# Children's Health Insurance Program Reauthorization Act of 2009/Title VI/Subtitle C
### SEC. 621. OUTREACH REGARDING HEALTH INSURANCE OPTIONS AVAILABLE TO CHILDREN.

    (a) DEFINITIONS.—In this section—
       (1) the terms ‘‘Administration’’ and ‘‘Administrator’’ means the Small Business Administration and the Administrator thereof, respectively;
       (2) the term ‘‘certified development company’’ means a development company participating in the program under title V of the Small Business Investment Act of 1958 (15 U.S.C. 695 et seq.);
       (3) the term ‘‘Medicaid program’’ means the program established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.);
       (4) the term ‘‘Service Corps of Retired Executives’’ means the Service Corps of Retired Executives authorized by section 8(b)(1) of the Small Business Act (15 U.S.C. 637(b)(1));
       (5) the term ‘‘small business concern’’ has the meaning given that term in section 3 of the Small Business Act (15 U.S.C. 632);
       (6) the term ‘‘small business development center’’ means a small business development center described in section 21 of the Small Business Act (15 U.S.C. 648);
       (7) the term ‘‘State’’ has the meaning given that term for purposes of title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.);
       (8) the term ‘‘State Children’s Health Insurance Program’’ means the State Children’s Health Insurance Program established under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.);
       (9) the term ‘‘task force’’ means the task force established under subsection (b)(1); and
       (10) the term ‘‘women’s business center’’ means a women’s business center described in section 29 of the Small Business Act (15 U.S.C. 656).
    (b) ESTABLISHMENT OF TASK FORCE.—
       (1) ESTABLISHMENT.—There is established a task force to conduct a nationwide campaign of education and outreach for small business concerns regarding the availability of coverage for children through private insurance options, the Medicaid program, and the State Children’s Health Insurance Program.
       (2) MEMBERSHIP.—The task force shall consist of the Administrator, the Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury.
       (3) RESPONSIBILITIES.—The campaign conducted under this subsection shall include—
          (A) efforts to educate the owners of small business concerns about the value of health coverage for children;
          (B) information regarding options available to the owners and employees of small business concerns to make insurance more affordable, including Federal and State tax deductions and credits for health care-related expenses and health insurance expenses and Federal tax exclusion for health insurance options available under employer-sponsored cafeteria plans under section 125 of the Internal Revenue Code of 1986;
          (C) efforts to educate the owners of small business concerns about assistance available through public programs; and
          (D) efforts to educate the owners and employees of small business concerns regarding the availability of the hotline operated as part of the Insure Kids Now program of the Department of Health and Human Services.
       (4) IMPLEMENTATION.—In carrying out this subsection, the task force may—
          (A) use any business partner of the Administration, including—
             (i) a small business development center;
             (ii) a certified development company;
             (iii) a women’s business center; and
             (iv) the Service Corps of Retired Executives;
          (B) enter into—
             (i) a memorandum of understanding with a chamber of commerce; and
             (ii) a partnership with any appropriate small business concern or health advocacy group; and
          (C) designate outreach programs at regional offices of the Department of Health and Human Services to work with district offices of the Administration.
       (5) WEBSITE.—The Administrator shall ensure that links to information on the eligibility and enrollment requirements for the Medicaid program and State Children’s Health Insurance Program of each State are prominently displayed on the website of the Administration.
       (6) REPORT.—
          (A) IN GENERAL.—Not later than 2 years after the date of enactment of this Act, and every 2 years thereafter, the Administrator shall submit to the Committee on Small Business and Entrepreneurship of the Senate and the Committee on Small Business of the House of Representatives a report on the status of the nationwide campaign conducted under paragraph (1).
          (B) CONTENTS.—Each report submitted under subparagraph (A) shall include a status update on all efforts made to educate owners and employees of small business concerns on options for providing health insurance for children through public and private alternatives.

### SEC. 622. SENSE OF THE SENATE REGARDING ACCESS TO AFFORDABLE AND MEANINGFUL HEALTH INSURANCE COVERAGE.

    (a) FINDINGS.—The Senate finds the following:
       (1) There are approximately 45 million Americans currently without health insurance.
       (2) More than half of uninsured workers are employed by businesses with less than 25 employees or are self-employed.
       (3) Health insurance premiums continue to rise at more than twice the rate of inflation for all consumer goods.
       (4) Individuals in the small group and individual health insurance markets usually pay more for similar coverage than those in the large group market.
       (5) The rapid growth in health insurance costs over the last few years has forced many employers, particularly small employers, to increase deductibles and co-pays or to drop coverage completely.
    (b) SENSE OF THE SENATE.—The Senate—
       (1) recognizes the necessity to improve affordability and access to health insurance for all Americans;
       (2) acknowledges the value of building upon the existing private health insurance market; and
       (3) affirms its intent to enact legislation this year that, with appropriate protection for consumers, improves access to affordable and meaningful health insurance coverage for employees of small businesses and individuals by—
          (A) facilitating pooling mechanisms, including pooling across State lines, and
          (B) providing assistance to small businesses and individuals, including financial assistance and tax incentives, for the purchase of private insurance coverage.

### SEC. 623. LIMITATION ON MEDICARE EXCEPTION TO THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS.

    (a) IN GENERAL.—Section 1877 (42 U.S.C. 1395nn) is amended—
       (1) in subsection (d)(2)—
          (A) in subparagraph (A), by striking ‘‘and’’ at the end;
          (B) in subparagraph (B), by striking the period at the end and inserting ‘‘; and’’; and
          (C) by adding at the end the following new subparagraph:
                   ‘‘(C) in the case where the entity is a hospital, the hospital meets the requirements of paragraph (3)(D).’’;
       (2) in subsection (d)(3)—
          (A) in subparagraph (B), by striking ‘‘and’’ at the end;
          (B) in subparagraph (C), by striking the period at the end and inserting ‘‘; and’’; and
          (C) by adding at the end the following new subparagraph:
                   ‘‘(D) the hospital meets the requirements described in subsection (i)(1).’’; and
       (3) by adding at the end the following new subsection:
             ‘‘(i) REQUIREMENTS FOR HOSPITALS TO QUALIFY FOR RURAL PROVIDER AND HOSPITAL EXCEPTION TO OWNERSHIP OR INVESTMENT PROHIBITION.—
                ‘‘(1) REQUIREMENTS DESCRIBED.—For purposes of subsection (d)(3)(D), the requirements described in this paragraph for a hospital are as follows:
                   ‘‘(A) PROVIDER AGREEMENT.—The hospital had—
                      ‘‘(i) physician ownership or investment on January 1, 2009; and
                      ‘‘(ii) a provider agreement under section 1866 in effect on such date.
                   ‘‘(B) PROHIBITION ON PHYSICIAN OWNERSHIP OR INVESTMENT.—The percentage of the total value of the ownership or investment interests held in the hospital, or in an entity whose assets include the hospital, by physician owners or investors in the aggregate does not exceed such percentage as of the date of enactment of this subsection.
                   ‘‘(C) PROHIBITION ON EXPANSION OF FACILITY CAPACITY.—Except as provided in paragraph (3), the number of operating rooms, procedure rooms, and beds of the hospital at any time on or after the date of the enactment of this subsection are no greater than the number of operating rooms, procedure rooms, and beds as of such date.
                   ‘‘(D) PREVENTING CONFLICTS OF INTEREST.—
                      ‘‘(i) The hospital submits to the Secretary an annual report containing a detailed description of—
                         ‘‘(I) the identity of each physician owner and physician investor and any other owners or investors of the hospital; and
                         ‘‘(II) the nature and extent of all ownership and investment interests in the hospital.
                      ‘‘(ii) The hospital has procedures in place to require that any referring physician owner or investor discloses to the patient being referred, by a time that permits the patient to make a meaningful decision regarding the receipt of care, as determined by the Secretary—
                         ‘‘(I) the ownership or investment interest, as applicable, of such referring physician in the hospital; and
                         ‘‘(II) if applicable, any such ownership or investment interest of the treating physician.
                      ‘‘(iii) The hospital does not condition any physician ownership or investment in terests either directly or indirectly on the physician owner or investor making or influencing referrals to the hospital or otherwise generating business for the hospital.
                      ‘‘(iv) The hospital discloses the fact that the hospital is partially owned by physicians—
                         ‘‘(I) on any public website for the hospital; and
                         ‘‘(II) in any public advertising for the hospital.
                   ‘‘(E) ENSURING BONA FIDE OWNERSHIP AND INVESTMENT.—
                      ‘‘(i) Any ownership or investment interests that the hospital offers to a physician owner or investor are not offered on more favorable terms than the terms offered to a person who is not a physician owner or investor.
                      ‘‘(ii) The hospital (or any investors in the hospital) does not directly or indirectly provide loans or financing for any physician owner or investor in the hospital.
                      ‘‘(iii) The hospital (or any investors in the hospital) does not directly or indirectly guarantee a loan, make a payment toward a loan, or otherwise subsidize a loan, for any individual physician owner or investor or group of physician owners or investors that is related to acquiring any ownership or investment interest in the hospital.
                      ‘‘(iv) Ownership or investment returns are distributed to each owner or investor in the hospital in an amount that is directly proportional to the ownership or investment interest of such owner or investor in the hospital.
                      ‘‘(v) Physician owners and investors do not receive, directly or indirectly, any guaranteed receipt of or right to purchase other business interests related to the hospital, including the purchase or lease of any property under the control of other owners or investors in the hospital or located near the premises of the hospital.
                      ‘‘(vi) The hospital does not offer a physician owner or investor the opportunity to purchase or lease any property under the control of the hospital or any other owner or investor in the hospital on more favorable terms than the terms offered to an individual who is not a physician owner or investor.
                   ‘‘(F) PATIENT SAFETY.—The hospital has the capacity to—
                      ‘‘(i) provide assessment and initial treatment for patients; and
                      ‘‘(ii) refer and transfer patients to hospitals with the capability to treat the needs of the patient involved.
                   ‘‘(G) LIMITATION ON APPLICATION TO CERTAIN CONVERTED FACILITIES.—The hospital was not converted from an ambulatory surgical center to a hospital on or after the date of enactment of this subsection.
                ‘‘(2) PUBLICATION OF INFORMATION REPORTED.—The Secretary shall publish, and update on an annual basis, the information submitted by hospitals under paragraph (1)(D)(i) on the public Internet website of the Centers for Medicare & Medicaid Services.
                ‘‘(3) EXCEPTION TO PROHIBITION ON EXPANSION OF FACILITY CAPACITY.—
                   ‘‘(A) PROCESS.—
                      ‘‘(i) ESTABLISHMENT.—The Secretary shall establish and implement a process under which an applicable hospital (as defined in subparagraph (E)) may apply for an exception from the requirement under paragraph (1)(C).
                      ‘‘(ii) OPPORTUNITY FOR COMMUNITY INPUT.—The process under clause (i) shall provide individuals and entities in the community in which the applicable hospital applying for an exception is located with the opportunity to provide input with respect to the application.
                      ‘‘(iii) TIMING FOR IMPLEMENTATION.—The Secretary shall implement the process under clause (i) on July 1, 2010.
                      ‘‘(iv) REGULATIONS.—Not later than June 1, 2010, the Secretary shall promulgate regulations to carry out the process under clause (i).
                   ‘‘(B) FREQUENCY.—The process described in subparagraph (A) shall permit an applicable hospital to apply for an exception up to once every 2 years.
                   ‘‘(C) PERMITTED INCREASE.—
                      ‘‘(i) IN GENERAL.—Subject to clause (ii) and subparagraph (D), an applicable hospital granted an exception under the process described in subparagraph (A) may increase the number of operating rooms, procedure rooms, and beds of the applicable hospital above the baseline number of operating rooms, procedure rooms, and beds of the applicable hospital (or, if the applicable hospital has been granted a previous exception under this paragraph, above the number of operating rooms, procedure rooms, and beds of the hospital after the application of the most recent increase under such an exception).
                      ‘‘(ii) 100 PERCENT INCREASE LIMITATION.—The Secretary shall not permit an increase in the number of operating rooms, procedure rooms, and beds of an applicable hospital under clause (i) to the extent such increase would result in the number of operating rooms, procedure rooms, and beds of the applicable hospital exceeding 200 percent of the baseline number of operating rooms, procedure rooms, and beds of the applicable hospital.
                      ‘‘(iii) BASELINE NUMBER OF OPERATING ROOMS, PROCEDURE ROOMS, AND BEDS.—In this paragraph, the term ‘baseline number of operating rooms, procedure rooms, and beds’ means the number of operating rooms, procedure rooms, and beds of the applicable hospital as of the date of enactment of this subsection.
                   ‘‘(D) INCREASE LIMITED TO FACILITIES ON THE MAIN CAMPUS OF THE HOSPITAL.— Any increase in the number of operating rooms, procedure rooms, and beds of an applicable hospital pursuant to this paragraph may only occur in facilities on the main campus of the applicable hospital.
                   ‘‘(E) APPLICABLE HOSPITAL.—In this paragraph, the term ‘applicable hospital’ means a hospital—
                      ‘‘(i) that is located in a county in which the percentage increase in the population during the most recent 5-year period (as of the date of the application under subparagraph (A)) is at least 150 percent of the percentage increase in the population growth of the State in which the hospital is located during that period, as estimated by Bureau of the Census and available to the Secretary;
                      ‘‘(ii) whose annual percent of total inpatient admissions that represent inpatient admissions under the program under title XIX is equal to or greater than the average percent with respect to such admissions for all hospitals located in the county in which the hospital is located;
                      ‘‘(iii) that does not discriminate against beneficiaries of Federal health care programs and does not permit physicians practicing at the hospital to discriminate against such beneficiaries;
                      ‘‘(iv) that is located in a State in which the average bed capacity in the State is less than the national average bed capacity; and
                      ‘‘(v) that has an average bed occupancy rate that is greater than the average bed occupancy rate in the State in which the hospital is located.
                   ‘‘(F) PROCEDURE ROOMS.—In this subsection, the term ‘procedure rooms’ includes rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed, except such term shall not include emergency rooms or departments (exclusive of rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed).
                   ‘‘(G) PUBLICATION OF FINAL DECISIONS.—Not later than 60 days after receiving a complete application under this paragraph, the Secretary shall publish in the Federal Register the final decision with respect to such application.
                   ‘‘(H) LIMITATION ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the process under this paragraph (including the establishment of such process).
                ‘‘(4) COLLECTION OF OWNERSHIP AND INVESTMENT INFORMATION.—For purposes of subparagraphs (A)(i) and (B) of paragraph (1), the Secretary shall collect physician ownership and investment information for each hospital.
                ‘‘(5) PHYSICIAN OWNER OR INVESTOR DEFINED.—For purposes of this subsection, the term ‘physician owner or investor’ means a physician (or an immediate family member of such physician) with a direct or an indirect ownership or investment interest in the hospital.
                ‘‘(6) PATIENT SAFETY REQUIREMENT.—In the case of a hospital to which the requirements of paragraph (1) apply, insofar as the hospital described in this subsection admits a patient and does not have any physician available on the premises to provide services during all hours in which the hospital is providing services to such patient, before admitting the patient—
                   ‘‘(A) the hospital shall disclose such fact to a patient; and
                   ‘‘(B) following such disclosure, the hospital shall receive from the patient a signed acknowledgment that the patient understands such fact.
                ‘‘(7) CLARIFICATION.—Nothing in this subsection shall be construed as preventing the Secretary from revoking a hospital’s provider agreement if not in compliance with regulations implementing section 1866.’’.
    (b) ENFORCEMENT.—
       (1) ENSURING COMPLIANCE.—The Secretary of Health and Human Services shall establish policies and procedures to ensure compliance with the requirements described in subsections (i)(1) and (i)(7) of section 1877 of the Social Security Act, as added by subsection (a)(3), beginning on the date such requirements first apply. Such policies and procedures may include unannounced site reviews of hospitals.
       (2) AUDITS.—Beginning not later than July 1, 2011, the Secretary of Health and Human Services shall conduct audits to determine if hospitals violate the requirements referred to in paragraph (1).