# H.R. 3200/Division B/Title IX
## TITLE IX — Miscellaneous Provisions
### Sec. 1901. Repeal of Trigger Provision.

    Subtitle A of title VIII of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173) is repealed and the provisions of law amended by such subtitle are restored as if such subtitle had never been enacted.

### Sec. 1902. Repeal of Comparative Cost Adjustment (CCA) Program.

    Section 1860C–1 of the Social Security Act (42 U.S.C. 1395w–29), as added by section 241(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173), is repealed.

### Sec. 1903. Extension of Gainsharing Demonstration.

    (a) In General.—
       Subsection (d)(3) of section 5007 of the Deficit Reduction Act of 2005 (Public Law 109-171) is amended by inserting ``(or September 30, 2011, in the case of a demonstration project in operation as of October 1, 2008)´´ after ``December 31, 2009´´.
    (b) Funding.—
          (1) In General.—
             Subsection (f)(1) of such section is amended by inserting ``and for fiscal year 2010, $1,600,000,´´ after ``$6,000,000,´´.
          (2) Availability.—
             Subsection (f)(2) of such section is amended by striking ``2010´´ and inserting ``2014 or until expended´´.
    (c) Reports.—
          (1) Quality Improvement and Savings.—
             Subsection (e)(3) of such section is amended by striking ``December 1, 2008´´ and inserting ``March 31, 2011´´.
          (2) Final Report.—
             Subsection (e)(4) of such section is amended by striking ``May 1, 2010´´ and inserting ``March 31, 2013´´.

### Sec. 1904. Grants to States for Quality Home Visitation Programs for Families with Young Children and Families Expecting Children.

    Part B of title IV of the Social Security Act (42 U.S.C. 621–629i) is amended by adding at the end the following:
``subpart 3—Support for quality home visitation programs
``SEC. 440. Home visitation programs for families with young children and families expecting children.
       ``(a) Purpose.—The purpose of this section is to improve the well-being, health, and development of children by enabling the establishment and expansion of high quality programs providing voluntary home visitation for families with young children and families expecting children.
       ``(b) Grant application.—A State that desires to receive a grant under this section shall submit to the Secretary for approval, at such time and in such manner as the Secretary may require, an application for the grant that includes the following:
          ``(1) Description of home visitation programs.—A description of the high quality programs of home visitation for families with young children and families expecting children that will be supported by a grant made to the State under this section, the outcomes the programs are intended to achieve, and the evidence supporting the effectiveness of the programs.
          ``(2) Results of needs assessment.—The results of a statewide needs assessment that describes—
             ``(A) the number, quality, and capacity of home visitation programs for families with young children and families expecting children in the State;
             ``(B) the number and types of families who are receiving services under the programs;
             ``(C) the sources and amount of funding provided to the programs;
             ``(D) the gaps in home visitation in the State, including identification of communities that are in high need of the services; and
             ``(E) training and technical assistance activities designed to achieve or support the goals of the programs.
          ``(3) Assurances.—Assurances from the State that—
             ``(A) in supporting home visitation programs using funds provided under this section, the State shall identify and prioritize serving communities that are in high need of such services, especially communities with a high proportion of low-income families or a high incidence of child maltreatment;
             ``(B) the State will reserve 5 percent of the grant funds for training and technical assistance to the home visitation programs using such funds;
             ``(C) in supporting home visitation programs using funds provided under this section, the State will promote coordination and collaboration with other home visitation programs (including programs funded under title XIX) and with other child and family services, health services, income supports, and other related assistance;
             ``(D) home visitation programs supported using such funds will, when appropriate, provide referrals to other programs serving children and families; and
             ``(E) the State will comply with subsection (i), and cooperate with any evaluation conducted under subsection (j).
          ``(4) Other information.—Such other information as the Secretary may require.
       ``(c) Allotments.—
          ``(1) Indian tribes.—From the amount reserved under subsection (l)(2) for a fiscal year, the Secretary shall allot to each Indian tribe that meets the requirement of subsection (d), if applicable, for the fiscal year the amount that bears the same ratio to the amount so reserved as the number of children in the Indian tribe whose families have income that does not exceed 200 percent of the poverty line bears to the total number of children in such Indian tribes whose families have income that does not exceed 200 percent of the poverty line.
          ``(2) States and territories.—From the amount appropriated under subsection (m) for a fiscal year that remains after making the reservations required by subsection (l), the Secretary shall allot to each State that is not an Indian tribe and that meets the requirement of subsection (d), if applicable, for the fiscal year the amount that bears the same ratio to the remainder of the amount so appropriated as the number of children in the State whose families have income that does not exceed 200 percent of the poverty line bears to the total number of children in such States whose families have income that does not exceed 200 percent of the poverty line.
          ``(3) Reallotments.—The amount of any allotment to a State under a paragraph of this subsection for any fiscal year that the State certifies to the Secretary will not be expended by the State pursuant to this section shall be available for reallotment using the allotment methodology specified in that paragraph. Any amount so reallotted to a State is deemed part of the allotment of the State under this subsection.
       ``(d) Maintenance of effort.—Beginning with fiscal year 2011, a State meets the requirement of this subsection for a fiscal year if the Secretary finds that the aggregate expenditures by the State from State and local sources for programs of home visitation for families with young children and families expecting children for the then preceding fiscal year was not less than 100 percent of such aggregate expenditures for the then 2nd preceding fiscal year.
       ``(e) Payment of grant.—
          ``(1) In general.—The Secretary shall make a grant to each State that meets the requirements of subsections (b) and (d), if applicable, for a fiscal year for which funds are appropriated under subsection (m), in an amount equal to the reimbursable percentage of the eligible expenditures of the State for the fiscal year, but not more than the amount allotted to the State under subsection (c) for the fiscal year.
          ``(2) Reimbursable percentage defined.—In paragraph (1), the term ‘reimbursable percentage’ means, with respect to a fiscal year—
             ``(A) 85 percent, in the case of fiscal year 2010;
             ``(B) 80 percent, in the case of fiscal year 2011; or
             ``(C) 75 percent, in the case of fiscal year 2012 and any succeeding fiscal year.
       ``(f) Eligible expenditures.—
          ``(1) In general.—In this section, the term ‘eligible expenditures’—
             ``(A) means expenditures to provide voluntary home visitation for as many families with young children (under the age of school entry) and families expecting children as practicable, through the implementation or expansion of high quality home visitation programs that—
                ``(i) adhere to clear evidence-based models of home visitation that have demonstrated positive effects on important program-determined child and parenting outcomes, such as reducing abuse and neglect and improving child health and development;
                ``(ii) employ well-trained and competent staff, maintain high quality supervision, provide for ongoing training and professional development, and show strong organizational capacity to implement such a program;
                ``(iii) establish appropriate linkages and referrals to other community resources and supports;
                ``(iv) monitor fidelity of program implementation to ensure that services are delivered according to the specified model; and
                ``(v) provide parents with—
                   ``(I) knowledge of age-appropriate child development in cognitive, language, social, emotional, and motor domains (including knowledge of second language acquisition, in the case of English language learners);
                   ``(II) knowledge of realistic expectations of age-appropriate child behaviors;
                   ``(III) knowledge of health and wellness issues for children and parents;
                   ``(IV) modeling, consulting, and coaching on parenting practices;
                   ``(V) skills to interact with their child to enhance age-appropriate development;
                   ``(VI) skills to recognize and seek help for issues related to health, developmental delays, and social, emotional, and behavioral skills; and
                   ``(VII) activities designed to help parents become full partners in the education of their children;
             ``(B) includes expenditures for training, technical assistance, and evaluations related to the programs; and
             ``(C) does not include any expenditure with respect to which a State has submitted a claim for payment under any other provision of Federal law.
          ``(2) Priority funding for programs with strongest evidence.—
             ``(A) In general.—The expenditures, described in paragraph (1), of a State for a fiscal year that are attributable to the cost of programs that do not adhere to a model of home visitation with the strongest evidence of effectiveness shall not be considered eligible expenditures for the fiscal year to the extent that the total of the expenditures exceeds the applicable percentage for the fiscal year of the allotment of the State under subsection (c) for the fiscal year.
             ``(B) Applicable percentage defined.—In subparagraph (A), the term ‘applicable percentage’ means, with respect to a fiscal year—
                ``(i) 60 percent for fiscal year 2010;
                ``(ii) 55 percent for fiscal year 2011;
                ``(iii) 50 percent for fiscal year 2012;
                ``(iv) 45 percent for fiscal year 2013; or
                ``(v) 40 percent for fiscal year 2014.
       ``(g) No use of other federal funds for state match.—A State to which a grant is made under this section may not expend any Federal funds to meet the State share of the cost of an eligible expenditure for which the State receives a payment under this section.
       ``(h) Waiver authority.—
          ``(1) In general.—The Secretary may waive or modify the application of any provision of this section, other than subsection (b) or (f), to an Indian tribe if the failure to do so would impose an undue burden on the Indian tribe.
          ``(2) Special rule.—An Indian tribe is deemed to meet the requirement of subsection (d) for purposes of subsections (c) and (e) if—
             ``(A) the Secretary waives the requirement; or
             ``(B) the Secretary modifies the requirement, and the Indian tribe meets the modified requirement.
       ``(i) State reports.—Each State to which a grant is made under this section shall submit to the Secretary an annual report on the progress made by the State in addressing the purposes of this section. Each such report shall include a description of—
          ``(1) the services delivered by the programs that received funds from the grant;
          ``(2) the characteristics of each such program, including information on the service model used by the program and the performance of the program;
          ``(3) the characteristics of the providers of services through the program, including staff qualifications, work experience, and demographic characteristics;
          ``(4) the characteristics of the recipients of services provided through the program, including the number of the recipients, the demographic characteristics of the recipients, and family retention;
          ``(5) the annual cost of implementing the program, including the cost per family served under the program;
          ``(6) the outcomes experienced by recipients of services through the program;
          ``(7) the training and technical assistance provided to aid implementation of the program, and how the training and technical assistance contributed to the outcomes achieved through the program;
          ``(8) the indicators and methods used to monitor whether the program is being implemented as designed; and
          ``(9) other information as determined necessary by the Secretary.
       ``(j) Evaluation.—
          ``(1) In general.—The Secretary shall, by grant or contract, provide for the conduct of an independent evaluation of the effectiveness of home visitation programs receiving funds provided under this section, which shall examine the following:
             ``(A) The effect of home visitation programs on child and parent outcomes, including child maltreatment, child health and development, school readiness, and links to community services.
             ``(B) The effectiveness of home visitation programs on different populations, including the extent to which the ability of programs to improve outcomes varies across programs and populations.
          ``(2) Reports to the congress.—
             ``(A) Interim report.—Within 3 years after the date of the enactment of this section, the Secretary shall submit to the Congress an interim report on the evaluation conducted pursuant to paragraph (1).
             ``(B) Final report.—Within 5 years after the date of the enactment of this section, the Secretary shall submit to the Congress a final report on the evaluation conducted pursuant to paragraph (1).
       ``(k) Annual reports to the congress.—The Secretary shall submit annually to the Congress a report on the activities carried out using funds made available under this section, which shall include a description of the following:
          ``(1) The high need communities targeted by States for programs carried out under this section.
          ``(2) The service delivery models used in the programs receiving funds provided under this section.
          ``(3) The characteristics of the programs, including—
             ``(A) the qualifications and demographic characteristics of program staff; and
             ``(B) recipient characteristics including the number of families served, the demographic characteristics of the families served, and family retention and duration of services.
          ``(4) The outcomes reported by the programs.
          ``(5) The research-based instruction, materials, and activities being used in the activities funded under the grant.
          ``(6) The training and technical activities, including on-going professional development, provided to the programs.
          ``(7) The annual costs of implementing the programs, including the cost per family served under the programs.
          ``(8) The indicators and methods used by States to monitor whether the programs are being been implemented as designed.
       ``(l) Reservations of funds.—From the amounts appropriated for a fiscal year under subsection (m), the Secretary shall reserve—
          ``(1) an amount equal to 5 percent of the amounts to pay the cost of the evaluation provided for in subsection (j), and the provision to States of training and technical assistance, including the dissemination of best practices in early childhood home visitation; and
          ``(2) after making the reservation required by paragraph (1), an amount equal to 3 percent of the amount so appropriated, to pay for grants to Indian tribes under this section.
       ``(m) Appropriations.—Out of any money in the Treasury of the United States not otherwise appropriated, there is appropriated to the Secretary to carry out this section—
          ``(1) $50,000,000 for fiscal year 2010;
          ``(2) $100,000,000 for fiscal year 2011;
          ``(3) $150,000,000 for fiscal year 2012;
          ``(4) $200,000,000 for fiscal year 2013; and
          ``(5) $250,000,000 for fiscal year 2014.
       ``(n) Indian tribes treated as States.—In this section, paragraphs (4), (5), and (6) of section 431(a) shall apply.´´.

### Sec. 1905. Improved Ccoordination and Protection for Dual Eligibles.

    Title XI of the Social Security Act is amended by inserting after section 1150 the following new section:
``Improved coordination and protection for dual eligibles
    ``Sec. 1150A. (a) In general.—The Secretary shall provide, through an identifiable office or program within the Centers for Medicare & Medicaid Services, for a focused effort to provide for improved coordination between Medicare and Medicaid and protection in the case of dual eligibles (as defined in subsection (e)). The office or program shall—
          ``(1) review Medicare and Medicaid policies related to enrollment, benefits, service delivery, payment, and grievance and appeals processes under parts A and B of title XVIII, under the Medicare Advantage program under part C of such title, and under title XIX;
          ``(2) identify areas of such policies where better coordination and protection could improve care and costs; and
          ``(3) issue guidance to States regarding improving such coordination and protection.
       ``(b) Elements.—The improved coordination and protection under this section shall include efforts—
          ``(1) to simplify access of dual eligibles to benefits and services under Medicare and Medicaid;
          ``(2) to improve care continuity for dual eligibles and ensure safe and effective care transitions;
          ``(3) to harmonize regulatory conflicts between Medicare and Medicaid rules with regard to dual eligibles; and
          ``(4) to improve total cost and quality performance under Medicare and Medicaid for dual eligibles.
       ``(c) Responsibilities.—In carrying out this section, the Secretary shall provide for the following:
          ``(1) An examination of Medicare and Medicaid payment systems to develop strategies to foster more integrated and higher quality care.
          ``(2) Development of methods to facilitate access to post-acute and community-based services and to identify actions that could lead to better coordination of community-based care.
          ``(3) A study of enrollment of dual eligibles in the Medicare Savings Program (as defined in section 1144(c)(7)), under Medicaid, and in the low-income subsidy program under section 1860D–14 to identify methods to more efficiently and effectively reach and enroll dual eligibles.
          ``(4) An assessment of communication strategies for dual eligibles to determine whether additional informational materials or outreach is needed, including an assessment of the Medicare website, 1–800–MEDICARE, and the Medicare handbook.
          ``(5) Research and evaluation of areas where service utilization, quality, and access to cost sharing protection could be improved and an assessment of factors related to enrollee satisfaction with services and care delivery.
          ``(6) Collection (and making available to the public) of data and a database that describe the eligibility, benefit and cost-sharing assistance available to dual eligibles by State.
          ``(7) Monitoring total combined Medicare and Medicaid program costs in serving dual eligibles and making recommendations for optimizing total quality and cost performance across both programs.
          ``(8) Coordination of activities relating to Medicare Advantage plans under 1859(b)(6)(B)(ii) and Medicaid.
       ``(d) Periodic reports.—Not later than 1 year after the date of the enactment of this section and every 3 years thereafter the Secretary shall submit to Congress a report on progress in activities conducted under this section.
       ``(e) Definitions.—In this section:
          ``(1) Dual eligible.—The term ‘dual eligible’ means an individual who is dually eligible for benefits under title XVIII, and medical assistance under title XIX, including such individuals who are eligible for benefits under the Medicare Savings Program (as defined in section 1144(c)(7)).
          ``(2) Medicare; Medicaid.—The terms ‘Medicare’ and ‘Medicaid’ mean the programs under titles XVIII and XIX, respectively.´´.