``(B) the detection, prevention, and treatment of
environmental health conditions; and
``(C) the availability of Medicare benefits for certain
individuals diagnosed with environmental health conditions
under section 1881A.
``(b) Eligible Entities.--
``(1) In general.--For purposes of this section, an
eligible entity is an entity described in paragraph (2) which
submits an application to the Secretary in such form and
manner, and containing such information and assurances, as
the Secretary determines appropriate.
``(2) Types of eligible entities.--The entities described
in this paragraph are the following:
``(A) A hospital or community health center.
``(B) A Federally qualified health center.
``(C) A facility of the Indian Health Service.
``(D) A National Cancer Institute-designated cancer center.
``(E) An agency of any State or local government.
``(F) A nonprofit organization.
``(G) Any other entity the Secretary determines
appropriate.
``(c) Definitions.--In this section:
``(1) At-risk individual.--The term `at-risk individual'
means an individual who--
``(A)(i) as demonstrated in such manner as the Secretary
determines appropriate, has been present for an aggregate
total of 6 months in the geographic area subject to an
emergency declaration specified under paragraph (2), during a
period ending--
``(I) not less than 10 years prior to the date of such
individual's application under subparagraph (B); and
``(II) prior to the implementation of all the remedial and
removal actions specified in the Record of Decision for
Operating Unit 4 and the Record of Decision for Operating
Unit 7; or
``(ii) meets such other criteria as the Secretary
determines appropriate considering the type of environmental
health condition at issue; and
``(B) has submitted an application (or has an application
submitted on the individual's behalf), to an eligible entity
receiving a grant under this section, for screening under the
program under this section.
``(2) Emergency declaration.--The term `emergency
declaration' means a declaration of a public health emergency
under section 104(a) of the Comprehensive Environmental
Response, Compensation, and Liability Act of 1980.
``(3) Environmental health condition.--The term
`environmental health condition' means--
``(A) asbestosis, pleural thickening, or pleural plaques,
as established by--
``(i) interpretation by a `B Reader' qualified physician of
a plain chest x-ray or interpretation of a computed
tomographic radiograph of the chest by a qualified physician,
as determined by the Secretary; or
``(ii) such other diagnostic standards as the Secretary
specifies;
``(B) mesothelioma, or malignancies of the lung, colon,
rectum, larynx, stomach, esophagus, pharynx, or ovary, as
established by---
``(i) pathologic examination of biopsy tissue;
``(ii) cytology from bronchioalveolar lavage; or
``(iii) such other diagnostic standards as the Secretary
specifies; and

[[Page S13511]]

``(C) any other medical condition which the Secretary
determines is caused by exposure to a hazardous substance or
pollutant or contaminant at a Superfund site to which an
emergency declaration applies, based on such criteria and as
established by such diagnostic standards as the Secretary
specifies.
``(4) Hazardous substance; pollutant; contaminant.--The
terms `hazardous substance', `pollutant', and `contaminant'
have the meanings given those terms in section 101 of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9601).
``(5) Superfund site.--The term `Superfund site' means a
site included on the National Priorities List developed by
the President in accordance with section 105(a)(8)(B) of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)).
``(d) Health Coverage Unaffected.--Nothing in this section
shall be construed to affect any coverage obligation of a
governmental or private health plan or program relating to an
at-risk individual.
``(e) Funding.--
``(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary, to carry out the program under this section--
``(A) $23,000,000 for the period of fiscal years 2010
through 2014; and
``(B) $20,000,000 for each 5-fiscal year period thereafter.
``(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until expended.
``(f) Nonapplication.--
``(1) In general.--Except as provided in paragraph (2), the
preceding sections of this title shall not apply to grants
awarded under this section.
``(2) Limitations on use of grants.--Section 2005(a) shall
apply to a grant awarded under this section to the same
extent and in the same manner as such section applies to
payments to States under this title, except that paragraph
(4) of such section shall not be construed to prohibit
grantees from conducting screening for environmental health
conditions as authorized under this section.''.

SEC. 10324. PROTECTIONS FOR FRONTIER STATES.

(a) Floor on Area Wage Index for Hospitals in Frontier
States.--
(1) In general.--Section 1886(d)(3)(E) of the Social
Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended--
(A) in clause (i), by striking ``clause (ii)'' and
inserting ``clause (ii) or (iii)''; and
(B) by adding at the end the following new clause:
``(iii) Floor on area wage index for hospitals in frontier
states.--

``(I) In general.--Subject to subclause (IV), for
discharges occurring on or after October 1, 2010, the area
wage index applicable under this subparagraph to any hospital
which is located in a frontier State (as defined in subclause
(II)) may not be less than 1.00.
``(II) Frontier state defined.--In this clause, the term
`frontier State' means a State in which at least 50 percent
of the counties in the State are frontier counties.
``(III) Frontier county defined.--In this clause, the term
`frontier county' means a county in which the population per
square mile is less than 6.
``(IV) Limitation.--This clause shall not apply to any
hospital located in a State that receives a non-labor related
share adjustment under paragraph (5)(H).''.

(2) Waiving budget neutrality.--Section 1886(d)(3)(E) of
the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as
amended by subsection (a), is amended in the third sentence
by inserting ``and the amendments made by section 10324(a)(1)
of the Patient Protection and Affordable Care Act'' after
``2003''.
(b) Floor on Area Wage Adjustment Factor for Hospital
Outpatient Department Services in Frontier States.--Section
1833(t) of the Social Security Act (42 U.S.C. 1395l(t)), as
amended by section 3138, is amended--
(1) in paragraph (2)(D), by striking ``the Secretary'' and
inserting ``subject to paragraph (19), the Secretary''; and
(2) by adding at the end the following new paragraph:
``(19) Floor on area wage adjustment factor for hospital
outpatient department services in frontier states.--
``(A) In general.--Subject to subparagraph (B), with
respect to covered OPD services furnished on or after January
1, 2011, the area wage adjustment factor applicable under the
payment system established under this subsection to any
hospital outpatient department which is located in a frontier
State (as defined in section 1886(d)(3)(E)(iii)(II)) may not
be less than 1.00. The preceding sentence shall not be
applied in a budget neutral manner.
``(B) Limitation.--This paragraph shall not apply to any
hospital outpatient department located in a State that
receives a non-labor related share adjustment under section
1886(d)(5)(H).''.
(c) Floor for Practice Expense Index for Physicians'
Services Furnished in Frontier States.--Section 1848(e)(1) of
the Social Security Act (42 U.S.C. 1395w-4(e)(1)), as amended
by section 3102, is amended--
(1) in subparagraph (A), by striking ``and (H)'' and
inserting ``(H), and (I)''; and
(2) by adding at the end the following new subparagraph:
``(I) Floor for practice expense index for services
furnished in frontier states.--
``(i) In general.--Subject to clause (ii), for purposes of
payment for services furnished in a frontier State (as
defined in section 1886(d)(3)(E)(iii)(II)) on or after
January 1, 2011, after calculating the practice expense index
in subparagraph (A)(i), the Secretary shall increase any such
index to 1.00 if such index would otherwise be less that
1.00. The preceding sentence shall not be applied in a budget
neutral manner.
``(ii) Limitation.--This subparagraph shall not apply to
services furnished in a State that receives a non-labor
related share adjustment under section 1886(d)(5)(H).''.

SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE
PAYMENT SYSTEM.

(a) Temporary Delay of RUG-IV.--Notwithstanding any other
provision of law, the Secretary of Health and Human Services
shall not, prior to October 1, 2011, implement Version 4 of
the Resource Utilization Groups (in this subsection refereed
to as ``RUG-IV'') published in the Federal Register on August
11, 2009, entitled ``Prospective Payment System and
Consolidated Billing for Skilled Nursing Facilities for FY
2010; Minimum Data Set, Version 3.0 for Skilled Nursing
Facilities and Medicaid Nursing Facilities'' (74 Fed. Reg.
40288). Beginning on October 1, 2010, the Secretary of Health
and Human Services shall implement the change specific to
therapy furnished on a concurrent basis that is a component
of RUG-IV and changes to the lookback period to ensure that
only those services furnished after admission to a skilled
nursing facility are used as factors in determining a case
mix classification under the skilled nursing facility
prospective payment system under section 1888(e) of the
Social Security Act (42 U.S.C. 1395yy(e)).
(b) Construction.--Nothing in this section shall be
interpreted as delaying the implementation of Version 3.0 of
the Minimum Data Sets (MDS 3.0) beyond the planned
implementation date of October 1, 2010.

SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR
CERTAIN MEDICARE PROVIDERS.

(a) In General.--Not later than January 1, 2016, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall, for each provider
described in subsection (b), conduct a separate pilot program
under title XVIII of the Social Security Act to test the
implementation of a value-based purchasing program for
payments under such title for the provider.
(b) Providers Described.--The providers described in this
paragraph are the following:
(1) Psychiatric hospitals (as described in clause (i) of
section 1886(d)(1)(B) of such Act (42 U.S.C.
1395ww(d)(1)(B))) and psychiatric units (as described in the
matter following clause (v) of such section).
(2) Long-term care hospitals (as described in clause (iv)
of such section).
(3) Rehabilitation hospitals (as described in clause (ii)
of such section).
(4) PPS-exempt cancer hospitals (as described in clause (v)
of such section).
(5) Hospice programs (as defined in section 1861(dd)(2) of
such Act (42 U.S.C. 1395x(dd)(2))).
(c) Waiver Authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act as may be necessary solely for purposes of carrying out
the pilot programs under this section.
(d) No Additional Program Expenditures.--Payments under
this section under the separate pilot program for value based
purchasing (as described in subsection (a)) for each provider
type described in paragraphs (1) through (5) of subsection
(b) for applicable items and services under title XVIII of
the Social Security Act for a year shall be established in a
manner that does not result in spending more under each such
value based purchasing program for such year than would
otherwise be expended for such provider type for such year if
the pilot program were not implemented, as estimated by the
Secretary.
(e) Expansion of Pilot Program.--The Secretary may, at any
point after January 1, 2018, expand the duration and scope of
a pilot program conducted under this subsection, to the
extent determined appropriate by the Secretary, if--
(1) the Secretary determines that such expansion is
expected to--
(A) reduce spending under title XVIII of the Social
Security Act without reducing the quality of care; or
(B) improve the quality of care and reduce spending;
(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under such title XVIII; and
(3) the Secretary determines that such expansion would not
deny or limit the coverage or provision of benefits under
such title XIII for Medicare beneficiaries.

SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING
SYSTEM.

(a) In General.--Section 1848(m) of the Social Security Act
(42 U.S.C. 1395w-4(m)) is amended by adding at the end the
following new paragraph:
``(7) Additional incentive payment.--
``(A) In general.--For 2011 through 2014, if an eligible
professional meets the requirements described in subparagraph
(B), the applicable quality percent for such year, as
described in clauses (iii) and (iv) of paragraph (1)(B),
shall be increased by 0.5 percentage points.

[[Page S13512]]

``(B) Requirements described.--In order to qualify for the
additional incentive payment described in subparagraph (A),
an eligible professional shall meet the following
requirements:
``(i) The eligible professional shall--

``(I) satisfactorily submit data on quality measures for
purposes of paragraph (1) for a year; and
``(II) have such data submitted on their behalf through a
Maintenance of Certification Program (as defined in
subparagraph (C)(i)) that meets--

``(aa) the criteria for a registry (as described in
subsection (k)(4)); or
``(bb) an alternative form and manner determined
appropriate by the Secretary.
``(ii) The eligible professional, more frequently than is
required to qualify for or maintain board certification
status--

``(I) participates in such a Maintenance of Certification
program for a year; and
``(II) successfully completes a qualified Maintenance of
Certification Program practice assessment (as defined in
subparagraph (C)(ii)) for such year.

``(iii) A Maintenance of Certification program submits to
the Secretary, on behalf of the eligible professional,
information--

``(I) in a form and manner specified by the Secretary, that
the eligible professional has successfully met the
requirements of clause (ii) (which may be in the form of a
structural measure);
``(II) if requested by the Secretary, on the survey of
patient experience with care (as described in subparagraph
(C)(ii)(II)); and
``(III) as the Secretary may require, on the methods,
measures, and data used under the Maintenance of
Certification Program and the qualified Maintenance of
Certification Program practice assessment.

``(C) Definitions.--For purposes of this paragraph:
``(i) The term `Maintenance of Certification Program' means
a continuous assessment program, such as qualified American
Board of Medical Specialties Maintenance of Certification
program or an equivalent program (as determined by the
Secretary), that advances quality and the lifelong learning
and self-assessment of board certified specialty physicians
by focusing on the competencies of patient care, medical
knowledge, practice-based learning, interpersonal and
communication skills and professionalism. Such a program
shall include the following:

``(I) The program requires the physician to maintain a
valid, unrestricted medical license in the United States.
``(II) The program requires a physician to participate in
educational and self-assessment programs that require an
assessment of what was learned.
``(III) The program requires a physician to demonstrate,
through a formalized, secure examination, that the physician
has the fundamental diagnostic skills, medical knowledge, and
clinical judgment to provide quality care in their respective
specialty.
``(IV) The program requires successful completion of a
qualified Maintenance of Certification Program practice
assessment as described in clause (ii).

``(ii) The term `qualified Maintenance of Certification
Program practice assessment' means an assessment of a
physician's practice that--

``(I) includes an initial assessment of an eligible
professional's practice that is designed to demonstrate the
physician's use of evidence-based medicine;
``(II) includes a survey of patient experience with care;
and
``(III) requires a physician to implement a quality
improvement intervention to address a practice weakness
identified in the initial assessment under subclause (I) and
then to remeasure to assess performance improvement after
such intervention.''.

(b) Authority.--Section 3002(c) of this Act is amended by
adding at the end the following new paragraph:
``(3) Authority.--For years after 2014, if the Secretary of
Health and Human Services determines it to be appropriate,
the Secretary may incorporate participation in a Maintenance
of Certification Program and successful completion of a
qualified Maintenance of Certification Program practice
assessment into the composite of measures of quality of care
furnished pursuant to the physician fee schedule payment
modifier, as described in section 1848(p)(2) of the Social
Security Act (42 U.S.C. 1395w-4(p)(2)).''.
(c) Elimination of MA Regional Plan Stabilization Fund.--
(1) In general.--Section 1858 of the Social Security Act
(42 U.S.C. 1395w-27a) is amended by striking subsection (e).
(2) Transition.--Any amount contained in the MA Regional
Plan Stabilization Fund as of the date of the enactment of
this Act shall be transferred to the Federal Supplementary
Medical Insurance Trust Fund.

SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY
MANAGEMENT (MTM) PROGRAMS.

(a) In General.--Section 1860D-4(c)(2) of the Social
Security Act (42 U.S.C. 1395w-104(c)(2)) is amended--
(1) by redesignating subparagraphs (C), (D), and (E) as
subparagraphs (E), (F), and (G), respectively; and
(2) by inserting after subparagraph (B) the following new
subparagraphs:
``(C) Required interventions.--For plan years beginning on
or after the date that is 2 years after the date of the
enactment of the Patient Protection and Affordable Care Act,
prescription drug plan sponsors shall offer medication
therapy management services to targeted beneficiaries
described in subparagraph (A)(ii) that include, at a minimum,
the following to increase adherence to prescription
medications or other goals deemed necessary by the Secretary:
``(i) An annual comprehensive medication review furnished
person-to-person or using telehealth technologies (as defined
by the Secretary) by a licensed pharmacist or other qualified
provider. The comprehensive medication review--

``(I) shall include a review of the individual's
medications and may result in the creation of a recommended
medication action plan or other actions in consultation with
the individual and with input from the prescriber to the
extent necessary and practicable; and
``(II) shall include providing the individual with a
written or printed summary of the results of the review.

The Secretary, in consultation with relevant stakeholders,
shall develop a standardized format for the action plan under
subclause (I) and the summary under subclause (II).
``(ii) Follow-up interventions as warranted based on the
findings of the annual medication review or the targeted
medication enrollment and which may be provided person-to-
person or using telehealth technologies (as defined by the
Secretary).
``(D) Assessment.--The prescription drug plan sponsor shall
have in place a process to assess, at least on a quarterly
basis, the medication use of individuals who are at risk but
not enrolled in the medication therapy management program,
including individuals who have experienced a transition in
care, if the prescription drug plan sponsor has access to
that information.
``(E) Automatic enrollment with ability to opt-out.--The
prescription drug plan sponsor shall have in place a process
to--
``(i) subject to clause (ii), automatically enroll targeted
beneficiaries described in subparagraph (A)(ii), including
beneficiaries identified under subparagraph (D), in the
medication therapy management program required under this
subsection; and
``(ii) permit such beneficiaries to opt-out of enrollment
in such program.''.
(b) Rule of Construction.--Nothing in this section shall
limit the authority of the Secretary of Health and Human
Services to modify or broaden requirements for a medication
therapy management program under part D of title XVIII of the
Social Security Act or to study new models for medication
therapy management through the Center for Medicare and
Medicaid Innovation under section 1115A of such Act, as added
by section 3021.

SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN
VALUE.

(a) Development.--The Secretary of Health and Human
Services (referred to in this section as the ``Secretary''),
in consultation with relevant stakeholders including health
insurance issuers, health care consumers, employers, health
care providers, and other entities determined appropriate by
the Secretary, shall develop a methodology to measure health
plan value. Such methodology shall take into consideration,
where applicable--
(1) the overall cost to enrollees under the plan;
(2) the quality of the care provided for under the plan;
(3) the efficiency of the plan in providing care;
(4) the relative risk of the plan's enrollees as compared
to other plans;
(5) the actuarial value or other comparative measure of the
benefits covered under the plan; and
(6) other factors determined relevant by the Secretary.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to Congress
a report concerning the methodology developed under
subsection (a).

SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE
CENTERS FOR MEDICARE & MEDICAID SERVICES TO
SUPPORT IMPROVEMENTS IN CARE DELIVERY.

(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a plan (and detailed budget for the resources needed
to implement such plan) to modernize the computer and data
systems of the Centers for Medicare & Medicaid Services (in
this section referred to as ``CMS'').
(b) Considerations.--In developing the plan, the Secretary
shall consider how such modernized computer system could--
(1) in accordance with the regulations promulgated under
section 264(c) of the Health Insurance Portability and
Accountability Act of 1996, make available data in a reliable
and timely manner to providers of services and suppliers to
support their efforts to better manage and coordinate care
furnished to beneficiaries of CMS programs; and
(2) support consistent evaluations of payment and delivery
system reforms under CMS programs.
(c) Posting of Plan.--By not later than 9 months after the
date of the enactment of this Act, the Secretary shall post
on the website of the Centers for Medicare & Medicaid
Services the plan described in subsection (a).

SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION.

(a) In General.--

[[Page S13513]]

(1) Development.--Not later than January 1, 2011, the
Secretary shall develop a Physician Compare Internet website
with information on physicians enrolled in the Medicare
program under section 1866(j) of the Social Security Act (42
U.S.C. 1395cc(j)) and other eligible professionals who
participate in the Physician Quality Reporting Initiative
under section 1848 of such Act (42 U.S.C. 1395w-4).
(2) Plan.--Not later than January 1, 2013, and with respect
to reporting periods that begin no earlier than January 1,
2012, the Secretary shall also implement a plan for making
publicly available through Physician Compare, consistent with
subsection (c), information on physician performance that
provides comparable information for the public on quality and
patient experience measures with respect to physicians
enrolled in the Medicare program under such section 1866(j).
To the extent scientifically sound measures that are
developed consistent with the requirements of this section
are available, such information, to the extent practicable,
shall include--
(A) measures collected under the Physician Quality
Reporting Initiative;
(B) an assessment of patient health outcomes and the
functional status of patients;
(C) an assessment of the continuity and coordination of
care and care transitions, including episodes of care and
risk-adjusted resource use;
(D) an assessment of efficiency;
(E) an assessment of patient experience and patient,
caregiver, and family engagement;
(F) an assessment of the safety, effectiveness, and
timeliness of care; and
(G) other information as determined appropriate by the
Secretary.
(b) Other Required Considerations.--In developing and
implementing the plan described in subsection (a)(2), the
Secretary shall, to the extent practicable, include--
(1) processes to assure that data made public, either by
the Centers for Medicare & Medicaid Services or by other
entities, is statistically valid and reliable, including risk
adjustment mechanisms used by the Secretary;
(2) processes by which a physician or other eligible
professional whose performance on measures is being publicly
reported has a reasonable opportunity, as determined by the
Secretary, to review his or her individual results before
they are made public;
(3) processes by the Secretary to assure that the
implementation of the plan and the data made available on
Physician Compare provide a robust and accurate portrayal of
a physician's performance;
(4) data that reflects the care provided to all patients
seen by physicians, under both the Medicare program and, to
the extent practicable, other payers, to the extent such
information would provide a more accurate portrayal of
physician performance;
(5) processes to ensure appropriate attribution of care
when multiple physicians and other providers are involved in
the care of a patient;
(6) processes to ensure timely statistical performance
feedback is provided to physicians concerning the data
reported under any program subject to public reporting under
this section; and
(7) implementation of computer and data systems of the
Centers for Medicare & Medicaid Services that support valid,
reliable, and accurate public reporting activities authorized
under this section.
(c) Ensuring Patient Privacy.--The Secretary shall ensure
that information on physician performance and patient
experience is not disclosed under this section in a manner
that violates sections 552 or 552a of title 5, United States
Code, with regard to the privacy of individually identifiable
health information.
(d) Feedback From Multi-Stakeholder Groups.--The Secretary
shall take into consideration input provided by multi-
stakeholder groups, consistent with sections 1890(b)(7) and
1890A of the Social Security Act, as added by section 3014 of
this Act, in selecting quality measures for use under this
section.
(e) Consideration of Transition to Value-Based
Purchasing.--In developing the plan under this subsection
(a)(2), the Secretary shall, as the Secretary determines
appropriate, consider the plan to transition to a value-based
purchasing program for physicians and other practitioners
developed under section 131 of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275).
(f) Report to Congress.--Not later than January 1, 2015,
the Secretary shall submit to Congress a report on the
Physician Compare Internet website developed under subsection
(a)(1). Such report shall include information on the efforts
of and plans made by the Secretary to collect and publish
data on physician quality and efficiency and on patient
experience of care in support of value-based purchasing and
consumer choice, together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(g) Expansion.--At any time before the date on which the
report is submitted under subsection (f), the Secretary may
expand (including expansion to other providers of services
and suppliers under title XVIII of the Social Security Act)
the information made available on such website.
(h) Financial Incentives to Encourage Consumers to Choose
High Quality Providers.--The Secretary may establish a
demonstration program, not later than January 1, 2019, to
provide financial incentives to Medicare beneficiaries who
are furnished services by high quality physicians, as
determined by the Secretary based on factors in subparagraphs
(A) through (G) of subsection (a)(2). In no case may Medicare
beneficiaries be required to pay increased premiums or cost
sharing or be subject to a reduction in benefits under title
XVIII of the Social Security Act as a result of such
demonstration program. The Secretary shall ensure that any
such demonstration program does not disadvantage those
beneficiaries without reasonable access to high performing
physicians or create financial inequities under such title.
(i) Definitions.--In this section:
(1) Eligible professional.--The term ``eligible
professional'' has the meaning given that term for purposes
of the Physician Quality Reporting Initiative under section
1848 of the Social Security Act (42 U.S.C. 1395w-4)
(2) Physician.--The term ``physician'' has the meaning
given that term in section 1861(r) of such Act (42 U.S.C.
1395x(r)).
(3) Physician compare.--The term ``Physician Compare''
means the Internet website developed under subsection (a)(1).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.

SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE
MEASUREMENT.

(a) In General.--Section 1874 of the Social Security Act
(42 U.S.C. 1395kk) is amended by adding at the end the
following new subsection:
``(e) Availability of Medicare Data.--
``(1) In general.--Subject to paragraph (4), the Secretary
shall make available to qualified entities (as defined in
paragraph (2)) data described in paragraph (3) for the
evaluation of the performance of providers of services and
suppliers.
``(2) Qualified entities.--For purposes of this subsection,
the term `qualified entity' means a public or private entity
that--
``(A) is qualified (as determined by the Secretary) to use
claims data to evaluate the performance of providers of
services and suppliers on measures of quality, efficiency,
effectiveness, and resource use; and
``(B) agrees to meet the requirements described in
paragraph (4) and meets such other requirements as the
Secretary may specify, such as ensuring security of data.
``(3) Data described.--The data described in this paragraph
are standardized extracts (as determined by the Secretary) of
claims data under parts A, B, and D for items and services
furnished under such parts for one or more specified
geographic areas and time periods requested by a qualified
entity. The Secretary shall take such actions as the
Secretary deems necessary to protect the identity of
individuals entitled to or enrolled for benefits under such
parts.
``(4) Requirements.--
``(A) Fee.--Data described in paragraph (3) shall be made
available to a qualified entity under this subsection at a
fee equal to the cost of making such data available. Any fee
collected pursuant to the preceding sentence shall be
deposited into the Federal Supplementary Medical Insurance
Trust Fund under section 1841.
``(B) Specification of uses and methodologies.--A qualified
entity requesting data under this subsection shall--
``(i) submit to the Secretary a description of the
methodologies that such qualified entity will use to evaluate
the performance of providers of services and suppliers using
such data;
``(ii)(I) except as provided in subclause (II), if
available, use standard measures, such as measures endorsed
by the entity with a contract under section 1890(a) and
measures developed pursuant to section 931 of the Public
Health Service Act; or
``(II) use alternative measures if the Secretary, in
consultation with appropriate stakeholders, determines that
use of such alternative measures would be more valid,
reliable, responsive to consumer preferences, cost-effective,
or relevant to dimensions of quality and resource use not
addressed by such standard measures;
``(iii) include data made available under this subsection
with claims data from sources other than claims data under
this title in the evaluation of performance of providers of
services and suppliers;
``(iv) only include information on the evaluation of
performance of providers and suppliers in reports described
in subparagraph (C);
``(v) make available to providers of services and
suppliers, upon their request, data made available under this
subsection; and
``(vi) prior to their release, submit to the Secretary the
format of reports under subparagraph (C).
``(C) Reports.--Any report by a qualified entity evaluating
the performance of providers of services and suppliers using
data made available under this subsection shall--
``(i) include an understandable description of the
measures, which shall include quality measures and the
rationale for use of other measures described in subparagraph
(B)(ii)(II), risk adjustment methods, physician attribution
methods, other applicable methods, data specifications and
limitations, and the sponsors, so that consumers, providers
of services and suppliers, health plans, researchers, and
other stakeholders can assess such reports;
``(ii) be made available confidentially, to any provider of
services or supplier to be identified in such report, prior
to the public

[[Page S13514]]

release of such report, and provide an opportunity to appeal
and correct errors;
``(iii) only include information on a provider of services
or supplier in an aggregate form as determined appropriate by
the Secretary; and
``(iv) except as described in clause (ii), be made
available to the public.
``(D) Approval and limitation of uses.--The Secretary shall
not make data described in paragraph (3) available to a
qualified entity unless the qualified entity agrees to
release the information on the evaluation of performance of
providers of services and suppliers. Such entity shall only
use such data, and information derived from such evaluation,
for the reports under subparagraph (C). Data released to a
qualified entity under this subsection shall not be subject
to discovery or admission as evidence in judicial or
administrative proceedings without consent of the applicable
provider of services or supplier.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on January 1, 2012.

SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

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

``Subpart XI--Community-Based Collaborative Care Network Program

``SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE NETWORK
PROGRAM.

``(a) In General.--The Secretary may award grants to
eligible entities to support community-based collaborative
care networks that meet the requirements of subsection (b).
``(b) Community-Based Collaborative Care Networks.--
``(1) Description.--A community-based collaborative care
network (referred to in this section as a `network') shall be
a consortium of health care providers with a joint governance
structure (including providers within a single entity) that
provides comprehensive coordinated and integrated health care
services (as defined by the Secretary) for low-income
populations.
``(2) Required inclusion.--A network shall include the
following providers (unless such provider does not exist
within the community, declines or refuses to participate, or
places unreasonable conditions on their participation):
``(A) A hospital that meets the criteria in section
1923(b)(1) of the Social Security Act; and
``(B) All Federally qualified health centers (as defined in
section 1861(aa) of the Social Security Act located in the
community.
``(3) Priority.--In awarding grants, the Secretary shall
give priority to networks that include--
``(A) the capability to provide the broadest range of
services to low-income individuals;
``(B) the broadest range of providers that currently serve
a high volume of low-income individuals; and
``(C) a county or municipal department of health.
``(c) Application.--
``(1) Application.--A network described in subsection (b)
shall submit an application to the Secretary.
``(2) Renewal.--In subsequent years, based on the
performance of grantees, the Secretary may provide renewal
grants to prior year grant recipients.
``(d) Use of Funds.--
``(1) Use by grantees.--Grant funds may be used for the
following activities:
``(A) Assist low-income individuals to--
``(i) access and appropriately use health services;
``(ii) enroll in health coverage programs; and
``(iii) obtain a regular primary care provider or a medical
home.
``(B) Provide case management and care management.
``(C) Perform health outreach using neighborhood health
workers or through other means.
``(D) Provide transportation.
``(E) Expand capacity, including through telehealth, after-
hours services or urgent care.
``(F) Provide direct patient care services.
``(2) Grant funds to hrsa grantees.--The Secretary may
limit the percent of grant funding that may be spent on
direct care services provided by grantees of programs
administered by the Health Resources and Services
Administration or impose other requirements on such grantees
deemed necessary.
``(e) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section such
sums as may be necessary for each of fiscal years 2011
through 2015.''.

SEC. 10334. MINORITY HEALTH.

(a) Office of Minority Health.--
(1) In general.--Section 1707 of the Public Health Service
Act (42 U.S.C. 300u-6) is amended--
(A) in subsection (a), by striking ``within the Office of
Public Health and Science'' and all that follows through the
end and inserting ``. The Office of Minority Health as
existing on the date of enactment of the Patient Protection
and Affordable Care Act shall be transferred to the Office of
the Secretary in such manner that there is established in the
Office of the Secretary, the Office of Minority Health, which
shall be headed by the Deputy Assistant Secretary for
Minority Health who shall report directly to the Secretary,
and shall retain and strengthen authorities (as in existence
on such date of enactment) for the purpose of improving
minority health and the quality of health care minorities
receive, and eliminating racial and ethnic disparities. In
carrying out this subsection, the Secretary, acting through
the Deputy Assistant Secretary, shall award grants,
contracts, enter into memoranda of understanding,
cooperative, interagency, intra-agency and other agreements
with public and nonprofit private entities, agencies, as well
as Departmental and Cabinet agencies and organizations, and
with organizations that are indigenous human resource
providers in communities of color to assure improved health
status of racial and ethnic minorities, and shall develop
measures to evaluate the effectiveness of activities aimed at
reducing health disparities and supporting the local
community. Such measures shall evaluate community outreach
activities, language services, workforce cultural competence,
and other areas as determined by the Secretary.''; and
(B) by striking subsection (h) and inserting the following:
``(h) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2011 through 2016.''.
(2) Transfer of functions.--There are transferred to the
Office of Minority Health in the office of the Secretary of
Health and Human Services, all duties, responsibilities,
authorities, accountabilities, functions, staff, funds, award
mechanisms, and other entities under the authority of the
Office of Minority Health of the Public Health Service as in
effect on the date before the date of enactment of this Act,
which shall continue in effect according to the terms in
effect on the date before such date of enactment, until
modified, terminated, superseded, set aside, or revoked in
accordance with law by the President, the Secretary, a court
of competent jurisdiction, or by operation of law.
(3) Reports.--Not later than 1 year after the date of
enactment of this section, and biennially thereafter, the
Secretary of Health and Human Services shall prepare and
submit to the appropriate committees of Congress a report
describing the activities carried out under section 1707 of
the Public Health Service Act (as amended by this subsection)
during the period for which the report is being prepared. Not
later than 1 year after the date of enactment of this
section, and biennially thereafter, the heads of each of the
agencies of the Department of Health and Human Services shall
submit to the Deputy Assistant Secretary for Minority Health
a report summarizing the minority health activities of each
of the respective agencies.
(b) Establishment of Individual Offices of Minority Health
Within the Department of Health and Human Services.--
(1) In general.--Title XVII of the Public Health Service
Act (42 U.S.C. 300u et seq.) is amended by inserting after
section 1707 the following section:

``SEC. 1707A. INDIVIDUAL OFFICES OF MINORITY HEALTH WITHIN
THE DEPARTMENT.

``(a) In General.--The head of each agency specified in
subsection (b)(1) shall establish within the agency an office
to be known as the Office of Minority Health. The head of
each such Office shall be appointed by the head of the agency
within which the Office is established, and shall report
directly to the head of the agency. The head of such agency
shall carry out this section (as this section relates to the
agency) acting through such Director.
``(b) Specified Agencies.--The agencies referred to in
subsection (a) are the Centers for Disease Control and
Prevention, the Health Resources and Services Administration,
the Substance Abuse and Mental Health Services
Administration, the Agency for Healthcare Research and
Quality, the Food and Drug Administration, and the Centers
for Medicare & Medicaid Services.
``(c) Director; Appointment.--Each Office of Minority
Health established in an agency listed in subsection (a)
shall be headed by a director, with documented experience and
expertise in minority health services research and health
disparities elimination.
``(d) References.--Except as otherwise specified, any
reference in Federal law to an Office of Minority Health (in
the Department of Health and Human Services) is deemed to be
a reference to the Office of Minority Health in the Office of
the Secretary.
``(e) Funding.--
``(1) Allocations.--Of the amounts appropriated for a
specified agency for a fiscal year, the Secretary must
designate an appropriate amount of funds for the purpose of
carrying out activities under this section through the
minority health office of the agency. In reserving an amount
under the preceding sentence for a minority health office for
a fiscal year, the Secretary shall reduce, by substantially
the same percentage, the amount that otherwise would be
available for each of the programs of the designated agency
involved.
``(2) Availability of funds for staffing.--The purposes for
which amounts made available under paragraph may be expended
by a minority health office include the costs of employing
staff for such office.''.
(2) No new regulatory authority.--Nothing in this
subsection and the amendments made by this subsection may be
construed as establishing regulatory authority or modifying
any existing regulatory authority.

[[Page S13515]]

(3) Limitation on termination.--Notwithstanding any other
provision of law, a Federal office of minority health or
Federal appointive position with primary responsibility over
minority health issues that is in existence in an office of
agency of the Department of Health and Human Services on the
date of enactment of this section shall not be terminated,
reorganized, or have any of its power or duties transferred
unless such termination, reorganization, or transfer is
approved by an Act of Congress.
(c) Redesignation of National Center on Minority Health and
Health Disparities.--
(1) Redesignation.--Title IV of the Public Health Service
Act (42 U.S.C. 281 et seq.) is amended--
(A) by redesignating subpart 6 of part E as subpart 20;
(B) by transferring subpart 20, as so redesignated, to part
C of such title IV;
(C) by inserting subpart 20, as so redesignated, after
subpart 19 of such part C; and
(D) in subpart 20, as so redesignated--
(i) by redesignating sections 485E through 485H as sections
464z-3 through 464z-6, respectively;
(ii) by striking ``National Center on Minority Health and
Health Disparities'' each place such term appears and
inserting ``National Institute on Minority Health and Health
Disparities''; and
(iii) by striking ``Center'' each place such term appears
and inserting ``Institute''.
(2) Purpose of institute; duties.--Section 464z-3 of the
Public Health Service Act, as so redesignated, is amended--
(A) in subsection (h)(1), by striking ``research endowments
at centers of excellence under section 736.'' and inserting
the following: ``research endowments--
``(1) at centers of excellence under section 736; and
``(2) at centers of excellence under section 464z-4.'';
(B) in subsection (h)(2)(A), by striking ``average'' and
inserting ``median''; and
(C) by adding at the end the following:
``(h) Interagency Coordination.--The Director of the
Institute, as the primary Federal officials with
responsibility for coordinating all research and activities
conducted or supported by the National Institutes of Health
on minority health and health disparities, shall plan,
coordinate, review and evaluate research and other activities
conducted or supported by the Institutes and Centers of the
National Institutes of Health.''.
(3) Technical and conforming amendments.--
(A) Section 401(b)(24) of the Public Health Service Act (42
U.S.C. 281(b)(24)) is amended by striking ``Center'' and
inserting ``Institute''.
(B) Subsection (d)(1) of section 903 of the Public Health
Service Act (42 U.S.C. 299a-1(d)(1)) is amended by striking
``section 485E'' and inserting ``section 464z-3''.

SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED
PURCHASING PROGRAM.

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

SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY
ACCESS TO HIGH-QUALITY DIALYSIS SERVICES.

(a) Study.--
(1) In general.--The Comptroller General of the United
States shall conduct a study on the impact on Medicare
beneficiary access to high-quality dialysis services of
including specified oral drugs that are furnished to such
beneficiaries for the treatment of end stage renal disease in
the bundled prospective payment system under section
1881(b)(14) of the Social Security Act (42 U.S.C.
1395rr(b)(14)) (pursuant to the proposed rule published by
the Secretary of Health and Human Services in the Federal
Register on September 29, 2009 (74 Fed. Reg. 49922 et seq.)).
Such study shall include an analysis of--
(A) the ability of providers of services and renal dialysis
facilities to furnish specified oral drugs or arrange for the
provision of such drugs;
(B) the ability of providers of services and renal dialysis
facilities to comply, if necessary, with applicable State
laws (such as State pharmacy licensure requirements) in order
to furnish specified oral drugs;
(C) whether appropriate quality measures exist to safeguard
care for Medicare beneficiaries being furnished specified
oral drugs by providers of services and renal dialysis
facilities; and
(D) other areas determined appropriate by the Comptroller
General.
(2) Specified oral drug defined.--For purposes of paragraph
(1), the term ``specified oral drug'' means a drug or
biological for which there is no injectable equivalent (or
other non-oral form of administration).
(b) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report containing the
results of the study conducted under subsection (a), together
with recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.

Subtitle D--Provisions Relating to Title IV

SEC. 10401. AMENDMENTS TO SUBTITLE A.

(a) Section 4001(h)(4) and (5) of this Act is amended by
striking ``2010'' each place such appears and inserting
``2020''.
(b) Section 4002(c) of this Act is amended--
(1) by striking ``research and health screenings'' and
inserting ``research, health screenings, and initiatives'';
and
(2) by striking ``for Preventive'' and inserting
``Regarding Preventive''.
(c) Section 4004(a)(4) of this Act is amended by striking
``a Gateway'' and inserting ``an Exchange''.

SEC. 10402. AMENDMENTS TO SUBTITLE B.

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

SEC. 10403. AMENDMENTS TO SUBTITLE C.

Section 4201 of this Act is amended--
(1) in subsection (a), by adding before the period the
following: ``, with not less than 20 percent of such grants
being awarded to rural and frontier areas'';
(2) in subsection (c)(2)(B)(vii), by striking ``both urban
and rural areas'' and inserting ``urban, rural, and frontier
areas''; and
(3) in subsection (f), by striking ``each fiscal years''
and inserting ``each of fiscal year''.

SEC. 10404. AMENDMENTS TO SUBTITLE D.

Section 399MM(2) of the Public Health Service Act, as added
by section 4303 of this Act, is amended by striking ``by
ensuring'' and inserting ``and ensuring''.

SEC. 10405. AMENDMENTS TO SUBTITLE E.

Subtitle E of title IV of this Act is amended by striking
section 4401.

SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR
PREVENTIVE SERVICES.

Section 4104(b) of this Act is amended to read as follows:
``(b) Payment and Elimination of Coinsurance in All
Settings.--Section 1833(a)(1) of the Social Security Act (42
U.S.C. 1395l(a)(1)), as amended by section 4103(c)(1), is
amended--
``(1) in subparagraph (T), by inserting `(or 100 percent if
such services are recommended with a grade of A or B by the
United States Preventive Services Task Force for any
indication or population and are appropriate for the
individual)' after `80 percent';
``(2) in subparagraph (W)--
``(A) in clause (i), by inserting `(if such subparagraph
were applied, by substituting ``100 percent'' for ``80
percent'')' after `subparagraph (D)'; and
``(B) in clause (ii), by striking `80 percent' and
inserting `100 percent';
``(3) by striking `and' before `(X)'; and
``(4) by inserting before the semicolon at the end the
following: `, and (Y) with respect to preventive services
described in subparagraphs (A) and (B) of section
1861(ddd)(3) that are appropriate for the individual and, in
the case of such services described in subparagraph (A), are
recommended with a grade of A or B by the United States
Preventive Services Task Force for any indication or
population, the amount paid shall be 100 percent of (i)
except as provided in clause (ii), the lesser of the actual
charge for the services or the amount determined under the
fee schedule that applies to such services under this part,
and (ii) in the case of such services that are covered OPD
services (as defined in subsection (t)(1)(B)), the amount
determined under subsection (t)'.''.

SEC. 10407. BETTER DIABETES CARE.

(a) Short Title.--This section may be cited as the
``Catalyst to Better Diabetes Care Act of 2009''.
(b) National Diabetes Report Card.--
(1) In general.--The Secretary, in collaboration with the
Director of the Centers for Disease Control and Prevention
(referred to in this section as the ``Director''), shall
prepare on a biennial basis a national diabetes report card
(referred to in this section as a ``Report Card'') and, to
the extent possible, for each State.
(2) Contents.--
(A) In general.--Each Report Card shall include aggregate
health outcomes related to individuals diagnosed with
diabetes and prediabetes including--
(i) preventative care practices and quality of care;
(ii) risk factors; and
(iii) outcomes.
(B) Updated reports.--Each Report Card that is prepared
after the initial Report Card shall include trend analysis
for the Nation and, to the extent possible, for each State,
for the purpose of--
(i) tracking progress in meeting established national goals
and objectives for improving diabetes care, costs, and
prevalence (including Healthy People 2010); and
(ii) informing policy and program development.
(3) Availability.--The Secretary, in collaboration with the
Director, shall make each Report Card publicly available,
including by posting the Report Card on the Internet.
(c) Improvement of Vital Statistics Collection.--

[[Page S13516]]

(1) In general.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention and in
collaboration with appropriate agencies and States, shall--
(A) promote the education and training of physicians on the
importance of birth and death certificate data and how to
properly complete these documents, including the collection
of such data for diabetes and other chronic diseases;
(B) encourage State adoption of the latest standard
revisions of birth and death certificates; and
(C) work with States to re-engineer their vital statistics
systems in order to provide cost-effective, timely, and
accurate vital systems data.
(2) Death certificate additional language.--In carrying out
this subsection, the Secretary may promote improvements to
the collection of diabetes mortality data, including the
addition of a question for the individual certifying the
cause of death regarding whether the deceased had diabetes.
(d) Study on Appropriate Level of Diabetes Medical
Education.--
(1) In general.--The Secretary shall, in collaboration with
the Institute of Medicine and appropriate associations and
councils, conduct a study of the impact of diabetes on the
practice of medicine in the United States and the
appropriateness of the level of diabetes medical education
that should be required prior to licensure, board
certification, and board recertification.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit a report on
the study under paragraph (1) to the Committees on Ways and
Means and Energy and Commerce of the House of Representatives
and the Committees on Finance and Health, Education, Labor,
and Pensions of the Senate.
(e) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section such sums as may
be necessary.

SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE
COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS.

(a) Establishment.--The Secretary shall award grants to
eligible employers to provide their employees with access to
comprehensive workplace wellness programs (as described under
subsection (c)).
(b) Scope.--
(1) Duration.--The grant program established under this
section shall be conducted for a 5-year period.
(2) Eligible employer.--The term ``eligible employer''
means an employer (including a non-profit employer) that--
(A) employs less than 100 employees who work 25 hours or
greater per week; and
(B) does not provide a workplace wellness program as of the
date of enactment of this Act.
(c) Comprehensive Workplace Wellness Programs.--
(1) Criteria.--The Secretary shall develop program criteria
for comprehensive workplace wellness programs under this
section that are based on and consistent with evidence-based
research and best practices, including research and practices
as provided in the Guide to Community Preventive Services,
the Guide to Clinical Preventive Services, and the National
Registry for Effective Programs.
(2) Requirements.--A comprehensive workplace wellness
program shall be made available by an eligible employer to
all employees and include the following components:
(A) Health awareness initiatives (including health
education, preventive screenings, and health risk
assessments).
(B) Efforts to maximize employee engagement (including
mechanisms to encourage employee participation).
(C) Initiatives to change unhealthy behaviors and lifestyle
choices (including counseling, seminars, online programs, and
self-help materials).
(D) Supportive environment efforts (including workplace
policies to encourage healthy lifestyles, healthy eating,
increased physical activity, and improved mental health).
(d) Application.--An eligible employer desiring to
participate in the grant program under this section shall
submit an application to the Secretary, in such manner and
containing such information as the Secretary may require,
which shall include a proposal for a comprehensive workplace
wellness program that meet the criteria and requirements
described under subsection (c).
(e) Authorization of Appropriation.--For purposes of
carrying out the grant program under this section, there is
authorized to be appropriated $200,000,000 for the period of
fiscal years 2011 through 2015. Amounts appropriated pursuant
to this subsection shall remain available until expended.

SEC. 10409. CURES ACCELERATION NETWORK.

(a) Short Title.--This section may be cited as the ``Cures
Acceleration Network Act of 2009''.
(b) Requirement for the Director of NIH to Establish a
Cures Acceleration Network.--Section 402(b) of the Public
Health Service Act (42 U.S.C. 282(b)) is amended--
(1) in paragraph (22), by striking ``and'' at the end;
(2) in paragraph (23), by striking the period and inserting
``; and''; and
(3) by inserting after paragraph (23), the following:
``(24) implement the Cures Acceleration Network described
in section 402C.''.
(c) Accepting Gifts to Support the Cures Acceleration
Network.--Section 499(c)(1) of the Public Health Service Act
(42 U.S.C. 290b(c)(1)) is amended by adding at the end the
following:
``(E) The Cures Acceleration Network described in section
402C.''.
(d) Establishment of the Cures Acceleration Network.--Part
A of title IV of the Public Health Service Act is amended by
inserting after section 402B (42 U.S.C. 282b) the following:

``SEC. 402C. CURES ACCELERATION NETWORK.

``(a) Definitions.--In this section:
``(1) Biological product.--The term `biological product'
has the meaning given such term in section 351 of the Public
Health Service Act.
``(2) Drug; device.--The terms `drug' and `device' have the
meanings given such terms in section 201 of the Federal Food,
Drug, and Cosmetic Act.
``(3) High need cure.--The term `high need cure' means a
drug (as that term is defined by section 201(g)(1) of the
Federal Food, Drug, and Cosmetic Act, biological product (as
that term is defined by section 262(i)), or device (as that
term is defined by section 201(h) of the Federal Food, Drug,
and Cosmetic Act) that, in the determination of the Director
of NIH--
``(A) is a priority to diagnose, mitigate, prevent, or
treat harm from any disease or condition; and
``(B) for which the incentives of the commercial market are
unlikely to result in its adequate or timely development.
``(4) Medical product.--The term `medical product' means a
drug, device, biological product, or product that is a
combination of drugs, devices, and biological products.
``(b) Establishment of the Cures Acceleration Network.--
Subject to the appropriation of funds as described in
subsection (g), there is established within the Office of the
Director of NIH a program to be known as the Cures
Acceleration Network (referred to in this section as `CAN'),
which shall--
``(1) be under the direction of the Director of NIH, taking
into account the recommendations of a CAN Review Board
(referred to in this section as the `Board'), described in
subsection (d); and
``(2) award grants and contracts to eligible entities, as
described in subsection (e), to accelerate the development of
high need cures, including through the development of medical
products and behavioral therapies.
``(c) Functions.--The functions of the CAN are to--
``(1) conduct and support revolutionary advances in basic
research, translating scientific discoveries from bench to
bedside;
``(2) award grants and contracts to eligible entities to
accelerate the development of high need cures;
``(3) provide the resources necessary for government
agencies, independent investigators, research organizations,
biotechnology companies, academic research institutions, and
other entities to develop high need cures;
``(4) reduce the barriers between laboratory discoveries
and clinical trials for new therapies; and
``(5) facilitate review in the Food and Drug Administration
for the high need cures funded by the CAN, through activities
that may include--
``(A) the facilitation of regular and ongoing communication
with the Food and Drug Administration regarding the status of
activities conducted under this section;
``(B) ensuring that such activities are coordinated with
the approval requirements of the Food and Drug
Administration, with the goal of expediting the development
and approval of countermeasures and products; and
``(C) connecting interested persons with additional
technical assistance made available under section 565 of the
Federal Food, Drug, and Cosmetic Act.
``(d) CAN Board.--
``(1) Establishment.--There is established a Cures
Acceleration Network Review Board (referred to in this
section as the `Board'), which shall advise the Director of
NIH on the conduct of the activities of the Cures
Acceleration Network.
``(2) Membership.--
``(A) In general.--
``(i) Appointment.--The Board shall be comprised of 24
members who are appointed by the Secretary and who serve at
the pleasure of the Secretary.
``(ii) Chairperson and vice chairperson.--The Secretary
shall designate, from among the 24 members appointed under
clause (i), one Chairperson of the Board (referred to in this
section as the `Chairperson') and one Vice Chairperson.
``(B) Terms.--
``(i) In general.--Each member shall be appointed to serve
a 4-year term, except that any member appointed to fill a
vacancy occurring prior to the expiration of the term for
which the member's predecessor was appointed shall be
appointed for the remainder of such term.
``(ii) Consecutive appointments; maximum terms.--A member
may be appointed to serve not more than 3 terms on the Board,
and may not serve more than 2 such terms consecutively.
``(C) Qualifications.--
``(i) In general.--The Secretary shall appoint individuals
to the Board based solely upon the individual's established
record of distinguished service in one of the areas of

[[Page S13517]]

expertise described in clause (ii). Each individual appointed
to the Board shall be of distinguished achievement and have a
broad range of disciplinary interests.
``(ii) Expertise.--The Secretary shall select individuals
based upon the following requirements:

``(I) For each of the fields of--

``(aa) basic research;
``(bb) medicine;
``(cc) biopharmaceuticals;
``(dd) discovery and delivery of medical products;
``(ee) bioinformatics and gene therapy;
``(ff) medical instrumentation; and
``(gg) regulatory review and approval of medical products,

the Secretary shall select at least 1 individual who is
eminent in such fields.
``(II) At least 4 individuals shall be recognized leaders
in professional venture capital or private equity
organizations and have demonstrated experience in private
equity investing.
``(III) At least 8 individuals shall represent disease
advocacy organizations.

``(3) Ex-officio members.--
``(A) Appointment.--In addition to the 24 Board members
described in paragraph (2), the Secretary shall appoint as
ex-officio members of the Board--
``(i) a representative of the National Institutes of
Health, recommended by the Secretary of the Department of
Health and Human Services;
``(ii) a representative of the Office of the Assistant
Secretary of Defense for Health Affairs, recommended by the
Secretary of Defense;
``(iii) a representative of the Office of the Under
Secretary for Health for the Veterans Health Administration,
recommended by the Secretary of Veterans Affairs;
``(iv) a representative of the National Science Foundation,
recommended by the Chair of the National Science Board; and
``(v) a representative of the Food and Drug Administration,
recommended by the Commissioner of Food and Drugs.
``(B) Terms.--Each ex-officio member shall serve a 3-year
term on the Board, except that the Chairperson may adjust the
terms of the initial ex-officio members in order to provide
for a staggered term of appointment for all such members.
``(4) Responsibilities of the board and the director of
nih.--
``(A) Responsibilities of the board.--
``(i) In general.--The Board shall advise, and provide
recommendations to, the Director of NIH with respect to--

``(I) policies, programs, and procedures for carrying out
the duties of the Director of NIH under this section; and
``(II) significant barriers to successful translation of
basic science into clinical application (including issues
under the purview of other agencies and departments).

``(ii) Report.--In the case that the Board identifies a
significant barrier, as described in clause (i)(II), the
Board shall submit to the Secretary a report regarding such
barrier.
``(B) Responsibilities of the director of nih.--With
respect to each recommendation provided by the Board under
subparagraph (A)(i), the Director of NIH shall respond in
writing to the Board, indicating whether such Director will
implement such recommendation. In the case that the Director
of NIH indicates a recommendation of the Board will not be
implemented, such Director shall provide an explanation of
the reasons for not implementing such recommendation.
``(5) Meetings.--
``(A) In general.--The Board shall meet 4 times per
calendar year, at the call of the Chairperson.
``(B) Quorum; requirements; limitations.--
``(i) Quorum.--A quorum shall consist of a total of 13
members of the Board, excluding ex-officio members, with
diverse representation as described in clause (iii).
``(ii) Chairperson or vice chairperson.--Each meeting of
the Board shall be attended by either the Chairperson or the
Vice Chairperson.
``(iii) Diverse representation.--At each meeting of the
Board, there shall be not less than one scientist, one
representative of a disease advocacy organization, and one
representative of a professional venture capital or private
equity organization.
``(6) Compensation and travel expenses.--
``(A) Compensation.--Members shall receive compensation at
a rate to be fixed by the Chairperson but not to exceed a
rate equal to the daily equivalent of the annual rate of
basic pay prescribed for level IV of the Executive Schedule
under section 5315 of title 5, United States Code, for each
day (including travel time) during which the member is
engaged in the performance of the duties of the Board. All
members of the Board who are officers or employees of the
Untied States shall serve without compensation in addition to
that received for their services as officers or employees of
the United States.
``(B) Travel expenses.--Members of the Board shall be
allowed travel expenses, including per diem in lieu of
subsistence, at rates authorized for persons employed
intermittently by the Federal Government under section
5703(b) of title 5, United States Code, while away from their
homes or regular places of business in the performance of
services for the Board.
``(e) Grant Program.--
``(1) Supporting innovation.--To carry out the purposes
described in this section, the Director of NIH shall award
contracts, grants, or cooperative agreements to the entities
described in paragraph (2), to--
``(A) promote innovation in technologies supporting the
advanced research and development and production of high need
cures, including through the development of medical products
and behavioral therapies.
``(B) accelerate the development of high need cures,
including through the development of medical products,
behavioral therapies, and biomarkers that demonstrate the
safety or effectiveness of medical products; or
``(C) help the award recipient establish protocols that
comply with Food and Drug Administration standards and
otherwise permit the recipient to meet regulatory
requirements at all stages of development, manufacturing,
review, approval, and safety surveillance of a medical
product.
``(2) Eligible entities.--To receive assistance under
paragraph (1), an entity shall--
``(A) be a public or private entity, which may include a
private or public research institution, an institution of
higher education, a medical center, a biotechnology company,
a pharmaceutical company, a disease advocacy organization, a
patient advocacy organization, or an academic research
institution;
``(B) submit an application containing--
``(i) a detailed description of the project for which the
entity seeks such grant or contract;
``(ii) a timetable for such project;
``(iii) an assurance that the entity will submit--

``(I) interim reports describing the entity's--

``(aa) progress in carrying out the project; and
``(bb) compliance with all provisions of this section and
conditions of receipt of such grant or contract; and

``(II) a final report at the conclusion of the grant
period, describing the outcomes of the project; and

``(iv) a description of the protocols the entity will
follow to comply with Food and Drug Administration standards
and regulatory requirements at all stages of development,
manufacturing, review, approval, and safety surveillance of a
medical product; and
``(C) provide such additional information as the Director
of NIH may require.
``(3) Awards.--
``(A) The cures acceleration partnership awards.--
``(i) Initial award amount.--Each award under this
subparagraph shall be not more than $15,000,000 per project
for the first fiscal year for which the project is funded,
which shall be payable in one payment.
``(ii) Funding in subsequent fiscal years.--An eligible
entity receiving an award under clause (i) may apply for
additional funding for such project by submitting to the
Director of NIH the information required under subparagraphs
(B) and (C) of paragraph (2). The Director may fund a project
of such eligible entity in an amount not to exceed
$15,000,000 for a fiscal year subsequent to the initial award
under clause (i).
``(iii) Matching funds.--As a condition for receiving an
award under this subsection, an eligible entity shall
contribute to the project non-Federal funds in the amount of
$1 for every $3 awarded under clauses (i) and (ii), except
that the Director of NIH may waive or modify such matching
requirement in any case where the Director determines that
the goals and objectives of this section cannot adequately be
carried out unless such requirement is waived.
``(B) The cures acceleration grant awards.--
``(i) Initial award amount.--Each award under this
subparagraph shall be not more than $15,000,000 per project
for the first fiscal year for which the project is funded,
which shall be payable in one payment.
``(ii) Funding in subsequent fiscal years.--An eligible
entity receiving an award under clause (i) may apply for
additional funding for such project by submitting to the
Board the information required under subparagraphs (B) and
(C) of paragraph (2). The Director of NIH may fund a project
of such eligible entity in an amount not to exceed
$15,000,000 for a fiscal year subsequent to the initial award
under clause (i).
``(C) The cures acceleration flexible research awards.--If
the Director of NIH determines that the goals and objectives
of this section cannot adequately be carried out through a
contract, grant, or cooperative agreement, the Director of
NIH shall have flexible research authority to use other
transactions to fund projects in accordance with the terms
and conditions of this section. Awards made under such
flexible research authority for a fiscal year shall not
exceed 20 percent of the total funds appropriated under
subsection (g)(1) for such fiscal year.
``(4) Suspension of awards for defaults, noncompliance with
provisions and plans, and diversion of funds; repayment of
funds.--The Director of NIH may suspend the award to any
entity upon noncompliance by such entity with provisions and
plans under this section or diversion of funds.
``(5) Audits.--The Director of NIH may enter into
agreements with other entities to conduct periodic audits of
the projects funded by grants or contracts awarded under this
subsection.

[[Page S13518]]

``(6) Closeout procedures.--At the end of a grant or
contract period, a recipient shall follow the closeout
procedures under section 74.71 of title 45, Code of Federal
Regulations (or any successor regulation).
``(7) Review.--A determination by the Director of NIH as to
whether a drug, device, or biological product is a high need
cure (for purposes of subsection (a)(3)) shall not be subject
to judicial review.
``(f) Competitive Basis of Awards.--Any grant, cooperative
agreement, or contract awarded under this section shall be
awarded on a competitive basis.
``(g) Authorization of Appropriations.--
``(1) In general.--For purposes of carrying out this
section, there are authorized to be appropriated $500,000,000
for fiscal year 2010, and such sums as may be necessary for
subsequent fiscal years. Funds appropriated under this
section shall be available until expended.
``(2) Limitation on use of funds otherwise appropriated.--
No funds appropriated under this Act, other than funds
appropriated under paragraph (1), may be allocated to the
Cures Acceleration Network.''.

SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION.

(a) Short Title.--This section may be cited as the
``Establishing a Network of Health-Advancing National Centers
of Excellence for Depression Act of 2009'' or the ``ENHANCED
Act of 2009''.
(b) Centers of Excellence for Depression.--Subpart 3 of
part B of title V of the Public Health Service Act (42 U.S.C.
290bb et seq.) is amended by inserting after section 520A the
following:

``SEC. 520B. NATIONAL CENTERS OF EXCELLENCE FOR DEPRESSION.

``(a) Depressive Disorder Defined.--In this section, the
term `depressive disorder' means a mental or brain disorder
relating to depression, including major depression, bipolar
disorder, and related mood disorders.
``(b) Grant Program.--
``(1) In general.--The Secretary, acting through the
Administrator, shall award grants on a competitive basis to
eligible entities to establish national centers of excellence
for depression (referred to in this section as `Centers'),
which shall engage in activities related to the treatment of
depressive disorders.
``(2) Allocation of awards.--If the funds authorized under
subsection (f) are appropriated in the amounts provided for
under such subsection, the Secretary shall allocate such
amounts so that--
``(A) not later than 1 year after the date of enactment of
the ENHANCED Act of 2009, not more than 20 Centers may be
established; and
``(B) not later than September 30, 2016, not more than 30
Centers may be established.
``(3) Grant period.--
``(A) In general.--A grant awarded under this section shall
be for a period of 5 years.
``(B) Renewal.--A grant awarded under subparagraph (A) may
be renewed, on a competitive basis, for 1 additional 5-year
period, at the discretion of the Secretary. In determining
whether to renew a grant, the Secretary shall consider the
report cards issued under subsection (e)(2).
``(4) Use of funds.--Grant funds awarded under this
subsection shall be used for the establishment and ongoing
activities of the recipient of such funds.
``(5) Eligible entities.--
``(A) Requirements.--To be eligible to receive a grant
under this section, an entity shall--
``(i) be an institution of higher education or a public or
private nonprofit research institution; and
``(ii) submit an application to the Secretary at such time
and in such manner as the Secretary may require, as described
in subparagraph (B).
``(B) Application.--An application described in
subparagraph (A)(ii) shall include--
``(i) evidence that such entity--

``(I) provides, or is capable of coordinating with other
entities to provide, comprehensive health services with a
focus on mental health services and subspecialty expertise
for depressive disorders;
``(II) collaborates with other mental health providers, as
necessary, to address co-occurring mental illnesses;
``(III) is capable of training health professionals about
mental health; and

``(ii) such other information, as the Secretary may
require.
``(C) Priorities.--In awarding grants under this section,
the Secretary shall give priority to eligible entities that
meet 1 or more of the following criteria:
``(i) Demonstrated capacity and expertise to serve the
targeted population.
``(ii) Existing infrastructure or expertise to provide
appropriate, evidence-based and culturally and linguistically
competent services.
``(iii) A location in a geographic area with
disproportionate numbers of underserved and at-risk
populations in medically underserved areas and health
professional shortage areas.
``(iv) Proposed innovative approaches for outreach to
initiate or expand services.
``(v) Use of the most up-to-date science, practices, and
interventions available.
``(vi) Demonstrated capacity to establish cooperative and
collaborative agreements with community mental health centers
and other community entities to provide mental health,
social, and human services to individuals with depressive
disorders.
``(6) National coordinating center.--
``(A) In general.--The Secretary, acting through the
Administrator, shall designate 1 recipient of a grant under
this section to be the coordinating center of excellence for
depression (referred to in this section as the `coordinating
center'). The Secretary shall select such coordinating center
on a competitive basis, based upon the demonstrated capacity
of such center to perform the duties described in
subparagraph (C).
``(B) Application.--A Center that has been awarded a grant
under paragraph (1) may apply for designation as the
coordinating center by submitting an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
``(C) Duties.--The coordinating center shall--
``(i) develop, administer, and coordinate the network of
Centers under this section;
``(ii) oversee and coordinate the national database
described in subsection (d);
``(iii) lead a strategy to disseminate the findings and
activities of the Centers through such database; and
``(iv) serve as a liaison with the Administration, the
National Registry of Evidence-based Programs and Practices of
the Administration, and any Federal interagency or
interagency forum on mental health.
``(7) Matching funds.--The Secretary may not award a grant
or contract under this section to an entity unless the entity
agrees that it will make available (directly or through
contributions from other public or private entities) non-
Federal contributions toward the activities to be carried out
under the grant or contract in an amount equal to $1 for each
$5 of Federal funds provided under the grant or contract.
Such non-Federal matching funds may be provided directly or
through donations from public or private entities and may be
in cash or in-kind, fairly evaluated, including plant,
equipment, or services.
``(c) Activities of the Centers.--Each Center shall carry
out the following activities:
``(1) General activities.--Each Center shall--
``(A) integrate basic, clinical, or health services
interdisciplinary research and practice in the development,
implementation, and dissemination of evidence-based
interventions;
``(B) involve a broad cross-section of stakeholders, such
as researchers, clinicians, consumers, families of consumers,
and voluntary health organizations, to develop a research
agenda and disseminate findings, and to provide support in
the implementation of evidence-based practices;
``(C) provide training and technical assistance to mental
health professionals, and engage in and disseminate
translational research with a focus on meeting the needs of
individuals with depressive disorders; and
``(D) educate policy makers, employers, community leaders,
and the public about depressive disorders to reduce stigma
and raise awareness of treatments.
``(2) Improved treatment standards, clinical guidelines,
diagnostic protocols, and care coordination practice.--Each
Center shall collaborate with other Centers in the network
to--
``(A) develop and implement treatment standards, clinical
guidelines, and protocols that emphasize primary prevention,
early intervention, treatment for, and recovery from,
depressive disorders;
``(B) foster communication with other providers attending
to co-occurring physical health conditions such as
cardiovascular, diabetes, cancer, and substance abuse
disorders;
``(C) leverage available community resources, develop and
implement improved self-management programs, and, when
appropriate, involve family and other providers of social
support in the development and implementation of care plans;
and
``(D) use electronic health records and telehealth
technology to better coordinate and manage, and improve
access to, care, as determined by the coordinating center.
``(3) Translational research through collaboration of
centers and community-based organizations.--Each Center
shall--
``(A) demonstrate effective use of a public-private
partnership to foster collaborations among members of the
network and community-based organizations such as community
mental health centers and other social and human services
providers;
``(B) expand interdisciplinary, translational, and patient-
oriented research and treatment; and
``(C) coordinate with accredited academic programs to
provide ongoing opportunities for the professional and
continuing education of mental health providers.
``(d) National Database.--
``(1) In general.--The coordinating center shall establish
and maintain a national, publicly available database to
improve prevention programs, evidence-based interventions,
and disease management programs for depressive disorders,
using data collected from the Centers, as described in
paragraph (2).
``(2) Data collection.--Each Center shall submit data
gathered at such center, as appropriate, to the coordinating
center regarding--
``(A) the prevalence and incidence of depressive disorders;
``(B) the health and social outcomes of individuals with
depressive disorders;
``(C) the effectiveness of interventions designed, tested,
and evaluated;

[[Page S13519]]

``(D) other information, as the Secretary may require.
``(3) Submission of data to the administrator.--The
coordinating center shall submit to the Administrator the
data and financial information gathered under paragraph (2).
``(4) Publication using data from the database.--A Center,
or an individual affiliated with a Center, may publish
findings using the data described in paragraph (2) only if
such center submits such data to the coordinating center, as
required under such paragraph.
``(e) Establishment of Standards; Report Cards and
Recommendations; Third Party Review.--
``(1) Establishment of standards.--The Secretary, acting
through the Administrator, shall establish performance
standards for--
``(A) each Center; and
``(B) the network of Centers as a whole.
``(2) Report cards.--The Secretary, acting through the
Administrator, shall--
``(A) for each Center, not later than 3 years after the
date on which such center of excellence is established and
annually thereafter, issue a report card to the coordinating
center to rate the performance of such Center; and
``(B) not later than 3 years after the date on which the
first grant is awarded under subsection (b)(1) and annually
thereafter, issue a report card to Congress to rate the
performance of the network of centers of excellence as a
whole.
``(3) Recommendations.--Based upon the report cards
described in paragraph (2), the Secretary shall, not later
than September 30, 2015--
``(A) make recommendations to the Centers regarding
improvements such centers shall make; and
``(B) make recommendations to Congress for expanding the
Centers to serve individuals with other types of mental
disorders.
``(4) Third party review.--Not later than 3 years after the
date on which the first grant is awarded under subsection
(b)(1) and annually thereafter, the Secretary shall arrange
for an independent third party to conduct an evaluation of
the network of Centers to ensure that such centers are
meeting the goals of this section.
``(f) Authorization of Appropriations.--
``(1) In general.--To carry out this section, there are
authorized to be appropriated--
``(A) $100,000,000 for each of the fiscal years 2011
through 2015; and
``(B) $150,000,000 for each of the fiscal years 2016
through 2020.
``(2) Allocation of funds authorized.--Of the amount
appropriated under paragraph (1) for a fiscal year, the
Secretary shall determine the allocation of each Center
receiving a grant under this section, but in no case may the
allocation be more than $5,000,000, except that the Secretary
may allocate not more than $10,000,000 to the coordinating
center.''.

SEC. 10411. PROGRAMS RELATING TO CONGENITAL HEART DISEASE.

(a) Short Title.--This subtitle may be cited as the
``Congenital Heart Futures Act''.
(b) Programs Relating to Congenital Heart Disease.--
(1) National congenital heart disease surveillance
system.--Part P of title III of the Public Health Service Act
(42 U.S.C. 280g et seq.), as amended by section 5405, is
further amended by adding at the end the following:

``SEC. 399V-2. NATIONAL CONGENITAL HEART DISEASE SURVEILLANCE
SYSTEM.

``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
may--
``(1) enhance and expand infrastructure to track the
epidemiology of congenital heart disease and to organize such
information into a nationally-representative, population-
based surveillance system that compiles data concerning
actual occurrences of congenital heart disease, to be known
as the `National Congenital Heart Disease Surveillance
System'; or
``(2) award a grant to one eligible entity to undertake the
activities described in paragraph (1).
``(b) Purpose.--The purpose of the Congenital Heart Disease
Surveillance System shall be to facilitate further research
into the types of health services patients use and to
identify possible areas for educational outreach and
prevention in accordance with standard practices of the
Centers for Disease Control and Prevention.
``(c) Content.--The Congenital Heart Disease Surveillance
System--
``(1) may include information concerning the incidence and
prevalence of congenital heart disease in the United States;
``(2) may be used to collect and store data on congenital
heart disease, including data concerning--
``(A) demographic factors associated with congenital heart
disease, such as age, race, ethnicity, sex, and family
history of individuals who are diagnosed with the disease;
``(B) risk factors associated with the disease;
``(C) causation of the disease;
``(D) treatment approaches; and
``(E) outcome measures, such that analysis of the outcome
measures will allow derivation of evidence-based best
practices and guidelines for congenital heart disease
patients; and
``(3) may ensure the collection and analysis of
longitudinal data related to individuals of all ages with
congenital heart disease, including infants, young children,
adolescents, and adults of all ages.
``(d) Public Access.--The Congenital Heart Disease
Surveillance System shall be made available to the public, as
appropriate, including congenital heart disease researchers.
``(e) Patient Privacy.--The Secretary shall ensure that the
Congenital Heart Disease Surveillance System is maintained in
a manner that complies with the regulations promulgated under
section 264 of the Health Insurance Portability and
Accountability Act of 1996.
``(f) Eligibility for Grant.--To be eligible to receive a
grant under subsection (a)(2), an entity shall--
``(1) be a public or private nonprofit entity with
specialized experience in congenital heart disease; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.''.
(2) Congenital heart disease research.--Subpart 2 of part C
of title IV of the Public Health Service Act (42 U.S.C. 285b
et seq.) is amended by adding at the end the following:

``SEC. 425. CONGENITAL HEART DISEASE.

``(a) In General.--The Director of the Institute may
expand, intensify, and coordinate research and related
activities of the Institute with respect to congenital heart
disease, which may include congenital heart disease research
with respect to--
``(1) causation of congenital heart disease, including
genetic causes;
``(2) long-term outcomes in individuals with congenital
heart disease, including infants, children, teenagers,
adults, and elderly individuals;
``(3) diagnosis, treatment, and prevention;
``(4) studies using longitudinal data and retrospective
analysis to identify effective treatments and outcomes for
individuals with congenital heart disease; and
``(5) identifying barriers to life-long care for
individuals with congenital heart disease.
``(b) Coordination of Research Activities.--The Director of
the Institute may coordinate research efforts related to
congenital heart disease among multiple research institutions
and may develop research networks.
``(c) Minority and Medically Underserved Communities.--In
carrying out the activities described in this section, the
Director of the Institute shall consider the application of
such research and other activities to minority and medically
underserved communities.''.
(c) Authorization of Appropriations.--There are authorized
to be appropriated to carry out the amendments made by this
section such sums as may be necessary for each of fiscal
years 2011 through 2015.

SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM'S MEMORY ACT.

Section 312 of the Public Health Service Act (42 U.S.C.
244) is amended--
(1) in subsection (c)(6), after ``clearinghouse'' insert
``, that shall be administered by an organization that has
substantial expertise in pediatric education, pediatric
medicine, and electrophysiology and sudden death,''; and
(2) in the first sentence of subsection (e), by striking
``fiscal year 2003'' and all that follows through ``2006''
and inserting ``for each of fiscal years 2003 through 2014''.

SEC. 10413. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT
OF YOUNG WOMEN DIAGNOSED WITH BREAST CANCER.

(a) Short Title.--This section may be cited as the ``Young
Women's Breast Health Education and Awareness Requires
Learning Young Act of 2009'' or the ``EARLY Act''.
(b) Amendment.--Title III of the Public Health Service Act
(42 U.S.C. 241 et seq.), as amended by this Act, is further
amended by adding at the end the following:

``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER

``SEC. 399NN. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND
SUPPORT OF YOUNG WOMEN DIAGNOSED WITH BREAST
CANCER.

``(a) Public Education Campaign.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall conduct a national evidence-based education campaign to
increase awareness of young women's knowledge regarding--
``(A) breast health in young women of all racial, ethnic,
and cultural backgrounds;
``(B) breast awareness and good breast health habits;
``(C) the occurrence of breast cancer and the general and
specific risk factors in women who may be at high risk for
breast cancer based on familial, racial, ethnic, and cultural
backgrounds such as Ashkenazi Jewish populations;
``(D) evidence-based information that would encourage young
women and their health care professional to increase early
detection of breast cancers; and
``(E) the availability of health information and other
resources for young women diagnosed with breast cancer.
``(2) Evidence-based, age appropriate messages.--The
campaign shall provide evidence-based, age-appropriate
messages and materials as developed by the Centers for
Disease Control and Prevention and the Advisory Committee
established under paragraph (4).

[[Page S13520]]

``(3) Media campaign.--In conducting the education campaign
under paragraph (1), the Secretary shall award grants to
entities to establish national multimedia campaigns oriented
to young women that may include advertising through
television, radio, print media, billboards, posters, all
forms of existing and especially emerging social networking
media, other Internet media, and any other medium determined
appropriate by the Secretary.
``(4) Advisory committee.--
``(A) Establishment.--Not later than 60 days after the date
of the enactment of this section, the Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall establish an advisory committee to assist
in creating and conducting the education campaigns under
paragraph (1) and subsection (b)(1).
``(B) Membership.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall appoint to the advisory committee under subparagraph
(A) such members as deemed necessary to properly advise the
Secretary, and shall include organizations and individuals
with expertise in breast cancer, disease prevention, early
detection, diagnosis, public health, social marketing,
genetic screening and counseling, treatment, rehabilitation,
palliative care, and survivorship in young women.
``(b) Health Care Professional Education Campaign.--The
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, and in consultation with the
Administrator of the Health Resources and Services
Administration, shall conduct an education campaign among
physicians and other health care professionals to increase
awareness--
``(1) of breast health, symptoms, and early diagnosis and
treatment of breast cancer in young women, including specific
risk factors such as family history of cancer and women that
may be at high risk for breast cancer, such as Ashkenazi
Jewish population;
``(2) on how to provide counseling to young women about
their breast health, including knowledge of their family
cancer history and importance of providing regular clinical
breast examinations;
``(3) concerning the importance of discussing healthy
behaviors, and increasing awareness of services and programs
available to address overall health and wellness, and making
patient referrals to address tobacco cessation, good
nutrition, and physical activity;
``(4) on when to refer patients to a health care provider
with genetics expertise;
``(5) on how to provide counseling that addresses long-term
survivorship and health concerns of young women diagnosed
with breast cancer; and
``(6) on when to provide referrals to organizations and
institutions that provide credible health information and
substantive assistance and support to young women diagnosed
with breast cancer.
``(c) Prevention Research Activities.--The Secretary,
acting through--
``(1) the Director of the Centers for Disease Control and
Prevention, shall conduct prevention research on breast
cancer in younger women, including--
``(A) behavioral, survivorship studies, and other research
on the impact of breast cancer diagnosis on young women;
``(B) formative research to assist with the development of
educational messages and information for the public, targeted
populations, and their families about breast health, breast
cancer, and healthy lifestyles;
``(C) testing and evaluating existing and new social
marketing strategies targeted at young women; and
``(D) surveys of health care providers and the public
regarding knowledge, attitudes, and practices related to
breast health and breast cancer prevention and control in
high-risk populations; and
``(2) the Director of the National Institutes of Health,
shall conduct research to develop and validate new screening
tests and methods for prevention and early detection of
breast cancer in young women.
``(d) Support for Young Women Diagnosed With Breast
Cancer.--
``(1) In general.--The Secretary shall award grants to
organizations and institutions to provide health information
from credible sources and substantive assistance directed to
young women diagnosed with breast cancer and pre-neoplastic
breast diseases.
``(2) Priority.--In making grants under paragraph (1), the
Secretary shall give priority to applicants that deal
specifically with young women diagnosed with breast cancer
and pre-neoplastic breast disease.
``(e) No Duplication of Effort.--In conducting an education
campaign or other program under subsections (a), (b), (c), or
(d), the Secretary shall avoid duplicating other existing
Federal breast cancer education efforts.
``(f) Measurement; Reporting.--The Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall--
``(1) measure--
``(A) young women's awareness regarding breast health,
including knowledge of family cancer history, specific risk
factors and early warning signs, and young women's proactive
efforts at early detection;
``(B) the number or percentage of young women utilizing
information regarding lifestyle interventions that foster
healthy behaviors;
``(C) the number or percentage of young women receiving
regular clinical breast exams; and
``(D) the number or percentage of young women who perform
breast self exams, and the frequency of such exams, before
the implementation of this section;
``(2) not less than every 3 years, measure the impact of
such activities; and
``(3) submit reports to the Congress on the results of such
measurements.
``(g) Definition.--In this section, the term `young women'
means women 15 to 44 years of age.
``(h) Authorization of Appropriations.--To carry out
subsections (a), (b), (c)(1), and (d), there are authorized
to be appropriated $9,000,000 for each of the fiscal years
2010 through 2014.''.

Subtitle E--Provisions Relating to Title V

SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE
SOCIAL SECURITY ACT, AND TITLE V OF THIS ACT.

(a) Section 5101 of this Act is amended--
(1) in subsection (c)(2)(B)(i)(II), by inserting ``,
including representatives of small business and self-employed
individuals'' after ``employers'';
(2) in subsection (d)(4)(A)--
(A) by redesignating clause (iv) as clause (v); and
(B) by inserting after clause (iii) the following:
``(iv) An analysis of, and recommendations for, eliminating
the barriers to entering and staying in primary care,
including provider compensation.''; and
(3) in subsection (i)(2)(B), by inserting ``optometrists,
ophthalmologists,'' after ``occupational therapists,''.
(b) Subtitle B of title V of this Act is amended by adding
at the end the following:

``SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE
ACCESS TO HEALTH CARE IN THE STATE OF ALASKA.

``(a) Establishment.--There is established a task force to
be known as the `Interagency Access to Health Care in Alaska
Task Force' (referred to in this section as the `Task
Force').
``(b) Duties.--The Task Force shall--
``(1) assess access to health care for beneficiaries of
Federal health care systems in Alaska; and
``(2) develop a strategy for the Federal Government to
improve delivery of health care to Federal beneficiaries in
the State of Alaska.
``(c) Membership.--The Task Force shall be comprised of
Federal members who shall be appointed, not later than 45
days after the date of enactment of this Act, as follows:
``(1) The Secretary of Health and Human Services shall
appoint one representative of each of the following:
``(A) The Department of Health and Human Services.
``(B) The Centers for Medicare and Medicaid Services.
``(C) The Indian Health Service.
``(2) The Secretary of Defense shall appoint one
representative of the TRICARE Management Activity.
``(3) The Secretary of the Army shall appoint one
representative of the Army Medical Department.
``(4) The Secretary of the Air Force shall appoint one
representative of the Air Force, from among officers at the
Air Force performing medical service functions.
``(5) The Secretary of Veterans Affairs shall appoint one
representative of each of the following:
``(A) The Department of Veterans Affairs.
``(B) The Veterans Health Administration.
``(6) The Secretary of Homeland Security shall appoint one
representative of the United States Coast Guard.
``(d) Chairperson.--One chairperson of the Task Force shall
be appointed by the Secretary at the time of appointment of
members under subsection (c), selected from among the members
appointed under paragraph (1).
``(e) Meetings.--The Task Force shall meet at the call of
the chairperson.
``(f) Report.--Not later than 180 days after the date of
enactment of this Act, the Task Force shall submit to
Congress a report detailing the activities of the Task Force
and containing the findings, strategies, recommendations,
policies, and initiatives developed pursuant to the duty
described in subsection (b)(2). In preparing such report, the
Task Force shall consider completed and ongoing efforts by
Federal agencies to improve access to health care in the
State of Alaska.
``(g) Termination.--The Task Force shall be terminated on
the date of submission of the report described in subsection
(f).''.
(c) Section 399V of the Public Health Service Act, as added
by section 5313, is amended--
(1) in subsection (b)(4), by striking ``identify, educate,
refer, and enroll'' and inserting ``identify and refer''; and
(2) in subsection (k)(1), by striking ``, as defined by the
Department of Labor as Standard Occupational Classification
[21-1094]''.
(d) Section 738(a)(3) of the Public Health Service Act (42
U.S.C. 293b(a)(3)) is amended by inserting ``schools offering
physician assistant education programs,'' after ``public
health,''.
(e) Subtitle D of title V of this Act is amended by adding
at the end the following:

[[Page S13521]]

``SEC. 5316. DEMONSTRATION GRANTS FOR FAMILY NURSE
PRACTITIONER TRAINING PROGRAMS.

``(a) Establishment of Program.--The Secretary of Health
and Human Services (referred to in this section as the
`Secretary') shall establish a training demonstration program
for family nurse practitioners (referred to in this section
as the `program') to employ and provide 1-year training for
nurse practitioners who have graduated from a nurse
practitioner program for careers as primary care providers in
Federally qualified health centers (referred to in this
section as `FQHCs') and nurse-managed health clinics
(referred to in this section as `NMHCs').
``(b) Purpose.--The purpose of the program is to enable
each grant recipient to--
``(1) provide new nurse practitioners with clinical
training to enable them to serve as primary care providers in
FQHCs and NMHCs;
``(2) train new nurse practitioners to work under a model
of primary care that is consistent with the principles set
forth by the Institute of Medicine and the needs of
vulnerable populations; and
``(3) create a model of FQHC and NMHC training for nurse
practitioners that may be replicated nationwide.
``(c) Grants.--The Secretary shall award 3-year grants to
eligible entities that meet the requirements established by
the Secretary, for the purpose of operating the nurse
practitioner primary care programs described in subsection
(a) in such entities.
``(d) Eligible Entities.--To be eligible to receive a grant
under this section, an entity shall--
``(1)(A) be a FQHC as defined in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)); or
``(B) be a nurse-managed health clinic, as defined in
section 330A-1 of the Public Health Service Act (as added by
section 5208 of this Act); and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(e) Priority in Awarding Grants.--In awarding grants
under this section, the Secretary shall give priority to
eligible entities that--
``(1) demonstrate sufficient infrastructure in size, scope,
and capacity to undertake the requisite training of a minimum
of 3 nurse practitioners per year, and to provide to each
awardee 12 full months of full-time, paid employment and
benefits consistent with the benefits offered to other full-
time employees of such entity;
``(2) will assign not less than 1 staff nurse practitioner
or physician to each of 4 precepted clinics;
``(3) will provide to each awardee specialty rotations,
including specialty training in prenatal care and women's
health, adult and child psychiatry, orthopedics, geriatrics,
and at least 3 other high-volume, high-burden specialty
areas;
``(4) provide sessions on high-volume, high-risk health
problems and have a record of training health care
professionals in the care of children, older adults, and
underserved populations; and
``(5) collaborate with other safety net providers, schools,
colleges, and universities that provide health professions
training.
``(f) Eligibility of Nurse Practitioners.--
``(1) In general.--To be eligible for acceptance to a
program funded through a grant awarded under this section, an
individual shall--
``(A) be licensed or eligible for licensure in the State in
which the program is located as an advanced practice
registered nurse or advanced practice nurse and be eligible
or board-certified as a family nurse practitioner; and
``(B) demonstrate commitment to a career as a primary care
provider in a FQHC or in a NMHC.
``(2) Preference.--In selecting awardees under the program,
each grant recipient shall give preference to bilingual
candidates that meet the requirements described in paragraph
(1).
``(3) Deferral of certain service.--The starting date of
required service of individuals in the National Health
Service Corps Service program under title II of the Public
Health Service Act (42 U.S.C. 202 et seq.) who receive
training under this section shall be deferred until the date
that is 22 days after the date of completion of the program.
``(g) Grant Amount.--Each grant awarded under this section
shall be in an amount not to exceed $600,000 per year. A
grant recipient may carry over funds from 1 fiscal year to
another without obtaining approval from the Secretary.
``(h) Technical Assistance Grants.--The Secretary may award
technical assistance grants to 1 or more FQHCs or NMHCs that
have demonstrated expertise in establishing a nurse
practitioner residency training program. Such technical
assistance grants shall be for the purpose of providing
technical assistance to other recipients of grants under
subsection (c).
``(i) Authorization of Appropriations.--To carry out this
section, there is authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through
2014.''.
(f)(1) Section 399W of the Public Health Service Act, as
added by section 5405, is redesignated as section 399V-1.
(2) Section 399V-1 of the Public Health Service Act, as so
redesignated, is amended in subsection (b)(2)(A) by striking
``and the departments of 1 or more health professions schools
in the State that train providers in primary care'' and
inserting ``and the departments that train providers in
primary care in 1 or more health professions schools in the
State''.
(3) Section 934 of the Public Health Service Act, as added
by section 3501, is amended by striking ``399W'' each place
such term appears and inserting ``399V-1''.
(4) Section 935(b) of the Public Health Service Act, as
added by section 3503, is amended by striking ``399W'' and
inserting ``399V-1''.
(g) Part P of title III of the Public Health Service Act 42
U.S.C. 280g et seq.), as amended by section 10411, is amended
by adding at the end the following:

``SEC. 399V-3. NATIONAL DIABETES PREVENTION PROGRAM.

``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish a national diabetes prevention program
(referred to in this section as the `program') targeted at
adults at high risk for diabetes in order to eliminate the
preventable burden of diabetes.
``(b) Program Activities.--The program described in
subsection (a) shall include--
``(1) a grant program for community-based diabetes
prevention program model sites;
``(2) a program within the Centers for Disease Control and
Prevention to determine eligibility of entities to deliver
community-based diabetes prevention services;
``(3) a training and outreach program for lifestyle
intervention instructors; and
``(4) evaluation, monitoring and technical assistance, and
applied research carried out by the Centers for Disease
Control and Prevention.
``(c) Eligible Entities.--To be eligible for a grant under
subsection (b)(1), an entity shall be a State or local health
department, a tribal organization, a national network of
community-based non-profits focused on health and wellbeing,
an academic institution, or other entity, as the Secretary
determines.
``(d) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2010 through 2014.''.
(h) The provisions of, and amendment made by, section
5501(c) of this Act are repealed.
(i)(1) The provisions of, and amendments made by, section
5502 of this Act are repealed.
(2)(A) Section 1861(aa)(3)(A) of the Social Security Act
(42 U.S.C. 1395w(aa)(3)(A)) is amended to read as follows:
``(A) services of the type described in subparagraphs (A)
through (C) of paragraph (1) and preventive services (as
defined in section 1861(ddd)(3)); and''.
(B) The amendment made by subparagraph (A) shall apply to
services furnished on or after January 1, 2011.
(3)(A) Section 1834 of the Social Security Act (42 U.S.C.
1395m), as amended by section 4105, is amended by adding at
the end the following new subsection:
``(o) Development and Implementation of Prospective Payment
System.--
``(1) Development.--
``(A) In general.--The Secretary shall develop a
prospective payment system for payment for Federally
qualified health center services furnished by Federally
qualified health centers under this title. Such system shall
include a process for appropriately describing the services
furnished by Federally qualified health centers and shall
establish payment rates for specific payment codes based on
such appropriate descriptions of services. Such system shall
be established to take into account the type, intensity, and
duration of services furnished by Federally qualified health
centers. Such system may include adjustments, including
geographic adjustments, determined appropriate by the
Secretary.
``(B) Collection of data and evaluation.--By not later than
January 1, 2011, the Secretary shall require Federally
qualified health centers to submit to the Secretary such
information as the Secretary may require in order to develop
and implement the prospective payment system under this
subsection, including the reporting of services using HCPCS
codes.
``(2) Implementation.--
``(A) In general.--Notwithstanding section 1833(a)(3)(A),
the Secretary shall provide, for cost reporting periods
beginning on or after October 1, 2014, for payments of
prospective payment rates for Federally qualified health
center services furnished by Federally qualified health
centers under this title in accordance with the prospective
payment system developed by the Secretary under paragraph
(1).
``(B) Payments.--
``(i) Initial payments.--The Secretary shall implement such
prospective payment system so that the estimated aggregate
amount of prospective payment rates (determined prior to the
application of section 1833(a)(1)(Z)) under this title for
Federally qualified health center services in the first year
that such system is implemented is equal to 100 percent of
the estimated amount of reasonable costs (determined without
the application of a per visit payment limit or productivity
screen and prior to the application of section
1866(a)(2)(A)(ii)) that would have occurred for such services
under this title in such year if the system had not been
implemented.

[[Page S13522]]

``(ii) Payments in subsequent years.--Payment rates in
years after the year of implementation of such system shall
be the payment rates in the previous year increased--

``(I) in the first year after implementation of such
system, by the percentage increase in the MEI (as defined in
section 1842(i)(3)) for the year involved; and
``(II) in subsequent years, by the percentage increase in a
market basket of Federally qualified health center goods and
services as promulgated through regulations, or if such an
index is not available, by the percentage increase in the MEI
(as defined in section 1842(i)(3)) for the year involved.

``(C) Preparation for pps implementation.--Notwithstanding
any other provision of law, the Secretary may establish and
implement by program instruction or otherwise the payment
codes to be used under the prospective payment system under
this section.''.
(B) Section 1833(a)(1) of the Social Security Act (42
U.S.C. 1395l(a)(1)), as amended by section 4104, is amended--
(i) by striking ``and'' before ``(Y)''; and
(ii) by inserting before the semicolon at the end the
following: ``, and (Z) with respect to Federally qualified
health center services for which payment is made under
section 1834(o), the amounts paid shall be 80 percent of the
lesser of the actual charge or the amount determined under
such section''.
(C) Section 1833(a) of the Social Security Act (42 U.S.C.
1395l(a)) is amended--
(i) in paragraph (3)(B)(i)--
(I) by inserting ``(I)'' after ``otherwise been provided'';
and
(II) by inserting ``, or (II) in the case of such services
furnished on or after the implementation date of the
prospective payment system under section 1834(o), under such
section (calculated as if `100 percent' were substituted for
`80 percent' in such section) for such services if the
individual had not been so enrolled'' after ``been so
enrolled''; and
(ii) by adding at the end the following flush sentence:

``Paragraph (3)(A) shall not apply to Federally qualified
health center services furnished on or after the
implementation date of the prospective payment system under
section 1834(0).''.
(j) Section 5505 is amended by adding at the end the
following new subsection:
``(d) Application.--The amendments made by this section
shall not be applied in a manner that requires reopening of
any settled cost reports as to which there is not a
jurisdictionally proper appeal pending as of the date of the
enactment of this Act on the issue of payment for indirect
costs of medical education under section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct
graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. 1395ww(h)).''.
(k) Subtitle G of title V of this Act is amended by adding
at the end the following:

``SEC. 5606. STATE GRANTS TO HEALTH CARE PROVIDERS WHO
PROVIDE SERVICES TO A HIGH PERCENTAGE OF
MEDICALLY UNDERSERVED POPULATIONS OR OTHER
SPECIAL POPULATIONS.

``(a) In General.--A State may award grants to health care
providers who treat a high percentage, as determined by such
State, of medically underserved populations or other special
populations in such State.
``(b) Source of Funds.--A grant program established by a
State under subsection (a) may not be established within a
department, agency, or other entity of such State that
administers the Medicaid program under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.), and no Federal
or State funds allocated to such Medicaid program, the
Medicare program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.), or the TRICARE program under
chapter 55 of title 10, United States Code, may be used to
award grants or to pay administrative costs associated with a
grant program established under subsection (a).''.
(l) Part C of title VII of the Public Health Service Act
(42 U.S.C. 293k et seq.) is amended--
(1) after the part heading, by inserting the following:

``Subpart I--Medical Training Generally'';

and
(2) by inserting at the end the following:

``Subpart II--Training in Underserved Communities

``SEC. 749B. RURAL PHYSICIAN TRAINING GRANTS.

``(a) In General.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall establish a grant program for the
purposes of assisting eligible entities in recruiting
students most likely to practice medicine in underserved
rural communities, providing rural-focused training and
experience, and increasing the number of recent allopathic
and osteopathic medical school graduates who practice in
underserved rural communities.
``(b) Eligible Entities.--In order to be eligible to
receive a grant under this section, an entity shall--
``(1) be a school of allopathic or osteopathic medicine
accredited by a nationally recognized accrediting agency or
association approved by the Secretary for this purpose, or
any combination or consortium of such schools; and
``(2) submit an application to the Secretary that includes
a certification that such entity will use amounts provided to
the institution as described in subsection (d)(1).
``(c) Priority.--In awarding grant funds under this
section, the Secretary shall give priority to eligible
entities that--
``(1) demonstrate a record of successfully training
students, as determined by the Secretary, who practice
medicine in underserved rural communities;
``(2) demonstrate that an existing academic program of the
eligible entity produces a high percentage, as determined by
the Secretary, of graduates from such program who practice
medicine in underserved rural communities;
``(3) demonstrate rural community institutional
partnerships, through such mechanisms as matching or
contributory funding, documented in-kind services for
implementation, or existence of training partners with
interprofessional expertise in community health center
training locations or other similar facilities; or
``(4) submit, as part of the application of the entity
under subsection (b), a plan for the long-term tracking of
where the graduates of such entity practice medicine.
``(d) Use of Funds.--
``(1) Establishment.--An eligible entity receiving a grant
under this section shall use the funds made available under
such grant to establish, improve, or expand a rural-focused
training program (referred to in this section as the
`Program') meeting the requirements described in this
subsection and to carry out such program.
``(2) Structure of program.--An eligible entity shall--
``(A) enroll no fewer than 10 students per class year into
the Program; and
``(B) develop criteria for admission to the Program that
gives priority to students--
``(i) who have originated from or lived for a period of 2
or more years in an underserved rural community; and
``(ii) who express a commitment to practice medicine in an
underserved rural community.
``(3) Curricula.--The Program shall require students to
enroll in didactic coursework and clinical experience
particularly applicable to medical practice in underserved
rural communities, including--
``(A) clinical rotations in underserved rural communities,
and in applicable specialties, or other coursework or
clinical experience deemed appropriate by the Secretary; and
``(B) in addition to core school curricula, additional
coursework or training experiences focused on medical issues
prevalent in underserved rural communities.
``(4) Residency placement assistance.--Where available, the
Program shall assist all students of the Program in obtaining
clinical training experiences in locations with postgraduate
programs offering residency training opportunities in
underserved rural communities, or in local residency training
programs that support and train physicians to practice in
underserved rural communities.
``(5) Program student cohort support.--The Program shall
provide and require all students of the Program to
participate in group activities designed to further develop,
maintain, and reinforce the original commitment of such
students to practice in an underserved rural community.
``(e) Annual Reporting.--An eligible entity receiving a
grant under this section shall submit an annual report to the
Secretary on the success of the Program, based on criteria
the Secretary determines appropriate, including the residency
program selection of graduating students who participated in
the Program.
``(f) Regulations.--Not later than 60 days after the date
of enactment of this section, the Secretary shall by
regulation define `underserved rural community' for purposes
of this section.
``(g) Supplement Not Supplant.--Any eligible entity
receiving funds under this section shall use such funds to
supplement, not supplant, any other Federal, State, and local
funds that would otherwise be expended by such entity to
carry out the activities described in this section.
``(h) Maintenance of Effort.--With respect to activities
for which funds awarded under this section are to be
expended, the entity shall agree to maintain expenditures of
non-Federal amounts for such activities at a level that is
not less than the level of such expenditures maintained by
the entity for the fiscal year preceding the fiscal year for
which the entity receives a grant under this section.
``(i) Authorization of Appropriations.--There are
authorized to be appropriated $4,000,000 for each of the
fiscal years 2010 through 2013.''.
(m)(1) Section 768 of the Public Health Service Act (42
U.S.C. 295c) is amended to read as follows:

``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING
GRANT PROGRAM.

``(a) Grants.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and in consultation with the Director of the
Centers for Disease Control and Prevention, shall award
grants to, or enter into contracts with, eligible entities to
provide training to graduate medical residents in preventive
medicine specialties.
``(b) Eligibility.--To be eligible for a grant or contract
under subsection (a), an entity shall be--
``(1) an accredited school of public health or school of
medicine or osteopathic medicine;
``(2) an accredited public or private nonprofit hospital;

[[Page S13523]]

``(3) a State, local, or tribal health department; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(c) Use of Funds.--Amounts received under a grant or
contract under this section shall be used to--
``(1) plan, develop (including the development of
curricula), operate, or participate in an accredited
residency or internship program in preventive medicine or
public health;
``(2) defray the costs of practicum experiences, as
required in such a program; and
``(3) establish, maintain, or improve--
``(A) academic administrative units (including departments,
divisions, or other appropriate units) in preventive medicine
and public health; or
``(B) programs that improve clinical teaching in preventive
medicine and public health.
``(d) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.''.
(2) Section 770(a) of the Public Health Service Act (42
U.S.C. 295e(a)) is amended to read as follows:
``(a) In General.--For the purpose of carrying out this
subpart, there is authorized to be appropriated $43,000,000
for fiscal year 2011, and such sums as may be necessary for
each of the fiscal years 2012 through 2015.''.
(n)(1) Subsection (i) of section 331 of the Public Health
Service Act (42 U.S.C. 254d) of the Public Health Service Act
is amended--
(A) in paragraph (1), by striking ``In carrying out subpart
III'' and all that follows through the period and inserting
``In carrying out subpart III, the Secretary may, in
accordance with this subsection, issue waivers to individuals
who have entered into a contract for obligated service under
the Scholarship Program or the Loan Repayment Program under
which the individuals are authorized to satisfy the
requirement of obligated service through providing clinical
practice that is half time.'';
(B) in paragraph (2)--
(i) in subparagraphs (A)(ii) and (B), by striking ``less
than full time'' each place it appears and inserting ``half
time'';
(ii) in subparagraphs (C) and (F), by striking ``less than
full-time service'' each place it appears and inserting
``half-time service''; and
(iii) by amending subparagraphs (D) and (E) to read as
follows:
``(D) the entity and the Corps member agree in writing that
the Corps member will perform half-time clinical practice;
``(E) the Corps member agrees in writing to fulfill all of
the service obligations under section 338C through half-time
clinical practice and either--
``(i) double the period of obligated service that would
otherwise be required; or
``(ii) in the case of contracts entered into under section
338B, accept a minimum service obligation of 2 years with an
award amount equal to 50 percent of the amount that would
otherwise be payable for full-time service; and''; and
(C) in paragraph (3), by striking ``In evaluating a
demonstration project described in paragraph (1)'' and
inserting ``In evaluating waivers issued under paragraph
(1)''.
(2) Subsection (j) of section 331 of the Public Health
Service Act (42 U.S.C. 254d) is amended by adding at the end
the following:
``(5) The terms `full time' and `full-time' mean a minimum
of 40 hours per week in a clinical practice, for a minimum of
45 weeks per year.
``(6) The terms `half time' and `half-time' mean a minimum
of 20 hours per week (not to exceed 39 hours per week) in a
clinical practice, for a minimum of 45 weeks per year.''.
(3) Section 337(b)(1) of the Public Health Service Act (42
U.S.C. 254j(b)(1)) is amended by striking ``Members may not
be reappointed to the Council.''.
(4) Section 338B(g)(2)(A) of the Public Health Service Act
(42 U.S.C. 254l-1(g)(2)(A)) is amended by striking
``$35,000'' and inserting ``$50,000, plus, beginning with
fiscal year 2012, an amount determined by the Secretary on an
annual basis to reflect inflation,''.
(5) Subsection (a) of section 338C of the Public Health
Service Act (42 U.S.C. 254m), as amended by section 5508, is
amended--
(A) by striking the second sentence and inserting the
following: ``The Secretary may treat teaching as clinical
practice for up to 20 percent of such period of obligated
service.''; and
(B) by adding at the end the following: ``Notwithstanding
the preceding sentence, with respect to a member of the Corps
participating in the teaching health centers graduate medical
education program under section 340H, for the purpose of
calculating time spent in full-time clinical practice under
this section, up to 50 percent of time spent teaching by such
member may be counted toward his or her service
obligation.''.

SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE.

(a) Appropriation.--There are authorized to be
appropriated, and there are appropriated to the Department of
Health and Human Services, $100,000,000 for fiscal year 2010,
to remain available for obligation until September 30, 2011,
to be used for debt service on, or direct construction or
renovation of, a health care facility that provides research,
inpatient tertiary care, or outpatient clinical services.
Such facility shall be affiliated with an academic health
center at a public research university in the United States
that contains a State's sole public academic medical and
dental school.
(b) Requirement.--Amount appropriated under subsection (a)
may only be made available by the Secretary of Health and
Human Services upon the receipt of an application from the
Governor of a State that certifies that--
(1) the new health care facility is critical for the
provision of greater access to health care within the State;
(2) such facility is essential for the continued financial
viability of the State's sole public medical and dental
school and its academic health center;
(3) the request for Federal support represents not more
than 40 percent of the total cost of the proposed new
facility; and
(4) the State has established a dedicated funding mechanism
to provide all remaining funds necessary to complete the
construction or renovation of the proposed facility.

SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NATIONAL HEALTH
SERVICE CORPS FUND.

(a) Purpose.--It is the purpose of this section to
establish a Community Health Center Fund (referred to in this
section as the ``CHC Fund''), to be administered through the
Office of the Secretary of the Department of Health and Human
Services to provide for expanded and sustained national
investment in community health centers under section 330 of
the Public Health Service Act and the National Health Service
Corps.
(b) Funding.--There is authorized to be appropriated, and
there is appropriated, out of any monies in the Treasury not
otherwise appropriated, to the CHC Fund--
(1) to be transferred to the Secretary of Health and Human
Services to provide enhanced funding for the community health
center program under section 330 of the Public Health Service
Act--
(A) $700,000,000 for fiscal year 2011;
(B) $800,000,000 for fiscal year 2012;
(C) $1,000,000,000 for fiscal year 2013;
(D) $1,600,000,000 for fiscal year 2014; and
(E) $2,900,000,000 for fiscal year 2015; and
(2) to be transferred to the Secretary of Health and Human
Services to provide enhanced funding for the National Health
Service Corps--
(A) $290,000,000 for fiscal year 2011;
(B) $295,000,000 for fiscal year 2012;
(C) $300,000,000 for fiscal year 2013;
(D) $305,000,000 for fiscal year 2014; and
(E) $310,000,000 for fiscal year 2015.
(c) Construction.--There is authorized to be appropriated,
and there is appropriated, out of any monies in the Treasury
not otherwise appropriated, $1,500,000,000 to be available
for fiscal years 2011 through 2015 to be used by the
Secretary of Health and Human Services for the construction
and renovation of community health centers.
(d) Use of Fund.--The Secretary of Health and Human
Services shall transfer amounts in the CHC Fund to accounts
within the Department of Health and Human Services to
increase funding, over the fiscal year 2008 level, for
community health centers and the National Health Service
Corps.
(e) Availability.--Amounts appropriated under subsections
(b) and (c) shall remain available until expended.

SEC. 10504. DEMONSTRATION PROJECT TO PROVIDE ACCESS TO
AFFORDABLE CARE.

(a) In General.--Not later than 6 months after the date of
enactment of this Act, the Secretary of Health and Human
Services (referred to in this section as the ``Secretary''),
acting through the Health Resources and Services
Administration, shall establish a 3 year demonstration
project in up to 10 States to provide access to comprehensive
health care services to the uninsured at reduced fees. The
Secretary shall evaluate the feasibility of expanding the
project to additional States.
(b) Eligibility.--To be eligible to participate in the
demonstration project, an entity shall be a State-based,
nonprofit, public-private partnership that provides access to
comprehensive health care services to the uninsured at
reduced fees. Each State in which a participant selected by
the Secretary is located shall receive not more than
$2,000,000 to establish and carry out the project for the 3-
year demonstration period.
(c) Authorization.--There is authorized to be appropriated
such sums as may be necessary to carry out this section.

Subtitle F--Provisions Relating to Title VI

SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EXCEPTION TO
THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS
FOR HOSPITALS.

(a) In General.--Section 1877(i) of the Social Security
Act, as added by section 6001(a), is amended--
(1) in paragraph (1)(A)(i), by striking ``February 1,
2010'' and inserting ``August 1, 2010''; and
(2) in paragraph (3)(A)--
(A) in clause (iii), by striking ``August 1, 2011'' and
inserting ``February 1, 2012''; and
(B) in clause (iv), by striking ``July 1, 2011'' and
inserting ``January 1, 2012''.
(b) Conforming Amendment.--Section 6001(b)(2) of this Act
is amended by striking ``November 1, 2011'' and inserting
``May 1, 2012''.

SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES
RESEARCH.

Section 1181 of the Social Security Act (as added by
section 6301) is amended--
(1) in subsection (d)(2)(B)--
(A) in clause (ii)(IV)--
(i) by inserting ``, as described in subparagraph
(A)(ii),'' after ``original research''; and

[[Page S13524]]

(ii) by inserting ``, as long as the researcher enters into
a data use agreement with the Institute for use of the data
from the original research, as appropriate'' after
``publication''; and
(B) by amending clause (iv) to read as follows:
``(iv) Subsequent use of the data.--The Institute shall not
allow the subsequent use of data from original research in
work-for-hire contracts with individuals, entities, or
instrumentalities that have a financial interest in the
results, unless approved under a data use agreement with the
Institute.'';
(2) in subsection (d)(8)(A)(iv), by striking ``not be
construed as mandates for'' and inserting ``do not include'';
and
(3) in subsection (f)(1)(C), by amending clause (ii) to
read as follows:
``(ii) 7 members representing physicians and providers,
including 4 members representing physicians (at least 1 of
whom is a surgeon), 1 nurse, 1 State-licensed integrative
health care practitioner, and 1 representative of a
hospital.''.

SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL
PROVIDER APPLICATION FEES.

(a) In General.--Section 1866(j)(2)(C) of the Social
Security Act, as added by section 6401(a), is amended--
(1) by striking clause (i);
(2) by redesignating clauses (ii) through (iv),
respectively, as clauses (i) through (iii); and
(3) in clause (i), as redesignated by paragraph (2), by
striking ``clause (iii)'' and inserting ``clause (ii)''.
(b) Technical Correction.--Section 6401(a)(2) of this Act
is amended to read as follows:
``(2) by redesignating paragraph (2) as paragraph (8);
and''.

SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405.

Paragraphs (1) and (2) of section 6405(b) are amended to
read as follows:
``(1) Part a.--Section 1814(a)(2) of the Social Security
Act (42 U.S.C. 1395(a)(2)) is amended in the matter preceding
subparagraph (A) by inserting `, or, in the case of services
described in subparagraph (C), a physician enrolled under
section 1866(j),' after `in collaboration with a physician,'.
``(2) Part b.--Section 1835(a)(2) of the Social Security
Act (42 U.S.C. 1395n(a)(2)) is amended in the matter
preceding subparagraph (A) by inserting `, or, in the case of
services described in subparagraph (A), a physician enrolled
under section 1866(j),' after `a physician'.''.

SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT FACE
TO FACE ENCOUNTER FOR HOME HEALTH SERVICES.

(a) Part A.--Section 1814(a)(2)(C) of the Social Security
Act (42 U.S.C. 1395f(a)(2)(C)), as amended by section
6407(a)(1), is amended by inserting ``, or a nurse
practitioner or clinical nurse specialist (as those terms are
defined in section 1861(aa)(5)) who is working in
collaboration with the physician in accordance with State
law, or a certified nurse-midwife (as defined in section
1861(gg)) as authorized by State law, or a physician
assistant (as defined in section 1861(aa)(5)) under the
supervision of the physician,'' after ``himself or herself''.
(b) Part B.--Section 1835(a)(2)(A)(iv) of the Social
Security Act, as added by section 6407(a)(2), is amended by
inserting ``, or a nurse practitioner or clinical nurse
specialist (as those terms are defined in section
1861(aa)(5)) who is working in collaboration with the
physician in accordance with State law, or a certified nurse-
midwife (as defined in section 1861(gg)) as authorized by
State law, or a physician assistant (as defined in section
1861(aa)(5)) under the supervision of the physician,'' after
``must document that the physician''.

SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.

(a) Fraud Sentencing Guidelines.--
(1) Definition.--In this subsection, the term ``Federal
health care offense'' has the meaning given that term in
section 24 of title 18, United States Code, as amended by
this Act.
(2) Review and amendments.--Pursuant to the authority under
section 994 of title 28, United States Code, and in
accordance with this subsection, the United States Sentencing
Commission shall--
(A) review the Federal Sentencing Guidelines and policy
statements applicable to persons convicted of Federal health
care offenses;
(B) amend the Federal Sentencing Guidelines and policy
statements applicable to persons convicted of Federal health
care offenses involving Government health care programs to
provide that the aggregate dollar amount of fraudulent bills
submitted to the Government health care program shall
constitute prima facie evidence of the amount of the intended
loss by the defendant; and
(C) amend the Federal Sentencing Guidelines to provide--
(i) a 2-level increase in the offense level for any
defendant convicted of a Federal health care offense relating
to a Government health care program which involves a loss of
not less than $1,000,000 and less than $7,000,000;
(ii) a 3-level increase in the offense level for any
defendant convicted of a Federal health care offense relating
to a Government health care program which involves a loss of
not less than $7,000,000 and less than $20,000,000;
(iii) a 4-level increase in the offense level for any
defendant convicted of a Federal health care offense relating
to a Government health care program which involves a loss of
not less than $20,000,000; and
(iv) if appropriate, otherwise amend the Federal Sentencing
Guidelines and policy statements applicable to persons
convicted of Federal health care offenses involving
Government health care programs.
(3) Requirements.--In carrying this subsection, the United
States Sentencing Commission shall--
(A) ensure that the Federal Sentencing Guidelines and
policy statements--
(i) reflect the serious harms associated with health care
fraud and the need for aggressive and appropriate law
enforcement action to prevent such fraud; and
(ii) provide increased penalties for persons convicted of
health care fraud offenses in appropriate circumstances;
(B) consult with individuals or groups representing health
care fraud victims, law enforcement officials, the health
care industry, and the Federal judiciary as part of the
review described in paragraph (2);
(C) ensure reasonable consistency with other relevant
directives and with other guidelines under the Federal
Sentencing Guidelines;
(D) account for any aggravating or mitigating circumstances
that might justify exceptions, including circumstances for
which the Federal Sentencing Guidelines, as in effect on the
date of enactment of this Act, provide sentencing
enhancements;
(E) make any necessary conforming changes to the Federal
Sentencing Guidelines; and
(F) ensure that the Federal Sentencing Guidelines
adequately meet the purposes of sentencing.
(b) Intent Requirement for Health Care Fraud.--Section 1347
of title 18, United States Code, is amended--
(1) by inserting ``(a)'' before ``Whoever knowingly''; and
(2) by adding at the end the following:
``(b) With respect to violations of this section, a person
need not have actual knowledge of this section or specific
intent to commit a violation of this section.''.
(c) Health Care Fraud Offense.--Section 24(a) of title 18,
United States Code, is amended--
(1) in paragraph (1), by striking the semicolon and
inserting ``or section 1128B of the Social Security Act (42
U.S.C. 1320a-7b); or''; and
(2) in paragraph (2)--
(A) by inserting ``1349,'' after ``1343,''; and
(B) by inserting ``section 301 of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 331), or section 501 of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1131),'' after ``title,''.
(d) Subpoena Authority Relating to Health Care.--
(1) Subpoenas under the health insurance portability and
accountability act of 1996.--Section 1510(b) of title 18,
United States Code, is amended--
(A) in paragraph (1), by striking ``to the grand jury'';
and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking ``grand jury
subpoena'' and inserting ``subpoena for records''; and
(ii) in the matter following subparagraph (B), by striking
``to the grand jury''.
(2) Subpoenas under the civil rights of institutionalized
persons act.--The Civil Rights of Institutionalized Persons
Act (42 U.S.C. 1997 et seq.) is amended by inserting after
section 3 the following:

``SEC. 3A. SUBPOENA AUTHORITY.

``(a) Authority.--The Attorney General, or at the direction
of the Attorney General, any officer or employee of the
Department of Justice may require by subpoena access to any
institution that is the subject of an investigation under
this Act and to any document, record, material, file, report,
memorandum, policy, procedure, investigation, video or audio
recording, or quality assurance report relating to any
institution that is the subject of an investigation under
this Act to determine whether there are conditions which
deprive persons residing in or confined to the institution of
any rights, privileges, or immunities secured or protected by
the Constitution or laws of the United States.
``(b) Issuance and Enforcement of Subpoenas.--
``(1) Issuance.--Subpoenas issued under this section--
``(A) shall bear the signature of the Attorney General or
any officer or employee of the Department of Justice as
designated by the Attorney General; and
``(B) shall be served by any person or class of persons
designated by the Attorney General or a designated officer or
employee for that purpose.
``(2) Enforcement.--In the case of contumacy or failure to
obey a subpoena issued under this section, the United States
district court for the judicial district in which the
institution is located may issue an order requiring
compliance. Any failure to obey the order of the court may be
punished by the court as a contempt that court.
``(c) Protection of Subpoenaed Records and Information.--
Any document, record, material, file, report, memorandum,
policy, procedure, investigation, video or audio recording,
or quality assurance report or other information obtained
under a subpoena issued under this section--

[[Page S13525]]

``(1) may not be used for any purpose other than to protect
the rights, privileges, or immunities secured or protected by
the Constitution or laws of the United States of persons who
reside, have resided, or will reside in an institution;
``(2) may not be transmitted by or within the Department of
Justice for any purpose other than to protect the rights,
privileges, or immunities secured or protected by the
Constitution or laws of the United States of persons who
reside, have resided, or will reside in an institution; and
``(3) shall be redacted, obscured, or otherwise altered if
used in any publicly available manner so as to prevent the
disclosure of any personally identifiable information.''.

SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE
ALTERNATIVES TO CURRENT MEDICAL TORT
LITIGATION.

Part P of title III of the Public Health Service Act (42
U.S.C. 280g et seq.), as amended by this Act, is further
amended by adding at the end the following:

``SEC. 399V-4. STATE DEMONSTRATION PROGRAMS TO EVALUATE
ALTERNATIVES TO CURRENT MEDICAL TORT
LITIGATION.

``(a) In General.--The Secretary is authorized to award
demonstration grants to States for the development,
implementation, and evaluation of alternatives to current
tort litigation for resolving disputes over injuries
allegedly caused by health care providers or health care
organizations. In awarding such grants, the Secretary shall
ensure the diversity of the alternatives so funded.
``(b) Duration.--The Secretary may award grants under
subsection (a) for a period not to exceed 5 years.
``(c) Conditions for Demonstration Grants.--
``(1) Requirements.--Each State desiring a grant under
subsection (a) shall develop an alternative to current tort
litigation that--
``(A) allows for the resolution of disputes over injuries
allegedly caused by health care providers or health care
organizations; and
``(B) promotes a reduction of health care errors by
encouraging the collection and analysis of patient safety
data related to disputes resolved under subparagraph (A) by
organizations that engage in efforts to improve patient
safety and the quality of health care.
``(2) Alternative to current tort litigation.--Each State
desiring a grant under subsection (a) shall demonstrate how
the proposed alternative described in paragraph (1)(A)--
``(A) makes the medical liability system more reliable by
increasing the availability of prompt and fair resolution of
disputes;
``(B) encourages the efficient resolution of disputes;
``(C) encourages the disclosure of health care errors;
``(D) enhances patient safety by detecting, analyzing, and
helping to reduce medical errors and adverse events;
``(E) improves access to liability insurance;
``(F) fully informs patients about the differences in the
alternative and current tort litigation;
``(G) provides patients the ability to opt out of or
voluntarily withdraw from participating in the alternative at
any time and to pursue other options, including litigation,
outside the alternative;
``(H) would not conflict with State law at the time of the
application in a way that would prohibit the adoption of an
alternative to current tort litigation; and
``(I) would not limit or curtail a patient's existing legal
rights, ability to file a claim in or access a State's legal
system, or otherwise abrogate a patient's ability to file a
medical malpractice claim.
``(3) Sources of compensation.--Each State desiring a grant
under subsection (a) shall identify the sources from and
methods by which compensation would be paid for claims
resolved under the proposed alternative to current tort
litigation, which may include public or private funding
sources, or a combination of such sources. Funding methods
shall to the extent practicable provide financial incentives
for activities that improve patient safety.
``(4) Scope.--
``(A) In general.--Each State desiring a grant under
subsection (a) shall establish a scope of jurisdiction (such
as Statewide, designated geographic region, a designated area
of health care practice, or a designated group of health care
providers or health care organizations) for the proposed
alternative to current tort litigation that is sufficient to
evaluate the effects of the alternative. No scope of
jurisdiction shall be established under this paragraph that
is based on a health care payer or patient population.
``(B) Notification of patients.--A State shall demonstrate
how patients would be notified that they are receiving health
care services that fall within such scope, and the process by
which they may opt out of or voluntarily withdraw from
participating in the alternative. The decision of the patient
whether to participate or continue participating in the
alternative process shall be made at any time and shall not
be limited in any way.
``(5) Preference in awarding demonstration grants.--In
awarding grants under subsection (a), the Secretary shall
give preference to States--
``(A) that have developed the proposed alternative through
substantive consultation with relevant stakeholders,
including patient advocates, health care providers and health
care organizations, attorneys with expertise in representing
patients and health care providers, medical malpractice
insurers, and patient safety experts;
``(B) that make proposals that are likely to enhance
patient safety by detecting, analyzing, and helping to reduce
medical errors and adverse events; and
``(C) that make proposals that are likely to improve access
to liability insurance.
``(d) Application.--
``(1) In general.--Each State desiring a grant under
subsection (a) shall submit to the Secretary an application,
at such time, in such manner, and containing such information
as the Secretary may require.
``(2) Review panel.--
``(A) In general.--In reviewing applications under
paragraph (1), the Secretary shall consult with a review
panel composed of relevant experts appointed by the
Comptroller General.
``(B) Composition.--
``(i) Nominations.--The Comptroller General shall solicit
nominations from the public for individuals to serve on the
review panel.
``(ii) Appointment.--The Comptroller General shall appoint,
at least 9 but not more than 13, highly qualified and
knowledgeable individuals to serve on the review panel and
shall ensure that the following entities receive fair
representation on such panel:

``(I) Patient advocates.
``(II) Health care providers and health care organizations.
``(III) Attorneys with expertise in representing patients
and health care providers.
``(IV) Medical malpractice insurers.
``(V) State officials.
``(VI) Patient safety experts.

``(C) Chairperson.--The Comptroller General, or an
individual within the Government Accountability Office
designated by the Comptroller General, shall be the
chairperson of the review panel.
``(D) Availability of information.--The Comptroller General
shall make available to the review panel such information,
personnel, and administrative services and assistance as the
review panel may reasonably require to carry out its duties.
``(E) Information from agencies.--The review panel may
request directly from any department or agency of the United
States any information that such panel considers necessary to
carry out its duties. To the extent consistent with
applicable laws and regulations, the head of such department
or agency shall furnish the requested information to the
review panel.
``(e) Reports.--
``(1) By state.--Each State receiving a grant under
subsection (a) shall submit to the Secretary an annual report
evaluating the effectiveness of activities funded with grants
awarded under such subsection. Such report shall, at a
minimum, include the impact of the activities funded on
patient safety and on the availability and price of medical
liability insurance.
``(2) By secretary.--The Secretary shall submit to Congress
an annual compendium of the reports submitted under paragraph
(1) and an analysis of the activities funded under subsection
(a) that examines any differences that result from such
activities in terms of the quality of care, number and nature
of medical errors, medical resources used, length of time for
dispute resolution, and the availability and price of
liability insurance.
``(f) Technical Assistance.--
``(1) In general.--The Secretary shall provide technical
assistance to the States applying for or awarded grants under
subsection (a).
``(2) Requirements.--Technical assistance under paragraph
(1) shall include--
``(A) guidance on non-economic damages, including the
consideration of individual facts and circumstances in
determining appropriate payment, guidance on identifying
avoidable injuries, and guidance on disclosure to patients of
health care errors and adverse events; and
``(B) the development, in consultation with States, of
common definitions, formats, and data collection
infrastructure for States receiving grants under this section
to use in reporting to facilitate aggregation and analysis of
data both within and between States.
``(3) Use of common definitions, formats, and data
collection infrastructure.--States not receiving grants under
this section may also use the common definitions, formats,
and data collection infrastructure developed under paragraph
(2)(B).
``(g) Evaluation.--
``(1) In general.--The Secretary, in consultation with the
review panel established under subsection (d)(2), shall enter
into a contract with an appropriate research organization to
conduct an overall evaluation of the effectiveness of grants
awarded under subsection (a) and to annually prepare and
submit a report to Congress. Such an evaluation shall begin
not later than 18 months following the date of implementation
of the first program funded by a grant under subsection (a).
``(2) Contents.--The evaluation under paragraph (1) shall
include--
``(A) an analysis of the effects of the grants awarded
under subsection (a) with regard to the measures described in
paragraph (3);
``(B) for each State, an analysis of the extent to which
the alternative developed under subsection (c)(1) is
effective in meeting the elements described in subsection
(c)(2);

[[Page S13526]]

``(C) a comparison among the States receiving grants under
subsection (a) of the effectiveness of the various
alternatives developed by such States under subsection
(c)(1);
``(D) a comparison, considering the measures described in
paragraph (3), of States receiving grants approved under
subsection (a) and similar States not receiving such grants;
and
``(E) a comparison, with regard to the measures described
in paragraph (3), of--
``(i) States receiving grants under subsection (a);
``(ii) States that enacted, prior to the date of enactment
of the Patient Protection and Affordable Care Act, any cap on
non-economic damages; and
``(iii) States that have enacted, prior to the date of
enactment of the Patient Protection and Affordable Care Act,
a requirement that the complainant obtain an opinion
regarding the merit of the claim, although the substance of
such opinion may have no bearing on whether the complainant
may proceed with a case.
``(3) Measures.--The evaluations under paragraph (2) shall
analyze and make comparisons on the basis of--
``(A) the nature and number of disputes over injuries
allegedly caused by health care providers or health care
organizations;
``(B) the nature and number of claims in which tort
litigation was pursued despite the existence of an
alternative under subsection (a);
``(C) the disposition of disputes and claims, including the
length of time and estimated costs to all parties;
``(D) the medical liability environment;
``(E) health care quality;
``(F) patient safety in terms of detecting, analyzing, and
helping to reduce medical errors and adverse events;
``(G) patient and health care provider and organization
satisfaction with the alternative under subsection (a) and
with the medical liability environment; and
``(H) impact on utilization of medical services,
appropriately adjusted for risk.
``(4) Funding.--The Secretary shall reserve 5 percent of
the amount appropriated in each fiscal year under subsection
(k) to carry out this subsection.
``(h) MedPAC and MACPAC Reports.--
``(1) MedPAC.--The Medicare Payment Advisory Commission
shall conduct an independent review of the alternatives to
current tort litigation that are implemented under grants
under subsection (a) to determine the impact of such
alternatives on the Medicare program under title XVIII of the
Social Security Act, and its beneficiaries.
``(2) MACPAC.--The Medicaid and CHIP Payment and Access
Commission shall conduct an independent review of the
alternatives to current tort litigation that are implemented
under grants under subsection (a) to determine the impact of
such alternatives on the Medicaid or CHIP programs under
titles XIX and XXI of the Social Security Act, and their
beneficiaries.
``(3) Reports.--Not later than December 31, 2016, the
Medicare Payment Advisory Commission and the Medicaid and
CHIP Payment and Access Commission shall each submit to
Congress a report that includes the findings and
recommendations of each respective Commission based on
independent reviews conducted under paragraphs (1) and (2),
including an analysis of the impact of the alternatives
reviewed on the efficiency and effectiveness of the
respective programs.
``(i) Option to Provide for Initial Planning Grants.--Of
the funds appropriated pursuant to subsection (k), the
Secretary may use a portion not to exceed $500,000 per State
to provide planning grants to such States for the development
of demonstration project applications meeting the criteria
described in subsection (c). In selecting States to receive
such planning grants, the Secretary shall give preference to
those States in which State law at the time of the
application would not prohibit the adoption of an alternative
to current tort litigation.
``(j) Definitions.--In this section:
``(1) Health care services.--The term `health care
services' means any services provided by a health care
provider, or by any individual working under the supervision
of a health care provider, that relate to--
``(A) the diagnosis, prevention, or treatment of any human
disease or impairment; or
``(B) the assessment of the health of human beings.
``(2) Health care organization.--The term `health care
organization' means any individual or entity which is
obligated to provide, pay for, or administer health benefits
under any health plan.
``(3) Health care provider.--The term `health care
provider' means any individual or entity--
``(A) licensed, registered, or certified under Federal or
State laws or regulations to provide health care services; or
``(B) required to be so licensed, registered, or certified
but that is exempted by other statute or regulation.
``(k) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section,
$50,000,000 for the 5-fiscal year period beginning with
fiscal year 2011.
``(l) Current State Efforts to Establish Alternative to
Tort Litigation.--Nothing in this section shall be construed
to limit any prior, current, or future efforts of any State
to establish any alternative to tort litigation.
``(m) Rule of Construction.--Nothing in this section shall
be construed as limiting states' authority over or
responsibility for their state justice systems.''.

SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE TO FREE
CLINICS.

(a) In General.--Section 224(o)(1) of the Public Health
Service Act (42 U.S.C. 233(o)(1)) is amended by inserting
after ``to an individual'' the following: ``, or an officer,
governing board member, employee, or contractor of a free
clinic shall in providing services for the free clinic,''.
(b) Effective Date.--The amendment made by this section
shall take effect on the date of enactment of this Act and
apply to any act or omission which occurs on or after that
date.

SEC. 10609. LABELING CHANGES.

Section 505(j) of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355(j)) is amended by adding at the end the
following:
``(10)(A) If the proposed labeling of a drug that is the
subject of an application under this subsection differs from
the listed drug due to a labeling revision described under
clause (i), the drug that is the subject of such application
shall, notwithstanding any other provision of this Act, be
eligible for approval and shall not be considered misbranded
under section 502 if--
``(i) the application is otherwise eligible for approval
under this subsection but for expiration of patent, an
exclusivity period, or of a delay in approval described in
paragraph (5)(B)(iii), and a revision to the labeling of the
listed drug has been approved by the Secretary within 60 days
of such expiration;
``(ii) the labeling revision described under clause (i)
does not include a change to the `Warnings' section of the
labeling;
``(iii) the sponsor of the application under this
subsection agrees to submit revised labeling of the drug that
is the subject of such application not later than 60 days
after the notification of any changes to such labeling
required by the Secretary; and
``(iv) such application otherwise meets the applicable
requirements for approval under this subsection.
``(B) If, after a labeling revision described in
subparagraph (A)(i), the Secretary determines that the
continued presence in interstate commerce of the labeling of
the listed drug (as in effect before the revision described
in subparagraph (A)(i)) adversely impacts the safe use of the
drug, no application under this subsection shall be eligible
for approval with such labeling.''.

Subtitle G--Provisions Relating to Title VIII

SEC. 10801. PROVISIONS RELATING TO TITLE VIII.

(a) Title XXXII of the Public Health Service Act, as added
by section 8002(a)(1), is amended--
(1) in section 3203--
(A) in subsection (a)(1), by striking subparagraph (E);
(B) in subsection (b)(1)(C)(i), by striking ``for
enrollment'' and inserting ``for reenrollment''; and
(C) in subsection (c)(1), by striking ``, as part of their
automatic enrollment in the CLASS program,''; and
(2) in section 3204--
(A) in subsection (c)(2), by striking subparagraph (A) and
inserting the following:
``(A) receives wages or income on which there is imposed a
tax under section 3101(a) or 3201(a) of the Internal Revenue
Code of 1986; or'';
(B) in subsection (d), by striking ``subparagraph (B) or
(C) of subsection (c)(1)'' and inserting ``subparagraph (A)
or (B) of subsection (c)(2)'';
(C) in subsection (e)(2)(A), by striking ``subparagraph
(A)'' and inserting ``paragraph (1)''; and
(D) in subsection (g)(1), by striking ``has elected to
waive enrollment'' and inserting ``has not enrolled''.
(b) Section 8002 of this Act is amended in the heading for
subsection (d), by striking ``Information on Supplemental
Coverage'' and inserting ``CLASS Program Information''.
(c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction Act
of 2005, as added by section 8002(d) of this Act, is amended
by striking ``and coverage available'' and all that follows
through ``that program,''.

Subtitle H--Provisions Relating to Title IX

SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST
EMPLOYER-SPONSORED HEALTH COVERAGE.

(a) Longshore Workers Treated as Employees Engaged in High-
Risk Professions.--Paragraph (3) of section 4980I(f) of the
Internal Revenue Code of 1986, as added by section 9001 of
this Act, is amended by inserting ``individuals whose primary
work is longshore work (as defined in section 258(b) of the
Immigration and Nationality Act (8 U.S.C. 1288(b)),
determined without regard to paragraph (2) thereof),'' before
``and individuals engaged in the construction, mining''.
(b) Exemption From High-Cost Insurance Tax Includes Certain
Additional Excepted Benefits.--Clause (i) of section
4980I(d)(1)(B) of the Internal Revenue Code of 1986, as added
by section 9001 of this Act, is amended by striking ``section
9832(c)(1)(A)'' and inserting ``section 9832(c)(1) (other
than subparagraph (G) thereof)''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.

SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH
FLEXIBLE SPENDING ARRANGEMENTS UNDER CAFETERIA
PLANS.

(a) In General.--Subsection (i) of section 125 of the
Internal Revenue Code of 1986, as

[[Page S13527]]

added by section 9005 of this Act, is amended to read as
follows:
``(i) Limitation on Health Flexible Spending
Arrangements.--
``(1) In general.--For purposes of this section, if a
benefit is provided under a cafeteria plan through employer
contributions to a health flexible spending arrangement, such
benefit shall not be treated as a qualified benefit unless
the cafeteria plan provides that an employee may not elect
for any taxable year to have salary reduction contributions
in excess of $2,500 made to such arrangement.
``(2) Adjustment for inflation.--In the case of any taxable
year beginning after December 31, 2011, the dollar amount in
paragraph (1) shall be increased by an amount equal to--
``(A) such amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which such taxable
year begins by substituting `calendar year 2010' for
`calendar year 1992' in subparagraph (B) thereof.
If any increase determined under this paragraph is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2010.

SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY
CHARITABLE HOSPITALS.

(a) In General.--Subparagraph (A) of section 501(r)(5) of
the Internal Revenue Code of 1986, as added by section 9007
of this Act, is amended by striking ``the lowest amounts
charged'' and inserting ``the amounts generally billed''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after the date of the
enactment of this Act.

SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE
MANUFACTURERS AND IMPORTERS.

(a) In General.--Section 9009 of this Act is amended--
(1) by striking ``2009'' in subsection (a)(1) and inserting
``2010'',
(2) by inserting ``($3,000,000,000 after 2017)'' after
``$2,000,000,000'', and
(3) by striking ``2008'' in subsection (i) and inserting
``2009''.
(b) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of section
9009.

SEC. 10905. MODIFICATION OF ANNUAL FEE ON HEALTH INSURANCE
PROVIDERS.

(a) Determination of Fee Amount.--Subsection (b) of section
9010 of this Act is amended to read as follows:
``(b) Determination of Fee Amount.--
``(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal
to an amount that bears the same ratio to the applicable
amount as--
``(A) the covered entity's net premiums written with
respect to health insurance for any United States health risk
that are taken into account during the preceding calendar
year, bears to
``(B) the aggregate net premiums written with respect to
such health insurance of all covered entities that are taken
into account during such preceding calendar year.
``(2) Amounts taken into account.--For purposes of
paragraph (1), the net premiums written with respect to
health insurance for any United States health risk that are
taken into account during any calendar year with respect to
any covered entity shall be determined in accordance with the
following table:

``With respect to a covered entity's    The percentage of net premiums
net premiums written during the        written that are taken into
calendar year that are:                    account is:

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

``(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such
amount, the Secretary shall determine such covered entity's
net premiums written with respect to any United States health
risk on the basis of reports submitted by the covered entity
under subsection (g) and through the use of any other source
of information available to the Secretary.''.
(b) Applicable Amount.--Subsection (e) of section 9010 of
this Act is amended to read as follows:
``(e) Applicable Amount.--For purposes of subsection
(b)(1), the applicable amount shall be determined in
accordance with the following table:

``Calendar year                          Applicable amount
2011.................................  $2,000,000,000
2012.................................  $4,000,000,000
2013.................................  $7,000,000,000
2014, 2015 and 2016..................  $9,000,000,000
2017 and thereafter..................  $10,000,000,000.''.

(c) Exemption From Annual Fee on Health Insurance for
Certain Nonprofit Entities.--Section 9010(c)(2) of this Act
is amended by striking ``or'' at the end of subparagraph (A),
by striking the period at the end of subparagraph (B) and
inserting a comma, and by adding at the end the following new
subparagraphs:
``(C) any entity--
``(i)(I) which is incorporated as, is a wholly owned
subsidiary of, or is a wholly owned affiliate of, a nonprofit
corporation under a State law, or
``(II) which is described in section 501(c)(4) of the
Internal Revenue Code of 1986 and the activities of which
consist of providing commercial-type insurance (within the
meaning of section 501(m) of such Code),
``(ii) the premium rate increases of which are regulated by
a State authority,
``(iii) which, as of the date of the enactment of this
section, acts as the insurer of last resort in the State and
is subject to State guarantee issue requirements, and
``(iv) for which the medical loss ratio (determined in a
manner consistent with the determination of such ratio under
section 2718(b)(1)(A) of the Public Health Service Act) with
respect to the individual insurance market for such entity
for the calendar year is not less than 100 percent,
``(D) any entity--
``(i)(I) which is incorporated as a nonprofit corporation
under a State law, or
``(II) which is described in section 501(c)(4) of the
Internal Revenue Code of 1986 and the activities of which
consist of providing commercial-type insurance (within the
meaning of section 501(m) of such Code), and
``(ii) for which the medical loss ratio (as so
determined)--

``(I) with respect to each of the individual, small group,
and large group insurance markets for such entity for the
calendar year is not less than 90 percent, and
``(II) with respect to all such markets for such entity for
the calendar year is not less than 92 percent, or

``(E) any entity--
``(i) which is a mutual insurance company,
``(ii) which for the period reported on the 2008 Accident
and Health Policy Experience Exhibit of the National
Association of Insurance Commissioners had--

``(I) a market share of the insured population of a State
of at least 40 but not more than 60 percent, and
``(II) with respect to all markets described in
subparagraph (D)(ii)(I), a medical loss ratio of not less
than 90 percent, and

``(iii) with respect to annual payment dates in calendar
years after 2011, for which the medical loss ratio
(determined in a manner consistent with the determination of
such ratio under section 2718(b)(1)(A) of the Public Health
Service Act) with respect to all such markets for such entity
for the preceding calendar year is not less than 89 percent
(except that with respect to such annual payment date for
2012, the calculation under 2718(b)(1)(B)(ii) of such Act is
determined by reference to the previous year, and with
respect to such annual payment date for 2013, such
calculation is determined by reference to the average for the
previous 2 years).''.
(d) Certain Insurance Exempted From Fee.--Paragraph (3) of
section 9010(h) of this Act is amended to read as follows:
``(3) Health insurance.--The term `health insurance' shall
not include--
``(A) any insurance coverage described in paragraph (1)(A)
or (3) of section 9832(c) of the Internal Revenue Code of
1986,
``(B) any insurance for long-term care, or
``(C) any medicare supplemental health insurance (as
defined in section 1882(g)(1) of the Social Security Act).''.
(e) Anti-Avoidance Guidance.--Subsection (i) of section
9010 of this Act is amended by inserting ``and shall
prescribe such regulations as are necessary or appropriate to
prevent avoidance of the purposes of this section, including
inappropriate actions taken

[[Page S13528]]

to qualify as an exempt entity under subsection (c)(2)''
after ``section''.
(f) Conforming Amendments.--
(1) Section 9010(a)(1) of this Act is amended by striking
``2009'' and inserting ``2010''.
(2) Section 9010(c)(2)(B) of this Act is amended by
striking ``(except'' and all that follows through ``1323)''.
(3) Section 9010(c)(3) of this Act is amended by adding at
the end the following new sentence: ``If any entity described
in subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph
(2) is treated as a covered entity by reason of the
application of the preceding sentence, the net premiums
written with respect to health insurance for any United
States health risk of such entity shall not be taken into
account for purposes of this section.''.
(4) Section 9010(g)(1) of this Act is amended by striking
``and third party administration agreement fees''.
(5) Section 9010(j) of this Act is amended--
(A) by striking ``2008'' and inserting ``2009'', and
(B) by striking ``, and any third party administration
agreement fees received after such date''.
(g) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of section
9010.

SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE
TAX ON HIGH-INCOME TAXPAYERS.

(a) FICA.--Section 3101(b)(2) of the Internal Revenue Code
of 1986, as added by section 9015(a)(1) of this Act, is
amended by striking ``0.5 percent'' and inserting ``0.9
percent''.
(b) SECA.--Section 1401(b)(2)(A) of the Internal Revenue
Code of 1986, as added by section 9015(b)(1) of this Act, is
amended by striking ``0.5 percent'' and inserting ``0.9
percent''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to remuneration received, and
taxable years beginning, after December 31, 2012.

SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF
ELECTIVE COSMETIC MEDICAL PROCEDURES.

(a) In General.--The provisions of, and amendments made by,
section 9017 of this Act are hereby deemed null, void, and of
no effect.
(b) Excise Tax on Indoor Tanning Services.--Subtitle D of
the Internal Revenue Code of 1986, as amended by this Act, is
amended by adding at the end the following new chapter:

``CHAPTER 49--COSMETIC SERVICES

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

``SEC. 5000B. IMPOSITION OF TAX ON INDOOR TANNING SERVICES.

``(a) In General.--There is hereby imposed on any indoor
tanning service a tax equal to 10 percent of the amount paid
for such service (determined without regard to this section),
whether paid by insurance or otherwise.
``(b) Indoor Tanning Service.--For purposes of this
section--
``(1) In general.--The term `indoor tanning service' means
a service employing any electronic product designed to
incorporate 1 or more ultraviolet lamps and intended for the
irradiation of an individual by ultraviolet radiation, with
wavelengths in air between 200 and 400 nanometers, to induce
skin tanning.
``(2) Exclusion of phototherapy services.--Such term does
not include any phototherapy service performed by a licensed
medical professional.
``(c) Payment of Tax.--
``(1) In general.--The tax imposed by this section shall be
paid by the individual on whom the service is performed.
``(2) Collection.--Every person receiving a payment for
services on which a tax is imposed under subsection (a) shall
collect the amount of the tax from the individual on whom the
service is performed and remit such tax quarterly to the
Secretary at such time and in such manner as provided by the
Secretary.
``(3) Secondary liability.--Where any tax imposed by
subsection (a) is not paid at the time payments for indoor
tanning services are made, then to the extent that such tax
is not collected, such tax shall be paid by the person who
performs the service.''.
(c) Clerical Amendment.--The table of chapter for subtitle
D of the Internal Revenue Code of 1986, as amended by this
Act, is amended by inserting after the item relating to
chapter 48 the following new item:

``Chapter 49--Cosmetic Services''.

(d) Effective Date.--The amendments made by this section
shall apply to services performed on or after July 1, 2010.

SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS
IN STATE STUDENT LOAN REPAYMENT PROGRAMS FOR
CERTAIN HEALTH PROFESSIONALS.

(a) In General.--Paragraph (4) of section 108(f) of the
Internal Revenue Code of 1986 is amended to read as follows:
``(4) Payments under national health service corps loan
repayment program and certain state loan repayment
programs.--In the case of an individual, gross income shall
not include any amount received under section 338B(g) of the
Public Health Service Act, under a State program described in
section 338I of such Act, or under any other State loan
repayment or loan forgiveness program that is intended to
provide for the increased availability of health care
services in underserved or health professional shortage areas
(as determined by such State).''.
(b) Effective Date.--The amendment made by this section
shall apply to amounts received by an individual in taxable
years beginning after December 31, 2008.

SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION
ASSISTANCE PROGRAMS.

(a) Increase in Dollar Limitation.--
(1) Adoption credit.--
(A) In general.--Paragraph (1) of section 23(b) of the
Internal Revenue Code of 1986 (relating to dollar limitation)
is amended by striking ``$10,000'' and inserting ``$13,170''.
(B) Child with special needs.--Paragraph (3) of section
23(a) of such Code (relating to $10,000 credit for adoption
of child with special needs regardless of expenses) is
amended--
(i) in the text by striking ``$10,000'' and inserting
``$13,170'', and
(ii) in the heading by striking ``$10,000'' and inserting
``$13,170''.
(C) Conforming amendment to inflation adjustment.--
Subsection (h) of section 23 of such Code (relating to
adjustments for inflation) is amended to read as follows:
``(h) Adjustments for Inflation.--
``(1) Dollar limitations.--In the case of a taxable year
beginning after December 31, 2010, each of the dollar amounts
in subsections (a)(3) and (b)(1) shall be increased by an
amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2009'
for `calendar year 1992' in subparagraph (B) thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.
``(2) Income limitation.--In the case of a taxable year
beginning after December 31, 2002, the dollar amount in
subsection (b)(2)(A)(i) shall be increased by an amount equal
to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2001'
for `calendar year 1992' in subparagraph (B) thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.''.
(2) Adoption assistance programs.--
(A) In general.--Paragraph (1) of section 137(b) of the
Internal Revenue Code of 1986 (relating to dollar limitation)
is amended by striking ``$10,000'' and inserting ``$13,170''.
(B) Child with special needs.--Paragraph (2) of section
137(a) of such Code (relating to $10,000 exclusion for
adoption of child with special needs regardless of expenses)
is amended--
(i) in the text by striking ``$10,000'' and inserting
``$13,170'', and
(ii) in the heading by striking ``$10,000'' and inserting
``$13,170''.
(C) Conforming amendment to inflation adjustment.--
Subsection (f) of section 137 of such Code (relating to
adjustments for inflation) is amended to read as follows:
``(f) Adjustments for Inflation.--
``(1) Dollar limitations.--In the case of a taxable year
beginning after December 31, 2010, each of the dollar amounts
in subsections (a)(2) and (b)(1) shall be increased by an
amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2009'
for `calendar year 1992' in subparagraph (B) thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.
``(2) Income limitation.--In the case of a taxable year
beginning after December 31, 2002, the dollar amount in
subsection (b)(2)(A) shall be increased by an amount equal
to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2001'
for `calendar year 1992' in subparagraph thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.''.
(b) Credit Made Refundable.--
(1) Credit moved to subpart relating to refundable
credits.--The Internal Revenue Code of 1986 is amended--
(A) by redesignating section 23, as amended by subsection
(a), as section 36C, and
(B) by moving section 36C (as so redesignated) from subpart
A of part IV of subchapter A of chapter 1 to the location
immediately before section 37 in subpart C of part IV of
subchapter A of chapter 1.
(2) Conforming amendments.--
(A) Section 24(b)(3)(B) of such Code is amended by striking
``23,''.
(B) Section 25(e)(1)(C) of such Code is amended by striking
``23,'' both places it appears.
(C) Section 25A(i)(5)(B) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.

[[Page S13529]]

(D) Section 25B(g)(2) of such Code is amended by striking
``23,''.
(E) Section 26(a)(1) of such Code is amended by striking
``23,''.
(F) Section 30(c)(2)(B)(ii) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.
(G) Section 30B(g)(2)(B)(ii) of such Code is amended by
striking ``23,''.
(H) Section 30D(c)(2)(B)(ii) of such Code is amended by
striking ``sections 23 and'' and inserting ``section''.
(I) Section 36C of such Code, as so redesignated, is
amended--
(i) by striking paragraph (4) of subsection (b), and
(ii) by striking subsection (c).
(J) Section 137 of such Code is amended--
(i) by striking ``section 23(d)'' in subsection (d) and
inserting ``section 36C(d)'', and
(ii) by striking ``section 23'' in subsection (e) and
inserting ``section 36C''.
(K) Section 904(i) of such Code is amended by striking
``23,''.
(L) Section 1016(a)(26) is amended by striking ``23(g)''
and inserting ``36C(g)''.
(M) Section 1400C(d) of such Code is amended by striking
``23,''.
(N) Section 6211(b)(4)(A) of such Code is amended by
inserting ``36C,'' before ``53(e)''.
(O) The table of sections for subpart A of part IV of
subchapter A of chapter 1 of such Code of 1986 is amended by
striking the item relating to section 23.
(P) Paragraph (2) of section 1324(b) of title 31, United
States Code, as amended by this Act, is amended by inserting
``36C,'' after ``36B,''.
(Q) The table of sections for subpart C of part IV of
subchapter A of chapter 1 of the Internal Revenue Code of
1986, as amended by this Act, is amended by inserting after
the item relating to section 36B the following new item:

``Sec. 36C. Adoption expenses.''.
(c) Application and Extension of EGTRRA Sunset.--
Notwithstanding section 901 of the Economic Growth and Tax
Relief Reconciliation Act of 2001, such section shall apply
to the amendments made by this section and the amendments
made by section 202 of such Act by substituting ``December
31, 2011'' for ``December 31, 2010'' in subsection (a)(1)
thereof.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2009.
______

SA 3277. Mr. REID proposed an amendment to amendment SA 3276 proposed
by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr.
Dodd, and Mr. Harkin) to the bill H.R. 3590, to amend the Internal
Revenue Code of 1986 to modify the first-time homebuyers credit in the
case of members of the Armed Forces and certain other Federal
employees, and for other purposes; as follows:

At the end of the amendment, add the following:
The provisions of this Act shall become effective 5 days
after enactment.
______

SA 3278. Mr. REID proposed an amendment to the bill H.R. 3590, to
amend the Internal Revenue Code of 1986 to modify the first-time
homebuyers credit in the case of members of the Armed Forces and
certain other Federal employees, and for other purposes; as follows:

At the end of the language proposed to be stricken, insert
the following:
This section shall become effective 4 days after enactment.
______

SA 3279. Mr. REID proposed an amendment to amendment SA 3278 proposed
by Mr. Reid to the bill H.R. 3590, to amend the Internal Revenue Code
of 1986 to modify the first-time homebuyers credit in the case of
members of the Armed Forces and certain other Federal employees, and
for other purposes; as follows:

In the amendment, strike ``4'' and insert ``3''.
______

SA 3280. Mr. REID proposed an amendment to the bill H.R. 3590, to
amend the Internal Revenue Code of 1986 to modify the first-time
homebuyers credit in the case of members of the Armed Forces and
certain other Federal employees, and for other purposes; as follows:

At the end, insert the following:
The provisions of this Act shall become effective 2 days
after enactment.
______

SA 3281. Mr. REID proposed an amendment to amendment SA 3280 proposed
by Mr. Reid to the bill H.R. 3590, to amend the Internal Revenue Code
of 1986 to modify the first-time homebuyers credit in the case of
members of the Armed Forces and certain other Federal employees; and
for other purposes; as follows:

Strike ``2 days'' and insert ``1 day''.
______

SA 3282. Mr. REID proposed an amendment to amendment SA 3281 proposed
by Mr. Reid to the amendment SA 3280 proposed by Mr. Reid to the bill
H.R. 3590, to amend the Internal Revenue Code of 1986 to modify the
first-time homebuyers credit in the case of members of the Armed Forces
and certain other Federal employees, and for other purposes; as
follows:

Strike ``1 day'' and insert ``immediately''.
______

SA 3283. Mr. COBURN submitted an amendment intended to be proposed to
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr.
Dodd, and Mr. Harkin) to the bill H.R. 3590, to amend the Internal
Revenue Code of 1986 to modify the first-time homebuyers credit in the
case of members of the Armed Forces and certain other Federal
employees, and for other purposes; which was ordered to lie on the
table; as follows:

Strike all after the enacting clause and insert the
following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title.--This Act may be cited as the ``Patients'
Choice Act''.
(b) Table of Contents.--The table of contents for this Act
is as follows:

Sec. 1. Short title; table of contents.

TITLE I--INVESTING IN PREVENTION

Sec. 101. Strategic approach to outcome-based prevention.
Sec. 102. State grants for outcome-based prevention effort.
Sec. 103. Focusing the food stamp program on nutrition.
Sec. 104. Immunizations.

TITLE II--STATE-BASED HEALTH CARE EXCHANGES

Sec. 201. State-based health care exchanges.
Sec. 202. Requirements.
Sec. 203. State Exchange incentives.

TITLE III--FAIR TAX TREATMENT FOR ALL AMERICANS TO AFFORD HEALTH CARE

Sec. 300. Reference.
Sec. 301. Refundable and advanceable credit for certain health
insurance coverage.
Sec. 302. Requiring employer transparency about employee benefits.
Sec. 303. Changes to existing tax preferences for medical coverage,
etc., for individuals eligible for qualified health
insurance credit.
Sec. 304. Adjustments.

TITLE IV--FAIRNESS FOR EVERY AMERICAN PATIENT

Subtitle A--Medicaid Modernization

Sec. 401. Medicaid modernization.
Sec. 402. Outreach.
Sec. 403. Transition rules; miscellaneous provisions.

Subtitle B--Supplemental Health Care Assistance for Low-Income Families

Sec. 411. Supplemental Health Care Assistance for Low-Income Families.

TITLE V--FIXING MEDICARE FOR AMERICAN SENIORS

Subtitle A--Increasing Programmatic Efficiency, Economy, and
Accountability

Sec. 501. Eliminating inefficiencies and increasing choice in Medicare
Advantage.
Sec. 502. Medicare Accountable Care Organization demonstration program.
Sec. 503. Reducing government handouts to wealthier seniors.
Sec. 504. Rewarding prevention.
Sec. 505. Promoting healthcare provider transparency.
Sec. 506. Availability of Medicare and Medicaid claims and patient
encounter data.

Subtitle B--Reducing Fraud and Abuse

Sec. 511. Requiring the Secretary of Health and Human Services to
change the Medicare beneficiary identifier used to
identify Medicare beneficiaries under the Medicare
program.
Sec. 512. Use of technology for real-time data review.
Sec. 513. Detection of medicare fraud and abuse.
Sec. 514. Edits on 855S Medicare enrollment application and exemption
of pharmacists from surety bond requirement.
Sec. 515. GAO study and report on effectiveness of surety bond
requirements for suppliers of durable medical equipment
in combating fraud.

TITLE VI--ENDING LAWSUIT ABUSE

Sec. 601. State grants to create health court solutions.

TITLE VII--PROMOTING HEALTH INFORMATION TECHNOLOGY

Subtitle A--Assisting the Development of Health Information Technology

Sec. 701. Purpose.
Sec. 702. Health record banking.
Sec. 703. Application of Federal and State security and confidentiality
standards.

Subtitle B--Removing Barriers to the Use of Health Information
Technology to Better Coordinate Health Care

Sec. 711. Safe harbors to antikickback civil penalties and criminal
penalties for provision of health information technology
and training services.

[[Page S13530]]

Sec. 712. Exception to limitation on certain physician referrals (under
Stark) for provision of health information technology and
training services to health care professionals.
Sec. 713. Rules of construction regarding use of consortia.

TITLE VIII--HEALTH CARE SERVICES COMMISSION

Subtitle A--Establishment and General Duties

Sec. 801. Establishment.
Sec. 802. General authorities and duties.
Sec. 803. Dissemination.

Subtitle B--Forum for Quality and Effectiveness in Health Care

Sec. 811. Establishment of office.
Sec. 812. Membership.
Sec. 813. Duties.
Sec. 814. Adoption and enforcement of guidelines and standards.
Sec. 815. Additional requirements.

Subtitle C--General Provisions

Sec. 821. Certain administrative authorities.
Sec. 822. Funding.
Sec. 823. Definitions.

Subtitle D--Terminations and Transition

Sec. 831. Termination of Agency for Healthcare Research and Quality.
Sec. 832. Transition.

Subtitle E--Independent Health Record Trust

Sec. 841. Short title.
Sec. 842. Purpose.
Sec. 843. Definitions.
Sec. 844. Establishment, certification, and membership of Independent
Health Record Trusts.
Sec. 845. Duties of IHRT to IHRT participants.
Sec. 846. Availability and use of information from records in IHRT
consistent with privacy protections and agreements.
Sec. 847. Voluntary nature of trust participation and information
sharing.
Sec. 848. Financing of activities.
Sec. 849. Regulatory oversight.

TITLE IX--MISCELLANEOUS

Sec. 901. Health care choice for veterans.
Sec. 902. Health care choice for Indians.
Sec. 903. Termination of Federal Coordinating Council for Comparative
Effectiveness Research.
Sec. 904. HHS and GAO joint study and report on costs of the 5 medical
conditions that have the greatest impact.
Sec. 905. Conscience protection.
Sec. 906. Nondiscrimination on abortion and respect for rights of
conscience
Sec. 907. Prohibition on government entities using comparative
effectiveness research for certain purposes.
Sec. 908. Solvency of Medicare program.
Sec. 909. To ensure patients receive doctor recommendations for
preventive health services, including mammograms and
cervical cancer screening, without interference from
government or insurance company bureaucrats.
Sec. 910. Ensuring that government health care rationing does not harm,
injure, or deny medically necessary care.
Sec. 911. Identification of Federal Government health care rationing.
Sec. 912. Using health care professionals to reduce fraud.

TITLE I--INVESTING IN PREVENTION

SEC. 101. STRATEGIC APPROACH TO OUTCOME-BASED PREVENTION.

(a) Interagency Coordinating Committee.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this title as the ``Secretary'') shall
convene an interagency coordinating committee to develop a
national strategic plan for prevention. The Secretary shall
serve as the chairperson of the committee.
(2) Composition.--In carrying out paragraph (1), the
Secretary shall include the participation of--
(A) the Director of the National Institutes of Health;
(B) the Director of the Centers for Disease Control and
Prevention;
(C) the Administrator of the Agency for Healthcare Research
and Quality;
(D) the Administrator of the Substance Abuse and Mental
Health Services Administration;
(E) the Administrator of the Health Resources and Services
Administration;
(F) the Secretary of Agriculture;
(G) the Director of the Centers for Medicare & Medicaid
Services;
(H) the Administrator of the Environmental Protection
Agency;
(I) the Director of the Indian Health Service;
(J) the Administrator of the Administration on Aging;
(K) the Secretary of Veterans Affairs;
(L) the Secretary of Defense;
(M) the Secretary of Education; and
(N) the Secretary of Labor.
(3) Report and plan.--Not later than 1 year after the date
of enactment of this Act, the Secretary, acting through the
coordinating committee convened under paragraph (1), shall
submit to Congress a report concerning the recommendation of
the committee for health promotion and disease prevention
activities. Such report shall include a specific strategic
plan that shall include--
(A) a list of national priorities on health promotion and
disease prevention to address lifestyle behavior modification
(smoking cessation, proper nutrition, and appropriate
exercise) and the prevention measures for the 5 leading
disease killers in the United States;
(B) specific science-based initiatives to achieve the
measurable goals of Healthy People 2010 regarding nutrition,
exercise, and smoking cessation, and targeting the 5 leading
disease killers in the United States;
(C) specific plans for consolidating Federal health
programs and Centers that exist to promote healthy behavior
and reduce disease risk (including eliminating programs and
offices determined to be ineffective in meeting the priority
goals of Healthy People 2010), that include transferring the
nutrition guideline development responsibility from the
Secretary of Agriculture to the Director of the Centers for
Disease Control and Prevention;
(D) specific plans to ensure that all Federal health care
programs are fully coordinated with science-based prevention
recommendations promulgated by the Director of the Centers
for Disease Control and Prevention;
(E) specific plans to ensure that all non-Department of
Health and Human Services prevention programs are based on
the science-based guidelines developed by the Centers for
Disease Control and Prevention under subparagraph (D); and
(F) a list of new non-Federal and non-government partners
identified by the committee to build Federal capacity in
health promotion and disease prevention efforts.
(4) Annual request to give testimony.--The Secretary shall
annually request an opportunity to testify before Congress
concerning the progress made by the United States in meeting
the outcome-based standards of Healthy People 2010 with
respect to disease prevention and measurable outcomes and
effectiveness of Federal programs related to this goal.
(5) Periodic reviews.--The Secretary shall conduct periodic
reviews, not less than every 5 years, and grading of every
Federal disease prevention and health promotion initiatives,
programs, and agencies. Such reviews shall be evaluated based
on effectiveness in meeting metrics-based goals with an
analysis posted on such agencies' public Internet websites.
(b) Federal Messaging on Health Promotion and Disease
Prevention.--
(1) Media campaigns.--
(A) In general.--Not later than 1 year after the date of
enactment of this Act, the Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish and implement a national science-based media
campaign on health promotion and disease prevention.
(B) Requirements of campaign.--The campaign implemented
under subparagraph (A)--
(i) shall be designed to address proper nutrition, regular
exercise, smoking cessation, obesity reduction, the 5 leading
disease killers in the United States, and secondary
prevention through disease screening promotion;
(ii) shall be carried out through competitively bid
contracts awarded to entities providing for the professional
production and design of such campaign;
(iii) may include the use of television, radio, Internet,
and other commercial marketing venues and may be targeted to
specific age groups based on peer-reviewed social research;
(iv) shall not be duplicative of any other Federal efforts
relating to health promotion and disease prevention; and
(v) may include the use of humor and nationally recognized
positive role models.
(C) Evaluation.--The Secretary shall ensure that the
campaign implemented under subparagraph (A) is subject to an
independent evaluation every 2 years and shall report every 2
years to Congress on the effectiveness of such campaigns
towards meeting science-based metrics.
(2) Website.--The Secretary, in consultation with private-
sector experts, shall maintain or enter into a contract to
maintain an Internet website to provide science-based
information on guidelines for nutrition, regular exercise,
obesity reduction, smoking cessation, and specific chronic
disease prevention. Such website shall be designed to provide
information to health care providers and consumers.
(3) Dissemination of information through providers.--The
Secretary, acting through the Centers for Disease Control and
Prevention, shall develop and implement a plan for the
dissemination of health promotion and disease prevention
information consistent with national priorities described in
the strategic and implementing plan under subsection
(a)(3)(A), to health care providers who participate in
Federal programs, including programs administered by the
Indian Health Service, the Department of Veterans Affairs,
the Department of Defense, and the Health Resources and
Services Administration, and the Medicare and Medicaid
Programs.
(4) Personalized prevention plans.--
(A) Contract.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention, shall
enter into a contract with a qualified entity for the
development and operation of a Federal Internet website
personalized prevention plan tool.
(B) Use.--The website developed under subparagraph (A)
shall be designed to be used as a source of the most up-to-
date scientific evidence relating to disease prevention for

[[Page S13531]]

use by individuals. Such website shall contain a component
that enables an individual to determine their disease risk
(based on personal health and family history, BMI, and other
relevant information) relating to the 5 leading diseases in
the United States, and obtain personalized suggestions for
preventing such diseases.
(5) Internet portal.--The Secretary shall establish an
Internet portal for accessing risk-assessment tools developed
and maintained by private and academic entities.
(6) Priority funding.--Funding for the activities
authorized under this section shall take priority over
funding from the Centers for Disease Control and Prevention
provided for grants to States and other entities for similar
purposes and goals as provided for in this section. Not to
exceed $500,000,000 shall be expended on the campaigns and
activities required under this Act.

SEC. 102. STATE GRANTS FOR OUTCOME-BASED PREVENTION EFFORT.

(a) In General.--If the Secretary determines that it is
essential to meeting the national priorities described in the
plan required under section 101(a)(3)(A), the Secretary may
award grants to States for the conduct of specific health
promotion and disease prevention activities.
(b) Eligibility.--To be eligible to receive a grant under
subsection (a), a State shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require, including a
strategic plan that shall--
(1) describe the specific health promotion and disease
prevention activities to be carried out under this grant;
(2) include a list of the barriers that exist within the
State to meeting specific goals of Healthy People 2010;
(3) include targeted demographic indicators and measurable
objectives with respect to health promotion and disease
prevention;
(4) contain a set of process outcomes and milestones, based
on the process outcomes and milestones developed by the
Secretary, for measuring the effectiveness of activities
carried out under the grant in the State; and
(5) outline the manner in which interventions to be carried
out under this grant will reduce morbidity and mortality
within the State over a 5-year period (or over a 10-year
period, if the Secretary determines such period appropriate
for adequately measuring progress).
(c) Process Outcomes and Milestones.--
(1) In general.--The Secretary shall develop process
outcomes and milestones to be used to measure the
effectiveness of activities carried out under a grant under
this section by a State.
(2) Determinations.--If, beginning 2 years after the date
on which a grant is awarded to a State under this section,
the Secretary determines that the State is failing to make
adequate progress in meeting the outcomes and milestones
contained in the State plan under subsection (b)(4), the
Secretary shall provide the State with technical assistance
on how to make such progress. Such technical assistance shall
continue for a period of 2 years.
(3) Continued failure to meet objectives.--If after the
expiration of the 2-year period described in paragraph (2),
the Secretary determines that the State is failing to make
adequate progress in meeting the outcomes and milestones
contained in the State plan under subsection (b)(4) over a 5-
year period, the Secretary shall terminate all funding to the
State under a grant under this section.
(d) Regional Activities.--A State may use an amount, not to
exceed 15 percent of the total grant amount to such State, to
carry out regional activities in conjunction with other
States.
(e) Targeted Activities.--A State may use grant funds to
target specific populations within the State to achieve
specific outcomes described in Healthy People 2010.
(f) Innovative Incentive Structures.--The Secretary may
award grants to States for the purposes of developing
innovative incentive structures to encourage individuals to
adopt specific prevention behaviors such as reducing their
body mass index or for smoking cessation.
(g) Wellness Bonuses.--
(1) In general.--The Secretary shall award wellness bonus
payments to at least 5, but not more than 10, States that
demonstrate the greatest progress in reducing disease rates
and risk factors and increasing heathy behaviors.
(2) Requirement.--To be eligible to receive a bonus payment
under paragraph (1), a State shall demonstrate--
(A) the progress described in paragraph (1); and
(B) that the State has met a specific floor for progress
outlined in the science-based metrics of Healthy People 2010.
(3) Use of payments.--Bonus payments under this subsection
may only be used by a State for the purposes of health
promotion and disease prevention.
(4) Funding.--Out of funds appropriated to the Director of
the Centers for Disease Control and Prevention for each
fiscal year beginning with fiscal year 2010, the Director
shall give priority to using $50,000,000 of such funds to
make bonus payments under this subsection.
(h) Administrative Expenses.--A State may use not more than
5 percent of the amount of a grant under this section to
carry out administrative activities.
(i) State.--In this section, the term ``State'' means the
50 States, the District of Columbia, the Commonwealth of
Puerto Rico, Guam, Samoa, the United States Virgin Islands,
and the Commonwealth of the Northern Mariana Islands.
(j) Authorization of Appropriations.--Funding for the
activities authorized under this section shall take priority
over funding from the Centers for Disease Control and
Prevention provided for grants to States and other entities
for similar purposes and goals as provided for in this
section, not to exceed $300,000,000 for each fiscal year.

SEC. 103. FOCUSING THE FOOD STAMP PROGRAM ON NUTRITION.

(a) Counseling Brochure.--The Director of the Centers for
Disease Control and Prevention shall develop, and the
Secretary of Agriculture shall distribute to each individual
and family enrolled in the Food Stamp Program under the Food
Stamp Act of 1977 (7 U.S.C. 2011 et seq.), a science-based
nutrition counseling brochure.
(b) Limitations on Food Stamp Purchases.--
(1) In general.--Not later than 6 months after the date of
enactment of this Act, the Secretary of Agriculture shall,
based on scientific, peer-reviewed recommendations provided
by a Commission that includes public health, medical, and
nutrition experts and the Director of the Centers for Disease
Control and Prevention, develop lists of foods that do not
meet science-based standards for proper nutrition and that
may not be purchased under the food stamp program. Such list
shall be updated on an annual basis to ensure the most
current science-based recommendations are applied to the food
stamp program.
(2) Automated enforcement.--The Secretary of Agriculture
shall, through regulations, ensure that the limitations on
food purchases under paragraph (1) is enforced through the
food stamp program's automated system.
(3) Implementation.--The Secretary of Agriculture shall
promulgate the regulations described in paragraph (2) by the
date that is not later than 1 year after the date of
enactment of this section.

SEC. 104. IMMUNIZATIONS.

(a) Purchase of Vaccines.--Notwithstanding any other
provision of law, a State may use amounts provided under
section 317 of the Public Health Service Act (42 U.S.C. 247b)
for immunization programs to purchase vaccines for use in
health care provider offices and schools.
(b) Technical Assistance and Reduction in Funding.--If a
State does not achieve a benchmark of 80 percent coverage
within the State for Centers for Disease Control and
Prevention-recommended vaccines, the Director of the Centers
shall provide technical assistance to the State for a period
of 2 years. If after the expiration of such 2-year period the
State continues to fail to achieve such benchmark, the
Secretary shall reduce funding provided under section 317 of
the Public Health Service Act to such State by 5 percent.
(c) Bonus Grant.--A State achieving a benchmark of 90
percent or greater coverage within the State for Centers for
Disease Control and Prevention-recommended vaccines shall be
eligible for a bonus grant from amounts appropriated under
subsection (d).
(d) Authorization of Appropriations.--Out of funds
appropriated to the Director of the Centers for Disease
Control and Prevention for each fiscal year beginning with
fiscal year 2010, there shall be made available to carry out
this section, $50,000,000 for each fiscal year.
(e) Funding for Section 317.--Section 317(j)(1) of the
Public Health Service Act (42 U.S.C. 247b(j)(1)) is amended
by striking ``2005'' and inserting ``2012''.

TITLE II--STATE-BASED HEALTH CARE EXCHANGES

SEC. 201. STATE-BASED HEALTH CARE EXCHANGES.

(a) In General.--The Secretary of Health and Human Services
(referred to in this title as the ``Secretary'') shall
establish a process for the review of applications submitted
by States for the establishment and implementation of State-
based health care Exchanges (referred to in this title as a
``State Exchange'') and for the certification of such
Exchanges. The Secretary shall certify a State Exchange if
the Secretary determines that such Exchange meets the
requirements of this title.
(b) Continued Certification.--The certification of a State
Exchange under subsection (a) shall remain in effect until
the Secretary determines that the Exchange has failed to meet
any of the requirements under this title.

SEC. 202. REQUIREMENTS.

(a) General Requirements for Certification.--An application
for certification under section 201(a) shall demonstrate
compliance with the following:
(1) Purpose.--The primary purpose of a State Exchange shall
be the facilitation of the individual purchase of innovative
private health insurance and the creation of a market where
private health plans compete for enrollees based on price and
quality.
(2) Administration.--A State shall ensure the operation of
the State Exchange through direct contracts with the health
insurance plans that are participating in the State Exchange
or through a contract with a third party administrator for
the operation of the Exchange.
(3) Plan participation.--A State shall not restrict or
otherwise limit the ability of a

[[Page S13532]]

health insurance plan to participate in, and offer health
insurance coverage through, the State Exchange, so long as
the health insurance issuers involved are duly licensed under
State insurance laws applicable to all health insurance
issuers in the State and otherwise comply with the
requirements of this title.
(4) Premiums.--
(A) Amount.--A State shall not determine premium or cost
sharing amounts for health insurance coverage offered through
the State Exchange.
(B) Collection method.--A State shall ensure the existence
of an effective and efficient method for the collection of
premiums for health insurance coverage offered through the
State Exchange.
(b) Benefit Parity With Members of Congress.--With respect
to health insurance issuers offering health insurance
coverage through the State Exchange, the State shall not
impose any requirement that such issuers provide coverage
that includes benefits different than requirements on plans
offered to Members of Congress under chapter 89 of title 5,
United States Code.
(c) Facilitating Universal Coverage for Americans.--
(1) Automatic enrollment.--The State Exchange shall ensure
that health insurance coverage offered through the Exchange
provides for the application of uniform mechanisms that are
designed to encourage and facilitate the enrollment of all
eligible individuals in Exchange-based health insurance
coverage. Such mechanisms shall include automatic enrollment
through various venues, which may include emergency rooms,
the submission of State tax forms, places of employment in
the State, and State departments of motor vehicles.
(2) Other enrollment opportunities.--
(A) In general.--The State Exchange shall ensure that
health insurance coverage offered through the Exchange
permits enrollment, and changes in enrollment, of individuals
at the time such individuals become eligible individuals in
the State.
(B) Annual open enrollment periods.--The State Exchange
shall ensure that health insurance coverage offered through
the Exchange permits eligible individuals to annually change
enrollment among the coverage offered through the Exchange,
subject to subparagraph (A).
(C) Incentives for continuous annual coverage.--The State
Exchange shall include an incentive for eligible individuals
to remain insured from plan year to plan year, and may
include incentives such as State tax incentives or premium-
based incentives.
(3) Guaranteed access for individuals.--The State Exchange
shall ensure that, with respect to health insurance coverage
offered through the Exchange, all eligible individuals are
able to enroll in the coverage of their choice provided that
such individuals agree to make applicable premium and cost
sharing payments.
(4) Limitation on pre-existing condition exclusions.--The
State Exchange shall ensure that health insurance coverage
offered through the Exchange meets the requirements of
section 9801 of the Internal Revenue Code of 1986 in the same
manner as if such coverage was a group health plan.
(5) Opt-out.--Nothing in this title shall be construed to
require that an individual be enrolled in health insurance
coverage.
(d) Limitation on Exorbitant Premiums.--
(1) Establishment of mechanism.--With respect to health
insurance coverage offered through the State Exchange, the
Exchange shall establish a mechanisms to protect enrollees
from the imposition of excessive premiums, to reduce adverse
selection, and to share risk.
(2) Mechanism options.--The mechanisms referred to in
paragraph (1) may include the following:
(A) Independent risk adjustment.--The implementation of
risk-adjustment among health insurance coverage offered
through the State Exchange through a contract entered into
with a private, independent board. Such board shall include
representation of health insurance issuers and State
officials but shall be independently controlled. The State
Exchange shall ensure that risk-adjustment implemented under
this subparagraph shall be based on a blend of patient
diagnoses and estimated costs.
(B) Health security pools.--The establishment (or continued
operation under section 2745 of the Public Health Service
Act) of a health security pool to guarantee high-risk
individuals access to affordable, quality health care.
(C) Reinsurance.--The implementation of a successful
reinsurance mechanisms to guarantee high-risk individuals
access to affordable, quality health care.
(e) Medicaid and SCHIP Beneficiaries.--The State Exchange
shall include procedures to permit eligible individuals who
are receiving (or who are eligible to receive) health care
under title XIX or XXI of the Social Security Act to enroll
in health insurance coverage offered through the Exchange.
(f) Dissemination of Coverage Information.--The State
Exchange shall ensure that each health insurance issuer that
provides health insurance coverage through the Exchange
disseminate to eligible individuals and employers within the
State information concerning health insurance coverage
options, including the plans offered and premiums and
benefits for such plans.
(g) Regional Options.--
(1) Interstate compacts.--Two or more States that establish
a State Exchange may enter into interstate compacts providing
for the regulations of health insurance coverage offered
within such States.
(2) Model legislation.--States adopting model legislation
as developed by the National Association of Insurance
Commissioners shall be eligible to enter into an interstate
compact as provided for in this section.
(3) Multi-state pooling arrangements.--State Exchanges may
implement a multi-state health care coverage pooling
arrangement under this title.
(h) Purchase Across State Lines.--Notwithstanding any other
provision of law, an eligible individual may enroll in health
insurance coverage offered through the Exchange in any State.
The regulation of such coverage (and the addressing of
greviances relating to such coverage) shall be subject to the
laws of the State in which such coverage is purchased,
regardless of the State in which the eligible individual
resides.
(i) Eligible Individual.--In this title, the term
``eligible individual'' means an individual who is--
(1) a citizen or national of the United States or an alien
lawfully admitted to the United States for permanent
residence or otherwise residing in the United States under
color of law;
(2) not incarcerated; and
(3) not eligible for coverage under parts A and B (or C) of
the Medicare program under title XVIII of the Social Security
Act.

SEC. 203. STATE EXCHANGE INCENTIVES.

(a) Grants.--The Secretary may award grants, pursuant to
subsection (b), to States for the development,
implementation, and evaluation of certified State Exchanges
and to provide more options and choice for individuals
purchasing health insurance coverage.
(b) One-Time Increase in Medicaid Payment.--In the case of
a State awarded a grant to carry out this section, the total
amount of the Federal payment determined for the State under
section 1913 of the Social Security Act (as amended by
section 401) for fiscal year 2011 shall be increased by an
amount equal to 1 percent of the total amount of payments
made to the State for fiscal year 2010 under section 1903(a)
of the Social Security Act (42 U.S.C. 1396b(a)) for purposes
of carrying out a grant awarded under this section. Amounts
paid to a State pursuant to this subsection shall remain
available until expended.

TITLE III--FAIR TAX TREATMENT FOR ALL AMERICANS TO AFFORD HEALTH CARE

SEC. 300. REFERENCE.

Except as otherwise expressly provided, whenever in this
title an amendment or repeal is expressed in terms of an
amendment to, or repeal of, a section or other provision, the
reference shall be considered to be made to a section or
other provision of the Internal Revenue Code of 1986.

SEC. 301. REFUNDABLE AND ADVANCEABLE CREDIT FOR CERTAIN
HEALTH INSURANCE COVERAGE.

(a) Advanceable Credit.--Subpart A of part IV of subchapter
A of chapter 1 (relating to nonrefundable personal credits)
is amended by adding at the end the following new section:

``SEC. 25E. QUALIFIED HEALTH INSURANCE CREDIT.

``(a) Allowance of Credit.--In the case of an individual,
there shall be allowed as a credit against the tax imposed by
this chapter for the taxable year the sum of the monthly
limitations determined under subsection (b) for the taxpayer
and the taxpayer's spouse and dependents.
``(b) Monthly Limitation.--
``(1) In general.--The monthly limitation for each month
during the taxable year for an eligible individual is \1/
12\th of--
``(A) the applicable adult amount, in the case that the
eligible individual is the taxpayer or the taxpayer's spouse,
``(B) the applicable adult amount, in the case that the
eligible individual is an adult dependent, and
``(C) the applicable child amount, in the case that the
eligible individual is a child dependent.
``(2) Limitation on aggregate amount.--Notwithstanding
paragraph (1), the aggregate monthly limitations for the
taxpayer and the taxpayer's spouse and dependents for any
month shall not exceed \1/12\th of the applicable aggregate
amount.
``(3) No credit for ineligible months.--With respect to any
individual, the monthly limitation shall be zero for any
month for which such individual is not an eligible
individual.
``(4) Applicable amount.--
``(A) In general.--For purposes of this section--
``(i) Applicable adult amount.--The applicable adult amount
is $2,290.
``(ii) Applicable child amount.--The applicable child
amount is $1,710.
``(iii) Applicable aggregate amount.--The applicable
aggregate amount is $5,710.
``(B) Cost-of-living adjustments.--
``(i) In general.--In the case of any taxable year
beginning in a calendar year after 2011, each dollar amount
contained in subparagraph (A) shall be increased by an amount
equal to such dollar amount multiplied by the blended cost-
of-living adjustment.
``(ii) Blended cost-of-living adjustment.--For purposes of
clause (i), the blended cost-of-living adjustment means one-
half of the sum of--

[[Page S13533]]

``(I) 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, plus
``(II) the cost-of-living adjustment determined under
section 213(d)(10)(B)(ii) for the calendar year in which the
taxable year begins by substituting `2010' for `1996' in
subclause (II) thereof.

``(iii) Rounding.--Any increase determined under clause (i)
shall be rounded to the nearest multiple of $10.
``(C) Revenue neutrality adjustments.--
``(i) In general.--In the case of any taxable year
beginning in a calendar year after 2011, each dollar amount
contained in subparagraph (A), as adjusted under subparagraph
(B), shall be further adjusted (if necessary) such that the
aggregate of such dollar amounts allowed as credits under
this section for such taxable year equals but does not exceed
the total increase in revenues in the Treasury resulting from
the amendments made by sections 303 and 401 of the Patients'
Choice Act for such taxable year as estimated by the
Secretary.
``(ii) Date of adjustment.--The Secretary shall announce
the adjustments for any taxable year under this subparagraph
not later than the preceding October 1.
``(c) Limitation Based on Amount of Tax.--In the case of a
taxable year to which section 26(a)(2) does not apply, the
credit allowed under subsection (a) for the taxable year
shall not exceed the excess of--
``(1) the sum of the regular tax liability (as defined in
section 26(b)) plus the tax imposed by section 55, over
``(2) the sum of the credits allowable under this subpart
(other than this section) and section 27 for the taxable
year.
``(d) Excess Credit Refundable to Certain Tax-Favored
Accounts.--If--
``(1) the credit which would be allowable under subsection
(a) if only qualified refund eligible health insurance were
taken into account under this section, exceeds
``(2) the limitation imposed by section 26 or subsection
(c) for the taxable year,
such excess shall be paid by the Secretary into the
designated account of the taxpayer.
``(e) Eligible Individual.--For purposes of this section--
``(1) In general.--The term `eligible individual' means,
with respect to any month, an individual who--
``(A) is the taxpayer, the taxpayer's spouse, or the
taxpayer's dependent, and
``(B) is covered under qualified health insurance as of the
1st day of such month.
``(2) Medicare coverage, medicaid disability coverage, and
military coverage.--The term `eligible individual' shall not
include any individual who for any month is--
``(A) entitled to benefits under part A of title XVIII of
the Social Security Act or enrolled under part B of such
title, and the individual is not a participant or beneficiary
in a group health plan or large group health plan that is a
primary plan (as defined in section 1862(b)(2)(A) of such
Act),
``(B) enrolled by reason of disability in the program under
title XIX of such Act, or
``(C) entitled to benefits under chapter 55 of title 10,
United States Code, including under the TRICARE program (as
defined in section 1072(7) of such title).
``(3) Identification requirements.--The term `eligible
individual' shall not include any individual for any month
unless the policy number associated with the qualified health
insurance and the TIN of each eligible individual covered
under such health insurance for such month are included on
the return of tax for the taxable year in which such month
occurs.
``(4) Prisoners.--The term `eligible individual' shall not
include any individual for a month if, as of the first day of
such month, such individual is imprisoned under Federal,
State, or local authority.
``(5) Aliens.--The term `eligible individual' shall not
include any alien individual who is not a lawful permanent
resident of the United States.
``(f) Health Insurance.--For purposes of this section--
``(1) Qualified health insurance.--The term `qualified
health insurance' means any insurance constituting medical
care which (as determined under regulations prescribed by the
Secretary)--
``(A) has a reasonable annual and lifetime benefit maximum,
and
``(B) provides coverage for inpatient and outpatient care,
emergency benefits, and physician care.
Such term does not include any insurance substantially all of
the coverage of which is coverage described in section
223(c)(1)(B).
``(2) Qualified refund eligible health insurance.--The term
`qualified refund eligible health insurance' means any
qualified health insurance which is coverage under a group
health plan (as defined in section 5000(b)(1)).
``(g) Designated Accounts.--
``(1) Designated account.--For purposes of this section,
the term `designated account' means any specified account
established and maintained by the provider of the taxpayer's
qualified refund eligible health insurance--
``(A) which is designated by the taxpayer (in such form and
manner as the Secretary may provide) on the return of tax for
the taxable year,
``(B) which, under the terms of the account, accepts the
payment described in subsection (d) on behalf of the
taxpayer, and
``(C) which, under such terms, provides for the payment of
expenses by the taxpayer or on behalf of such taxpayer by the
trustee or custodian of such account, including payment to
such provider.
``(2) Specified account.--For purposes of this paragraph,
the term `specified account' means--
``(A) any health savings account under section 223 or
Archer MSA under section 220, or
``(B) any health insurance reserve account.
``(3) Health insurance reserve account.--For purposes of
this subsection, the term `health insurance reserve account'
means a trust created or organized in the United States as a
health insurance reserve account exclusively for the purpose
of paying the qualified medical expenses (within the meaning
of section 223(d)(2)) of the account beneficiary (as defined
in section 223(d)(3)), but only if the written governing
instrument creating the trust meets the requirements
described in subparagraphs (B), (C), (D), and (E) of section
223(d)(1). Rules similar to the rules under subsections (g)
and (h) of section 408 shall apply for purposes of this
subparagraph.
``(4) Treatment of payment.--Any payment under subsection
(d) to a designated account shall not be taken into account
with respect to any dollar limitation which applies with
respect to contributions to such account (or to tax benefits
with respect to such contributions).
``(h) Other Definitions.--For purposes of this section--
``(1) Dependent.--The term `dependent' has the meaning
given such term by section 152 (determined without regard to
subsections (b)(1), (b)(2), and (d)(1)(B) thereof). An
individual who is a child to whom section 152(e) applies
shall be treated as a dependent of the custodial parent for a
coverage month unless the custodial and noncustodial parent
provide otherwise.
``(2) Adult.--The term `adult' means an individual who is
not a child.
``(3) Child.--The term `child' means a qualifying child (as
defined in section 152(c)).
``(i) Special Rules.--
``(1) Coordination with medical deduction.--Any amount paid
by a taxpayer for insurance which is taken into account for
purposes of determining the credit allowable to the taxpayer
under subsection (a) shall not be taken into account in
computing the amount allowable to the taxpayer as a deduction
under section 213(a) or 162(l).
``(2) Coordination with health care tax credit.--No credit
shall be allowed under subsection (a) for any taxable year to
any taxpayer and qualifying family members with respect to
whom a credit under section 35 is allowed for such taxable
year.
``(3) Denial of credit to dependents.--No credit shall be
allowed under this section to any individual with respect to
whom a deduction under section 151 is allowable to another
taxpayer for a taxable year beginning in the calendar year in
which such individual's taxable year begins.
``(4) Married couples must file joint return.--
``(A) In general.--If the taxpayer is married at the close
of the taxable year, the credit shall be allowed under
subsection (a) only if the taxpayer and his spouse file a
joint return for the taxable year.
``(B) Marital status; certain married individuals living
apart.--Rules similar to the rules of paragraphs (3) and (4)
of section 21(e) shall apply for purposes of this paragraph.
``(5) Verification of coverage, etc.--No credit shall be
allowed under this section with respect to any individual
unless such individual's coverage (and such related
information as the Secretary may require) is verified in such
manner as the Secretary may prescribe.
``(6) Insurance which covers other individuals; treatment
of payments.--Rules similar to the rules of paragraphs (7)
and (8) of section 35(g) shall apply for purposes of this
section.
``(j) Coordination With Advance Payments.--
``(1) Reduction in credit for advance payments.--With
respect to any taxable year, the amount which would (but for
this subsection) be allowed as a credit to the taxpayer under
subsection (a) shall be reduced (but not below zero) by the
aggregate amount paid on behalf of such taxpayer under
section 7527A for months beginning in such taxable year.
``(2) Recapture of excess advance payments.--If the
aggregate amount paid on behalf of the taxpayer under section
7527A for months beginning in the taxable year exceeds the
sum of the monthly limitations determined under subsection
(b) for the taxpayer and the taxpayer's spouse and dependents
for such months, then the tax imposed by this chapter for
such taxable year shall be increased by the sum of--
``(A) such excess, plus
``(B) interest on such excess determined at the
underpayment rate established under section 6621 for the
period from the date of the payment under section 7527A to
the date such excess is paid.
For purposes of subparagraph (B), an equal part of the
aggregate amount of the excess shall be deemed to be
attributable to payments made under section 7527A on the
first day of each month beginning in such taxable year,
unless the taxpayer establishes the date on which each such
payment giving rise to such excess occurred, in which case
subparagraph (B) shall be applied with respect to each date
so established. The Secretary may rescind or waive all or any
portion of

[[Page S13534]]

any amount imposed by reason of subparagraph (B) if such
excess was not the result of the actions of the taxpayer.''.
(b) Advance Payment of Credit.--Chapter 77 (relating to
miscellaneous provisions) is amended by inserting after
section 7527 the following new section:

``SEC. 7527A. ADVANCE PAYMENT OF CREDIT FOR QUALIFIED REFUND
ELIGIBLE HEALTH INSURANCE.

``(a) In General.--The Secretary shall establish a program
for making payments on behalf of individuals to providers of
qualified refund eligible health insurance (as defined in
section 25E(f)(2)) for such individuals.
``(b) Limitation.--The Secretary may make payments under
subsection (a) only to the extent that the Secretary
determines that the amount of such payments made on behalf of
any taxpayer for any month does not exceed the sum of the
monthly limitations determined under section 25E(b) for the
taxpayer and taxpayer's spouse and dependents for such
month.''.
(c) Information Reporting.--
(1) In general.--Subpart B of part III of subchapter A of
chapter 61 (relating to information concerning transactions
with other persons) is amended by inserting after section
6050W the following new section:

``SEC. 6050X. RETURNS RELATING TO CREDIT FOR QUALIFIED REFUND
ELIGIBLE HEALTH INSURANCE.

``(a) Requirement of Reporting.--Every person who is
entitled to receive payments for any month of any calendar
year under section 7527A (relating to advance payment of
credit for qualified refund eligible health insurance) with
respect to any individual shall, at such time as the
Secretary may prescribe, make the return described in
subsection (b) with respect to each 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, with respect to each individual referred to
in subsection (a)--
``(A) the name, address, and TIN of each such individual,
``(B) the months for which amounts payments under section
7527A were received,
``(C) the amount of each such payment,
``(D) the type of insurance coverage provided by such
person with respect to such individual and the policy number
associated with such coverage,
``(E) the name, address, and TIN of the spouse and each
dependent covered under such coverage, and
``(F) such other information as the Secretary may
prescribe.
``(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 individual whose name is required to be set forth in
such return a written statement showing--
``(1) the contact information of the person required to
make such return, 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) Returns Which Would Be Required To Be Made by 2 or
More Persons.--Except to the extent provided in regulations
prescribed by the Secretary, in the case of any amount
received by any person on behalf of another person, only the
person first receiving such amount shall be required to make
the return under subsection (a).''.
(2) Assessable penalties.--
(A) Subparagraph (B) of section 6724(d)(1) (relating to
definitions) is amended by striking ``or'' at the end of
clause (xxii), by striking ``and'' at the end of clause
(xxiii) and inserting ``or'', and by inserting after clause
(xxiii) the following new clause:
``(xxiv) section 6050X (relating to returns relating to
credit for qualified refund eligible health insurance),
and''.
(B) Paragraph (2) of section 6724(d) 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
credit for qualified refund eligible health insurance).''.
(d) Conforming Amendments.--
(1) Paragraph (2) of section 1324(b) of title 31, United
States Code, is amended by inserting ``25E,'' before ``35,''.
(2)(A) Section 24(b)(3)(B) is amended by inserting ``,
25E,'' after ``25D''.
(B) Section 25(e)(1)(C)(ii) is amended by inserting
``25E,'' after ``25D,''.
(C) Section 25B(g)(2) is amended by inserting ``25E,''
after ``25D,''.
(D) Section 26(a)(1) is amended by inserting ``25E,'' after
``25D,''.
(E) Section 30(c)(2)(B)(ii) is amended by inserting
``25E,'' after ``25D,''.
(F) Section 30D(c)(2)(B)(ii) is amended by striking ``and
25D'' and inserting ``, 25D, and 25E''.
(G) Section 904(i) is amended by inserting ``25E,'' after
``25B,''.
(H) Section 1400C(d)(2) is amended by inserting ``25E,''
after ``25D,''.
(3) The table of sections for subpart A of part IV of
subchapter A of chapter 1 is amended by inserting after the
item relating to section 25D the following new item:

``Sec. 25E. Qualified health insurance credit.''.
(4) The table of sections for chapter 77 is amended by
inserting after the item relating to section 7527 the
following new item:

``Sec. 7527A. Advance payment of credit for qualified refund eligible
health insurance.''.
(5) 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 credit for qualified refund eligible
health insurance.''.
(e) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2010.

SEC. 302. REQUIRING EMPLOYER TRANSPARENCY ABOUT EMPLOYEE
BENEFITS.

(a) In General.--Section 6051(a) (relating to W-2
requirement) is amended by striking ``and'' at the end of
paragraph (12), by striking the period at the end of
paragraph (13) and inserting ``, and'' and by inserting after
paragraph (13) the following new paragraph:
``(14) the aggregate cost (within the meaning of section
4980B(f)(4)) for coverage of the employee under an accident
or health plan which is excludable from the gross income of
the employee under section 106(a) (other than coverage under
a health flexible spending arrangement).''.
(b) Effective Date.--The amendments made by this section
shall apply to statements for calendar years beginning after
2009.

SEC. 303. CHANGES TO EXISTING TAX PREFERENCES FOR MEDICAL
COVERAGE, ETC., FOR INDIVIDUALS ELIGIBLE FOR
QUALIFIED HEALTH INSURANCE CREDIT.

(a) Exclusion for Contributions by Employer to Accident and
Health Plans.--
(1) In general.--Section 106 (relating to contributions by
employer to accident and health plans) is amended by adding
at the end the following new subsection:
``(f) No Exclusion for Individuals Eligible for Qualified
Health Insurance Credit.--Subsection (a) shall not apply with
respect to any employer-provided coverage under an accident
or health plan for any individual for any month unless such
individual is described in paragraph (2) or (5) of section
25E(e) for such month. The amount includible in gross income
by reason of this subsection shall be determined under rules
similar to the rules of section 4980B(f)(4).''.
(2) Conforming amendments.--
(A) Section 106(b)(1) is amended--
(i) by inserting ``gross income does not include'' before
``amounts contributed'', and
(ii) by striking ``shall be treated as employer-provided
coverage for medical expenses under an accident or health
plan''.
(B) Section 106(d)(1) is amended--
(i) by inserting ``gross income does not include'' before
``amounts contributed'', and
(ii) by striking ``shall be treated as employer-provided
coverage for medical expenses under an accident or health
plan''.
(b) Amounts Received Under Accident and Health Plans.--
Section 105 (relating to amounts received under accident and
health plans) is amended by adding at the end the following
new subsection:
``(f) No Exclusion for Individuals Eligible for Qualified
Health Insurance Credit.--Subsection (b) shall not apply with
respect to any employer-provided coverage under an accident
or health plan for any individual for any month unless such
individual is described in paragraph (2) or (5) of section
25E(e) for such month.''.
(c) Special Rules for Health Insurance Costs of Self-
Employed Individuals.--Subsection (l) of section 162
(relating to special rules for health insurance costs of
self-employed individuals) is amended by adding at the end
the following new paragraph:
``(6) No deduction to individuals eligible for qualified
health insurance.--Paragraph (1) shall not apply for any
individual for any month unless such individual is described
in paragraph (2) or (5) of section 25E(e) for such month.''.
(d) Earned Income Credit Unaffected by Repealed
Exclusions.--Subparagraph (B) of section 32(c)(2) is amended
by redesignating clauses (v) and (vi) as clauses (vi) and
(vii), respectively, and by inserting after clause (iv) the
following new clause:
``(v) the earned income of an individual shall be computed
without regard to sections 105(f) and 106(f),''.
(e) Modification of Deduction for Medical Expenses.--
Subsection (d) of section 213 is amended by adding at the end
the following new paragraph:
``(12) Premiums for qualified health insurance.--The term
`medical care' does not include any amount paid as a premium
for coverage of an eligible individual (as defined in section
25E(e)) under qualified health insurance (as defined in
section 25E(f)) for any month.''.
(f) Reporting Requirement.--Subsection (a) of section 6051
is amended by striking ``and'' at the end of paragraph (12),
by striking the period at the end of paragraph (13) and
inserting ``and'', and by inserting after paragraph (13) the
following new paragraph:
``(14) the total amount of employer-provided coverage under
an accident or health plan which is includible in gross
income by reason of sections 105(f) and 106(f).''.
(g) Retired Public Safety Officers.--Section 402(l)(4)(D)
is amended by adding at the end the following: ``Such term
shall not include any premium for coverage by an accident or
health insurance plan for any

[[Page S13535]]

month unless such individual is described in paragraph (2) or
(5) of section 25E(e) for such month.''.
(h) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2010.
(i) No Intent To Encourage State Taxation of Health
Benefits.--No intent to encourage any State to treat health
benefits as taxable income for the purpose of increasing
State income taxes may be inferred from the provisions of,
and amendments made by, this section.

SEC. 304. DETERMINATION OF ELIGIBILITY.

(a) Application of Income and Eligibility Verification
System (IEVS) and the Systematic Alien Verification for
Entitlements (SAVE) Programs.--In order to obtain coverage
through an Exchange, an individual must have had his or her
eligibility determined and approved under the Income and
Eligibility Verification System (IEVS) and the Systematic
Alien Verification for Entitlements (SAVE) programs under
section 1137 of the Social Security Act. The benefit
determination and approval under this subsection shall be the
responsibility of the Exchange-participating health plans
involved.
(b) Credits.--In addition to satisfying the eligibility
requirements specified in subsection (a), to be considered a
credit eligible individual under the amendments made by this
title, an individual must have had his or her eligibility for
the credit determined and approved under the Income and
Eligibility Verification System (IEVS) and the Systematic
Alien Verification for Entitlements (SAVE) programs under
section 1137 of the Social Security Act. The benefit
determination and approval under this subsection shall be the
responsibility of the Exchange-participating health plans in
which the individual enrolls and attempts to utilize the
credit.
(c) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2009.

SEC. 305. ADJUSTMENTS.

Notwithstanding any other provision of law, the Secretary
of the Treasury shall adjust the growth of tax credits
provided for under this amendments made by this title at such
levels as appropriate so that this Act will remain budget
neutral.

TITLE IV--FAIRNESS FOR EVERY AMERICAN PATIENT

Subtitle A--Medicaid Modernization

SEC. 401. MEDICAID MODERNIZATION.

(a) In General.--Effective January 1, 2011, title XIX of
the Social Security Act (42 U.S.C. 1396 et seq.) is amended
to read as follows:

``TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

``TABLE OF CONTENTS OF TITLE

``Sec. 1900. References to pre-modernized Medicaid provisions;
continuity for commonwealths and territories.

``Part A--Grants to States for Acute Care for Individuals With
Disabilities and Certain Low-Income Individuals

``Sec. 1901. Purpose; Appropriation.
``Sec. 1902. Payments to States for acute care medical assistance.
``Sec. 1903. Definitions of eligible individuals and acute care medical
assistance.
``Sec. 1904. State plan requirements for acute care medical assistance.
``Sec. 1905. Definitions.
``Sec. 1906. Enrollment of individuals under group health plans and
other arrangements.
``Sec. 1907. Drug rebates.
``Sec. 1908. Managed care.
``Sec. 1909. Annual reports.

``Part B--Grants to States for Long-Term Care Services and Supports

``Sec. 1911. Purpose.
``Sec. 1912. State plan.
``Sec. 1913. State allotments.
``Sec. 1914. Use of grants.
``Sec. 1915. Administrative provisions.
``Sec. 1916. Definition of long-term care services and supports.
``Sec. 1917. Provision requirements for long-term care services and
supports, including option for self-directed services and
supports.
``Sec. 1918. Treatment of income and resources for certain
institutionalized spouses.
``Sec. 1919. Annual reports.

``Part C--Grants to States for Survey and Certification of Medical
Facilities and Other Requirements

``Sec. 1931. Authorization of appropriations.
``Sec. 1932. Application of certain requirements under pre-modernized
Medicaid.

``Part D--Grants to States for Program Integrity

``Sec. 1941. Authorization of appropriations.
``Sec. 1942. Application of certain requirements under pre-modernized
Medicaid.

``Part E--Grants to States for Administration

``Sec. 1951. Authorization of appropriations; payments to states.
``Sec. 1952. Cost-sharing protections.
``Sec. 1953. Application of certain requirements under pre-modernized
Medicaid.

``Part F--Other Provisions

``Sec. 1961. Application of certain requirements under pre-modernized
Medicaid.

``SEC. 1900. REFERENCES TO PRE-MODERNIZED MEDICAID
PROVISIONS; CONTINUITY FOR COMMONWEALTHS AND
TERRITORIES.

``(a) In General.--In this title, if a reference to this
title or to a provision of this title is prefaced by the term
`old', such reference is to this title or a provision of this
title as in effect on December 31, 2010.
``(b) Regulations.--The Secretary shall promulgate
regulations to bring requirements imposed under an old
provision of this title that applies under this title after
December 31, 2010, into conformity with the policies embodied
in this title as in effect on and after January 1, 2011.
``(c) Continuity for Commonwealths and Territories.--In the
case of Puerto Rico, the United States Virgin Islands, Guam,
the Northen Mariana Islands, and American Samoa, this title
as in effect on and after January 1, 2011, shall not apply to
such commonwealths and territories, and old title XIX shall
apply to a Medicaid program operated by such commonwealths or
territories on and after that date.

``PART A--GRANTS TO STATES FOR ACUTE CARE FOR INDIVIDUALS WITH
DISABILITIES AND CERTAIN LOW-INCOME INDIVIDUALS

``SEC. 1901. PURPOSE; APPROPRIATION.

``(a) Purpose.--It is the purpose of this part to enable
each State, as far as practicable under the conditions in the
State, to provide acute care medical assistance to eligible
individuals described in section 1903 whose income and
resources are insufficient to meet the costs of necessary
medical services, and (2) rehabilitation and other services
to help such individuals attain or retain capability for
independence or self-care.
``(b) Appropriation.--For the purpose of making payments to
States under this part, there is appropriated out of any
money in the Treasury not otherwise appropriated, such sums
as are necessary for fiscal year 2011 and each fiscal year
thereafter.

``SEC. 1902. PAYMENTS TO STATES FOR ACUTE CARE MEDICAL
ASSISTANCE.

``(a) In General.--From the amounts appropriated under
section 1901 for a fiscal year, the Secretary shall pay to
each State which has a plan approved under this part, for
each quarter, beginning with the quarter commencing January
1, 2011, an amount equal to the Federal medical assistance
percentage (as defined in section 1905(b)) of the total
amount expended during such quarter as acute care medical
assistance under the State plan under this part.
``(b) Administrative Expenses.--Each State with a plan
approved under this part shall receive a payment determined
in accordance with part E for administrative expenses
incurred in carrying out the plan under this part and part B
(if the State has a plan approved under that part).

``SEC. 1903. DEFINITIONS OF ELIGIBLE INDIVIDUALS AND ACUTE
CARE MEDICAL ASSISTANCE.

``(a) Eligible Individuals.--
``(1) In general.--In this part, the term `eligible
individual' means an individual--
``(A) who is--
``(i) a blind or disabled individual; or
``(ii) an individual described in paragraph (2); and
``(B) who the State determines satisfies--
``(i) the income and resources eligibility requirements
established by the State under the State plan under this
part; and
``(ii) such other requirements for assistance as are
imposed under this title, including documentation of
citizenship or status as a qualified alien under title IV of
the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996.
``(2) Individuals described.--For purposes of paragraph
(1)(A)(ii), the following individuals are described in this
paragraph:
``(A) A child in foster care under the responsibility of
the State.
``(B) A low-income woman with breast or cervical cancer
described in old section 1902(aa).
``(C) Certain TB-infected individuals described in old
section 1902(z)(1).
``(3) Grandfathered individuals.--An individual shall be an
eligible individual under the State plan under this part if--
``(A) the individual is described in paragraph (1)(A);
``(B) the individual satisfies the documentation
requirements referred to in paragraph (1)(B)(ii); and
``(C) the State would have provided medical assistance
under the State plan under old title XIX to the individual,
but only so long as the individual continues to satisfy such
old eligibility requirements.
``(4) Concurrent eligibility for part b.--An eligible
individual under this part may be eligible under part B, but
only if the individual satisfies the eligibility requirements
of part B in addition to satisfying the requirements for
eligibility under this part.
``(5) Presumptive eligibility for certain breast or
cervical cancer patients.--Old section 1920B (relating to
presumptive eligibility for certain breast or cervical cancer
patients) shall apply under this part.
``(b) Benefits.--Subject to paragraph (3), in this part,
the term `acute care medical assistance' means the following:
``(1) Mandatory benefits.--The care and services listed in
paragraphs (1) through (5), (17), and (21) of old section
1905(a) (but, in the case of paragraph (4)(A) of such
section, without regard to any limitation based on

[[Page S13536]]

age or services in an institution for mental diseases).
``(2) Optional benefits.--Any care or services listed in a
paragraph of old section 1905(a) (other than paragraph (16)).
``(3) Exceptions.--
``(A) Certain services limited to part b.--Services
described in paragraphs (15), (22), (23), (24), and (26) of
old section 1905(a) shall only be provided under the State
plan under part B.
``(B) Limit on provision of long-term care services and
supports.--A care or service that the Secretary determines is
a long-term care service and support (including nursing
facility services described in old section 1905(a)(4)(A))
shall not be provided to an individual under the State plan
under this part for more than 30 days within any 12-month
period.
``(C) Exclusions.--Such term shall not include any payments
with respect to care or services for any individual who is an
inmate of a public institution or a patient in an institution
for mental diseases (regardless of age).

``SEC. 1904. STATE PLAN REQUIREMENTS FOR ACUTE CARE MEDICAL
ASSISTANCE.

``(a) In General.--In order to receive payments under this
part, a State shall have an approved State plan for acute
care medical assistance. For purposes of this part, such
assistance includes payments for preventive care, primary
care, diagnosis and treatment of acute and chronic health
conditions, emergency care, diagnosis and treatment of mental
illnesses and related conditions, and rehabilitation and
other services to help eligible individuals attain or retain
capability for independence or self-care. A State medical
assistance plan shall include a description, consistent with
the requirements of this part of--
``(1) eligibility standards, including income and asset
standards;
``(2) benefits, including the amount, duration, and scope
of covered items and services;
``(3) strategies for improving access and quality of care;
and
``(4) methods of service delivery.
``(b) Public Availability of State Plan.--The State shall
make available to the public the State plan under this part
and any amendments submitted by the State to the plan.
``(c) Amount, Duration, and Scope.--The State plan shall
provide that the acute care medical assistance made available
to any eligible individual shall not be less in amount,
duration, or scope than the acute care medical assistance
made available to any other eligible individual.
``(d) Application of Certain Pre-Modernized Medicaid
Requirements.--
``(1) Old state plan requirements.--The following
provisions of old section 1902 shall apply to the State plans
under this part:
``(A) Old section 1902(a)(10)(C) (relating to certain
eligibility and other requirements).
``(B) Old section 1902(a)(10)(D) (relating to home health
services).
``(C) Old section 1902(a)(10)(G) (relating to
nonapplication of certain supplemental security income
eligibility criteria).
``(D) The subclauses in the flush matter following old
section 1902(a)(10)(G) (relating to the provision of certain
services) other than subclauses (V), (VII), (VIII), and (IX).
``(E) Old section 1902(a)(17) (relating to reasonable
standards for determining eligibility).
``(F) Old section 1902(a)(19) (relating to eligibility
safeguards).
``(G) Old section 1902(a)(34) (relating to eligibility
beginning with the third month prior to the month of
application).
``(H) Subparagraphs (A), (B), and (C) of old section
1902(a)(43) (relating to early and periodic screening,
diagnostic, and treatment services).
``(I) Old section 1902(a)(46)(A) (relating to compliance
with section 1137 requirements).
``(J) The fourth and sixth sentences of old section 1902(a)
(relating to eligibility for certain individuals).
``(2) Other old title xix requirements.--
``(A) Old section 1902(e)(3) (relating to optional
eligibility for certain disabled individuals).
``(B) Old section 1902(e)(9) (relating to optional
respiratory care services).
``(C) Old section 1902(f) (relating to eligibility of
certain aged, blind, or disabled individuals).
``(D) Old section 1902(m) (relating to eligibility of
certain aged or disabled individuals), other than paragraph
(4).
``(E) Old section 1902(o) (relating to disregard of certain
supplemental security income benefits).
``(F) Old section 1902(v) (relating to eligibility
determinations of blind or disabled individuals).
``(e) Other Requirements.--The State plan under this part
shall--
``(1) comply with the requirements of the other parts of
this title; and
``(2) provide that the State will make the contributions
specified under section 340A-1(e) of the Public Health
Service Act .

``SEC. 1905. DEFINITIONS.

``(a) In General.--The definitions specified in this
section shall apply for purposes of this part and, to the
extent applicable and consistent with the policy embodied in
such part, parts B, C, D, E, and F.
``(b) Federal Medical Assistance Percentage.--The term
`Federal medical assistance percentage' for any State shall
be 100 percent less the State percentage; and the State
percentage shall be that percentage which bears the same
ratio to 45 percent as the square of the per capita income of
such State bears to the square of the per capita income of
the continental United States (including Alaska) and Hawaii,
except that the Federal medical assistance percentage shall
in no case be less than 50 percent or more than 83 percent.
The Federal medical assistance percentage for any State shall
be determined and promulgated in accordance with the
provisions of section 1101(a)(8)(B).
``(c) Application of Certain Pre-Modernized Medicaid
Provisions.--The following old provisions shall apply under
this part:
``(1) Old section 1905 provisions.--The following
provisions of old section 1905:
``(A) Old section 1905(d) (relating to the definition of an
intermediate care facility for the mentally retarded).
``(B) Old section 1905(e) (relating to the definition of
physicians services).
``(C) Old section 1905(f) (relating to the definition of
nursing facility services).
``(D) Old section 1905(g) (relating to the provision of
chiropractors' services).
``(E) Old section 1905(j) (relating to State supplementary
payments).
``(F) Old section 1905(k) (relating to supplemental
security income benefits payable pursuant to section 211 of
Public Law 93-66).
``(G) Old section 1905(l)(1) (relating to rural health
clinic services).
``(H) Old section 1905(o) (relating to hospice care).
``(I) Old section 1905(q) (relating to the definition of a
qualified severely impaired individual).
``(J) Old section 1905(r) (relating to the definition of
early and periodic screening, diagnostic, and treatment
services).
``(K) Old section 1905(s) (relating to the definition of a
qualified disabled and working individual).
``(L) Old section 1905(t) (relating to the definition of
primary care case management services).
``(M) Old section 1905(v) (relating to the definition of an
employed individual with a medically improved disability).
``(N) Paragraphs (1) and (3) of old section 1905(w)
(relating to the definition of an independent foster care
adolescent).
``(O) Old section 1905(x) (relating to strategies,
treatment, and services for individuals with Sickle Cell
Disease).
``(2) Other old provisions.--
``(A) Old section 1903(m) (relating to the definition of a
medicaid managed care organization).

``SEC. 1906. ENROLLMENT OF INDIVIDUALS UNDER GROUP HEALTH
PLANS AND OTHER ARRANGEMENTS.

``The following old provisions shall apply under this part:
``(1) Old section 1906 (relating to enrollment of
individuals under group health plans).
``(2) Old section 1902(a)(70) (relating to State option to
establish a non-emergency medical transportation brokerage
program).
``(3) Paragraphs (2) and (11) of old section 1902(e)
(relating to eligibility for individuals enrolled with a
group health plan or under a managed care arrangement during
a minimum enrollment period).

``SEC. 1907. DRUG REBATES.

``Old sections 1902(a)(54) and 1927 (relating to payment
for covered outpatient drugs and rebates) shall apply under
this part.

``SEC. 1908. MANAGED CARE.

``The following old provisions shall apply under this part:
``(1) Old section 1932 (relating to managed care), other
than subsection (a)(2) of such section.
``(2) Old section 1903(k) (relating to technical and
actuarial assistance for States).

``SEC. 1909. ANNUAL REPORTS.

``(a) In General.--Each State that receives payments under
this part shall submit an annual report to the Secretary, in
such form and manner as the Secretary shall specify.
``(b) Application of Old EPSDT Reporting Requirements.--
Each annual report shall include the information required to
be reported under old section 1902(a)(43)(D)(iv).

``PART B--GRANTS TO STATES FOR LONG-TERM CARE SERVICES AND SUPPORTS

``SEC. 1911. PURPOSE.

``(a) In General.--The purpose of this part is to increase
the flexibility of States in operating a system of long-term
care services and supports designed to--
``(1) provide assistance to needy families so that
individuals with disabilities and low-income senior citizens
may be served and supported in their own homes and
communities;
``(2) emphasize the independence and dignity of the person
served by public programs;
``(3) end the institutional bias that existed under the
Medicaid program prior to January 1, 2011;
``(4) provide stable and predictable funding for States as
they rebalance their long-term care systems from institutions
to communities;
``(5) provide flexibility to States to adopt new and
innovative service delivery methods; and
``(6) promote independence and support activities that will
enable individuals to return or maintain ties to the
community, including through employment.
``(b) No Individual Entitlement.--No individual determined
eligible for long-term care services and supports under this
part shall be entitled to a specific service or type of
delivery of service.

``SEC. 1912. STATE PLAN.

``(a) In General.--In order to receive payments under this
part, a State must have an

[[Page S13537]]

approved State plan for long-term care services and supports.
A State long term care services and supports plan shall
include a description, consistent with the requirements of
this part, of--
``(1) income and assets eligibility standards and spousal
impoverishment protections consistent with subsection (b);
``(2) the standardized assessments tools used to determine
eligibility for specific long-term care services and
supports;
``(3) the person-centered plans used to provide such
services and supports;
``(4) the proposed uses of funding, if applicable, to
provide targeted methods to meet individual level of support
needs including tiering (preventive, emergency, low, medium,
high); and
``(5) the long-term care services and supports to be
available under the plan based on individual assessment of
need in accordance with sections 1916 and 1917.
``(b) Minimum Eligibility Standards.--
``(1) Populations covered.--The State plan shall specify
the disabled and elderly populations who are eligible for
long-term care services and supports.
``(2) Needs-based criteria.--The plan shall include a
description of the needs-based criteria the State will use to
assess an individual's need for specific services and
supports available under the State plan.
``(3) Other eligibility requirements.--
``(A) Income and assets.--A State may use different income
and asset standards and methodologies for determining
eligibility than those used for determining eligibility for
acute care medical assistance under part A. A State may not
make eligibility standards related to income, asset, and
spousal impoverishment protection more restrictive than the
Federal minimum requirements of December 31, 2008.
``(B) Application of spousal impoverishment protections.--
The State plan shall provide that the State shall comply with
the requirements of section 1918 (relating to spousal
impoverishment protections).
``(C) Statewideness.--The State plan shall provide that,
except with respect to methods used for determining homestead
exemptions, the income and asset standards and methodologies
shall be in effect in all political subdivisions of the
State.
``(4) Transition assistance.--The State plan shall specify
how the State will provide transition assistance for
individuals who, on December 31, 2010, are enrolled under the
State plan under old title XIX (or under a waiver of that
plan) and receiving long-term care services or supports on
that date. The State shall provide such assistance to
individuals who are and are not likely to be determined
eligible for long-term care services and supports under the
State plan under this part, as in effect on January 1, 2011
(or the first day on which the State plan is in effect under
this part).
``(c) Payment Methodologies to Providers.--
``(1) In general.--The State plan shall describe the
methodologies used to determine payments to providers. Such
methodologies--
``(A) may be varied to assist in transitioning from
facilities-based to community-based care; and
``(B) shall not be subject to Secretarial approval.
``(2) Transparency.--The State plan shall provide that the
State shall make publicly available--
``(A) the payment methodologies applicable under the plan;
and
``(B) the name of any provider that receives $1,000,000 or
more in any 12-month period and the actual amount paid to the
provider during that period.
``(d) Coordination of Effort With Other Related Public and
Private Programs.--The plan shall include a description of
the State's efforts to coordinate the delivery of services
and supports under the plan with other related public and
private programs that serve individuals with disabilities or
aged populations that need or may be at risk of needing long
term care.
``(e) Public Availability of State Plan.--The State shall
make available to the public the State plan under this part
and any amendments submitted by the State to the plan.
``(f) Application of Old Title XIX Requirements.--The
following old title XIX provisions shall apply to a State
plan under this part:
``(1) Subsections (a)(50) and (q) of old section 1902
(relating to a monthly personal needs allowance for certain
institutionalized individuals and couples).
``(2) Old section 1902(a)(67) (relating to payment for
certain services furnished to a PACE program eligible
individual).
``(3) Paragraph (1) of old section 1902(r) (relating to the
post-eligibility treatment of income for certain individuals)
and paragraph (2) of such section (relating to methodologies
for determining income and resource eligibility for
individuals, but only with respect to individuals who are
eligible under this part on or after January 1, 2011).
``(4) Old section 1905(i) (relating to the definition of an
institution for mental diseases).
``(g) Other Requirements of Other Parts.--The State plan
under this part shall--
``(1) comply with the requirements of the other parts of
this title; and
``(2) provide that the State will make the contributions
specified under section 340A-1(e) of the Public Health
Service Act.

``SEC. 1913. STATE ALLOTMENTS.

``(a) Appropriation.--For the purpose of providing
allotments to States under this section, there is
appropriated out of any money in the Treasury not otherwise
appropriated--
``(1) for fiscal year 2011, $65,274,560,000;
``(2) for fiscal year 2012, $67,885,540,000;
``(3) for fiscal year 2013, $70,600,964,100;
``(4) for fiscal year 2014, $73,425,000,000;
``(5) for fiscal year 2015, $76,362,000,000;
``(6) for fiscal year 2016, $79,416,480,000;
``(7) for fiscal year 2017, $82,593,140,000;
``(8) for fiscal year 2018, $85,896,870,000; and
``(9) for fiscal year 2019, $89,332,743,000.
``(b) Allotments to 50 States and the District of
Columbia.--
``(1) Fiscal year 2011 allotments.--Subject to subsection
(e), the Secretary shall allot to each State with a long term
care plan approved under this title an amount in fiscal year
2011 equal to the Federal expenditures made by the State for
long-term care as defined in section 1916 in fiscal year
2008, increased by 8 percent.
``(2) Subsequent fiscal year allotments.--For fiscal year
2012 and each subsequent fiscal year through fiscal year
2019, the allotment for a State under this section is equal
to the allotment for the State determined for the preceding
fiscal year, increased by 4 percent.
``(c) Limitation.--
``(1) In general.--Except as provided in paragraph (2), no
other Federal funds are available under this title for
expenditures incurred for long-term care services and
supports after December 31, 2010, except as provided under a
State plan approved under this part.
``(2) Exception.--
``(A) In general.--If a State does not have an approved
State plan by October 1, 2010, the Secretary may make
payments equal to 85 percent of the State's estimated
quarterly allotment until June 30, 2011.
``(B) Full funding.--A State shall receive 100 percent of
its allotment for fiscal year 2011 if the State has a plan
approved under this part by June 30, 2011.
``(d) Maintenance of Effort.--In order to qualify for the
grant payable under this section, the State must demonstrate
in each fiscal year that it made long-term care service and
supports expenditures (including funding from local
government sources) equal to the amount of not less than 95
percent of the nonfederal share amount spent in fiscal year
2009 under the State plan under old title XIX on long term
care services and supports (as defined in section 1916).
Expenditures not made under this part shall not be recognized
by the Secretary for purposes of this requirement.
``(e) Grants Reduced if Insufficient Appropriations.--
``(1) In general.--If the amount appropriated for fiscal
year 2011 under subsection (a)(1) is less than the amount
necessary to fund each State's allotment for that fiscal
year, the Secretary shall reduce the allotment for each State
for that fiscal year based on the applicable percentage
determined for the State under paragraph (2).
``(2) Applicable percentage.--For purposes of paragraph
(1), the applicable percentage determined with respect to a
State is as follows:

``If the ratio of the State's non-       The applicable percentage is:
institutional spending to total long-
term care spending for fiscal year
2009 is:
50 percent or greater................  100
at least 46, but less than 50 percent  99
at least 40, but less than 46 percent  98
at least 36, but less than 40........  97
at least 30, but less than 36........  96
less than 30 percent.................  95.

``(f) Administrative Expenses.--
``(1) In general.--Each State with a plan approved under
this part shall receive a payment determined in accordance
with amounts appropriated for part E for administrative
expenses incurred in carrying out the plan under this part
and part A.
``(2) Assessment-related costs.--Costs attributable to
providing an individualized needs-based assessment for
purposes of identifying the long-term care services and
supports to be provided under the State plan to an individual
shall be considered a long-term care service and support and
shall not be treated as an administrative expense.

[[Page S13538]]

``SEC. 1914. USE OF GRANTS.

``(a) In General.--A State shall use funds for long-term
care services and supports as defined in section 1916.
``(b) Self-Direction.--A State shall offer individuals the
opportunity to self-direct their long-term care services and
supports.

``SEC. 1915. ADMINISTRATIVE PROVISIONS.

``(a) Funding on a Quarterly Basis.--The Secretary shall
make payments to States in equal amounts of a State's annual
allotment on a quarterly basis. Each quarterly payment shall
remain available for use by the State for twelve succeeding
fiscal year quarters.
``(b) Publication.--The Secretary shall publish each
State's allotment--
``(1) for fiscal year 2011 not later than December 15,
2009; and
``(2) for each subsequent fiscal year, not later than
December 15 of the calendar year preceding the calendar year
in which the fiscal year begins.

``SEC. 1916. DEFINITION OF LONG-TERM CARE SERVICES AND
SUPPORTS.

``(a) Definition.--
``(1) In general.--Subject to subsection (e), in this part,
the term `long-term care services and supports' means any of
the services or supports specified in paragraphs (2) or (3)
that may be provided in a nursing facility, an institution, a
home, or other setting.
``(2) Services and supports described.--For purposes of
paragraph (1), the services and supports described in this
paragraph include assistive technology, adaptive equipment,
remote monitoring equipment, case management for the aged,
case management for individuals with disabilities, nursing
home services, long-term rehabilitative services necessary to
restore functional abilities, services provided in
intermediate care facilities for people with disabilities,
habilitation services (including adult day care programs),
community treatment teams for individuals with mental
illness, home health services, services provided in an
institution for mental disease, a Program of All-Inclusive
Care for the Elderly (PACE), personal care (including
personal assistance services), recovery support including
peer counseling, supportive employment, training skills
necessary to assist the individual in achieving or
maintaining independence, training of family members
including foster parents in supportive and behavioral
modification skills, ongoing and periodic training to
maintain life skills, transitional care including room and
board not to exceed 60 days within a 12-month period.
``(3) Inclusion of certain benefits under old title xix.--
Such services and supports may include any of the following
services:
``(A) Old section 1905(a)(15) (relating to services in an
intermediate care facility for the mentally retarded).
``(B) Services described in subsections (a)(16) and (h) of
old section 1905, but without regard to any restriction on
such services on the basis of age (relating to inpatient
psychiatric hospital services).
``(C) Old section 1905(a)(22) (relating to home and
community care (to the extent allowed and as defined in old
section 1929) for functionally disabled elderly individuals).
``(D) Old section 1905(a)(23) (relating to community
supported living arrangements services (to the extent allowed
and as defined in old section 1930)).
``(E) Subject to subsection (e), old section 1905(a)(24)
but without regard to any restriction on furnishing services
to patients or residents of facilities or institutions
(relating to personal care services).
``(F) Old sections 1905(a)(26) and 1934 (relating to
services furnished under a PACE program under old section
1934 to PACE program eligible individuals enrolled under the
program under such old section).
``(G) Old section 1915(c)(5) (relating to the definition of
habilitation services).
``(4) Limitation.--Long-term care services and supports
cannot be used for services and administrative costs provided
through the foster care (with the exception of training of
foster care parents), child welfare, adult protective
services, juvenile justice, public guardianship, or
correctional systems.
``(b) Rehabilitative Care.--For purposes of rehabilitation
due to acute care medical needs, a State may claim
rehabilitative services provided in an institutional setting,
nursing home, or as part of home health expenditures as acute
care benefits under the State plan under part A rather than
under the State plan under this part for a cumulative period
of 30 days within a 12-month period if such care is directly
related to the onset of an acute care need. A State shall
demonstrate the services were provided as a direct result of
an acute care need.
``(c) Managed Care.--If a State provides long-term care
services and supports through managed care, the State shall
submit a methodology for determining the level of
expenditures attributed to long term care for approval by the
Secretary.
``(d) Application of Part A Definitions.--A definition
specified in section 1905 shall apply to the same term used
in this part, unless the Secretary determines that the
application of such definition would be inconsistent with the
purpose of this part.
``(e) Exclusion.--No payments shall be made under the State
plan under this part with respect to long-term care supports
and services provided for any individual who is an inmate of
a public institution. Nothing in the preceding sentence shall
be construed as precluding the provision of long-term care
services and supports under the State plan under this part to
an individual who is a patient in an institution for mental
diseases.

``SEC. 1917. PROVISION REQUIREMENTS FOR LONG-TERM CARE
SERVICES AND SUPPORT, INCLUDING OPTION FOR
SELF-DIRECTED SERVICES AND SUPPORTS.

``(a) Requirements for the Provision of Long-Term Care
Services and Supports.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, a State may provide through a State plan
amendment for the provision of long-term care services and
supports for individuals eligible under the State plan under
this part, subject to the following requirements:
``(A) Needs-based criteria for eligibility for, and receipt
of, long-term care services and supports.--The State
establishes needs-based criteria for determining an
individual's eligibility under the State plan for medical
assistance for such long-term care services and supports, and
if the individual is eligible for such services and supports,
the specific services and supports that will be available
under the State plan to the individual.
``(B) Criteria for institutionalized versus non-
institutionalized services.--In establishing needs-based
criteria, the State may establish criteria for determining
eligibility for, and receipt of, services and supports
provided in a facility or institution that are more stringent
that the criteria established for eligibility and receipt of
services and supports in a non-facility or non-
institutionalized setting.
``(C) Authority to limit number of eligible individuals.--A
State may limit the number of individuals who are eligible
for such services and supports and may establish waiting
lists for the receipt of such services and supports.
``(D) Criteria based on individual assessment.--
``(i) In general.--The criteria established by the State
shall require an assessment of an individual's support needs
and capabilities, and may take into account the inability of
the individual to perform 2 or more activities of daily
living (as defined in section 7702B(c)(2)(B) of the Internal
Revenue Code of 1986) or the need for significant assistance
to perform such activities, and such other risk factors as
the State determines to be appropriate.
``(ii) Adjustment authority.--The State plan amendment
provides the State with the option to modify the criteria
established under subparagraph (A) (without having to obtain
prior approval from the Secretary) in the event that the
enrollment of individuals eligible for services exceeds the
projected enrollment, but only if--

``(I) the State provides at least 60 days notice to the
Secretary and the public of the proposed modification;
``(II) the State deems an individual receiving long-term
care services and supports on the basis of the most recent
version of the criteria in effect prior to the effective date
of the modification to be eligible for such services and
supports for a period of at least 12 months beginning on the
date the individual first received medical assistance for
such services and supports; and
``(III) after the effective date of such modification, the
State, at a minimum, applies the criteria for determining
whether an individual requires the level of care provided in
a facility or institutionalized setting which applied under
the State plan immediately prior to the application of the
modified criteria.

``(E) Independent evaluation and assessment.--
``(i) Eligibility determination.--The State uses an
independent evaluation for making the determinations
described in subparagraph (A).
``(ii) Assessment.--In the case of an individual who is
determined to be eligible for long-term care services and
supports, the State uses an independent assessment, based on
the needs of the individual to--

``(I) determine a necessary level of services and supports
to be provided, consistent with an individual's physical and
mental capacity;
``(II) prevent the provision of unnecessary or
inappropriate care; and
``(III) establish an individualized care plan for the
individual in accordance with subparagraph (G).

``(F) Assessment.--The independent assessment required
under subparagraph (E)(ii) shall include the following:
``(i) An objective evaluation of an individual's inability
to perform 2 or more activities of daily living (as defined
in section 7702B(c)(2)(B) of the Internal Revenue Code of
1986) or the need for significant assistance to perform such
activities.
``(ii) A face-to-face evaluation of the individual by an
individual trained in the assessment and evaluation of
individuals whose physical or mental conditions trigger a
potential need for long-term care services and supports.
``(iii) Where appropriate, consultation with the
individual's family, spouse, guardian, or other responsible
individual.
``(iv) Consultation with appropriate treating and
consulting health and support professionals caring for the
individual.
``(v) An examination of the individual's relevant history,
medical records, and care and support needs, guided by best
practices and research on effective strategies that result in
improved health and quality of life outcomes.
``(vi) An evaluation of the ability of the individual or
the individual's representative to

[[Page S13539]]

self-direct the purchase of, or control the receipt of, such
services and supports if the individual so elects.
``(G) Individualized care plan.--
``(i) In general.--In the case of an individual who is
determined to be eligible for long-term care services and
supports, the State uses the independent assessment required
under subparagraph (E)(ii) to establish a written
individualized care plan for the individual.
``(ii) Plan requirements.--The State ensures that the
individualized care plan for an individual--

``(I) is developed--

``(aa) in consultation with the individual, the
individual's treating physician, health care or support
professional, or other appropriate individuals, as defined by
the State, and, where appropriate the individual's family,
caregiver, or representative; and
``(bb) taking into account the extent of, and need for, any
family or other supports for the individual;

``(II) identifies the long-term care services and supports
to be furnished to the individual (or, if the individual
elects to self-direct the purchase of, or control the receipt
of, such services and supports, funded for the individual);
and
``(III) is reviewed at least annually and as needed when
there is a significant change in the individual's
circumstances.

``(iii) State requirement to offer election for self-
directed services and supports.--

``(I) Individual choice.--The State shall allow an
individual or the individual's representative the opportunity
to elect to receive self-directed long-term care services and
supports in a manner which gives them the most control over
such services and supports consistent with the individual's
abilities and the requirements of subclauses (II) and (III).
``(II) Self-directed.--The term `self-directed' means, with
respect to the long-term care services and supports offered
under the State plan amendment, such services and supports
for the individual which are planned and purchased under the
direction and control of such individual or the individual's
authorized representative, including the amount, duration,
scope, provider, and location of such services and supports,
under the State plan consistent with the following
requirements:

``(aa) Assessment.--There is an assessment of the needs,
capabilities, and preferences of the individual with respect
to such services and supports.
``(bb) Service plan.--Based on such assessment, there is
developed jointly with such individual or the individual's
authorized representative a plan for such services and
supports for such individual that is approved by the State
and that satisfies the requirements of subclause (III).

``(III) Plan requirements.--For purposes of subclause
(II)(bb), the requirements of this subclause are that the
plan--

``(aa) specifies those services and supports which the
individual or the individual's authorized representative
would be responsible for directing;
``(bb) identifies the methods by which the individual or
the individual's authorized representative will select,
manage, and dismiss providers of such services and supports;
``(cc) specifies the role of family members and others
whose participation is sought by the individual or the
individual's authorized representative with respect to such
services and supports;
``(dd) is developed through a person-centered process that
is directed by the individual or the individual's authorized
representative, builds upon the individual's capacity to
engage in activities that promote community life and that
respects the individual's preferences, choices, and
abilities, and involves families, friends, and professionals
as desired or required by the individual or the individual's
authorized representative;
``(ee) includes appropriate risk management techniques that
recognize the roles and sharing of responsibilities in
obtaining services and supports in a self-directed manner and
assure the appropriateness of such plan based upon the
resources and capabilities of the individual or the
individual's authorized representative; and
``(ff) may include an individualized budget which
identifies the dollar value of the services and supports
under the control and direction of the individual or the
individual's authorized representative.

``(IV) Budget process.--With respect to individualized
budgets described in subclause (III)(ff), the State plan
amendment--

``(aa) describes the method for calculating the dollar
values in such budgets based on reliable costs and service
utilization;
``(bb) defines a process for making adjustments in such
dollar values to reflect changes in individual assessments
and service plans; and
``(cc) provides a procedure to evaluate expenditures under
such budgets.
``(H) Quality assurance; conflict of interest standards.--
``(i) Quality assurance.--The State ensures that the
provision of long-term care services and supports meets
Federal and State guidelines for quality assurance.
``(ii) Conflict of interest standards.--The State
establishes standards for the conduct of the independent
evaluation and the independent assessment to safeguard
against conflicts of interest.
``(I) Redeterminations and appeals.--The State allows for
at least annual redeterminations of eligibility, and appeals
in accordance with the frequency of, and manner in which,
redeterminations and appeals of eligibility are made under
the State plan.
``(J) Presumptive eligibility for assessment.--The State,
at its option, elects to provide for a period of presumptive
eligibility (not to exceed a period of 60 days) only for
those individuals that the State has reason to believe may be
eligible for long-term care services and supports. Such
presumptive eligibility shall be limited to medical
assistance for carrying out the independent evaluation and
assessment under subparagraph (E) to determine an
individual's eligibility for such services and if the
individual is so eligible, the specific long-term care
services and supports that the individual will receive.
``(2) Definition of individual's representative.--In this
section, the term `individual's representative' means, with
respect to an individual, a parent, a family member, or a
guardian of the individual, an advocate for the individual,
or any other individual who is authorized to represent the
individual.
``(b) Self-Directed Personal Assistance Services.--If a
State includes personal care or personal assistance services
in the long-term care services and supports available under
the State plan, the State shall comply with the requirements
of old section 1915(j) in the case of an individual who
elects to self-direct the receipt of such care or services.

``SEC. 1918. TREATMENT OF INCOME AND RESOURCES FOR CERTAIN
INSTITUTIONALIZED SPOUSES.

``Old section 1924 (relating to treatment of income and
resources for certain institutionalized spouses), other than
paragraphs (2) and (4)(A) of subsection (a) of such section,
shall apply under this part.

``SEC. 1919. ANNUAL REPORTS.

``(a) In General.--Each State that receives payments under
this part shall submit an annual report to the Secretary, in
such form and manner as the Secretary shall specify.
``(b) Requirements.--The report shall include the following
with respect to the most recent fiscal year ended:
``(1) The number of individuals served under the plan.
``(2) The number of individuals served by tier (preventive,
emergency, low, medium, and high needs).
``(3) The number of individuals known to the State on
waiting list for services (if any) and type of disability
(physical, developmental, mental health) or aged.
``(4) Expenditures by service category.

``PART C--GRANTS TO STATES FOR SURVEY AND CERTIFICATION OF MEDICAL
FACILITIES AND OTHER REQUIREMENTS

``SEC. 1931. AUTHORIZATION OF APPROPRIATIONS.

``For the purpose of carrying our Federal activities and
providing grants to States for expenses necessary to carry
out this part, there is authorized to be appropriated--
``(1) for fiscal year 2011, $300,000,000; and
``(2) for each succeeding fiscal year, the amount
authorized under this section for the preceding fiscal year,
increased by 5 percent.

``SEC. 1932. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
MODERNIZED MEDICAID.

``The following old provisions shall apply under this part:
``(1) Old section 1902(a)(9) (relating to health standards
and applicable requirements for laboratory services).
``(2) Old section 1902(a)(28) (relating to nursing
facilities and nursing facility services).
``(3) Old sections 1902(a)(29) and 1908 (relating to a
State program for the licensing of administrators of nursing
homes).
``(4) Old section 1902(a)(33)(B) (relating to licensing
health institutions).
``(5) Old section 1902(d) (relating to medical or
utilization review functions).
``(6) Old section 1902(i) (relating to intermediate care
facilities for the mentally retarded).
``(7) Old section 1902(y) (relating to psychiatric
hospitals).
``(8) Paragraphs (2) and (6) of old section 1903(g)
(relating to the Secretarial requirement to conduct sample
onsite surveys of private and public institutions and
recertifications for the need for certain services).
``(9) Old section 1903(q)(4)(B) (relating to the definition
of a board and care facility).
``(10) Old section 1910 (relating to certification and
approval of rural health clinics and intermediate care
facilities for the mentally retarded).
``(11) Old section 1911 (relating to Indian Health Service
facilities).
``(12) Old section 1913 (relating to hospital providers of
nursing facility services).
``(13) Old section 1919 (relating to requirements for
nursing facilities).

``PART D--GRANTS TO STATES FOR PROGRAM INTEGRITY

``SEC. 1941. AUTHORIZATION OF APPROPRIATIONS.

``(a) In General.--For the purpose of carrying out Federal
activities under this part and providing grants to States for
expenses necessary to carry out this part, there is
authorized to be appropriated--
``(1) for fiscal year 2011, $100,000,000; and
``(2) for each succeeding fiscal year, the amount
authorized under this section for the preceding fiscal year,
increased by 5 percent.
``(b) Availability; Authority for Use of Funds.--

[[Page S13540]]

``(1) Availability.--Amounts appropriated pursuant to
subsection (a) shall remain available until expended.
``(2) Authority for use of funds for transportation and
travel expenses for attendees at education, training, or
consultative activities.--
``(A) In general.--The Secretary may use amounts
appropriated pursuant to subsection (a) to pay for
transportation and the travel expenses, including per diem in
lieu of subsistence, at rates authorized for employees of
agencies under subchapter I of chapter 57 of title 5, United
States Code, while away from their homes or regular places of
business, of individuals described in subsection (b)(4) who
attend education, training, or consultative activities
conducted under the authority of that subsection.
``(B) Public disclosure.--The Secretary shall make
available on a website of the Centers for Medicare & Medicaid
Services that is accessible to the public--
``(i) the total amount of funds expended for each
conference conducted under the authority of subsection
(b)(4); and
``(ii) the amount of funds expended for each such
conference that were for transportation and for travel
expenses.
``(c) Annual Report.--Not later than 180 days after the end
of each fiscal year, the Secretary shall submit a report to
Congress which identifies--
``(1) the use of funds appropriated pursuant to subsection
(a); and
``(2) the effectiveness of the use of such funds.

``SEC. 1942. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
MODERNIZED MEDICAID.

``The following old provisions shall apply under this part:
``(1) Old subsections (a)(25) (other than subparagraph (E))
and (g) of section 1902 and section 1903(o) (relating to
third party liability).
``(2) Old section 1902(a)(30)(B) (relating to hospital,
intermediate care facility for the mentally retarded, or
hospital for mental diseases admission screening and review
requirements).
``(3) Old section 1902(a)(32) (relating to certain payment
requirements).
``(4) Old section 1902(a)(35) (relating to disclosing
entities under section 1124).
``(5) Old section 1902(a)(37) and the fifth sentence
(relating to claims payment procedures).
``(6) Old section 1902(a)(44) (relating to payment for
inpatient hospital services, services in an intermediate care
facility for the mentally retarded, or inpatient mental
hospital services).
``(7) Old sections 1902(a)(45) and 1912 (relating to
assignment of rights of payment).
``(8) Old sections 1902(a)(49) and 1921 (relating to
information and access to information concerning sanctions
taken by State licensing authorities against health care
practitioners and providers).
``(9) Old sections 1902(a)(61) and 1903(q) (relating to
requirements for a medicaid fraud and abuse control unit).
``(10) Old section 1902(a)(64) (relating to reports from
beneficiaries and others and data compilation requirements
concerning alleged instances of waste, fraud, and abuse).
``(11) Old section 1902(a)(65) (relating to provider number
and surety bond requirement for suppliers of durable medical
equipment).
``(12) Old section 1902(a)(68) (relating to requirements
for certain entities).
``(13) Old sections 1902(a)(69) and 1936 (relating to the
Medicaid Integrity Program) other than paragraphs (1),
(2)(A), and (3) of old section 1936(e).
``(14) Old section 1902(a)(70)(B)(iv) (relating to
prohibitions on referrals and conflict of interest for
certain brokers of non-emergency medical transportation).
``(15) Old sections 1902(a)(71) and 1940 (relating to a
required asset verification program).
``(16) Old section 1902(p) (relating to exclusion of
certain individuals or entities).
``(17) Old section 1902(x) (relating to unique identifiers
for physicians).
``(18) Old section 1903(p) (relating to interstate
collection of rights of support).
``(19) Old section 1903(r)(2) (relating to requirements for
mechanized claims processing and information retrieval
systems).
``(20) Old section 1903(u) (relating to erroneous excess
payments), other than clause (v) of paragraph (1)(D).
``(21) Old section 1903(v) and the seventh sentence of old
section 1902(a) (relating to limitations on payments for
services furnished to aliens), other than subparagraphs (A)
and (B) of paragraph (4).
``(22) Old section 1903(x) (relating to citizenship
documentation).
``(23) Old section 1909 (relating to State false claims act
requirements for increased State share of recoveries).
``(24) Old section 1914 (relating to withholding of Federal
share of payments for certain Medicare providers).
``(25) Old section 1917 (relating to liens, adjustments and
recoveries, and transfers of assets).
``(26) Old section 1922 (relating to correction and
reduction plans for intermediate care facilities for the
mentally retarded).

``PART E--GRANTS TO STATES FOR ADMINISTRATION

``SEC. 1951. AUTHORIZATION OF APPROPRIATIONS; PAYMENTS TO
STATES.

``(a) In General.--For the purpose of providing grants to
States for administrative expenses necessary to carry out
parts A and B, there is authorized to be appropriated--
``(1) for fiscal year 2011, $7,000,000,000; and
``(2) for each succeeding fiscal year, the amount
authorized under this subsection for the preceding fiscal
year, increased by 3 percent.
``(b) Payments to States.--
``(1) In general.--From the amount appropriated pursuant to
subsection (a) for a fiscal year, the Secretary shall pay
each State with approved plans under parts A and B for the
fiscal year an amount equal to the product of the amount
appropriated for the fiscal year and the ratio of the total
amount of payments made to the State under paragraphs (2)
through (7) of section 1903(a) for fiscal year 2008 (as such
section was in effect for that fiscal year) to the total
amount of such payments made to all States for such fiscal
year.
``(2) Pro rata adjustment.--The Secretary shall make pro
rata adjustments to the amounts determined under paragraph
(1) for a fiscal year as necessary so as to not exceed the
amount appropriated pursuant to subsection (a) for the fiscal
year.

``SEC. 1952. COST-SHARING PROTECTIONS.

``(a) In General.--A State may impose cost-sharing for
individuals provided acute care medical assistance under a
State plan under part A or long-term care services and
supports under a State plan under part B consistent with the
following:
``(1) The State may (in a uniform manner) require payment
of monthly premiums or other cost-sharing set on a sliding
scale based on family income.
``(2) A premium or other cost-sharing requirement imposed
under paragraph (1) may only apply to the extent that, in the
case of an individual whose family income--
``(A) exceeds 150 percent of the poverty line, the
aggregate annual amount of such premium and other cost-
sharing charges imposed under the plan does not exceed 5
percent of the individual's annual income; and
``(B) exceeds 250 percent of the poverty line, the
aggregate annual amount of such premium and other cost-
sharing charges do not exceed 7.5 percent of the individual's
annual income.
``(3) A State shall not require prepayment of any premium
or cost-sharing imposed pursuant to paragraph (1) and shall
not terminate eligibility of an individual under the State
plan on the basis of failure to pay any such premium or cost-
sharing until such failure continues for a period of at least
60 days from the date on which the premium or cost-sharing
became past due. The State may waive payment of any such
premium or cost-sharing in any case where the State
determines that requiring such payment would create an undue
hardship.
``(b) Application to Institutionalized Individuals.--A
State may impose cost-sharing consistent with subsection (a)
to individuals who are patients in, or residents of, a
medical institution or nursing facility except that rules
relating to the post-eligibility treatment of income
(including a minium monthly personal needs allowance)
applicable to institutionalized individuals under old title
XIX shall apply in the same manner to individuals eligible
for long-term care services and supports under a State plan
under part B.
``(c) Poverty Line Defined.--In this section, the term
`poverty line' has the meaning given such term in section
673(2) of the Community Services Block Grant Act (42 U.S.C.
9902(2)), including any revision required by such section.

``SEC. 1953. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
MODERNIZED MEDICAID.

``The following old provisions shall apply to the State
plans under this title:
``(1) Old state plan requirements.--
``(A) Old section 1902(a)(1) (relating to the requirement
for plans to be in effect in all political subdivisions of
the State).
``(B) Old section 1902(a)(2) (relating to State financial
participation).
``(C) Old section 1902(a)(3) (relating to opportunity for a
fair hearing).
``(D) Old section 1902(a)(4) (relating to administration).
``(E) Old section 1902(a)(5) (relating to designation of a
single State agency).
``(F) Old section 1902(a)(6) (relating to reporting
requirements).
``(G) Old section 1902(a)(7) (relating to restrictions on
the use or disclosure of information).
``(H) Old section 1902(a)(8) (relating to applications for
assistance).
``(I) Old section 1902(a)(11) (relating to cooperative
agreements with other State agencies).
``(J) Old section 1902(a)(12) (relating to determinations
of blindness).
``(K) Old section 1902(a)(13) (relating to determination of
rates of payment for certain services), other than clause
(iv) of subparagraph (A).
``(L) Subsections (a)(15) and (bb) of old section 1902(a)
(relating to payment for services provided by rural health
clinics and federally qualified health centers).
``(M) Old section 1902(a)(16) (relating to furnishing
services to individuals when absent from the State).
``(N) Old section 1902(a)(22) (relating to certain
administrative provisions).
``(O) Paragraphs (23) and (25)(D) of old section 1902(a)
(relating to any willing provider requirements).
``(P) Old section 1902(a)(24) (relating to consultative
services by other agencies).
``(Q) Old section 1902(a)(26) (relating to review of need
for inpatient mental hospital services and written plan of
care requirements).

[[Page S13541]]

``(R) Old section 1902(a)(27) (relating to provider record
keeping requirements).
``(S) Old section 1902(a)(30)(A) (relating to utilization
review).
``(T) Old section 1902(a)(31) (relating to written plan of
care for services and review for intermediate care facility
for the mentally retarded services).
``(U) Old section 1902(a)(33)(A) (relating to quality
review requirements).
``(V) Old section 1902(a)(36) (relating to public
availability of facility surveys).
``(W) Old section 1902(a)(38) (relating to the provision of
information described in section 1128(b)(9) by certain
entities).
``(X) Old section 1902(a)(39) (relating to the exclusion of
certain entities).
``(Y) Old section 1902(a)(40) (relating to requirement for
uniform reporting systems).
``(Z) Old section 1902(a)(41) (relating to notice to State
medical licensing boards).
``(AA) Old section 1902(a)(42) (relating to certain audit
requirements).
``(BB) Old section 1902(a)(48) (relating to eligibility
cards).
``(CC) Old section 1902(a)(55) (relating to the receipt and
initial processing of applications, but only to the extent
such section is consistent with the policy embodied in the
State plans under parts A and B).
``(DD) Subsections (a)(56) and (s) of old section 1902
(relating to adjusted payments for certain inpatient hospital
services).
``(EE) Old section 1902(a)(59) (relating to maintenance of
list of participating physicians).
``(FF) The second sentence of old section 1902 (relating to
designation of certain State agencies).
``(GG) Old section 1902(b) (relating to limitations on
approval of plans).
``(HH) Old section 1902(j) (relating to application of
requirements to American Samoa and the Northern Mariana
Islands).
``(2) Other old title xix requirements.--
``(A) Old section 1903(b)(4) (relating to limitations on
payments to enrollment brokers).
``(B) Old section 1903(c) (relating to furnishing of
services included in a program or plan under part B or C of
the Individuals with Disabilities Education Act).
``(C) Old section 1903(d) (relating to payments).
``(D) Old section 1903(e) (relating to costs with respect
to certain hospital services).
``(E) Old section 1903(i) (relating to limitations on
payments).
``(F) Old section 1903(r) (relating to requirements for
mechanized claims processing and information retrieval
systems).
``(G) Subsections (b)(5) and (w) of old section 1903
(relating to limitations on payments related to provider
taxes).
``(H) Old section 1904 (relating to operation of State
plans).
``(I) Old sections 1902(a)(60) and 1908A (relating to
medical child support).
``(J) Paragraphs (32)(D) and (62) of old section 1902(a)
and section 1928 (relating to program for distribution of
pediatric vaccines).

``PART F--OTHER PROVISIONS

``SEC. 1961. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
MODERNIZED MEDICAID.

``The following old provisions shall apply under this part:
``(1) The third sentence of old section 1902 (relating to
nonapplication of certain old provisions to a religious
nonmedical health care institution).
``(2) Old section 1918 (relating to application of
provisions of title II relating to subpoenas).
``(3) Old section 1939 (relating to references to laws
directly affecting the Medicaid program.''.
(b) Repeal of Title XXI.--Effective January 1, 2011, title
XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) is
repealed.

SEC. 402. OUTREACH.

(a) Authorization of Appropriations.--The following amounts
are authorized to be appropriated to the Secretary of Health
and Human Services:
(1) For fiscal year 2009, $100,000,000 for the design and
implementation of a public outreach campaign to inform the
public about the changes to the programs under such titles
that take effect on January 1, 2011, as a result of the
amendment made by section 401.
(2) For each of fiscal years 2010 and 2011, $200,000,000 to
carry out such public outreach campaign.
(3) For fiscal year 2012, $50,000,000 to carry out such
public outreach campaign.
(b) Availability.--Funds appropriated under subsection (a)
shall remain available for expenditure through September 30,
2012.
(c) Authority for Use of Funds.--The Secretary may use
funds made available under paragraphs (2) and (3) of
subsection (a) to award grants to, or enter into contracts
with, public or private entities, including States, local
governments, schools, churches, and community groups.

SEC. 403. TRANSITION RULES; MISCELLANEOUS PROVISIONS.

(a) In General.--
(1) Not later than June 30, 2010, a State that is one of
the 50 States or the District of Columbia shall inform all
individuals enrolled in a State plan under title XIX or XXI
of the Social Security Act on such date (and any new
enrollees after such date) of the changes to the programs
under such titles that take effect on January 1, 2011, as a
result of the amendment made by section 401.
(2) No State that is one of the 50 States or the District
of Columbia shall approve any applications for medical
assistance or child health assistance under a State plan
under title XIX or XXI (as in effect for fiscal year 2010)
after December 31, 2010.
(b) Submission of Legislative Proposal for Technical and
Conforming Amendments.--Not later than 6 months after the
date of enactment of this Act, the Secretary of Health and
Human Services shall submit to Congress a legislative
proposal for such technical and conforming amendments as are
necessary to carry out the amendments made by this Act.

Subtitle B--Supplemental Health Care Assistance for Low-Income Families

SEC. 411. SUPPLEMENTAL HEALTH CARE ASSISTANCE FOR LOW-INCOME
FAMILIES.

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

``Subpart XI--Health Care Assistance to Low-Income Families

``SEC. 340A-1. FINANCIAL ASSISTANCE TO LOW-INCOME FAMILIES.

``(a) In General.--The Secretary shall supplement the costs
of private health insurance for eligible low-income families
through the distribution of supplemental debit cards to
eligible families, which may be used to pay for costs
associated with health care for the members of such eligible
families and provide direct support to such families in
accessing health care.
``(b) Eligibility.--
``(1) Eligible families.--To be eligible for financial
assistance under this section--
``(A) a family shall--
``(i) consist of 2 or more individuals living together who
are related by marriage, birth, adoption, or guardianship;
``(ii) have a gross income that does not exceed 200 percent
of the poverty line, as applicable to a family of the size
involved; and
``(iii) include at least 1 individual who is a dependent
under the age of 19; and
``(B) no member of the family shall be covered by private
health insurance.
``(2) Determination of gross income.--The gross income of a
family shall be determined by taking the sum of the income of
each family member who is at least age 21 but not older than
age 65, except that the income of any member of the family
who qualifies for coverage under Medicaid Part A or B shall
not be counted.
``(3) Limitation on individual eligibility; assistance.--
``(A) In general.--No individual who is a member of an
eligible family under paragraph (1) is eligible to qualify
separately for financial assistance under this section.
``(B) Aliens.--The Secretary shall ensure that financial
assistance under this section is not provided for costs
associated with health care for any member of an eligible
family who is an alien individual who is not a lawful
permanent resident of the United States.
``(c) Supplemental Debit Card for Health Care
Expenditures.--
``(1) In general.--The Secretary shall issue to each
eligible family that enrolls in the program in accordance
with subsection (f) a supplemental debit card with a dollar-
amount value, in accordance with subsection (d), that may be
used to pay for qualifying health care expenses.
``(2) Use of the debit card.--
``(A) Qualifying health care expenses.--A supplemental
debit card issued under this section may be used by members
of the eligible family to pay for--
``(i) the purchase of health care insurance for any member
of the family;
``(ii) cost sharing expenses related to health care,
including deductibles, copayments, and coinsurance, for any
member of the family; and
``(iii) the direct purchase of health care services and
supplies for any member of the family.
``(B) Geographic range.--Each supplemental debit card may
be used to pay for qualifying health care expenses incurred
anywhere in the 50 States or the District of Columbia.
``(C) Limitations.--No supplemental debit card shall be
used to make a payment for any cost--
``(i) incurred prior to the determination of the family's
eligibility for assistance under this section; or
``(ii) that is not a health-related expense.
``(3) Rollover of unused amounts.--Not more than one-
quarter of the annual dollar amount of a supplemental debit
card that is unexpended at the end of each 12-month period
may rollover--
``(A) to the family's supplemental debit card for
expenditure during the subsequent 12-month period, provided
that the family to which the supplemental debit card was
issued in the previous 12-month period is eligible to receive
a supplemental debit card in the subsequent 12-month period;
or
``(B) to the family's health savings account (as defined in
section 223(g)(2) of the Internal Revenue Code of 1986).
``(4) Monthly statements.--The Secretary shall issue a
monthly statement to each family to which a supplemental
debit card has been issued under this section, which shall
state each payment made with the family's supplemental debit
card during the month covered by the statement, the dollar
amount of each such payment, and the provider to which each
such payment was made.
``(d) Amount of Financial Assistance.--
``(1) Amounts for calendar year 2011.--Subject to paragraph
(5), the amount of financial assistance available to each
eligible

[[Page S13542]]

family during the calendar year 2011 shall be determined as
follows:
``(A) Each family whose annual income does not exceed 100
percent of the poverty level, as applicable to a family of
the size involved, shall receive $5,000.
``(B) Each family whose annual income exceeds 100 percent,
but does not exceed 200 percent, of the poverty level, as
applicable to a family of the size involved, shall receive an
amount as follows:
``(i) For families whose annual income exceeds 100 percent
but does not exceed 120 percent, of the poverty level,
$4,000.
``(ii) For families whose annual income exceeds 120 percent
but does not exceed 140 percent, of the poverty level,
$3,500.
``(iii) For families whose annual income exceeds 140
percent but does not exceed 160 percent, of the poverty
level, $3,000.
``(iv) For families whose annual income exceeds 160 percent
but does not exceed 180 percent, of the poverty level,
$2,500.
``(v) For families whose annual income exceeds 180 percent
but does not exceed 200 percent, of the poverty level,
$2,000.
``(2) Additional amounts.--In addition to the amounts under
paragraph (1), subject to paragraph (5), the following
amounts shall be added to the supplemental debit cards of
qualifying families:
``(A) For each pregnancy during which a pregnant woman's
family is eligible for assistance under this section, an
additional amount of $1,000 shall be added to the family's
supplemental debit card, except that no family shall receive
such additional $1,000 for any pregnancy for which the family
received such amount in the previous 12-month period.
``(B) For each member of an eligible family who is less
than 1 year old on any day within the calendar year in which
the family is eligible for assistance, an additional amount
of $500 shall be added to the family's supplemental debit
card.
``(3) Cost of living adjustments.--In the case of any
taxable year beginning in a calendar year after 2011, each
dollar amount contained in paragraphs (1) and (2) shall be
increased in the same manner as the dollar amounts specified
in section 25E(b)(3) of the Internal Revenue Code of 1986 are
increased by the blended cost-of-living adjustment determined
under subsection (k)(2) of section 25E of the Internal
Revenue Code for the taxable year involved.
``(4) State option to increase amounts.--At the option of
each State, amounts in excess of the annual dollar amounts
under paragraphs (1) and (2) may be provided through the
supplemental debit card to eligible families in that State,
but no Federal funds shall be paid to any State for any
amount provided in excess of such annual dollar amount.
``(5) Risk adjustment.--The Secretary may adjust the amount
of financial assistance available to an eligible family for a
calendar year under this section based on age, health
indicators, and other factors that represent distinct
patterns of health care services utilization and costs.
``(e) Contributions of States.--
``(1) In general.--As a condition for receiving Federal
funds under Part A or Part B of Medicaid, each State shall
contribute 50 percent of the total amount expended under the
supplemental debit card program by the participating families
that reside within the State during the time that the family
resides in that State. For purposes of this section, the
residency of a family is determined by the residency the
legally responsible head of the household.
``(2) Payments from states.--
``(A) Billing notification.--
``(i) Timing.--On June 30th and December 31st of each year,
the Secretary shall send written notification to each State
of that State's 50 percent share of expenses, as described in
paragraph (1), for the 6-month period ending on the last day
of the month previous to such notification.
``(ii) Contents.--Each such notification to a State shall
clearly state--

``(I) the payment amount due from the State;
``(II) the name of each individual for whom payment was
made through the supplemental debit card program;
``(III) the health care provider to whom each payment was
made;
``(IV) the amount of each payment; and
``(V) any other information, as the Secretary requires.

``(B) Payments.--Each State shall make a payment to the
Secretary, in the amount billed, not later than 30 days after
the billing notification date, in accordance with
subparagraph (A)(i).
``(C) Penalties.--If a State fails to pay to the Secretary
an amount required under subparagraph (B), interest shall
accrue on such amount at the rate provided under old section
1903(d)(5) of the Social Security Act. The amount so owed and
applicable interest shall be immediately offset against
amounts otherwise payable to the State under this section, in
accordance with the Federal Claims Collection Act of 1996 and
applicable regulations.
``(f) Enrollment.--
``(1) In general.--The Secretary shall establish procedures
and times for enrollment in the supplemental debit card
program. Open enrollment shall be available not less than 4
times per calendar year.
``(2) Transition of individuals enrolled in medicaid or the
state children's health insurance program.--
``(A) Information from the states.--Each State shall--
``(i) not later than June 30, 2010, inform all individuals
then enrolled in Medicaid or the State Children's Health
Insurance Program (SCHIP), of the changes in effect beginning
on January 1, 2011; and
``(ii) not later than October 31, 2010, redetermine the
eligibility of each individual enrolled in Medicaid or SCHIP,
other than those individuals who qualify for Medicaid or
SCHIP as disabled, elderly, or a special population, for the
supplemental debit card program, according to the eligibility
criteria under subsection (b).
``(B) Automatic enrollment.--The Secretary shall provide
for the automatic enrollment in the supplemental debit card
program of all individuals who are enrolled in Medicaid or
SCHIP and who have been redetermined by a State under
subparagraph (A) to be eligible for Medicaid or SCHIP. Any
individual who is determined by a State not to qualify for
the supplemental debit card program may retain coverage under
Medicaid or SCHIP until June 30, 2011.
``(3) Assistance with qualified health insurance credit.--
Each State shall, to the extent practicable, provide
individuals residing within the State with information
regarding the qualified health insurance credit described in
section 25E of the Internal Revenue Code of 1986, including
information regarding eligibility for, and how to claim, such
credit.
``(g) Administration.--
``(1) National system.--The Secretary may enter into
contracts or agreements with a State, a consortium of States,
or a private entity, including a bank, enrollment broker, or
similar entity, to establish and maintain a unified national
system to support the processes and transactions necessary to
administer this section.
``(2) Automated system.--The Secretary shall establish an
automated means, such as an electronic benefit transfer
system, by which the benefits under this section shall be
transferred to eligible families.
``(3) Verification of applicant information.--The Secretary
may verify information provided by applicants with the
appropriate Federal, State, and local agencies, including the
Internal Revenue Service, the Social Security Administration,
the Department of Labor, and child support enforcement
agencies.
``(4) Choice counseling.--The Secretary may enter into
contracts or agreements with a State, a consortium of a
State, or a private entity, including an enrollment broker or
community organization or other organization, to educate
eligible families about their options and to assist in their
enrollment in the supplemental debit card plan.
``(5) Appeals.--The Secretary shall establish an
independent appeals process, to be administered by an entity
separate from the entity that makes initial eligibility
determinations, which shall be available to individuals who
are denied benefits under the supplemental debit card
program.
``(6) Resolution of errors.--The Secretary shall provide
for a reconciliation process with the States to resolve any
errors and adjudicate disputes due to incomplete or false
information in a family's application or in the billing
process described in subsection (e).
``(7) Penalties for false information.--Any person who
provides false information to qualify for the supplemental
debit card program shall pay a penalty in the amount of 110
percent of the amount of assistance paid on behalf of such
person and all members of such person's family.
``(h) Implementation Plan.--Not later than 6 months after
the date of enactment of this section, the Secretary shall
submit to Congress a plan for implementing this program
during fiscal years 2009-2012.
``(i) Authorization of Appropriations.--
``(1) Administration of the supplemental debit card
program.--To administer the program under this section, there
are authorized to be appropriated--
``(A) for fiscal year 2009, $300,000,000, for the design of
a unified, national system of conducting the supplemental
debit card program;
``(B) for fiscal year 2010, $1,000,000,000 for start-up
costs, including, contracting, hiring and training employees,
and testing the program; and
``(C) for fiscal year 2011 and each subsequent fiscal year,
$3,000,000,000.
``(2) Authorization of benefits under the supplemental
debit card program.--To provide the supplemental debit card
benefits described in this section, there are authorized to
be appropriated--
``(A) for fiscal year 2011, $24,020,000,000;
``(B) for fiscal year 2012, $25,220,000,000;
``(C) for fiscal year 2013, $26,480,000,000;
``(D) for fiscal year 2014, $27,810,000,000; and
``(E) for fiscal year 2015, $29,200,000,000.''.

TITLE V--FIXING MEDICARE FOR AMERICAN SENIORS

Subtitle A--Increasing Programmatic Efficiency, Economy, and
Accountability

SEC. 501. ELIMINATING INEFFICIENCIES AND INCREASING CHOICE IN
MEDICARE ADVANTAGE.

Part C of title XVIII of the Social Security Act is amended
by adding at the end the following new section:

``protecting medicare benefits for seniors

``Sec. 1860C-2.  (a) Competitive Bidding.--
``(1) In general.--In order to promote competition among
Medicare Advantage plans and to increase the quality of care
furnished

[[Page S13543]]

under such plans, the Secretary shall establish and implement
a competitive bidding mechanism under this part.
``(2) Mechanism to begin in 2011.--The mechanism
established under paragraph (1) shall apply to all MA
organizations and plans beginning in 2011.
``(3) No effect on part d benefits.--The mechanism
established under paragraph (1) shall not affect the
provisions of this part relating to benefits under part D,
including the bidding mechanism used for benefits under such
part.
``(b) Rules for Competitive Bidding Mechanism.--
Notwithstanding any other provision of this part, the
following rules shall apply under the competitive bidding
mechanism established under subsection (a).
``(1) Benchmark.--Benchmark amounts for an area for a year
shall be established solely through the competitive bids of
MA plans. The benchmark amount for each area for a year shall
be the average bid of the plans in that area for that year.
In establishing the benchmark for an area for a year under
the preceding sentence, the Secretary shall exclude the
highest and lowest bid for that area and year. The benchmark
amount for an area for a year may not exceed the benchmark
amount for that area and year that would have applied if this
section had not been enacted.
``(2) Bids.--The MA plan bid shall reflect the per capita
payments that the MA plan will accept for providing a benefit
package that is actuarially equivalent to 106 percent of the
value of the original Medicare fee-for-service program
option. MA plan bid submissions shall include data on plan
average provider network contract rates compared to the rates
under the original Medicare fee-for-service program option
for the top 5 most common claim submissions per provider
type.
``(3) Risk adjustment.--The benchmark under paragraph (1)
and the MA plan bid shall be risk adjusted using the risk
adjustment requirements under this part.
``(4) Beneficiary premiums.--The MA monthly basic
beneficiary premium for a beneficiary who enrolls in an MA
plan whose plan bid is at or below the benchmark shall be
zero and the beneficiary shall receive the full difference
(if any) between the bid and the benchmark in the form of
additional benefits or as a rebate on their premiums under
this title. The MA monthly basic beneficiary premium for a
beneficiary who enrolls in an MA plan whose plan bid is above
the benchmark shall be equal to the amount by which the bid
exceeds the benchmark.
``(5) Benchmark amounts for rural counties.--The Secretary
may adjust the benchmark amount established under paragraph
(1) for any rural county (as identified by the Secretary
after consultation with the Secretary of Commerce) to
encourage plan participation in such county.
``(6) Existing requirements.--Requirements relating to
licensure, quality, and beneficiary protections that would
otherwise apply under this part shall apply under the
competitive bidding mechanism established under subsection
(a).
``(c) Waiver.--In order to implement the competitive
bidding mechanism under established subsection (a), the
Secretary may waive or modify requirements under this
part.''.

SEC. 502. MEDICARE ACCOUNTABLE CARE ORGANIZATION
DEMONSTRATION PROGRAM.

(a) Establishment.--
(1) In general.--In order to promote innovative care
coordination and delivery that is cost-effective, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall conduct a
demonstration program under the Medicare program under
which--
(A) groups of providers meeting certain criteria may work
together to manage and coordinate care for Medicare fee-for-
service beneficiaries through an Accountable Care
Organization (in this section referred to as an ``ACO''); and
(B) providers in participating ACOs are eligible for
bonuses based on performance.
(2) Medicare fee-for-service beneficiary defined.--In this
section, the term ``Medicare fee-for-service beneficiary''
means an individual who is enrolled in the original medicare
fee-for-service program under parts A and B of title XVIII of
the Social Security Act and not enrolled in an MA plan under
part C of such title.
(b) Eligible ACOs.--
(1) In general.--Subject to paragraph (2), the following
provider groups are eligible to participate as ACOs under the
demonstration program under this section:
(A) Physicians in group practice arrangements.
(B) Networks of individual physician practices.
(C) Partnerships or joint venture arrangements between
hospitals and physicians.
(D) Partnerships or joint ventures, which may include
pharmacists providing medication therapy management.
(E) Hospitals employing physicians.
(F) Integrated delivery systems.
(G) Community-based coalitions of providers.
(2) Requirements.--An ACO shall meet the following
requirements:
(A) The ACO shall have a formal legal structure that would
allow the organization to receive and distribute bonuses to
participating providers.
(B) The ACO shall include the primary care providers of at
least 5,000 Medicare fee-for-service beneficiaries.
(C) The ACO shall be willing to become accountable for the
overall care of the Medicare fee-for-service beneficiaries.
(D) The ACO shall provide the Secretary with a list of
primary care and specialist physicians participating in the
ACO to support the beneficiary assignment, implementation of
performance measures, and the determination of bonus payments
under the demonstration program.
(E) The ACO shall have in place contracts with a core group
of key specialist physicians, a leadership and management
structure, and processes to promote evidence-based medicine
and to coordinate care.
(c) Assignment of Medicare Fee-for-Service Beneficiaries.--
(1) In general.--Under the demonstration program under this
section, each Medicare fee-for-service Medicare beneficiary
shall be automatically assigned to a primary care provider.
Such assignment shall be based on the physician from whom the
beneficiary received the most primary care in the preceding
year.
(2) Beneficiaries may continue to see providers outside of
the aco.--Under the demonstration program under this section,
a Medicare fee-for-service Medicare beneficiary may continue
to see providers in and outside of the ACO to which they have
been assigned.
(d) Bonus Payments.--
(1) In general.--Under the demonstration program, Medicare
payments shall continue to be made to providers under the
original Medicare fee-for-service program in the same manner
as they would otherwise be made except that a participating
ACO is eligible for bonuses if--
(A) it meets certain quality performance measures; and
(B) spending for their Medicare fee-for-service
beneficiaries meets the requirement under paragraph (3).
(2) Quality.--Under the demonstration program under this
section, providers meet the requirement under paragraph
(1)(A) if they generally follow consensus-based guidelines
established by non-government professional medical societies.
Patient satisfaction and risk-adjusted outcomes shall be
determined through an independent entity with medical
expertise.
(3) Requirement relating to spending.--
(A) In general.--An ACO shall only be eligible to receive a
bonus payment if the average Medicare expenditures under the
ACO for Medicare fee-for-service beneficiaries over a two-
year period is at least 2 percent below the average benchmark
for the corresponding two-year period. The benchmark for each
ACO shall be set using the most recent three years of total
per-beneficiary spending for Medicare fee-for-service
beneficiaries assigned to the ACO. Such benchmark shall be
updated by the projected rate of growth in national per
capita spending for the original medicare fee-for-service
program, as projected (using the most recent three years of
data) by the Chief Actuary of the Centers for Medicare &
Medicaid Services.
(4) Amount of bonus payments.--The amount of the bonus
payment to a participating ACO shall be one-half of the
percentage point difference between the two-year average of
their patients' Medicare expenditures and 98 percent of the
two-year average benchmark. The bonus amount, in dollars,
shall be equal to the bonus share multiplied by the benchmark
for the most recent year.
(5) Limitation.--Bonus payments may only be made to an ACO
if the primary care provider to which the Medicare fee-for-
service beneficiary has been assigned under subsection (c)
elects to participate in such ACO.
(e) 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.; 1395 et seq.) as may be
appropriate for the purpose of carrying out the demonstration
program under this section.
(f) Report.--Upon completion of the demonstration program
under this section, the Secretary shall submit to Congress a
report on the program together with such recommendations as
the Secretary determines appropriate.

SEC. 503. REDUCING GOVERNMENT HANDOUTS TO WEALTHIER SENIORS.

(a) Elimination of Annual Indexing of Income Thresholds for
Reduced Part B Premium Subsidies.--
(1) In general.--Paragraph (5) of section 1839(i) of the
Social Security Act (42 U.S.C. 1395r(i)) is repealed.
(2) Effective date.--The repeal made by paragraph (1) shall
apply to premiums for months beginning after December 2010.
(b) Income-Related Reduction in Part D Premium Subsidy.--
(1) Income-related reduction in part d premium subsidy.--
(A) In general.--Section 1860D-13(a) of the Social Security
Act (42 U.S.C. 1395w-113(a)) is amended by adding at the end
the following new paragraph:
``(7) Reduction in premium subsidy based on income.--
``(A) In general.--In the case of an individual whose
modified adjusted gross income exceeds the threshold amount
applicable under paragraph (2) of section 1839(i) (including
application of paragraph (5) of such section) for the
calendar year, the monthly amount of the premium subsidy
applicable to the premium under this section for a month
after December 2010 shall be reduced (and the monthly
beneficiary premium shall

[[Page S13544]]

be increased) by the monthly adjustment amount specified in
subparagraph (B).
``(B) Monthly adjustment amount.--The monthly adjustment
amount specified in this subparagraph for an individual for a
month in a year is equal to the product of--
``(i) the quotient obtained by dividing--

``(I) the applicable percentage determined under paragraph
(3)(C) of section 1839(i) (including application of paragraph
(5) of such section) for the individual for the calendar year
reduced by 25.5 percent; by
``(II) 25.5 percent; and

``(ii) the base beneficiary premium (as computed under
paragraph (2)).
``(C) Modified adjusted gross income.--For purposes of this
paragraph, the term `modified adjusted gross income' has the
meaning given such term in subparagraph (A) of section
1839(i)(4), determined for the taxable year applicable under
subparagraphs (B) and (C) of such section.
``(D) Determination by commissioner of social security.--
The Commissioner of Social Security shall make any
determination necessary to carry out the income-related
reduction in premium subsidy under this paragraph.
``(E) Procedures to assure correct income-related reduction
in premium subsidy.--
``(i) Disclosure of base beneficiary premium.--Not later
than September 15 of each year beginning with 2010, the
Secretary shall disclose to the Commissioner of Social
Security the amount of the base beneficiary premium (as
computed under paragraph (2)) for the purpose of carrying out
the income-related reduction in premium subsidy under this
paragraph with respect to the following year.
``(ii) Additional disclosure.--Not later than October 15 of
each year beginning with 2010, the Secretary shall disclose
to the Commissioner of Social Security the following
information for the purpose of carrying out the income-
related reduction in premium subsidy under this paragraph
with respect to the following year:

``(I) The modified adjusted gross income threshold
applicable under paragraph (2) of section 1839(i) (including
application of paragraph (5) of such section).
``(II) The applicable percentage determined under paragraph
(3)(C) of section 1839(i) (including application of paragraph
(5) of such section).
``(III) The monthly adjustment amount specified in
subparagraph (B).
``(IV) Any other information the Commissioner of Social
Security determines necessary to carry out the income-related
reduction in premium subsidy under this paragraph.

``(F) Rule of construction.--The formula used to determine
the monthly adjustment amount specified under subparagraph
(B) shall only be used for the purpose of determining such
monthly adjustment amount under such subparagraph.''.
(B) Collection of monthly adjustment amount.--Section
1860D-13(c) of the Social Security Act (42 U.S.C. 1395w-
113(c)) is amended--
(i) in paragraph (1), by striking ``(2) and (3)'' and
inserting ``(2), (3), and (4)''; and
(ii) by adding at the end the following new paragraph:
``(4) Collection of monthly adjustment amount.--
``(A) In general.--Notwithstanding any provision of this
subsection or section 1854(d)(2), subject to subparagraph
(B), the amount of the income-related reduction in premium
subsidy for an individual for a month (as determined under
subsection (a)(7)) shall be paid through withholding from
benefit payments in the manner provided under section 1840.
``(B) Agreements.--In the case where the monthly benefit
payments of an individual that are withheld under
subparagraph (A) are insufficient to pay the amount described
in such subparagraph, the Commissioner of Social Security
shall enter into agreements with the Secretary, the Director
of the Office of Personnel Management, and the Railroad
Retirement Board as necessary in order to allow other
agencies to collect the amount described in subparagraph (A)
that was not withheld under such subparagraph.''.
(2) Conforming amendments.--
(A) Medicare.--Part D of title XVIII of the Social Security
Act (42 U.S.C. 1395w-101 et seq.) is amended--
(i) in section 1860D-13(a)(1)--

(I) by redesignating subparagraph (F) as subparagraph (G);
(II) in subparagraph (G), as redesignated by subparagraph
(A), by striking ``(D) and (E)'' and inserting ``(D), (E),
and (F)''; and
(III) by inserting after subparagraph (E) the following new
subparagraph:

``(F) Increase based on income.--The monthly beneficiary
premium shall be increased pursuant to paragraph (7).''; and
(ii) in section 1860D-15(a)(1)(B), by striking ``paragraph
(1)(B)'' and inserting ``paragraphs (1)(B) and (1)(F)''.
(B) Internal revenue code.--Section 6103(l)(20) of the
Internal Revenue Code of 1986 (relating to disclosure of
return information to carry out Medicare part B premium
subsidy adjustment) is amended--
(i) in the heading, by striking ``part b premium subsidy
adjustment'' and inserting ``parts b and d premium subsidy
adjustments'';
(ii) in subparagraph (A)--

(I) in the matter preceding clause (i), by inserting ``or
1860D-13(a)(7)'' after ``1839(i)''; and
(II) in clause (vii), by inserting after ``subsection (i)
of such section'' the following: ``or under section 1860D-
13(a)(7) of such Act'';

(iii) in subparagraph (B)--

(I) by inserting ``or such section 1860D-13(a)(7)'' before
the period at the end;
(II) as amended by clause (i), by inserting ``or for the
purpose of resolving tax payer appeals with respect to any
such premium adjustment'' before the period at the end; and
(III) by adding at the end the following new sentence:
``Officers, employees, and contractors of the Social Security
Administration may disclose such return information to
officers, employees, and contractors of the Department of
Health and Human Services, the Office of Personnel
Management, the Railroad Retirement Board, the Department of
Justice, and the courts of the United States to the extent
necessary to carry out the purposes described in the
preceding sentence.''; and

(iv) by adding at the end the following new subparagraph:
``(C) Timing of disclosure.--Return information shall be
disclosed to officers, employees, and contractors of the
Social Security Administration under subparagraph (A) not
later than the date that is 90 days prior to the date on
which the taxpayer first becomes entitled to benefits under
part A of title XVIII of the Social Security Act or eligible
to enroll for benefits under part B of such title.''.

SEC. 504. REWARDING PREVENTION.

Section 1839 of the Social Security Act (42 U.S.C. 1395r)
is amended--
(1) in subsection (a)(2), by striking ``and (i)'' and
inserting ``(i), and (j)''; and
(2) by adding at the end the following new subsection:
``(j)(1) With respect to the monthly premium amount for
months after December 2010, the Secretary may adjust (under
procedures established by the Secretary) the amount of such
premium for an individual based on whether or not the
individual participates in certain healthy behaviors, such as
weight management, exercise, nutrition counseling, refraining
from tobacco use, designating a health home, and other
behaviors determined appropriate by the Secretary.
``(2) In making the adjustments under paragraph (1) for a
month, the Secretary shall ensure that the total amount of
premiums to be paid under this part for the month is equal to
the total amount of premiums that would have been paid under
this part for the month if no such adjustments had been made,
as estimated by the Secretary.''.

SEC. 505. PROMOTING HEALTHCARE PROVIDER TRANSPARENCY.

(a) Transparency.--Title XVIII of the Social Security Act
is amended by adding at the end the following new section:

``price transparency requirements

``Sec. 1899.  (a) Pre-Treatment Disclosure.--A provider of
services (as defined in section 1861(u)) and a supplier (as
defined in section 1861(d)) shall provide to each individual
(regardless of whether or not the individual is a beneficiary
under this title) who is scheduled to receive a treatment (or
to begin a course of treatment) that is not for an emergency
medical condition the estimated price that the provider of
services or supplier will charge for the treatment (or course
of treatment). Such price shall be determined at the time of
scheduling.
``(b) Post-Treatment Disclosure.--A provider of services
(as so defined) and a supplier (as so defined) shall include
with any bill that includes the charges for a treatment with
respect to an individual (regardless of whether or not the
individual is a beneficiary under this title), an itemized
list of component charges for such treatment, including
charges for drugs and medical equipment involved, as
determined at the time of billing. With respect to each item
included on such list, the provider of services or supplier
shall include the price charged for the item.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to providers of services and suppliers on and
after January 1, 2011.

SEC. 506. AVAILABILITY OF MEDICARE AND MEDICAID CLAIMS AND
PATIENT ENCOUNTER DATA.

(a) Public Availability.--Not later than 1 year after the
date of enactment of this Act (and annually thereafter), the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary''), shall make available to
the public (including through an Internet website) data on
claims and patient encounters under titles XVIII and XIX of
the Social Security Act during the preceding calendar year.
Such data shall be appropriately disaggregated and patient
deidentified, as determined necessary by the Secretary in
order to comply with the Federal regulations (concerning the
privacy of individually identifiable health information)
promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996.
(b) Provision of Data to State Exchanges and Health
Insurance Issuers Under the State Exchange.--The Secretary
shall submit such data directly to a State Exchange under
title II and health insurance issuers under such Exchange (in
a form and manner determined appropriate by the Secretary).
(c) Matching of Data.--The Secretary shall ensure that the
total amount of claims under such titles during the preceding
year

[[Page S13545]]

for which data is made available under subsection (a) is
equal to the reported outlays from the Federal government and
the States under such titles during the preceding years.

Subtitle B--Reducing Fraud and Abuse

SEC. 511. REQUIRING THE SECRETARY OF HEALTH AND HUMAN
SERVICES TO CHANGE THE MEDICARE BENEFICIARY
IDENTIFIER USED TO IDENTIFY MEDICARE
BENEFICIARIES UNDER THE MEDICARE PROGRAM.

(a) Procedures.--
(1) In general.--Not later than 1 year after the date of
enactment of this Act, in order to protect beneficiaries from
identity theft, the Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish and implement procedures to change the Medicare
beneficiary identifier used to identify individuals entitled
to benefits under part A of title XVIII of the Social
Security Act or enrolled under part B of such title so that
such an individual's social security account number is not
used. Such procedures shall provide that the new Medicare
beneficiary identifier includes biometric identification
protections.
(2) Maintaining existing hicn structure.--In order to
minimize the impact of the change under paragraph (1) on
systems that communicate with Medicare beneficiary
eligibility systems, the procedures under paragraph (1) shall
provide that the new Medicare beneficiary identifier maintain
the existing Health Insurance Claim Number structure.
(3) Protection against fraud.--The procedures under
paragraph (1) shall provide for a process for changing the
Medicare beneficiary identifier for an individual to a
different identifier in the case of the discovery of fraud,
including identity theft.
(4) Phase-in authority.--
(A) In general.--Subject to subparagraphs (B) and (C), the
Secretary may phase in the change under paragraph (1) in such
manner as the Secretary determines appropriate.
(B) Limit.--The phase-in period under subparagraph (A)
shall not exceed 10 years.
(C) Newly entitled and enrolled individuals.--The Secretary
shall ensure that the change under paragraph (1) is
implemented not later than January 1, 2010, with respect to
any individual who first becomes entitled to benefits under
part A of title XVIII of the Social Security Act or enrolled
under part B of such title on or after such date.
(b) Education and Outreach.--The Secretary shall establish
a program of education and outreach for individuals entitled
to, or enrolled for, benefits under part A of title XVIII of
the Social Security Act or enrolled under part B of such
title, providers of services (as defined in subsection (u) of
section 1861 of such Act (42 U.S.C. 1395x)), and suppliers
(as defined in subsection (d) of such section) on the change
under paragraph (1).
(c) Data Matching.--
(1) Access to certain information.--Section 205(r) of the
Social Security Act (42 U.S.C. 405(r)) is amended by adding
at the end the following new paragraph:
``(9)(A) The Commissioner of Social Security shall, upon
the request of the Secretary--
``(i) enter into an agreement with the Secretary for the
purpose of matching data in the system of records of the
Commissioner with data in the system of records of the
Secretary, so long as the requirements of subparagraphs (A)
and (B) of paragraph (3) are met, in order to determine--
``(I) whether a beneficiary under the program under title
XVIII, XIX, or XXI is dead, imprisoned, or otherwise not
eligible for benefits under such program; and
``(II) whether a provider of services or a supplier under
the program under title XVIII, XIX, or XXI is dead,
imprisoned, or otherwise not eligible to furnish or receive
payment for furnishing items and services under such program;
and
``(ii) include in such agreement safeguards to assure the
maintenance of the confidentiality of any information
disclosed and procedures to permit the Secretary to use such
information for the purpose described in clause (i).
``(B) Information provided pursuant to an agreement under
this paragraph shall be provided at such time, in such place,
and in such manner as the Commissioner determines
appropriate.
``(C) Information provided pursuant to an agreement under
this paragraph shall include information regarding whether--
``(i) the name (including the first name and any family
name or surname), the date of birth (including the month,
day, and year), and social security number of an individual
provided to the Commissioner match the information
contained in the Commissioner's records, and
``(ii) such individual is shown on the records of the
Commissioner as being deceased.''.
(2) Investigation based on certain information.--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. ACCESS TO CERTAIN DATA AND INVESTIGATION OF
CLAIMS INVOLVING INDIVIDUALS WHO ARE NOT
ELIGIBLE FOR BENEFITS OR ARE NOT ELIGIBLE
PROVIDERS OF SERVICES OR SUPPLIERS.

``(a) Data Agreement.--The Secretary shall enter into an
agreement with the Commissioner of Social Security pursuant
to section 205(r)(9).
``(b) Investigation of Claims Involving Certain Individuals
Who Are Not Eligible for Benefits or Are Not Eligible
Providers of Services or Suppliers.--
``(1) In general.--The Secretary shall, in the case where a
provider of services or a supplier under the program under
title XVIII, XIX, or XXI submits a claim for payment for
items or services furnished to an individual who the
Secretary determines, as a result of information provided
pursuant to such agreement, is not eligible for benefits
under such program, or where the Secretary determines, as a
result of such information, that such provider of services or
supplier is not eligible to furnish or receive payment for
furnishing such items or services, conduct an investigation
with respect to the provider of services or supplier. If the
Secretary determines further action is appropriate, the
Secretary shall refer the investigation to the Inspector
General of the Department of Health and Human Services as
soon as practicable.
``(2) Assessment of implementation and effectiveness by the
oig.--The Inspector General of the Department of Health and
Human Services shall test the implementation of the
provisions of this section (including the implementation of
the agreement under section 205(r)(9)) and conduct such
period assessments of such implementation as the Inspector
General determines necessary to determine the effectiveness
of such implementation.''.
(d) Authorization of Appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this section.

SEC. 512. USE OF TECHNOLOGY FOR REAL-TIME DATA REVIEW.

Title XVIII of the Social Security Act, as amended by this
Act, is amended by adding at the end the following new
section:

``use of technology for real-time data review

``Sec. 1899A.  (a) In General.--The Secretary shall
establish procedures for the use of technology (including
front-end, pre-payment technology similar to that used by
hedge funds, investment funds, and banks) to provide real-
time data analysis of claims for payment under this title to
identify and investigate unusual billing or order practices
under this title that could indicate fraud or abuse.
``(b) Competitive Bidding.--The procedures established
under subsection (a) shall ensure that the implementation of
such technology is conducted through a competitive bidding
process.''.

SEC. 513. DETECTION OF MEDICARE FRAUD AND ABUSE.

(a) In General.--Section 1893 of the Social Security Act
(42 U.S.C. 1395ddd) is amended--
(1) in subsection (b), by adding at the end the following
new paragraph:
``(7) Implementation of fraud and abuse detection methods
under subsection (i).'';
(2) in subsection (c), by adding at the end of the flush
matter following paragraph (4), the following new sentence
``In the case of an activity described in subsection (b)(8),
an entity shall only be eligible to enter into a contract
under the Program to carry out the activity if the entity is
selected through a competitive bidding process in accordance
with subsection (i)(3).''; and
(3) by adding at the end the following new subsection:
``(i) Detection of Medicare Fraud and Abuse.--
``(1) Establishment of system to identify counties most
vulnerable to fraud.--Not later than 6 months after the date
of enactment of this subsection, the Secretary shall
establish a system to identify the 50 counties most
vulnerable to fraud with respect to items and services
furnished by providers of services (other than hospitals and
critical access hospitals) and suppliers based on the degree
of county-specific reimbursement and analysis of payment
trends under this title. The Secretary shall designate the
counties identified under the preceding sentence as `high
risk areas'.
``(2) Fraud and abuse detection.--
``(A) Initial implementation.--The Secretary shall
establish procedures for the implementation of fraud and
abuse detection methods under this title with respect to
items and services furnished by such providers of services
and suppliers in high risk areas designated under paragraph
(1) (and, beginning not later than 18 months after the date
of enactment of this subsection, with respect to items and
services furnished by such providers of services and
suppliers in areas not so designated) including the
following:
``(i) Data analysis to establish prepayment claim edits
designed to target the claims for payment under this title
for such items and services that are most likely to be
fraudulent.
``(ii) Prepayment benefit integrity reviews for claims for
payment under this title for such items and services that are
suspended as a result of such edits.
``(B) Requirement for participation.--In no case may a
provider of services or supplier who does not meet the
requirements under subparagraph (A) participate in the
program under this title.
``(C) Expanded implementation.--Not later than 24 months
after the date of enactment of this subsection, the Secretary
shall establish procedures for the implementation of such
fraud and abuse detection methods under this title with
respect to items and services furnished by all providers of
services

[[Page S13546]]

and suppliers, including those not in high risk areas
designated under paragraph (1).
``(3) Competitive bidding.--In selecting entities to carry
out this subsection, the Secretary shall use a competitive
bidding process.
``(4) Report to congress.--The Secretary shall submit to
Congress an annual report on the effectiveness of activities
conducted under this subsection, including a description of
any savings to the program under this title as a result of
such activities and the overall administrative cost of such
activities and a determination as to the amount of funding
needed to carry out this subsection for subsequent fiscal
years, together with recommendations for such legislation and
administrative action as the Secretary determines
appropriate.''.
(b) Authorization of Appropriations.--To carry out the
amendments made by this section, there are authorized to be
appropriated--
(1) such sums as may be necessary, not to exceed
$50,000,000, for each of fiscal years 2010 through 2014; and
(2) such sums as may be necessary, not to exceed an amount
the Secretary determines appropriate in the most recent
report submitted to Congress under section 1893(j)(4) of the
Social Security Act, as added by subsection (a), for each
subsequent fiscal year.

SEC. 514. EDITS ON 855S MEDICARE ENROLLMENT APPLICATION AND
EXEMPTION OF PHARMACISTS FROM SURETY BOND
REQUIREMENT.

(a) Edits on 855S Medicare Enrollment Application.--Section
1834(a) of the Social Security Act (42 U.S.C. 1395m(a)) is
amended by adding at the end the following new paragraphs:
``(22) Confirmation with national supplier clearinghouse
prior to payment.--
``(A) In general.--Not later than 1 year after the date of
enactment of this paragraph, the Secretary shall establish
procedures to require carriers, prior to paying a claim for
payment for durable medical equipment, prosthetics,
orthotics, and supplies under this title, to confirm with the
National Supplier Clearinghouse--
``(i) that the National Provider Identifier of the
physician or practitioner prescribing or ordering the item or
service is valid and active;
``(ii) that the Medicare identification number of the
supplier is valid and active; and
``(iii) that the item or service for which the claim for
payment is submitted was properly identified on the CMS-855S
Medicare enrollment application.
``(B) Online database for implementation.--Not later than
18 months after the date of enactment of this paragraph, the
Secretary shall establish an online database similar to that
used for the National Provider Identifier to enable providers
of services, accreditors, carriers, and the National Supplier
Clearinghouse to view information on specialties and the
types of items and services each supplier has indicated on
the CMS-855S Medicare enrollment application submitted by the
supplier.
``(C) Notification of claim denial and resubmission.--In
the case where a claim for payment for durable medical
equipment, prosthetics, orthotics, and supplies under this
title is denied because the item or service furnished does
not correctly match up with the information on file with the
National Supplier Clearinghouse--
``(i) the National Supplier Clearinghouse shall--

``(I) provide the supplier written notification of the
reason for such denial; and
``(II) allow the supplier 60 days to provide the National
Supplier Clearinghouse with appropriate certification,
licensing, or accreditation; and

``(ii) the Secretary shall waive applicable requirements
relating to the time frame for the submission of claims for
payment under this title in order to permit the resubmission
of such claim if payment of such claim would otherwise be
allowed under this title.
``(D) Improvements to medicare enrollment application.--The
Secretary shall establish procedures under which a
prospective supplier of durable medical equipment,
prosthetics, orthotics, and supplies under this title shall
certify, as part of the CMS-855S Medicare enrollment
application submitted by such supplier, under penalty of
perjury, that the information provided by the supplier on
such application is accurate to the best of the supplier's
knowledge.
``(23) Termination of participation for submission of
fraudulent claims.--If the Secretary finds that a supplier of
durable medical equipment, prosthetics, orthotics, and
supplies under this title has submitted fraudulent claims for
payment under this title, the Secretary shall terminate the
suppliers participation under this title. Not later than 1
year after the date of enactment of this paragraph, the
Secretary shall establish a process under which a supplier
whose participation has been terminated under the preceding
sentence may appeal such termination and such appeal shall be
resolved not later than 60 days after the date on which the
appeal was made.''.
(b) Exemption of Pharmacists From Surety Bond
Requirement.--Section 1834(a)(16) of the Social Security Act
(42 U.S.C. 1395m(a)(16)) is amended, in the second sentence,
by inserting ``and shall waive such requirement in the case
of a pharmacist'' before the period at the end.

SEC. 515. GAO STUDY AND REPORT ON EFFECTIVENESS OF SURETY
BOND REQUIREMENTS FOR SUPPLIERS OF DURABLE
MEDICAL EQUIPMENT IN COMBATING FRAUD.

(a) Study.--The Comptroller General of the United States
shall conduct a study on the effectiveness of the surety bond
requirement under section 1834(a)(16) of the Social Security
Act (42 U.S.C. 1395m(a)(16)) in combating fraud.
(b) Report.--Not later than 1 year after the date of
enactment of this Act, the Comptroller General shall submit
to Congress a report containing the results of the study
conducted under subsection (a), together with recommendations
for such legislation and administrative action as the
Comptroller General determines appropriate.

TITLE VI--ENDING LAWSUIT ABUSE

SEC. 601. STATE GRANTS TO CREATE HEALTH COURT SOLUTIONS.

Part P of title III of the Public Health Service Act (42
U.S.C. 280g et seq.) is amended by adding at the end the
following:

``SEC. 399R. STATE GRANTS TO CREATE HEALTH COURT SOLUTIONS.

``(a) In General.--The Secretary may award grants to States
for the development, implementation, and evaluation of
alternatives to current tort litigation that comply with this
section, for the resolution of disputes concerning injuries
allegedly caused by health care providers or health care
organizations.
``(b) Conditions for Demonstration Grants.--
``(1) Application.--To be eligible to receive a grant under
this section, a State shall submit to the Secretary an
application at such time, in such manner, and containing such
information as may be required by the Secretary. A grant
shall be awarded under this section on such terms and
conditions as the Secretary determines appropriate.
``(2) State requirements.--To be eligible to receive a
grant under this section, a State shall--
``(A) develop and implement an alternative to current tort
litigation for resolving disputes over injuries allegedly
caused by health care providers or health care organizations
based on one or more of the models described in subsection
(d); and
``(B) implement policies that provide for a reduction in
health care errors through the collection and analysis by
organizations that engage in voluntary efforts to improve
patient safety and the quality of health care delivery, of
patient safety data related to disputes resolved under the
alternatives under subparagraph (A).
``(3) Demonstration of effectiveness.--To be eligible to
receive a grant under subsection (a), a State shall
demonstrate how the proposed alternative to be implemented
under paragraph (2)(A) will--
``(A) make the medical liability system of the State more
reliable through the prompt and fair resolution of disputes;
``(B) encourage the early disclosure of health care errors;
``(C) enhance patient safety; and
``(D) maintain access to medical liability insurance.
``(4) Sources of compensation.--To be eligible to receive a
grant under subsection (a), a State shall identify the
sources from, and methods by which, compensation would be
paid for medical liability claims resolved under the proposed
alternative to current tort litigation implemented under
paragraph (2)(A). Funding methods shall, to the extent
practicable, provide financial incentives for activities that
improve patient safety.
``(5) Scope.--
``(A) In general.--To be eligible to receive a grant under
subsection (a), a State shall utilize the proposed
alternative identified under paragraph (2)(A) for the
resolution of all types of disputes concerning injuries
allegedly caused by health care providers or health care
organizations.
``(B) Current state efforts to establish alternative to
tort litigation.--
``(i) In general.--Nothing in this section shall be
construed to limit the efforts that any State has made prior
to the date of enactment of this section to establish any
alternative to tort litigation.
``(ii) Alternative for practice areas or injuries.--In the
case of a State that has established an alternative to tort
litigation for a certain area of health care practice or a
category of injuries, the alternative selected as provided
for in this section shall supplement not replace or
invalidate such established alternative unless the State
intends otherwise.
``(6) Notification of patients.--To be eligible to receive
a grant under subsection (a), the State shall demonstrate how
patients will be notified when they are receiving health care
services that fall within the scope of the alternative
selected under this section by the State to current tort
litigation.
``(c) Representation by Counsel.--A State that receives a
grant under this section may not preclude any party to a
dispute that falls within the jurisdiction of the alternative
to current tort litigation that is implemented under the
grant from obtaining legal representation at any point during
the consideration of the claim under such alternative.
``(d) Models.--
``(1) In general.--The models in this section are the
following:
``(2) Expert panel review and early offer guidelines.--
``(A) In general.--A State may use amounts received under a
grant under this

[[Page S13547]]

section to develop and implement an expert panel and early
offer review system that meets the requirements of this
paragraph.
``(B) Establishment of panel.--Under the system under this
paragraph, the State shall establish an expert panel to
review any disputes concerning injuries allegedly caused by
health care providers or health care organizations according
to the guidelines described in this paragraph.
``(C) Composition.--
``(i) In general.--An expert panel under this paragraph
shall be composed of 3 medical experts (either physicians or
health care professionals) and 3 attorneys to be appointed by
the head of the State agency responsible for health.
``(ii) Licensure and expertise.--Each physician or health
care professional appointed to an expert panel under clause
(i) shall--

``(I) be appropriately credentialed or licensed in the
State in which the dispute takes place to deliver health care
services; and
``(II) typically treat the condition, make the diagnosis,
or provide the type of treatment that is under review.

``(iii) Independence.--

``(I) In general.--Subject to subclause (II), each
individual appointed to an expert panel under this paragraph
shall--

``(aa) not have a material familial, financial, or
professional relationship with a party involved in the
dispute reviewed by the panel; and
``(bb) not otherwise have a conflict of interest with such
a party.

``(II) Exception.--Nothing in subclause (I) shall be
construed to prohibit an individual who has staff privileges
at an institution where the treatment involved in the dispute
was provided from serving as a member of an expert panel
merely on the basis of such affiliation, if the affiliation
is disclosed to the parties and neither party objects.

``(iv) Practicing health care professional in same field.--

``(I) In general.--In a dispute before an expert panel that
involves treatment, or the provision of items or services--

``(aa) by a physician, the medical experts on the expert
panel shall be practicing physicians (allopathic or
osteopathic) of the same or similar specialty as a physician
who typically treats the condition, makes the diagnosis, or
provides the type of treatment under review; or
``(bb) by a health care professional other than a
physician, at least two medical experts on the expert panel
shall be practicing physicians (allopathic or osteopathic) of
the same or similar specialty as the health care professional
who typically treats the condition, makes the diagnosis, or
provides the type of treatment under review, and, if
determined appropriate by the State agency, the third medical
expert shall be a practicing health care professional (other
than such a physician) of such a same or similar specialty.

``(II) Practicing defined.--In this paragraph, the term
`practicing' means, with respect to an individual who is a
physician or other health care professional, that the
individual provides health care services to individual
patients on average at least 2 days a week.

``(v) Pediatric expertise.--In the case of dispute relating
to a child, at least 1 medical expert on the expert panel
shall have expertise described in clause (iv)(I) in
pediatrics.
``(D) Determination.--After a review, an expert panel shall
make a determination as to the liability of the parties
involved and compensation based on a schedule of compensation
that is developed by the panel. Such a schedule shall at
least include--
``(i) payment for the net economic loss incurred by the
patient, on a periodic basis, reduced by any payments
received by the patient under--

``(I) any health or accident insurance;
``(II) any wage or salary continuation plan; or
``(III) any disability income insurance;

``(ii) payment for the non-economic damages incurred by the
patient, if appropriate for the injury, based on a defined
payment schedule developed by the State, in consultation with
relevant experts and with the Secretary;
``(iii) reasonable attorney's fees; and
``(iv) regular updates of the schedule under clause (ii) as
necessary.
``(E) Acceptance.--If the parties to a dispute who come
before an expert panel under this paragraph accept the
determination of the expert panel concerning liability and
compensation, such compensation shall be paid to the claimant
and the claimant shall agree to forgo any further action
against the health care providers or health care
organizations involved.
``(F) Failure to accept.--If any party decides not to
accept the expert panel's determination under this paragraph,
the State may choose whether to allow the panel to review the
determination de novo, with deference, or to provide an
opportunity for parties to reject the determination of the
panel.
``(G) Review by state court after exhaustion of
administrative remedies.--
``(i) Right to file.--If the State elects not to permit the
expert panel under this paragraph to conduct its own reviews
of determinations, or if the State elects to permit such
reviews but a party is not satisfied with the final decision
of the panel after such a review, the party shall have the
right to file a claim relating to the injury involved in a
State court of competent jurisdiction.
``(ii) Forfeit of awards.--Any party filing an action in a
State court under clause (i) shall forfeit any compensation
award made under subparagraph (C).
``(iii) Admissibility.--The determinations of the expert
panel pursuant to a review under subparagraph (C) shall be
admissible into evidence in any State court proceeding under
this subparagraph.
``(3) Administrative health care tribunals.--
``(A) In general.--A State may use amounts received under a
grant under this section to develop and implement an
administrative health care tribunal system under which the
parties involved shall have the right to request a hearing to
review any dispute concerning injuries allegedly caused by
health care providers or health care organizations before an
administrative health care tribunal established by the State
involved.
``(B) Requirements.--In establishing an administrative
health care tribunal under this paragraph, a State shall--
``(i) ensure that such tribunals are presided over by
special judges with health care expertise who meet applicable
State standards for judges and who agree to preside over such
court voluntarily;
``(ii) provide authority to such judges to make binding
rulings, rendered in written decisions, on standards of care,
causation, compensation, and related issues with reliance on
independent expert witnesses commissioned by the tribunal;
``(iii) establish a legal standard for the tribunal that
shall be the same as the standard that would apply in the
State court of competent jurisdiction which would otherwise
handle the claim; and
``(iv) provide for an appeals process to allow for review
of decisions by State courts.
``(C) Determination.--After a tribunal conducts a review
under this paragraph, the tribunal shall make a determination
as to the liability of the parties involved and the amount of
compensation that should be paid based on a schedule of
compensation developed by the tribunal. Such a schedule shall
at a minimum include--
``(i) payment for the net economic loss incurred by the
patient, on a periodic basis, reduced by any payments
received by the patient under--

``(I) any health or accident insurance;
``(II) any wage or salary continuation plan; or
``(III) any disability income insurance;

``(ii) payment for the non-economic damages incurred by the
patient, if appropriate for the injury, based on a defined
payment schedule developed by the State in consultation with
relevant experts and with the Secretary;
``(iii) reasonable attorney's fees; and
``(iv) regular updates of the schedule under clause (ii) as
necessary.
``(D) Review by state court after exhaustion of
administrative remedies.--
``(i) Right to file.--Nothing in this paragraph shall be
construed to prohibit any individual who is not satisfied
with the determinations of a tribunal under this paragraph,
from filing a claim for the injury involved in a State court
of competent jurisdiction.
``(ii) Forfeit of award.--Any party filing an action in a
State court under clause (i) shall forfeit any compensation
award made under subparagraph (C).
``(iii) Admissibility.--The determinations of the tribunal
under subparagraph (C) shall be admissible into evidence in
any State court proceeding under this subparagraph.
``(4) Expert panel review and administrative health care
tribunal combination model.--
``(A) In general.--A State may use amounts received under a
grant under this section to develop and implement an expert
panel review and administrative health care tribunal
combination system to review any dispute concerning injuries
allegedly caused by health care providers or health care
organizations. Under such system, a dispute concerning
injuries allegedly caused by health care providers or health
care organizations shall proceed through the procedures
described in this subparagraph prior to the submission of
such dispute to a State court.
``(B) General procedure.--
``(i) Establishment of expert panel.--Prior to submitting
any dispute described in subparagraph (A) to an
administrative health care tribunal under the system
established under this paragraph, the State shall establish
an expert panel (in accordance with subparagraph (C)) to
review the allegations involved in such dispute.
``(ii) Referral to tribunal.--If either party to a dispute
described in clause (i) fails to accept the determination of
the expert panel, the dispute shall then be referred to an
administrative health care tribunal (in accordance with
subparagraph (D).
``(C) Expert review panel.--
``(i) In general.--The provisions of paragraph (2) shall
apply with respect to the establishment and operation of an
expert review panel under this subparagraph, except that the
subparagraphs (F) and (G) of such paragraph shall not apply.
``(ii) Failure to accept determination of panel.--If any
party to a dispute before an expert panel under this
subparagraph refuses to accept the panel's determination, the
dispute shall be referred to an administrative health care
tribunal under subparagraph (D).
``(D) Administrative health care tribunals.--

[[Page S13548]]

``(i) In general.--Upon the failure of any party to accept
the determination of an expert panel under subparagraph (C),
the parties shall request a hearing concerning the liability
or compensation involved by an administrative health care
tribunal established by the State involved under this
subparagraph.
``(ii) Requirements.--The provisions of paragraph (3) shall
apply with respect to the establishment and operation of an
administrative health care tribunal under this subparagraph.
``(iii) Forfeit of awards.--Any party proceeding to the
second step-administrative health care tribunal-under this
model shall forfeit any compensation awarded by the expert
panel.
``(iv) Admissibility.--The determinations of the expert
panel under subparagraph (C) shall be admissible into
evidence in any administrative health care tribunal
proceeding under this subparagraph.
``(E) Right to file.--Nothing in this paragraph shall be
construed to prohibit any individual who is not satisfied
with the determination of the tribunal (after having
proceeded through both the expert panel under subparagraph
(C) and the tribunal under subparagraph (D)) from filing a
claim for the injury involved in a State court of competent
jurisdiction.
``(F) Admissibility.--The determinations of both the expert
panel and the tribunal under this paragraph shall be
admissible into evidence in any State court proceeding under
this paragraph.
``(G) Forfeit of awards.--Any party filing an action in
State court under subparagraph (E) shall forfeit any
compensation award made by both the expert panel and the
administrative health care tribunal under this paragraph.
``(e) Definitions.--In this section:
``(1) Current tort litigation.--The term `current tort
litigation' means the tort litigation system existing in the
State on the date on which the State submits an application
under subsection (b)(1), for the resolution of disputes
concerning injuries allegedly caused by health care providers
or health care organizations.
``(2) Health care organization.--The term `health care
organization' means any individual or entity that is
obligated to provide, pay for, or administer health benefits
under any health plan.
``(3) Net economic loss.--The term `net economic loss'
means--
``(A) reasonable expenses incurred for products, services
and accommodations needed for health care, training and other
remedial treatment and care of an injured individual;
``(B) reasonable and appropriate expenses for
rehabilitation treatment and occupational training;
``(C) 100 percent of the loss of income from work that an
injured individual would have performed if not injured,
reduced by any income from substitute work actually
performed; and
``(D) reasonable expenses incurred in obtaining ordinary
and necessary services to replace services an injured
individual would have performed for the benefit of the
individual or the family of such individual if the individual
had not been injured.
``(4) Non-economic damages.--The term `non-economic
damages' means losses for physical and emotional pain,
suffering, inconvenience, physical impairment, mental
anguish, disfigurement, loss of enjoyment of life, loss of
society and companionship, loss of consortium (other than
loss of domestic service), injury to reputation, and all
other non-pecuniary losses of any kind or nature, to the
extent permitted under State law.
``(f) Funding.--
``(1) One-time increase in medicaid payment.--In the case
of a State awarded a grant to carry out this section, the
total amount of the Federal payment determined for the State
under section 1913 of the Social Security Act (as amended by
section 401) for fiscal year 2011 (in addition to the any
increase applicable for that fiscal year under section 203(b)
but determined without regard to any such increase) shall be
increased by an amount equal to 1 percent of the total amount
of payments made to the State for fiscal year 2010 under
section 1903(a) of the Social Security Act (42 U.S.C.
1396b(a)) for purposes of carrying out a grant awarded under
this section. Amounts paid to a State pursuant to this
subsection shall remain available until expended.
``(2) Authorization of appropriations.--There are
authorized to be appropriated for any fiscal year such sums
as may be necessary for purposes of making payments to States
pursuant to paragraph (1).''.

TITLE VII--PROMOTING HEALTH INFORMATION TECHNOLOGY

Subtitle A--Assisting the Development of Health Information Technology

SEC. 701. PURPOSE.

It is the purpose of this subtitle to promote the
utilization of health record banking by improving the
coordination of health information through an infrastructure
for the secure and authorized exchange and use of healthcare
information.

SEC. 702. HEALTH RECORD BANKING.

(a) Establishment.--Not later than 1 year after the date of
enactment of this Act, the Secretary of Health and Human
Services shall promulgate regulations to provide for the
certification and auditing of the banking of electronic
medical records.
(b) General Rights.--An individual who has a health record
contained in a health record bank shall maintain ownership
over the health record and shall have the right to review the
contents of the record.

SEC. 703. APPLICATION OF FEDERAL AND STATE SECURITY AND
CONFIDENTIALITY STANDARDS.

(a) In General.--Current Federal security and
confidentiality standards and State security and
confidentiality laws shall apply to this subtitle until such
time as Congress acts to amend such standards.
(b) Definitions.--In this section:
(1) Current federal security and confidentiality
standards.--The term ``current Federal security and
confidentiality standards'' means the Federal privacy
standards established pursuant to section 264(c) of the
Health Insurance Portability and Accountability Act of 1996
(42 U.S.C. 1320d-2 note) and security standards established
under section 1173(d) of the Social Security Act (42 U.S.C.
1320d-2(d)).
(2) State security and confidentiality laws.--The term
``State security and confidentiality laws'' means State laws
and regulations relating to the privacy and confidentiality
of individually identifiable health information or to the
security of such information.
(3) State.--The term ``State'' has the meaning given such
term for purposes of title XI of the Social Security Act, as
provided under section 1101(a) of such Act (42 U.S.C.
1301(a)).

Subtitle B--Removing Barriers to the Use of Health Information
Technology to Better Coordinate Health Care

SEC. 711. SAFE HARBORS TO ANTIKICKBACK CIVIL PENALTIES AND
CRIMINAL PENALTIES FOR PROVISION OF HEALTH
INFORMATION TECHNOLOGY AND TRAINING SERVICES.

(a) For Civil Penalties.--Section 1128A of the Social
Security Act (42 U.S.C. 1320a-7a) is amended--
(1) in subsection (b), by adding at the end the following
new paragraph:
``(4) For purposes of this subsection, inducements to
reduce or limit services described in paragraph (1) shall not
include the practical or other advantages resulting from
health information technology or related installation,
maintenance, support, or training services.''; and
(2) in subsection (i), by adding at the end the following
new paragraph:
``(8) The term `health information technology' means
hardware, software, license, right, intellectual property,
equipment, or other information technology (including new
versions, upgrades, and connectivity) designed or provided
primarily for the electronic creation, maintenance, or
exchange of health information to better coordinate care or
improve health care quality, efficiency, or research.''.
(b) For Criminal Penalties.--Section 1128B of such Act (42
U.S.C. 1320a-7b) is amended--
(1) in subsection (b)(3)--
(A) in subparagraph (G), by striking ``and'' at the end;
(B) in the subparagraph (H) added by section 237(d) of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173; 117 Stat. 2213)--
(i) by moving such subparagraph 2 ems to the left; and
(ii) by striking the period at the end and inserting a
semicolon;
(C) in the subparagraph (H) added by section 431(a) of such
Act (117 Stat. 2287)--
(i) by redesignating such subparagraph as subparagraph (I);
(ii) by moving such subparagraph 2 ems to the left; and
(iii) by striking the period at the end and inserting ``;
and''; and
(D) by adding at the end the following new subparagraph:
``(J) any nonmonetary remuneration (in the form of health
information technology, as defined in section 1128A(i)(8), or
related installation, maintenance, support or training
services) made to a person by a specified entity (as defined
in subsection (g)) if--
``(i) the provision of such remuneration is without an
agreement between the parties or legal condition that--
``(I) limits or restricts the use of the health information
technology to services provided by the physician to
individuals receiving services at the specified entity;
``(II) limits or restricts the use of the health
information technology in conjunction with other health
information technology; or
``(III) conditions the provision of such remuneration on
the referral of patients or business to the specified entity;
``(ii) such remuneration is arranged for in a written
agreement that is signed by the parties involved (or their
representatives) and that specifies the remuneration
solicited or received (or offered or paid) and states that
the provision of such remuneration is made for the primary
purpose of better coordination of care or improvement of
health quality, efficiency, or research; and
``(iii) the specified entity providing the remuneration (or
a representative of such entity) has not taken any action to
disable any basic feature of any hardware or software
component of such remuneration that would permit
interoperability.''; and
(2) by adding at the end the following new subsection:
``(g) Specified Entity Defined.--For purposes of subsection
(b)(3)(J), the term `specified entity' means an entity that
is a hospital, group practice, prescription drug plan
sponsor, a Medicare Advantage organization, or any other such
entity specified by the

[[Page S13549]]

Secretary, considering the goals and objectives of this
section, as well as the goals to better coordinate the
delivery of health care and to promote the adoption and use
of health information technology.''.
(c) Effective Date and Effect on State Laws.--
(1) Effective date.--The amendments made by subsections (a)
and (b) shall take effect on the date that is 120 days after
the date of the enactment of this Act.
(2) Preemption of state laws.--No State (as defined in
section 1101(a) of the Social Security Act (42 U.S.C.
1301(a)) for purposes of title XI of such Act) shall have in
effect a State law that imposes a criminal or civil penalty
for a transaction described in section 1128A(b)(4) or section
1128B(b)(3)(J) of such Act, as added by subsections (a)(1)
and (b), respectively, if the conditions described in the
respective provision, with respect to such transaction, are
met.
(d) Study and Report To Assess Effect of Safe Harbors on
Health System.--
(1) In general.--The Secretary of Health and Human Services
shall conduct a study to determine the impact of each of the
safe harbors described in paragraph (3). In particular, the
study shall examine the following:
(A) The effectiveness of each safe harbor in increasing the
adoption of health information technology.
(B) The types of health information technology provided
under each safe harbor.
(C) The extent to which the financial or other business
relationships between providers under each safe harbor have
changed as a result of the safe harbor in a way that
adversely affects or benefits the health care system or
choices available to consumers.
(D) The impact of the adoption of health information
technology on health care quality, cost, and access under
each safe harbor.
(2) Report.--Not later than 3 years after the effective
date described in subsection (c)(1), the Secretary of Health
and Human Services shall submit to Congress a report on the
study under paragraph (1).
(3) Safe harbors described.--For purposes of paragraphs (1)
and (2), the safe harbors described in this paragraph are--
(A) the safe harbor under section 1128A(b)(4) of such Act
(42 U.S.C. 1320a-7a(b)(4)), as added by subsection (a)(1);
and
(B) the safe harbor under section 1128B(b)(3)(J) of such
Act (42 U.S.C. 1320a-7b(b)(3)(J)), as added by subsection
(b).

SEC. 712. EXCEPTION TO LIMITATION ON CERTAIN PHYSICIAN
REFERRALS (UNDER STARK) FOR PROVISION OF HEALTH
INFORMATION TECHNOLOGY AND TRAINING SERVICES TO
HEALTH CARE PROFESSIONALS.

(a) In General.--Section 1877(b) of the Social Security Act
(42 U.S.C. 1395nn(b)) is amended by adding at the end the
following new paragraph:
``(6) Information technology and training services.--
``(A) In general.--Any nonmonetary remuneration (in the
form of health information technology or related
installation, maintenance, support or training services) made
by a specified entity to a physician if--
``(i) the provision of such remuneration is without an
agreement between the parties or legal condition that--

``(I) limits or restricts the use of the health information
technology to services provided by the physician to
individuals receiving services at the specified entity;
``(II) limits or restricts the use of the health
information technology in conjunction with other health
information technology; or
``(III) conditions the provision of such remuneration on
the referral of patients or business to the specified entity;

``(ii) such remuneration is arranged for in a written
agreement that is signed by the parties involved (or their
representatives) and that specifies the remuneration made and
states that the provision of such remuneration is made for
the primary purpose of better coordination of care or
improvement of health quality, efficiency, or research; and
``(iii) the specified entity (or a representative of such
entity) has not taken any action to disable any basic feature
of any hardware or software component of such remuneration
that would permit interoperability.
``(B) Health information technology defined.--For purposes
of this paragraph, the term `health information technology'
means hardware, software, license, right, intellectual
property, equipment, or other information technology
(including new versions, upgrades, and connectivity) designed
or provided primarily for the electronic creation,
maintenance, or exchange of health information to better
coordinate care or improve health care quality, efficiency,
or research.
``(C) Specified entity defined.--For purposes of this
paragraph, the term `specified entity' means an entity that
is a hospital, group practice, prescription drug plan
sponsor, a Medicare Advantage organization, or any other such
entity specified by the Secretary, considering the goals and
objectives of this section, as well as the goals to better
coordinate the delivery of health care and to promote the
adoption and use of health information technology.''.
(b) Effective Date; Effect on State Laws.--
(1) Effective date.--The amendment made by subsection (a)
shall take effect on the date that is 120 days after the date
of the enactment of this Act.
(2) Preemption of state laws.--No State (as defined in
section 1101(a) of the Social Security Act (42 U.S.C.
1301(a)) for purposes of title XI of such Act) shall have in
effect a State law that imposes a criminal or civil penalty
for a transaction described in section 1877(b)(6) of such
Act, as added by subsection (a), if the conditions described
in such section, with respect to such transaction, are met.
(c) Study and Report To Assess Effect of Exception on
Health System.--
(1) In general.--The Secretary of Health and Human Services
shall conduct a study to determine the impact of the
exception under section 1877(b)(6) of such Act (42 U.S.C.
1395nn(b)(6)), as added by subsection (a). In particular, the
study shall examine the following:
(A) The effectiveness of the exception in increasing the
adoption of health information technology.
(B) The types of health information technology provided
under the exception.
(C) The extent to which the financial or other business
relationships between providers under the exception have
changed as a result of the exception in a way that adversely
affects or benefits the health care system or choices
available to consumers.
(D) The impact of the adoption of health information
technology on health care quality, cost, and access under the
exception.
(2) Report.--Not later than 3 years after the effective
date described in subsection (b)(1), the Secretary of Health
and Human Services shall submit to Congress a report on the
study under paragraph (1).

SEC. 713. RULES OF CONSTRUCTION REGARDING USE OF CONSORTIA.

(a) Application to Safe Harbor From Criminal Penalties.--
Section 1128B(b)(3) of the Social Security Act (42 U.S.C.
1320a-7b(b)(3)) is amended by adding after and below
subparagraph (J), as added by section 711(b)(1), the
following: ``For purposes of subparagraph (J), nothing in
such subparagraph shall be construed as preventing a
specified entity, consistent with the specific requirements
of such subparagraph, from forming a consortium composed of
health care providers, payers, employers, and other
interested entities to collectively purchase and donate
health information technology, or from offering health care
providers a choice of health information technology products
in order to take into account the varying needs of such
providers receiving such products.''.
(b) Application to Stark Exception.--Paragraph (6) of
section 1877(b) of the Social Security Act (42 U.S.C.
1395nn(b)), as added by section 712(a), is amended by adding
at the end the following new subparagraph:
``(D) Rule of construction.--For purposes of subparagraph
(A), nothing in such subparagraph shall be construed as
preventing a specified entity, consistent with the specific
requirements of such subparagraph, from--
``(i) forming a consortium composed of health care
providers, payers, employers, and other interested entities
to collectively purchase and donate health information
technology; or
``(ii) offering health care providers a choice of health
information technology products in order to take into account
the varying needs of such providers receiving such
products.''.

TITLE VIII--HEALTH CARE SERVICES COMMISSION

Subtitle A--Establishment and General Duties

SEC. 801. ESTABLISHMENT.

(a) In General.--There is hereby established a Health Care
Services Commission (in this title, referred to as the
``Commission'') to be composed of 5 commissioners (in this
title referred to as the ``Commissioners'') to be appointed
by the President by and with the advice and consent of the
Senate. Not more than 3 of such Commissioners shall be
members of the same political party, and in making
appointments members of different political parties shall be
appointed alternately as nearly as may be practicable. No
Commissioner shall engage in any other business, vocation, or
employment than that of serving as Commissioner. Each
Commissioner shall hold office for a term of 5 years and
until a successor is appointed and has qualified, except
that--
(1) such Commissioner shall not so continue to serve beyond
the expiration of the next session of Congress subsequent to
the expiration of said fixed term of office;
(2) any Commissioner appointed to fill a vacancy occurring
prior to the expiration of the term for which a predecessor
was appointed shall be appointed for the remainder of such
term; and
(3) the terms of office of the Commissioners first taking
office after the date of the enactment of this Act shall
expire as designated by the President at the time of
nomination, 1 at the end of 1 year, 1 at the end of 2 years,
1 at the end of 3 years, 1 at the end of 4 years, and 1 at
the end of 5 years, after the date of the enactment of this
Act.
(b) Purpose.--The purpose of the Commission is to enhance
the quality, appropriateness, and effectiveness of health
care services, and access to such services, through the
establishment of a broad base of scientific research and
through the promotion of improvements in clinical practice
and in the organization, financing, and delivery of health
care services.
(c) Appointment of Chairman.--The President shall, from
among the Commissioners appointed under subsection (a),
designate an individual to serve as the Chairman of the
Commission.

SEC. 802. GENERAL AUTHORITIES AND DUTIES.

(a) In General.--In carrying out section 801(b), the
Commissioners shall conduct and

[[Page S13550]]

support research, demonstration projects, evaluations,
training, guideline development, and the dissemination of
information, on health care services and on systems for the
delivery of such services, including activities with respect
to--
(1) the effectiveness, efficiency, and quality of health
care services;
(2) the outcomes of health care services and procedures;
(3) clinical practice, including primary care and practice-
oriented research;
(4) health care technologies, facilities, and equipment;
(5) health care costs, productivity, and market forces;
(6) health promotion and disease prevention;
(7) health statistics and epidemiology; and
(8) medical liability.
(b) Requirements With Respect to Rural Areas and
Underserved Populations.--In carrying out subsection (a), the
Commissioners shall undertake and support research,
demonstration projects, and evaluations with respect to--
(1) the delivery of health care services in rural areas
(including frontier areas); and
(2) the health of low-income groups, minority groups, and
the elderly.

SEC. 803. DISSEMINATION.

(a) In General.--The Commissioners shall--
(1) promptly publish, make available, and otherwise
disseminate, in a form understandable and on as broad a basis
as practicable so as to maximize its use, the results of
research, demonstration projects, and evaluations conducted
or supported under this title and the guidelines, standards,
and review criteria developed under this title;
(2) promptly make available to the public data developed in
such research, demonstration projects, and evaluations; and
(3) as appropriate, provide technical assistance to State
and local government and health agencies and conduct liaison
activities to such agencies to foster dissemination.
(b) Prohibition Against Restrictions.--Except as provided
in subsection (c), the Commissioners may not restrict the
publication or dissemination of data from, or the results of,
projects conducted or supported under this title.
(c) Limitation on Use of Certain Information.--No
information, if an establishment or person supplying the
information or described in it is identifiable, obtained in
the course of activities undertaken or supported under this
title may be used for any purpose other than the purpose for
which it was supplied unless such establishment or person has
consented (as determined under regulations of the Secretary)
to its use for such other purpose. Such information may not
be published or released in other form if the person who
supplied the information or who is described in it is
identifiable unless such person has consented (as determined
under regulations of the Secretary) to its publication or
release in other form.
(d) Certain Interagency Agreement.--The Commissioners and
the Director of the National Library of Medicine shall enter
into an agreement providing for the implementation of
subsection (a)(1).

Subtitle B--Forum for Quality and Effectiveness in Health Care

SEC. 811. ESTABLISHMENT OF OFFICE.

There is established within the Commission an office to be
known as the Office of the Forum for Quality and
Effectiveness in Health Care. The office shall be headed by a
director (referred to in this title as the ``Director'') who
shall be appointed by the Commissioners.

SEC. 812. MEMBERSHIP.

(a) In General.--The Office of the Forum for Quality and
Effectiveness in Health Care shall be composed of 15
individuals nominated by private sector health
care organizations and appointed by the Commission and
shall include representation from at least the following:
(1) Health insurance industry.
(2) Health care provider groups.
(3) Non-profit organizations.
(4) Rural health organizations.
(b) Terms.--
(1) In general.--Except as provided in paragraph (2),
members of the Office of the Forum for Quality and
Effectiveness in Health Care shall serve for a term of 5
years.
(2) Staggered rotation.--Of the members first appointed to
the Office of the Forum for Quality and Effectiveness in
Health Care, the Commission shall appoint 5 members to serve
for a term of 2 years, 5 members to serve for a term of 3
years, and 5 members to serve for a term of 4 years.
(c) Treatment of Other Employment.--Each member of the
Office of the Forum for Quality and Effectiveness in Health
Care shall serve the Office independently from any other
position of employment.

SEC. 813. DUTIES.

(a) Establishment of Forum Program.--The Commissioners,
acting through the Director, shall establish a program to be
known as the Forum for Quality and Effectiveness in Health
Care. For the purpose of promoting transparency in price,
quality, appropriateness, and effectiveness of health care,
the Director, using the process set forth in section 814,
shall arrange for the development and periodic review and
updating of standards of quality, performance measures, and
medical review criteria through which health care providers
and other appropriate entities may assess or review the
provision of health care and assure the quality of such care.
(b) Certain Requirements.--Guidelines, standards,
performance measures, and review criteria under subsection
(a) shall--
(1) be based on the best available research and
professional judgment regarding the effectiveness and
appropriateness of health care services and procedures; and
(2) be presented in formats appropriate for use by
physicians, health care practitioners, providers, medical
educators, and medical review organizations and in formats
appropriate for use by consumers of health care.
(c) Authority for Contracts.--In carrying out this
subtitle, the Director may enter into contracts with public
or nonprofit private entities.
(d) Public Disclosure of Recommendations.--For each fiscal
year beginning with 2010, the Director shall make publicly
available the following:
(1) Quarterly reports for public comment that include
proposed recommendations for guidelines, standards,
performance measures, and review criteria under subsection
(a) and any updates to such guidelines, standards,
performance measures, and review criteria.
(2) After consideration of such comments, a final report
that contains final recommendations for such guidelines,
standards, performance measures, review criteria, and
updates.
(e) Date Certain for Initial Guidelines and Standards.--The
Commissioners, by not later than January 1, 2012, shall
assure the development of an initial set of guidelines,
standards, performance measures, and review criteria under
subsection (a).

SEC. 814. ADOPTION AND ENFORCEMENT OF GUIDELINES AND
STANDARDS.

(a) Adoption of Recommendations of Forum for Quality and
Effectiveness in Health Care.--For each fiscal year, the
Commissioners shall adopt the recommendations made for such
year in the final report under subsection (d)(2) of section
813 for guidelines, standards, performance measures, and
review criteria described in subsection (a) of such section.
(b) Enforcement Authority.--The Commissioners, in
consultation with the Secretary of Health and Human Services,
have the authority to make recommendations to the Secretary
to enforce compliance of health care providers with the
guidelines, standards, performance measures, and review
criteria adopted under subsection (a). Such recommendations
may include the following, with respect to a health care
provider who is not in compliance with such guidelines,
standards, measures, and criteria:
(1) Exclusion from participation in Federal health care
programs (as defined in section 1128B(f) of the Social
Security Act (42 U.S.C. 1320a-7b(f))).
(2) Imposition of a civil money penalty on such provider.

SEC. 815. ADDITIONAL REQUIREMENTS.

(a) Program Agenda.--The Commissioners shall provide for an
agenda for the development of the guidelines, standards,
performance measures, and review criteria described in
section 813(a), including with respect to the standards,
performance measures, and review criteria, identifying
specific aspects of health care for which the standards,
performance measures, and review criteria are to be developed
and those that are to be given priority in the development of
the standards, performance measures, and review criteria.

Subtitle C--General Provisions

SEC. 821. CERTAIN ADMINISTRATIVE AUTHORITIES.

The Commissioners, in carrying out this title, may accept
voluntary and uncompensated services.

SEC. 822. FUNDING.

For the purpose of carrying out this title, there are
authorized to be appropriated such sums as may be necessary
for fiscal years 2010 through 2014.

SEC. 823. DEFINITIONS.

For purposes of this title:
(1) The term ``Commissioners'' means the Commissioners of
the Health Care Services Commission.
(2) The term ``Commission'' means the Health Care Services
Commission.
(3) The term ``Director'' means the Director of the Office
of the Forum for Quality and Effectiveness in Health Care.
(4) The term ``Secretary'' means the Secretary of Health
and Human Services.

Subtitle D--Terminations and Transition

SEC. 831. TERMINATION OF AGENCY FOR HEALTHCARE RESEARCH AND
QUALITY.

As of the date of the enactment of this Act, the Agency for
Healthcare Research and Quality is terminated, and title IX
of the Public Health Service Act is repealed.

SEC. 832. TRANSITION.

All orders, grants, contracts, privileges, and other
determinations or actions of the Agency for Healthcare
Research and Quality that are effective as of the date before
the date of the enactment of this Act, shall be transferred
to the Secretary and shall continue in effect according to
their terms unless changed pursuant to law.

Subtitle E--Independent Health Record Trust

SEC. 841. SHORT TITLE.

This subtitle may be cited as the ``Independent Health
Record Trust Act of 2009''.

SEC. 842. PURPOSE.

It is the purpose of this subtitle to provide for the
establishment of a nationwide health information technology
network that--

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(1) improves health care quality, reduces medical errors,
increases the efficiency of care, and advances the delivery
of appropriate, evidence-based health care services;
(2) promotes wellness, disease prevention, and the
management of chronic illnesses by increasing the
availability and transparency of information related to the
health care needs of an individual;
(3) ensures that appropriate information necessary to make
medical decisions is available in a usable form at the time
and in the location that the medical service involved is
provided;
(4) produces greater value for health care expenditures by
reducing health care costs that result from inefficiency,
medical errors, inappropriate care, and incomplete
information;
(5) promotes a more effective marketplace, greater
competition, greater systems analysis, increased choice,
enhanced quality, and improved outcomes in health care
services;
(6) improves the coordination of information and the
provision of such services through an effective
infrastructure for the secure and authorized exchange and use
of health information; and
(7) ensures that the health information privacy, security,
and confidentiality of individually identifiable health
information is protected.

SEC. 843. DEFINITIONS.

In this subtitle:
(1) Access.--The term ``access'' means, with respect to an
electronic health record, entering information into such
account as well as retrieving information from such account.
(2) Account.--The term ``account'' means an electronic
health record of an individual contained in an independent
health record trust.
(3) Affirmative consent.--The term ``affirmative consent''
means, with respect to an electronic health record of an
individual contained in an IHRT, express consent given by the
individual for the use of such record in response to a clear
and conspicuous request for such consent or at the
individual's own initiative.
(4) Authorized ehr data user.--The term ``authorized EHR
data user'' means, with respect to an electronic health
record of an IHRT participant contained as part of an IHRT,
any entity (other than the participant) authorized (in the
form of affirmative consent) by the participant to access the
electronic health record.
(5) Confidentiality.--The term ``confidentiality'' means,
with respect to individually identifiable health information
of an individual, the obligation of those who receive such
information to respect the health information privacy of the
individual.
(6) Electronic health record.--The term ``electronic health
record'' means a longitudinal collection of information
concerning a single individual, including medical records and
personal health information, that is stored electronically.
(7) Health information privacy.--The term ``health
information privacy'' means, with respect to individually
identifiable health information of an individual, the right
of such individual to control the acquisition, uses, or
disclosures of such information.
(8) Health plan.--The term ``health plan'' means a group
health plan (as defined in section 2208(1) of the Public
Health Service Act (42 U.S.C. 300bb-8(1))) as well as a plan
that offers health insurance coverage in the individual
market.
(9) HIPAA privacy regulations.--The term ``HIPAA privacy
regulations'' means the regulations promulgated under section
264(c) of the Health Insurance Portability and Accountability
Act of 1996 (42 U.S.C. 1320d-2 note).
(10) Independent health record trust; ihrt.--The terms
``independent health record trust'' and ``IHRT'' mean a legal
arrangement under the administration of an IHRT operator that
meets the requirements of this subtitle with respect to
electronic health records of individuals participating in the
trust or IHRT.
(11) IHRT operator.--The term ``IHRT operator'' means, with
respect to an IHRT, the organization that is responsible for
the administration and operation of the IHRT in accordance
with this subtitle.
(12) IHRT participant.--The term ``IHRT participant''
means, with respect to an IHRT, an individual who has a
participation agreement in effect with respect to the
maintenance of the individual's electronic health record by
the IHRT.
(13) Individually identifiable health information.--The
term ``individually identifiable health information'' has the
meaning given such term in section 1171(6) of the Social
Security Act (42 U.S.C. 1320d(6)).
(14) Security.--The term ``security'' means, with respect
to individually identifiable health information of an
individual, the physical, technological, or administrative
safeguards or tools used to protect such information from
unwarranted access or disclosure.

SEC. 844. ESTABLISHMENT, CERTIFICATION, AND MEMBERSHIP OF
INDEPENDENT HEALTH RECORD TRUSTS.

(a) Establishment.--Not later than one year after the date
of the enactment of this Act, the Federal Trade Commission,
in consultation with the National Committee on Vital and
Health Statistics, shall prescribe standards for the
establishment, certification, operation, and interoperability
of IHRTs to carry out the purposes described in section 842
in accordance with the provisions of this subtitle.
(b) Certification.--
(1) Certification by ftc.--The Federal Trade Commission
shall provide for the certification of IHRTs. No IHRT may be
certified unless the IHRT is determined to meet the standards
for certification established under subsection (a).
(2) Decertification.--The Federal Trade Commission shall
establish a process for the revocation of certification of an
IHRT under this section in the case that the IHRT violates
the standards established under subsection (a).
(c) Membership.--
(1) In general.--To be eligible to be a participant in an
IHRT, an individual shall--
(A) submit to the IHRT information as required by the IHRT
to establish an electronic health record with the IHRT; and
(B) enter into a privacy protection agreement described in
section 846(b)(1) with the IHRT.
The process to determine eligibility of an individual under
this subsection shall allow for the establishment by such
individual of an electronic health record as expeditiously as
possible if such individual is determined so eligible.
(2) No limitation on membership.--Nothing in this
subsection shall be construed to permit an IHRT to restrict
membership, including on the basis of health condition.

SEC. 845. DUTIES OF IHRT TO IHRT PARTICIPANTS.

(a) Fiduciary Duty of IHRT; Penalties for Violations of
Fiduciary Duty.--
(1) Fiduciary duty.--With respect to the electronic health
record of an IHRT participant maintained by an IHRT, the IHRT
shall have a fiduciary duty to act for the benefit and in the
interests of such participant and of the IHRT as a whole.
Such duty shall include obtaining the affirmative consent of
such participant prior to the release of information in such
participant's electronic health record in accordance with the
requirements of this subtitle.
(2) Penalties.--If the IHRT knowingly or recklessly
breaches the fiduciary duty described in paragraph (1), the
IHRT shall be subject to the following penalties:
(A) Loss of certification of the IHRT.
(B) A fine that is not in excess of $50,000.
(C) A term of imprisonment for the individuals involved of
not more than 5 years.
(b) Electronic Health Record Deemed To Be Held in Trust by
IHRT.--With respect to an individual, an electronic health
record maintained by an IHRT shall be deemed to be held in
trust by the IHRT for the benefit of the individual and the
IHRT shall have no legal or equitable interest in such
electronic health record.

SEC. 846. AVAILABILITY AND USE OF INFORMATION FROM RECORDS IN
IHRT CONSISTENT WITH PRIVACY PROTECTIONS AND
AGREEMENTS.

(a) Protected Electronic Health Records Use and Access.--
(1) General rights regarding uses of information.--
(A) In general.--With respect to the electronic health
record of an IHRT participant maintained by an IHRT, subject
to paragraph (2)(C), primary uses and secondary uses
(described in subparagraphs (B) and (C), respectively) of
information within such record (other than by such
participant) shall be permitted only upon the authorization
of such use, prior to such use, by such participant.
(B) Primary uses.--For purposes of subparagraph (A) and
with respect to an electronic health record of an individual,
a primary use is a use for purposes of the individual's self-
care or care by health care professionals.
(C) Secondary uses.--For purposes of subparagraph (B) and
with respect to an electronic health record of an individual,
a secondary use is any use not described in subparagraph (B)
and includes a use for purposes of public health research or
other related activities. Additional authorization is
required for a secondary use extending beyond the original
purpose of the secondary use authorized by the IHRT
participant involved. Nothing in this paragraph shall be
construed as requiring authorization for every secondary use
that is within the authorized original purpose.
(2) Rules for primary use of records for health care
purposes.--With respect to the electronic health record of an
IHRT participant (or specified parts of such electronic
health record) maintained by an IHRT standards for access to
such record shall provide for the following:
(A) Access by ihrt participants to their electronic health
records.--
(i) Ownership.--The participant maintains ownership over
the entire electronic health record (and all portions of such
record) and shall have the right to electronically access and
review the contents of the entire record (and any portion of
such record) at any time, in accordance with this
subparagraph.
(ii) Addition of personal information.--The participant may
add personal health information to the health record of that
participant, except that such participant shall not alter
information that is entered into the electronic health record
by any authorized EHR data user. Such participant shall have
the right to propose an amendment to information that is
entered by an authorized EHR data user pursuant to standards
prescribed by the Federal Trade Commission for purposes of
amending such information.

[[Page S13552]]

(iii) Identification of information entered by
participant.--Any additions or amendments made by the
participant to the health record shall be identified and
disclosed within such record as being made by such
participant.
(B) Access by entities other than ihrt participant.--
(i) Authorized access only.--Except as provided under
subparagraph (C) and paragraph (4), access to the electronic
health record (or any portion of the record)--

(I) may be made only by authorized EHR data users and only
to such portions of the record as specified by the
participant; and
(II) may be limited by the participant for purposes of
entering information into such record, retrieving information
from such record, or both.

(ii) Identification of entity that enters information.--Any
information that is added by an authorized EHR data user to
the health record shall be identified and disclosed within
such record as being made by such user.
(iii) Satisfaction of hipaa privacy regulations.--In the
case of a record of a covered entity (as defined for purposes
of HIPAA privacy regulations), with respect to an individual,
if such individual is an IHRT participant with an independent
health record trust and such covered entity is an authorized
EHR data user, the requirement under the HIPAA privacy
regulations for such entity to provide the record to the
participant shall be deemed met if such entity, without
charge to the IHRT or the participant--

(I) forwards to the trust an appropriately formatted
electronic copy of the record (and updates to such records)
for inclusion in the electronic health record of the
participant maintained by the trust;
(II) enters such record into the electronic health record
of the participant so maintained; or
(III) otherwise makes such record available for electronic
access by the IHRT or the individual in a manner that permits
such record to be included in the account of the individual
contained in the IHRT.

(iv) Notification of sensitive information.--Any
information, with respect to the participant, that is
sensitive information, as specified by the Federal Trade
Commission, shall not be forwarded or entered by an
authorized EHR data user into the electronic health record of
the participant maintained by the trust unless the user
certifies that the participant has been notified of such
information.
(C) Deemed authorization for access for emergency health
care.--
(i) Findings.--Congress finds that--

(I) given the size and nature of visits to emergency
departments in the United States, readily available health
information could make the difference between life and death;
and
(II) because of the case mix and volume of patients
treated, emergency departments are well positioned to provide
information for public health surveillance, community risk
assessment, research, education, training, quality
improvement, and other uses.

(ii) Use of information.--With respect to the electronic
health record of an IHRT participant (or specified parts of
such electronic health record) maintained by an IHRT, the
participant shall be deemed as providing authorization (in
the form of affirmative consent) for health care providers to
access, in connection with providing emergency care services
to the participant, a limited, authenticated information set
concerning the participant for emergency response purposes,
unless the participant specifies that such information set
(or any portion of such information set) may not be so
accessed. Such limited information set may include
information--

(I) patient identification data, as determined appropriate
by the participant;
(II) provider identification that includes the use of
unique provider identifiers;
(III) payment information;
(IV) information related to the individual's vitals,
allergies, and medication history;
(V) information related to existing chronic problems and
active clinical conditions of the participant; and
(VI) information concerning physical examinations,
procedures, results, and diagnosis data.

(3) Rules for secondary uses of records for research and
other purposes.--
(A) In general.--With respect to the electronic health
record of an IHRT participant (or specified parts of such
electronic health record) maintained by an IHRT, the IHRT may
sell such record (or specified parts of such record) only
if--
(i) the transfer is authorized by the participant pursuant
to an agreement between the participant and the IHRT and is
in accordance with the privacy protection agreement described
in subsection (b)(1) entered into between such participant
and such IHRT;
(ii) such agreement includes parameters with respect to the
disclosure of information involved and a process for the
authorization of the further disclosure of information in
such record;
(iii) the information involved is to be used for research
or other activities only as provided for in the agreement;
(iv) the recipient of the information provides assurances
that the information will not be further transferred or
reused in violation of such agreement; and
(v) the transfer otherwise meets the requirements and
standards prescribed by the Federal Trade Commission.
(B) Treatment of public health reporting.--Nothing in this
paragraph shall be construed as prohibiting or limiting the
use of health care information of an individual, including an
individual who is an IHRT participant, for public health
reporting (or other research) purposes prior to the inclusion
of such information in an electronic health record maintained
by an IHRT.
(4) Law enforcement clarification.--Nothing in this
subtitle shall prevent an IHRT from disclosing information
contained in an electronic health record maintained by the
IHRT when required for purposes of a lawful investigation or
official proceeding inquiring into a violation of, or failure
to comply with, any criminal or civil statute or any
regulation, rule, or order issued pursuant to such a statute.
(5) Rule of construction.--Nothing in this section shall be
construed to require a health care provider that does not
utilize electronic methods or appropriate levels of health
information technology on the date of the enactment of this
Act to adopt such electronic methods or technology as a
requirement for participation or compliance under this
subtitle.
(b) Privacy Protection Agreement; Treatment of State
Privacy and Security Laws.--
(1) Privacy protection agreement.--A privacy protection
agreement described in this subsection is an agreement, with
respect to an electronic health record of an IHRT participant
to be maintained by an independent health record trust,
between the participant and the trust--
(A) that is consistent with the standards described in
subsection (a)(2);
(B) under which the participant specifies the portions of
the record that may be accessed, under what circumstances
such portions may be accessed, any authorizations for
indicated authorized EHR data users to access information
contained in the record, and the purposes for which the
information (or portions of the information) in the record
may be used;
(C) which provides a process for the authorization of the
transfer of information contained in the record to a third
party, including for the sale of such information for
purposes of research, by an authorized EHR data user and
reuse of such information by such third party, including a
provision requiring that such transfer and reuse is not in
violation of any privacy or transfer restrictions placed by
the participant on the independent health record of such
participant; and
(D) under which the trust provides assurances that the
trust will not transfer, disclose, or provide access to the
record (or any portion of the record) in violation of the
parameters established in the agreement or to any person or
entity who has not agreed to use and transfer such record (or
portion of such record) in accordance with such agreement.
(2) Treatment of state laws.--
(A) In general.--Except as provided under subparagraph (B),
the provisions of a privacy protection agreement entered into
between an IHRT and an IHRT participant shall preempt any
provision of State law (or any State regulation) relating to
the privacy and confidentiality of individually identifiable
health information or to the security of such health
information.
(B) Exception for privileged information.--The provisions
of a privacy protection agreement shall not preempt any
provision of State law (or any State regulation) that
recognizes privileged communications between physicians,
health care practitioners, and patients of such physicians or
health care practitioners, respectively.
(C) State defined.--For purposes of this section, the term
``State'' has the meaning given such term when used in title
XI of the Social Security Act, as provided under section
1101(a) of such Act (42 U.S.C. 1301(a)).

SEC. 847. VOLUNTARY NATURE OF TRUST PARTICIPATION AND
INFORMATION SHARING.

(a) In General.--Participation in an independent health
record trust, or authorizing access to information from such
a trust, is voluntary. No employer, health insurance issuer,
group health plan, health care provider, or other person may
require, as a condition of employment, issuance of a health
insurance policy, coverage under a group health plan, the
provision of health care services, payment for such services,
or otherwise, that an individual participate in, or authorize
access to information from, an independent health record
trust.
(b) Enforcement.--The penalties provided for in subsection
(a) of section 1177 of the Social Security Act (42 U.S.C.
1320d-6) shall apply to a violation of subsection (a) in the
same manner as such penalties apply to a person in violation
of subsection (a) of such section.

SEC. 848. FINANCING OF ACTIVITIES.

(a) In General.--Except as provided in subsection (b), an
IHRT may generate revenue to pay for the operations of the
IHRT through--
(1) charging IHRT participants account fees for use of the
trust;
(2) charging authorized EHR data users for accessing
electronic health records maintained in the trust;
(3) the sale of information contained in the trust (as
provided for in section 846(a)(3)(A)); and
(4) any other activity determined appropriate by the
Federal Trade Commission.

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(b) Prohibition Against Access Fees for Health Care
Providers.--For purposes of providing incentives to health
care providers to access information maintained in an IHRT,
as authorized by the IHRT participants involved, the IHRT may
not charge a fee for services specified by the IHRT. Such
services shall include the transmittal of information from a
health care provider to be included in an independent
electronic health record maintained by the IHRT (or
permitting such provider to input such information into the
record), including the transmission of or access to
information described in section 846(a)(2)(C)(ii) by
appropriate emergency responders.
(c) Required Disclosures.--The sources and amounts of
revenue derived under subsection (a) for the operations of an
IHRT shall be fully disclosed to each IHRT participant of
such IHRT and to the public.
(d) Treatment of Income.--For purposes of the Internal
Revenue Code of 1986, any revenue described in subsection (a)
shall not be included in gross income of any IHRT, IHRT
participant, or authorized EHR data user.

SEC. 849. REGULATORY OVERSIGHT.

(a) In General.--In carrying out this subtitle, the Federal
Trade Commission shall promulgate regulations for independent
health record trusts.
(b) Establishment of Interagency Steering Committee.--
(1) In general.--The Secretary of Health and Human Services
shall establish an Interagency Steering Committee in
accordance with this subsection.
(2) Chairperson.--The Secretary of Health and Human
Services shall serve as the chairperson of the Interagency
Steering Committee.
(3) Membership.--The members of the Interagency Steering
Committee shall consist of the Attorney General, the
Chairperson of the Federal Trade Commission, the Chairperson
for the National Committee for Vital and Health Statistics, a
representative of the Federal Reserve, and other Federal
officials determined appropriate by the Secretary of Health
and Human Services.
(4) Duties.--The Interagency Steering Committee shall
coordinate the implementation of this title, including the
implementation of policies described in subsection (d) based
upon the recommendations provided under such subsection, and
regulations promulgated under this subtitle.
(c) Federal Advisory Committee.--
(1) In general.--The National Committee for Vital and
Health Statistics shall serve as an advisory committee for
the IHRTs. The membership of such advisory committee shall
include a representative from the Federal Trade Commission
and the chairperson of the Interagency Steering Committee.
Not less than 60 percent of such membership shall consist of
representatives of nongovernment entities, at least one of
whom shall be a representative from an organization
representing health care consumers.
(2) Duties.--The National Committee for Vital and Health
Statistics shall issue periodic reports and review policies
concerning IHRTs based on each of the following factors:
(A) Privacy and security policies.
(B) Economic progress.
(C) Interoperability standards.
(d) Policies Recommended by Federal Trade Commission.--The
Federal Trade Commission, in consultation with the National
Committee for Vital and Health Statistics, shall recommend
policies to--
(1) provide assistance to encourage the growth of
independent health record trusts;
(2) track economic progress as it pertains to operators of
independent health records trusts and individuals receiving
nontaxable income with respect to accounts;
(3) conduct public education activities regarding the
creation and usage of the independent health records trusts;
(4) establish standards for the interoperability of health
information technology to ensure that information contained
in such record may be shared between the trust involved, the
participant, and authorized EHR data users, including for the
standardized collection and transmission of individual health
records (or portions of such records) to authorized EHR data
users through a common interface and for the portability of
such records among independent health record trusts; and
(5) carry out any other activities determined appropriate
by the Federal Trade Commission.
(e) Regulations Promulgated by Federal Trade Commission.--
The Federal Trade Commission shall promulgate regulations
based on, at a minimum, the following factors:
(1) Requiring that an IHRT participant, who has an
electronic health record that is maintained by an IHRT, be
notified of a security breech with respect to such record,
and any corrective action taken on behalf of the participant.
(2) Requiring that information sent to, or received from,
an IHRT that has been designated as high-risk should be
authenticated through the use of methods such as the periodic
changing of passwords, the use of biometrics, the use of
tokens or other technology as determined appropriate by the
council.
(3) Requiring a delay in releasing sensitive health care
test results and other similar information to patients
directly in order to give physicians time to contact the
patient.
(4) Recommendations for entities operating IHRTs, including
requiring analysis of the potential risk of health
transaction security breeches based on set criteria.
(5) The conduct of audits of IHRTs to ensure that they are
in compliance with the requirements and standards established
under this subtitle.
(6) Disclosure to IHRT participants of the means by which
such trusts are financed, including revenue from the sale of
patient data.
(7) Prevention of certification of an entity seeking
independent heath record trust certification based on--
(A) the potential for conflicts between the interests of
such entity and the security of the health information
involved; and
(B) the involvement of the entity in any activity that is
contrary to the best interests of a patient.
(8) Prevention of the use of revenue sources that are
contrary to a patient's interests.
(9) Public disclosure of audits in a manner similar to
financial audits required for publicly traded stock
companies.
(10) Requiring notification to a participating entity that
the information contained in such record may not be
representative of the complete or accurate electronic health
record of such account holder.
(f) Compliance Report.--Not later than 1 year after the
date of the enactment of this Act, and annually thereafter,
the Commission shall submit to the Committee on Health,
Education, Labor, and Pensions and the Committee on Finance
of the Senate and the Committee on Energy and Commerce and
the Committee on Ways and Means of the House of
Representatives, a report on compliance by and progress of
independent health record trusts with this subtitle. Such
report shall describe the following:
(1) The number of complaints submitted about independent
health record trusts, which shall be divided by complaints
related to security breaches, and complaints not related to
security breaches, and may include other categories as the
Interagency Steering Committee established under subsection
(b) determines appropriate.
(2) The number of enforcement actions undertaken by the
Commission against independent health record trusts in
response to complaints under paragraph (1), which shall be
divided by enforcement actions related to security breaches
and enforcement actions not related to security breaches and
may include other categories as the Interagency Steering
Committee established under subsection (b) determines
appropriate.
(3) The economic progress of the individual owner or
institution operator as achieved through independent health
record trust usage and existing barriers to such usage.
(4) The progress in security auditing as provided for by
the Interagency Steering Committee council under subsection
(b).
(5) The other core responsibilities of the Commission as
described in subsection (a).
(g) Interagency Memorandum of Understanding.--The
Interagency Steering Committee shall ensure, through the
execution of an interagency memorandum of understanding,
that--
(1) regulations, rulings, and interpretations issued by
Federal officials relating to the same matter over which 2 or
more such officials have responsibility under this subtitle
are administered so as to have the same effect at all times;
and
(2) the memorandum provides for the coordination of
policies related to enforcing the same requirements through
such officials in order to have coordinated enforcement
strategy that avoids duplication of enforcement efforts and
assigns priorities in enforcement.

TITLE IX--MISCELLANEOUS

SEC. 901. HEALTH CARE CHOICE FOR VETERANS.

Beginning not later than 2 years after the date of the
enactment of this Act, the Secretary of Veterans Affairs
may--
(1) permit veterans, and survivors and dependents of
veterans, who are eligible for health care and services under
the laws administered by the Secretary to receive such care
and services through such non-Department of Veterans Affairs
providers and facilities as the Secretary may approve for
purposes of this section; and
(2) pursuant to such procedures as the Secretary of Veteran
Affairs shall prescribe for purposes of this section, make
payments to such providers and facilities for the provision
of such care and services to veterans, and such survivors and
dependents, at such rates as the Secretary may specify in
such procedures and in such manner so that the Secretary
ensures that the aggregate payments made by the Secretary to
such providers and facilities do not exceed the aggregate
amounts which the Secretary would have paid for such care and
services if this section had not been enacted.

SEC. 902. HEALTH CARE CHOICE FOR INDIANS.

(a) In General.--Beginning not later than 2 years after the
date of enactment of this Act, the Secretary of Health and
Human Services shall--
(1) permit Indians who are eligible for health care and
services under a health care program operated or financed by
the Indian Health Service or by an Indian Tribe, Tribal
Organization, or Urban Indian Organization (and any such
other individuals who are so eligible as the Secretary may
specify), to receive such care and services through such non-
Indian Health Service, Indian Tribe, Tribal Organization, or
Urban Indian Organization providers and facilities as the
Secretary shall approve for purposes of this section; and
(2) pursuant to such procedures as the Secretary of Health
and Human Services shall

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prescribe for purposes of this section, make payments to such
providers and facilities for the provision of such care and
services to Indians and individuals described in paragraph
(1), at such rates as the Secretary shall specify in such
procedures and in such manner so that the Secretary ensures
that the aggregate payments made by the Secretary to such
providers and facilities do not exceed the aggregate amounts
which the Secretary would have paid for such care and
services if this section had not been enacted.
(b) Definitions.--In this section, the terms ``Indian'',
``Indian Health Program'', ``Indian Tribe'', ``Tribal
Organization'', and ``Urban Indian Organization'' have the
meanings given those terms in section 4 of the Indian Health
Care Improvement Act.

SEC. 903. TERMINATION OF FEDERAL COORDINATING COUNCIL FOR
COMPARATIVE EFFECTIVENESS RESEARCH.

The Federal Coordinating Council for Comparative
Effectiveness Research is hereby terminated and section 804
of the American Recovery and Reinvestment Act of 2009
establishing and funding such Council is hereby repealed.

SEC. 904. HHS AND GAO JOINT STUDY AND REPORT ON COSTS OF THE
5 MEDICAL CONDITIONS THAT HAVE THE GREATEST
IMPACT.

(a) Study.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') and the
Comptroller General of the United States (in this section
referred to as the ``Comptroller General'') shall jointly
conduct a study on the costs of the top 5 medical conditions
facing the public which have the greatest impact in terms of
morbidity, mortality, and financial cost. Such study shall
include--
(1) current estimates as well as a ``generational score''
to capture the financial cost and health toll certain medical
conditions will inflict on the baby boomer generation and on
other individuals; and
(2) a careful review of certain medical conditions,
including heart disease, obesity, diabetes, stroke, cancer,
Alzheimers, and other medical conditions the Secretary and
Comptroller General determine appropriate.
(b) Report.--Not later than 1 year after the date of
enactment of this Act, the Secretary and the Comptroller
General shall jointly 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 and the Comptroller
General determine appropriate.
(c) Targeting of Prevention and Wellness Efforts.--The
Secretary shall target prevention and wellness efforts
conducted under the provisions of and amendments made by this
Act in order to combat medical conditions identified in the
report submitted under subsection (b), including such medical
conditions identified as the top 5 medical conditions facing
the public which have the greatest impact in terms of
morbidity, mortality, and financial cost as of or after the
date of enactment of this Act.

SEC. 905. CONSCIENCE PROTECTION.

(a) In General.--None of the funds made available in this
Act (or an amendment made by this Act) may be made available
to a Federal agency or program, or to a State or local
government, if such agency, program, or government subjects
any institutional or individual health care entity to
discrimination on the basis that the health care entity does
not provide, pay for, provide coverage of, or refer for
abortions.
(b) Health Care Entity.--In this section, the term ``health
care entity'' shall include an individual physician or other
health care professional, a hospital, a provider-sponsored
organization, a health maintenance organization, a health
insurance plan, or any other kind of health care facility,
organization, or plan.

SEC. 906. NONDISCRIMINATION ON ABORTION AND RESPECT FOR
RIGHTS OF CONSCIENCE.

(a) Nondiscrimination.--A Federal agency or program, and
any State or local government, or institutional health care
entity that receives Federal financial assistance under this
Act (or an amendment made by this Act), shall not--
(1) subject any individual or institutional health care
entity to discrimination; or
(2) require any health care entity that is established or
regulated under this Act (or an amendment made by this Act)
to subject any individual or institutional health care entity
to discrimination;
on the basis that such health care entity does not provide,
pay for, provide coverage of, or refer for abortions.
(b) Definition.--In this section, the term ``health care
entity'' includes an individual physician or other health
care professional, a hospital, a provider-sponsored
organization, a health maintenance organization, a health
insurance plan, a plan sponsor, a health insurance issuer, a
qualified health plan or issuer offering such a plan, or any
other kind of health care facility, organization, or plan.
(c) Administration.--The Office for Civil Rights of the
Department of Health and Human Services is designated to
receive complaints of discrimination based on this section,
and coordinate the investigation of such complaints.

SEC. 907. PROHIBITION ON GOVERNMENT ENTITIES USING
COMPARATIVE EFFECTIVENESS RESEARCH FOR CERTAIN
PURPOSES.

Comparative effectiveness research and clinical
effectiveness research shall not be used by any government
entity for payment, coverage, or treatment decisions based on
costs. Nothing in the preceding sentence shall limit a
physician or other health care provider from using reports
and recommendations of a government entity when making
decisions about the best treatment for an individual patient
in an individual circumstance.

SEC. 908. SOLVENCY OF MEDICARE PROGRAM.

Any savings achieved under the Medicare program pursuant to
the measures developed and implemented by the Secretary of
Health and Human Services under this Act (or an amendment
made by this Act) shall be reinvested into the Federal
Hospital Insurance Trust Fund, as established under section
1817 of the Social Security Act (4218 U.S.C. 1395i), or the
Federal Supplementary Medical Insurance Trust Fund, as
established under section 1841 of such Act (42 U.S.C. 1395t).

SEC. 909. TO ENSURE PATIENTS RECEIVE DOCTOR RECOMMENDATIONS
FOR PREVENTIVE HEALTH SERVICES, INCLUDING
MAMMOGRAMS AND CERVICAL CANCER SCREENING,
WITHOUT INTERFERENCE FROM GOVERNMENT OR
INSURANCE COMPANY.

(a) In General.--Notwithstanding any other provision of
law, the Secretary of Health and Human Services shall not use
any recommendation made by the United States Preventive
Services Task Force to deny coverage of an item or service by
a group health plan or health insurance issuer offering group
or individual health insurance coverage or under a Federal
health care program (as defined in section 1128B(f) of the
Social Security Act (42 U.S.C.1320a-7b(f))) or private
insurance.
(b) Determinations of Benefits Coverage.--A group health
plan and a health insurance issuer offering group or
individual health insurance coverage shall, in determining
which preventive items and services to provide coverage for
under the plan or coverage, consult the medical guidelines
and recommendations of relevant professional medical
organizations of relevant medical practice areas (such as the
American Society of Clinical Oncology, the American College
of Surgeons, the American College of Radiation Oncology, the
American College of Obstetricians and Gynecologists, and
other similar organizations), including guidelines and
recommendations relating to the coverage of women's
preventive services (such as mammograms and cervical cancer
screenings).

SEC. 910. ENSURING THAT GOVERNMENT HEALTH CARE RATIONING DOES
NOT HARM, INJURE, OR DENY MEDICALLY NECESSARY
CARE.

Notwithstanding any other provision of law--
(1) no individual may be denied health care based on age or
life expectancy by any Federal health program; and
(2) no entity of the Federal Government may develop
Quality-Adjusted Life Year measures or other similarly
designed government formulas based on an individual's social
utility for limiting access to necessary medical treatment.

SEC. 911. IDENTIFICATION OF FEDERAL GOVERNMENT HEALTH CARE
RATIONING.

(a) In General.--The Comptroller General of the United
States shall conduct, and submit to Congress a report
describing the results of, a study that compares, with regard
to the programs described in subsection (b)--
(1) any restrictions or limitations regarding access to
health care providers (including the percentage of health
care providers willing or permitted to care for patients
insured by each program);
(2) any restrictions, denials, or rationing relating to the
provision of health care, including medical procedures, tests
(including mammograms and cervical cancer screenings), and
prescription drug formularies;
(3) average wait times to see a primary care doctor;
(4) average wait times for medically necessary surgeries
and medical procedures; and
(5) the estimated waste, fraud, and abuse (including
improper payments) in each program.
(b) Programs.----The programs referred to in subsection (a)
are--
(1) Medicare;
(2) Medicaid;
(3) the Indian Health Service;
(4) the Department of Veterans Affairs; and
(5) the Federal Employee Health Benefits Program.

SEC. 912. USING HEALTH CARE PROFESSIONALS TO REDUCE FRAUD.

(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'' shall
establish a demonstration project that uses practicing health
care professionals to conduct undercover investigations of
other health care professionals.
(b) Demonstration Project.--
(1) In general.--The Secretary, in coordination with the
Office of the Inspector General of the Department of Health
and Human Services (referred to in this section as the ``
`Inspector General' ''), shall establish a demonstration
project in which the Secretary enters into contracts with
practicing health care professionals to conduct
investigations of health care providers that receive
reimbursements through any Federal public health care
program.
(2) Scope.--The Secretary shall conduct the demonstration
project under this section in States or regions that have--
(A) above-average rates of Medicare fraud; or

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(B) any level of Medicaid fraud.
(c) Eligibility.--To be eligible to receive a contract
under subsection (b)(1), a health care professional shall--
(1) be a licensed and practicing medical professional who
holds an advanced medical degree from an accredited American
university or college and has experience within the health
care industry; and
(2) submit to the Secretary such information, at such time,
and in such manner, as the Secretary may require.
(d) Activities.--Each health care professional awarded a
contract under subsection (b)(1) shall assist the Secretary
and the Inspector General in conducting random audits of the
practices of health care providers that receive
reimbursements through any Federal public health care
program. Such audits may include--
(1) statistically random visits to the practices of such
health care providers;
(2) attempts to purchase pharmaceutical products illegally
from such health care providers;
(3) purchasing durable medical equipment from such health
care providers;
(4) hospital visits; and
(5) other activities, as the Secretary determines
appropriate.
(e) Follow-up by the Inspector General.--The Inspector
General shall follow up on any notable findings of the
investigations conducted under subsection (d) in order to
report fraudulent practices and refer individual cases to the
appropriate State and local authorities.
(f) Limitation.--The Secretary shall not contract with a
health care professional if, due to physical proximity or a
personal, familial, proprietary, or monetary relationship
with such health care professional to individuals that such
professional would be investigating, a conflict of interest
could be inferred.
(g) Funding.--To carry out this section, the Secretary and
the Inspector General are each authorized to reserve, from
amounts appropriated to the Department of Health and Human
Services and the Office of the Inspector General of the
Department of Health and Human Services, respectively,
$500,000 for each of fiscal years 2010 through 2014.

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