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61–643 

" JOINT COMMITTEE PRINT 

111TH CONGRESS

2d Session 

2010

COMPILATION OF PATIENT PROTECTION 

AND AFFORDABLE CARE ACT 

As Amended Through November 1, 2010 

INCLUDING

PATIENT PROTECTION AND AFFORDABLE CARE ACT

HEALTH-RELATED PORTIONS OF THE HEALTH CARE AND

EDUCATION RECONCILIATION ACT OF 2010 

PREPARED FOR THE USE OF THE

COMMITTEE ON WAYS AND MEANS 

COMMITTEE ON ENERGY AND COMMERCE 

COMMITTEE ON EDUCATION AND LABOR 

U.S. HOUSE OF REPRESENTATIVES 

Serial No. 111–5 

(COMMITTEE ON WAYS AND MEANS)

Serial No. 111–A 

(COMMITTEE ON ENERGY AND COMMERCE)

Serial No. 111–A 

(COMMITTEE ON EDUCATION AND LABOR)

NOVEMBER 2010 
COMMITTEE ON WAYS AND MEANS 

SANDER M. LEVIN, Michigan, Acting Chairman 

CHARLES B. RANGEL, New York 

FORTNEY PETE STARK, California 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

JOHN S. TANNER, Tennessee 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

EARL POMEROY, North Dakota 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL JR., New Jersey 

SHELLEY BERKLEY, Nevada 

JOSEPH CROWLEY, New York 

CHRIS VAN HOLLEN, Maryland 

KENDRICK MEEK, Florida 

ALLYSON Y. SCHWARTZ, Pennsylvania 

ARTUR DAVIS, Alabama 

DANNY K. DAVIS, Illinois 

BOB ETHERIDGE, North Carolina 

LINDA T. SA ́ NCHEZ, California 

BRIAN HIGGINS, New York 

JOHN A. YARMUTH, Kentucky 

DAVID CAMP, Michigan 

Ranking Member 

WALLY HERGER, California 

SAM JOHNSON, Texas 

KEVIN BRADY, Texas 

PAUL RYAN, Wisconsin 

ERIC CANTOR, Virginia 

JOHN LINDER, Georgia 

DEVIN NUNES, California 

PAT TIBERI, Ohio 

GINNY BROWN-WAITE, Florida 

GEOFF DAVIS, Kentuckyn 

DAVE G. REICHERT, Washington 

CHARLES W. BOUSTANY JR., Louisiana 

DEAN HELLER, Nevada 

PETER J. ROSKAM, Illinois 

JANICE MAYS, Chief Counsel and Staff Director 

JON TRAUB, Minority Staff Director and Chief Counsel 

(II) 
COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chair 

LOIS CAPPS, California 

MIKE DOYLE, Pennsylvania 

JANE HARMAN, California 

JAN SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

ROY BLUNT, Missouri 

Deputy Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN SHADEGG, Arizona 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

PARKER GRIFFITH, Alabama 

ROBERT E. LATTA, Ohio 

PHILIP S. BARNETT, Staff Director 

DAVID CAVICKE, Minority Chief of Staff 

(III) 
COMMITTEE ON EDUCATION AND LABOR 

GEORGE MILLER, California, Chairman 

DALE E. KILDEE, Michigan 

DONALD M PAYNE, New Jersey 

ROBERT E. ANDREWS, New Jersey 

ROBERT C. SCOTT, Virginia 

LYNN C. WOOLSEY, California 

RUBE ́ N HINOJOSA, Texas 

CAROLYN MCCARTHY, New York 

JOHN F. TIERNEY, Massachusetts 

DENNIS J. KUCINICH, Ohio 

DAVID WU, Oregon 

RUSH D. HOLT, New Jersey 

SUSAN A. DAVIS, California 

RAU ́ L M. GRIJALVA, Arizona 

TIMOTHY H. BISHOP, New York 

JOE SESTAK, Pennsylvania 

DAVE LOEBSACK, Iowa 

MAZIE HIRONO, Hawaii 

JASON ALTMIRE, Pennsylvania 

PHIL HARE, Illinois 

YVETTE CLARKE, New York 

JOE COURTNEY, Connecticut 

CAROL SHEA-PORTER, New Hampshire 

MARCIA FUDGE, Ohio 

JARED POLIS, Colorado 

PAUL TONKO, New York 

PEDRO PIERLUISI, Puerto Rico 

GREGORIO KILILI CAMACHO SABLAN, 

Northern Mariana Islands 

DINA TITUS, Nevada 

JUDY CHU, California 

JOHN KLINE, Minnesota 

Ranking Member 

THOMAS E. PETRI, Wisconsin 

HOWARD ‘‘BUCK’’ MCKEON, California 

PETER HOEKSTRA, Michigan 

MICHAEL N. CASTLE, Delaware 

VERNON J. EHLERS, Michigan 

JUDY BIGGERT, Illinois 

TODD RUSSELL PLATTS, Pennsylvania 

JOE WILSON, South Carolina 

CATHY MCMORRIS RODGERS, Washington 

TOM PRICE, Georgia 

ROB BISHOP, Utah 

BRETT GUTHRIE, Kentucky 

BILL CASSIDY, Louisiana 

TOM MCCLINTOCK, CaliforniA 

DUNCAN D. HUNTER, California 

DAVID P. ROE, Tennessee 

GLENN ‘‘GT’’ THOMPSON, Pennsylvania 

[Vacant] 

MARK ZUCKERMAN, Staff Director 

BARRETT KARR, Minority Staff Director 

Prepared by the staff of the Office of the Legislative Counsel, House of Representatives 

EDWARD G. GROSSMAN, Deputy Legislative Counsel 

with the assistance of 

CRAIG A. STERKX, Publications Coordinator 

ELONDA C. BLOUNT, Staff Assistant 

EMILY M. VOLBERDING, Staff Assistant 

(IV) 
PREFACE 

Description of document.—This document shows the Patient Protection and Affordable Care Act (‘‘PPACA’’; Public Law 

111–148) and the health-care related portions of the Health Care 

and Education Reconciliation Act of 2010 (‘‘HCERA’’; Public Law 

111–152). It consolidates in PPACA the amendments made by title 

X of PPACA and HCERA as well as changes made by public laws 

enacted through October 1, 2010--namely Public Law 111–159, 

Public Law 111–173, and section 202 of Public Law 111–226. 

Preparation of document.—This document was prepared by 

the attorneys and staff of the House Office of the Legislative Counsel (HOLC) originally for the use of its attorneys and clients and 

is being made available by the Committees on Education and 

Labor, Energy and Commerce, and Ways and Means for more general use. This is not intended as an ‘‘official’’ version of the law. Errors in this document are solely the responsibility of HOLC. Please 

email any corrections to ‘‘hlccomments@mail.house.gov’’. 

United States Code citations.—United States Code section 

numbers assigned to sections in PPACA are specified in brackets 

after the section numbers in the heading of each section, viz., 2711 

ø42 U.S.C. 300gg–11¿. 

Updating.—Previous versions of this compilation (dated May 

24, 2010, and July 29, 2010) have been distributed through HOLC 

and were made available for downloading at http://docs.house.gov/ 

energycommerce/ppacacon.pdf. This print is an update of those 

versions to incorporate changes in law made by Public Laws 111– 

159, 111–173, & 111–226 (on pages 150 & 221), as well as a correction on p. 117 of placement of flush sentence in paragraph (2)(B)(ii) 

of sec. 36B(f) of Internal Revenue Code of 1986 (sec. 1401(a) of 

PPACA), a note on p. 801 concerning effective date in sec. 9005(b) 

of PPACA, and the addition of notations on technical errors in execution identified by readers. Please check the various Committee 

websites for further electronic updates. 

(V) 

vii 

C O N T E N T S 

Page 

Patient Protection and Affordable Care Act (Public Law 111–148) 

Sec. 1. Short title; table of contents .............................................................. 1 

TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS 

Subtitle A—Immediate Improvements in Health Care Coverage for All Americans 

Sec. 1001. Amendments to the Public Health Service Act .......................... 13 

Sec. 1002. Health insurance consumer information .................................... 27 

Sec. 1003. Ensuring that consumers get value for their dollars ................. 28 

Sec. 1004. Effective dates ............................................................................... 30 

Subtitle B—Immediate Actions to Preserve and Expand Coverage 

Sec. 1101. Immediate access to insurance for uninsured individuals with 

a preexisting condition ................................................................................. 30 

Sec. 1102. Reinsurance for early retirees ..................................................... 33 

Sec. 1103. Immediate information that allows consumers to identify affordable coverage options ............................................................................. 36 

Sec. 1104. Administrative simplification ...................................................... 37 

Sec. 1105. Effective date ................................................................................. 44 

Subtitle C—Quality Health Insurance Coverage for All Americans 

PART 1—HEALTH INSURANCE MARKET REFORMS

Sec. 1201. Amendment to the Public Health Service Act ............................ 45 

PART 2—OTHER PROVISIONS

Sec. 1251. Preservation of right to maintain existing coverage .................. 55 

Sec. 1252. Rating reforms must apply uniformly to all health insurance 

issuers and group health plans .................................................................... 56 

Sec. 1253. Annual report on self-insured plans ............................................ 56 

Sec. 1254. Study of large group market ........................................................ 57 

Sec. 1255. Effective dates ............................................................................... 57 

Subtitle D—Available Coverage Choices for All Americans 

PART 1—ESTABLISHMENT OF QUALIFIED HEALTH PLANS

Sec. 1301. Qualified health plan defined ...................................................... 58 

Sec. 1302. Essential health benefits requirements ...................................... 59 

Sec. 1303. Special rules .................................................................................. 64 

Sec. 1304. Related definitions ........................................................................ 68 

PART 2—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH

BENEFIT EXCHANGES

Sec. 1311. Affordable choices of health benefit plans .................................. 69 

Sec. 1312. Consumer choice ........................................................................... 80 

Sec. 1313. Financial integrity ........................................................................ 83 
Page

viii 

PART 3—STATE FLEXIBILITY RELATING TO EXCHANGES

Sec. 1321. State flexibility in operation and enforcement of Exchanges 

and related requirements ............................................................................. 85 

Sec. 1322. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers ............................................. 86 

Sec. 1323. Community health insurance option østricken¿ ......................... 92 

Sec. 1323. Funding for the territories ........................................................... 92 

Sec. 1324. Level playing field ........................................................................ 93 

PART 4—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS

Sec. 1331. State flexibility to establish basic health programs for lowincome individuals not eligible for Medicaid .............................................. 93 

Sec. 1332. Waiver for State innovation ......................................................... 98 

Sec. 1333. Provisions relating to offering of plans in more than one 

State ............................................................................................................... 100 

Sec. 1334. Multi-State plans .......................................................................... 101 

PART 5—REINSURANCE AND RISK ADJUSTMENT

Sec. 1341. Transitional reinsurance program for individual market in 

each State ...................................................................................................... 105 

Sec. 1342. Establishment of risk corridors for plans in individual and 

small group markets ..................................................................................... 108 

Sec. 1343. Risk adjustment ............................................................................ 109 

Subtitle E—Affordable Coverage Choices for All Americans 

PART I—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS

SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS

Sec. 1401. Refundable tax credit providing premium assistance for coverage under a qualified health plan ............................................................ 110 

Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified 

health plans ................................................................................................... 119 

SUBPART B—ELIGIBILITY DETERMINATIONS

Sec. 1411. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual 

responsibility exemptions ............................................................................. 123 

Sec. 1412. Advance determination and payment of premium tax credits 

and cost-sharing reductions ......................................................................... 131 

Sec. 1413. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs ........... 133 

Sec. 1414. Disclosures to carry out eligibility requirements for certain 

programs ........................................................................................................ 135 

Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs ............................. 137 

Sec. 1416. Study of geographic variation in application of FPL ................. 137 

PART II—SMALL BUSINESS TAX CREDIT

Sec. 1421. Credit for employee health insurance expenses of small businesses ............................................................................................................. 138 

Subtitle F—Shared Responsibility for Health Care 

PART I—INDIVIDUAL RESPONSIBILITY

Sec. 1501. Requirement to maintain minimum essential coverage ............ 143 

Sec. 1502. Reporting of health insurance coverage ...................................... 152 
Page

ix 

PART II—EMPLOYER RESPONSIBILITIES

Sec. 1511. Automatic enrollment for employees of large employers ........... 154 

Sec. 1512. Employer requirement to inform employees of coverage options ................................................................................................................ 154 

Sec. 1513. Shared responsibility for employers ............................................ 155 

Sec. 1514. Reporting of employer health insurance coverage ..................... 159 

Sec. 1515. Offering of Exchange-participating qualified health plans 

through cafeteria plans ................................................................................ 161 

Subtitle G—Miscellaneous Provisions 

Sec. 1551. Definitions ..................................................................................... 164 

Sec. 1552. Transparency in government ....................................................... 164 

Sec. 1553. Prohibition against discrimination on assisted suicide ............. 165 

Sec. 1554. Access to therapies ........................................................................ 165 

Sec. 1555. Freedom not to participate in Federal health insurance programs ............................................................................................................. 165 

Sec. 1556. Equity for certain eligible survivors ............................................ 166 

Sec. 1557. Nondiscrimination ........................................................................ 166 

Sec. 1558. Protections for employees ............................................................. 166 

Sec. 1559. Oversight ....................................................................................... 167 

Sec. 1560. Rules of construction .................................................................... 167 

Sec. 1561. Health information technology enrollment standards and protocols .............................................................................................................. 168 

Sec. 1562. GAO study regarding the rate of denial of coverage and enrollment by health insurance issuers and group health plans .................. 170 

Sec. 1563. Small business procurement ........................................................ 171 

Sec. 1563 [sic]. Conforming amendments ..................................................... 171 

Sec. 1563 [sic]. Sense of the Senate promoting fiscal responsibility ........... 178 

TITLE II—ROLE OF PUBLIC PROGRAMS 

Subtitle A—Improved Access to Medicaid 

Sec. 2001. Medicaid coverage for the lowest income populations ............... 179 

Sec. 2002. Income eligibility for nonelderly determined using modified 

gross income .................................................................................................. 186 

Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance ............................................................................................. 190 

Sec. 2004. Medicaid coverage for former foster care children ..................... 191 

Sec. 2005. Payments to territories ................................................................. 191 

Sec. 2006. Special adjustment to FMAP determination for certain States 

recovering from a major disaster ................................................................. 192 

Sec. 2007. Medicaid Improvement Fund rescission ..................................... 193 

Subtitle B—Enhanced Support for the Children’s Health Insurance Program 

Sec. 2101. Additional federal financial participation for CHIP .................. 194 

Sec. 2102. Technical corrections .................................................................... 197 

Subtitle C—Medicaid and CHIP Enrollment Simplification 

Sec. 2201. Enrollment Simplification and coordination with State Health 

Insurance Exchanges .................................................................................... 198 

Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations .......................................... 200 

Subtitle D—Improvements to Medicaid Services 

Sec. 2301. Coverage for freestanding birth center services ......................... 201 

Sec. 2302. Concurrent care for children ........................................................ 202 
Page

x 

Sec. 2303. State eligibility option for family planning services .................. 203 

Sec. 2304. Clarification of definition of medical assistance ......................... 206 

Subtitle E—New Options for States to Provide Long-Term Services and Supports 

Sec. 2401. Community First Choice Option .................................................. 206 

Sec. 2402. Removal of barriers to providing home and community-based 

services ........................................................................................................... 211 

Sec. 2403. Money Follows the Person Rebalancing Demonstration ........... 214 

Sec. 2404. Protection for recipients of home and community-based services against spousal impoverishment .......................................................... 215 

Sec. 2405. Funding to expand State Aging and Disability Resource Centers ................................................................................................................. 215 

Sec. 2406. Sense of the Senate regarding long-term care ........................... 215 

Subtitle F—Medicaid Prescription Drug Coverage 

Sec. 2501. Prescription drug rebates ............................................................. 216 

Sec. 2502. Elimination of exclusion of coverage of certain drugs ............... 219 

Sec. 2503. Providing adequate pharmacy reimbursement .......................... 220 

Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments 

Sec. 2551. Disproportionate share hospital payments ................................. 223 

Subtitle H—Improved Coordination for Dual Eligible Beneficiaries 

Sec. 2601. 5-year period for demonstration projects .................................... 224 

Sec. 2602. Providing Federal coverage and payment coordination for dual 

eligible beneficiaries ..................................................................................... 225 

Subtitle I—Improving the Quality of Medicaid for Patients and Providers 

Sec. 2701. Adult health quality measures .................................................... 227 

Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions ..... 229 

Sec. 2703. State option to provide health homes for enrollees with chronic conditions ................................................................................................... 229 

Sec. 2704. Demonstration project to evaluate integrated care around a 

hospitalization ............................................................................................... 233 

Sec. 2705. Medicaid Global Payment System Demonstration Project ........ 235 

Sec. 2706. Pediatric Accountable Care Organization Demonstration 

Project ............................................................................................................ 236 

Sec. 2707. Medicaid emergency psychiatric demonstration project ............ 237 

Subtitle J—Improvements to the Medicaid and CHIP Payment and Access 

Commission (MACPAC) 

Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries .......................................................................................................... 239 

Subtitle K—Protections for American Indians and Alaska Natives 

Sec. 2901. Special rules relating to Indians ................................................ 244 

Sec. 2902. Elimination of sunset for reimbursement for all medicare part 

B services furnished by certain indian hospitals and clinics .................... 244 

Subtitle L—Maternal and Child Health Services 

Sec. 2951. Maternal, infant, and early childhood home visiting programs 245 

Sec. 2952. Support, education, and research for postpartum depression ... 255 

Sec. 2953. Personal responsibility education ................................................ 258 

Sec. 2954. Restoration of funding for abstinence education ........................ 263 
Page

xi 

Sec. 2955. Inclusion of information about the importance of having a 

health care power of attorney in transition planning for children aging 

out of foster care and independent living programs .................................. 264 

TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE 

Subtitle A—Transforming the Health Care Delivery System 

PART 1—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE

PROGRAM

Sec. 3001. Hospital Value-Based purchasing program ................................ 266 

Sec. 3002. Improvements to the physician quality reporting system ......... 277 

Sec. 3003. Improvements to the physician feedback program .................... 279 

Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs ................................................. 282 

Sec. 3005. Quality reporting for PPS-exempt cancer hospitals ................... 285 

Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies ...................................................... 286 

Sec. 3007. Value-based payment modifier under the physician fee schedule ................................................................................................................... 288 

Sec. 3008. Payment adjustment for conditions acquired in hospitals ........ 291 

PART 2—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY

Sec. 3011. National strategy .......................................................................... 293 

Sec. 3012. Interagency Working Group on Health Care Quality ................ 295 

Sec. 3013. Quality measure development ..................................................... 296 

Sec. 3014. Quality measurement ................................................................... 300 

Sec. 3015. Data collection; public reporting .................................................. 304 

PART 3—ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS

Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within CMS ............................................................................................ 306 

Sec. 3022. Medicare shared savings program ............................................... 313 

Sec. 3023. National pilot program on payment bundling ............................ 318 

Sec. 3024. Independence at home demonstration program ......................... 324 

Sec. 3025. Hospital readmissions reduction program .................................. 328 

Sec. 3026. Community-Based Care Transitions Program ........................... 333 

Sec. 3027. Extension of gainsharing demonstration .................................... 335 

Subtitle B—Improving Medicare for Patients and Providers 

PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES

Sec. 3101. øIncrease in the physician payment update¿ørepealed¿ ........... 336 

Sec. 3102. Extension of the work geographic index floor and revisions 

to the practice expense geographic adjustment under the Medicare 

physician fee schedule .................................................................................. 336 

Sec. 3103. Extension of exceptions process for Medicare therapy caps ...... 338 

Sec. 3104. Extension of payment for technical component of certain physician pathology services .............................................................................. 338 

Sec. 3105. Extension of ambulance add-ons ................................................. 338 

Sec. 3106. Extension of certain payment rules for long-term care hospital 

services and of moratorium on the establishment of certain hospitals 

and facilities .................................................................................................. 338 

Sec. 3107. Extension of physician fee schedule mental health add-on ....... 338 

Sec. 3108. Permitting physician assistants to order post-Hospital extended care services ...................................................................................... 339 

Sec. 3109. Exemption of certain pharmacies from accreditation requirements ............................................................................................................. 339 
Page

xii 

Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries .......................................................................................................... 340 

Sec. 3111. Payment for bone density tests ................................................... 341 

Sec. 3112. Revision to the Medicare Improvement Fund ............................ 342 

Sec. 3113. Treatment of certain complex diagnostic laboratory tests ........ 342 

Sec. 3114. Improved access for certified nurse-midwife services ................ 343 

PART II—RURAL PROTECTIONS

Sec. 3121. Extension of outpatient hold harmless provision ....................... 344 

Sec. 3122. Extension of Medicare reasonable costs payments for certain 

clinical diagnostic laboratory tests furnished to hospital patients in 

certain rural areas ........................................................................................ 344 

Sec. 3123. Extension of the Rural Community Hospital Demonstration 

Program ......................................................................................................... 344 

Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program ............................................................................................................... 345 

Sec. 3125. Temporary improvements to the Medicare inpatient hospital 

payment adjustment for low-volume hospitals ........................................... 346 

Sec. 3126. Improvements to the demonstration project on community 

health integration models in certain rural counties .................................. 346 

Sec. 3127. MedPAC study on adequacy of Medicare payments for health 

care providers serving in rural areas .......................................................... 347 

Sec. 3128. Technical correction related to critical access hospital services .................................................................................................................. 347 

Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program ................................................................................................ 347 

PART III—IMPROVING PAYMENT ACCURACY

Sec. 3131. Payment adjustments for home health care ............................... 348 

Sec. 3132. Hospice reform .............................................................................. 352 

Sec. 3133. Improvement to medicare disproportionate share hospital 

(DSH) payments ............................................................................................ 354 

Sec. 3134. Misvalued codes under the physician fee schedule .................... 356 

Sec. 3135. Modification of equipment utilization factor for advanced imaging services ................................................................................................ 358 

Sec. 3136. Revision of payment for power-driven wheelchairs ................... 359 

Sec. 3137. Hospital wage index improvement .............................................. 360 

Sec. 3138. Treatment of certain cancer hospitals ......................................... 362 

Sec. 3139. Payment for biosimilar biological products ................................. 362 

Sec. 3140. Medicare hospice concurrent care demonstration program ....... 363 

Sec. 3141. Application of budget neutrality on a national basis in the 

calculation of the Medicare hospital wage index floor ............................... 364 

Sec. 3142. HHS study on urban Medicare-dependent hospitals ................. 364 

Sec. 3143. Protecting home health benefits .................................................. 365 

Subtitle C—Provisions Relating to Part C 

Sec. 3201. øMedicare Advantage payment¿ørepealed & replaced¿ ............. 365 

Sec. 3202. Benefit protection and simplification .......................................... 370 

Sec. 3203. øApplication of coding intensity adjustment during MA payment transition¿ørepealed and replaced¿ ................................................... 372 

Sec. 3204. Simplification of annual beneficiary election periods ................ 373 

Sec. 3205. Extension for specialized MA plans for special needs individuals ................................................................................................................. 373 

Sec. 3206. Extension of reasonable cost contracts ....................................... 376 

Sec. 3207. Technical correction to MA private fee-for-service plans ........... 376 

Sec. 3208. Making senior housing facility demonstration permanent ........ 376 

Sec. 3209. Authority to deny plan bids ......................................................... 377 
Page

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Sec. 3210. Development of new standards for certain Medigap plans ....... 377 

Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA– 

PD Plans 

Sec. 3301. Medicare coverage gap discount program ................................... 378 

Sec. 3302. Improvement in determination of Medicare part D low-income 

benchmark premium ..................................................................................... 386 

Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals 

under prescription drug plans and MA–PD plans ..................................... 386 

Sec. 3304. Special rule for widows and widowers regarding eligibility 

for low-income assistance ............................................................................. 387 

Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA–PD plans ................................ 387 

Sec. 3306. Funding outreach and assistance for low-income programs ..... 388 

Sec. 3307. Improving formulary requirements for prescription drug plans 

and MA–PD plans with respect to certain categories or classes of drugs 389 

Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries .......................................................................................................... 390 

Sec. 3309. Elimination of cost sharing for certain dual eligible individuals ................................................................................................................. 393 

Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs 

in long-term care facilities under prescription drug plans and MA– 

PD plans ........................................................................................................ 393 

Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan 

complaint system .......................................................................................... 394 

Sec. 3312. Uniform exceptions and appeals process for prescription drug 

plans and MA–PD plans ............................................................................... 394 

Sec. 3313. Office of the Inspector General studies and reports .................. 395 

Sec. 3314. Including costs incurred by AIDS drug assistance programs 

and Indian Health Service in providing prescription drugs toward the 

annual out-of-pocket threshold under part D ............................................. 396 

Sec. 3315. øImmediate reduction in coverage gap in 2010¿ørepealed and 

replaced¿ ........................................................................................................ 397 

Subtitle E—Ensuring Medicare Sustainability 

Sec. 3401. Revision of certain market basket updates and incorporation 

of productivity improvements into market basket updates that do not 

already incorporate such improvements ..................................................... 398 

Sec. 3402. Temporary adjustment to the calculation of part B premiums . 407 

Sec. 3403. Independent øMedicare¿Payment Advisory Board .................... 407 

Subtitle F—Health Care Quality Improvements 

Sec. 3501. Health care delivery system research; Quality improvement 

technical assistance ...................................................................................... 429 

Sec. 3502. Establishing community health teams to support the patientcentered medical home ................................................................................. 435 

Sec. 3503. Medication management services in treatment of chronic disease ................................................................................................................ 438 

Sec. 3504. Design and implementation of regionalized systems for emergency care ...................................................................................................... 440 

Sec. 3505. Trauma care centers and service availability ............................. 444 

Sec. 3506. Program to facilitate shared decisionmaking ............................. 450 

Sec. 3507. Presentation of prescription drug benefit and risk information ................................................................................................................. 453 

Sec. 3508. Demonstration program to integrate quality improvement and 

patient safety training into clinical education of health professionals ..... 453 

Sec. 3509. Improving women’s health ........................................................... 454 

Sec. 3510. Patient navigator program ........................................................... 460 

Sec. 3511. Authorization of appropriations ................................................... 461 
Page

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Sec. 3512. GAO study and report on causes of action ................................. 461 

Subtitle G—Protecting and Improving Guaranteed Medicare Benefits 

Sec. 3601. Protecting and improving guaranteed Medicare benefits .......... 462 

Sec. 3602. No cuts in guaranteed benefits .................................................... 462 

TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC 

HEALTH 

Subtitle A—Modernizing Disease Prevention and Public Health Systems 

Sec. 4001. National Prevention, Health Promotion and Public Health 

Council ........................................................................................................... 463 

Sec. 4002. Prevention and Public Health Fund ............................................ 466 

Sec. 4003. Clinical and community Preventive Services ............................. 466 

Sec. 4004. Education and outreach campaign regarding preventive benefits .................................................................................................................. 469 

Subtitle B—Increasing Access to Clinical Preventive Services 

Sec. 4101. School-based health centers ......................................................... 471 

Sec. 4102. Oral healthcare prevention activities .......................................... 476 

Sec. 4103. Medicare coverage of annual wellness visit providing a personalized prevention plan ............................................................................. 478 

Sec. 4104. Removal of barriers to preventive services in Medicare ............ 482 

Sec. 4105. Evidence-based coverage of preventive services in Medicare .... 483 

Sec. 4106. Improving access to preventive services for eligible adults 

in Medicaid .................................................................................................... 484 

Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant women in Medicaid .............................................................................. 485 

Sec. 4108. Incentives for prevention of chronic diseases in medicaid ........ 486 

Subtitle C—Creating Healthier Communities 

Sec. 4201. Community transformation grants .............................................. 489 

Sec. 4202. Healthy aging, living well; evaluation of community-based 

prevention and wellness programs for Medicare beneficiaries ................. 492 

Sec. 4203. Removing barriers and improving access to wellness for individuals with disabilities ............................................................................... 496 

Sec. 4204. Immunizations .............................................................................. 496 

Sec. 4205. Nutrition labeling of standard menu items at Chain Restaurants ......................................................................................................... 499 

Sec. 4206. Demonstration project concerning individualized wellness 

plan ................................................................................................................ 502 

Sec. 4207. Reasonable break time for nursing mothers ............................... 503 

Subtitle D—Support for Prevention and Public Health Innovation 

Sec. 4301. Research on optimizing the delivery of public health services . 504 

Sec. 4302. Understanding health disparities: data collection and analysis ................................................................................................................. 504 

Sec. 4303. CDC and employer-based wellness programs ............................. 509 

Sec. 4304. Epidemiology-Laboratory Capacity Grants ................................. 510 

Sec. 4305. Advancing research and treatment for pain care management 511 

Sec. 4306. Funding for Childhood Obesity Demonstration Project ............. 513 

Subtitle E—Miscellaneous Provisions 

Sec. 4401. Sense of the Senate concerning CBO scoring ............................. 514 

Sec. 4402. Effectiveness of Federal health and wellness initiatives ........... 514 
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TITLE V—HEALTH CARE WORKFORCE 

Subtitle A—Purpose and Definitions 

Sec. 5001. Purpose .......................................................................................... 515 

Sec. 5002. Definitions ..................................................................................... 515 

Subtitle B—Innovations in the Health Care Workforce 

Sec. 5101. National health care workforce commission ............................... 519 

Sec. 5102. State health care workforce development grants ....................... 526 

Sec. 5103. Health care workforce assessment .............................................. 531 

Sec. 5104. Interagency task force to assess and improve access to health 

care in the State of Alaska ........................................................................... 534 

Subtitle C—Increasing the Supply of the Health Care Workforce 

Sec. 5201. Federally supported student loan funds ..................................... 535 

Sec. 5202. Nursing student loan program .................................................... 535 

Sec. 5203. Health care workforce loan repayment programs ...................... 536 

Sec. 5204. Public health workforce recruitment and retention programs .. 538 

Sec. 5205. Allied health workforce recruitment and retention programs .. 540 

Sec. 5206. Grants for State and local programs ........................................... 540 

Sec. 5207. Funding for National Health Service Corps ............................... 541 

Sec. 5208. Nurse-managed health clinics ...................................................... 542 

Sec. 5209. Elimination of cap on commissioned corps ................................. 543 

Sec. 5210. Establishing a Ready Reserve Corps ........................................... 543 

Subtitle D—Enhancing Health Care Workforce Education and Training 

Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship ............................................... 544 

Sec. 5302. Training opportunities for direct care workers .......................... 547 

Sec. 5303. Training in general, pediatric, and public health dentistry ...... 548 

Sec. 5304. Alternative dental health care providers demonstration 

project ............................................................................................................ 550 

Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education ................................................................................ 552 

Sec. 5306. Mental and behavioral health education and training grants .. 555 

Sec. 5307. Cultural competency, prevention, and public health and individuals with disabilities training ................................................................. 558 

Sec. 5308. Advanced nursing education grants ............................................ 559 

Sec. 5309. Nurse education, practice, and retention grants ........................ 559 

Sec. 5310. Loan repayment and scholarship program ................................. 561 

Sec. 5311. Nurse faculty loan program ......................................................... 561 

Sec. 5312. Authorization of appropriations for parts B through D of title 

VIII ................................................................................................................. 563 

Sec. 5313. Grants to promote the community health workforce ................. 564 

Sec. 5314. Fellowship training in public health ........................................... 566 

Sec. 5315. United States Public Health Sciences Track .............................. 567 

Sec. 5316. Demonstration grants for family nurse practitioner training 

programs ........................................................................................................ 572 

Subtitle E—Supporting the Existing Health Care Workforce 

Sec. 5401. Centers of excellence .................................................................... 574 

Sec. 5402. Health care professionals training for diversity ......................... 576 

Sec. 5403. Interdisciplinary, community-based linkages ............................. 576 

Sec. 5404. Workforce diversity grants ........................................................... 581 

Sec. 5405. Primary care extension program ................................................. 582 
Page

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Subtitle F—Strengthening Primary Care and Other Workforce Improvements 

Sec. 5501. Expanding access to primary care services and general surgery services .................................................................................................. 585 

Sec. 5502. øMedicare Federally qualified health center improvements¿ørepealed¿ .......................................................................................... 587 

Sec. 5503. Distribution of additional residency positions ............................ 587 

Sec. 5504. Counting resident time in nonprovider settings ........................ 590 

Sec. 5505. Rules for counting resident time for didactic and scholarly 

activities and other activities ....................................................................... 591 

Sec. 5506. Preservation of resident cap positions from closed hospitals .... 593 

Sec. 5507. Demonstration projects To address health professions workforce needs; extension of family-to-family health information centers ..... 595 

Sec. 5508. Increasing teaching capacity ........................................................ 601 

Sec. 5509. Graduate nurse education demonstration .................................. 606 

Subtitle G—Improving Access to Health Care Services 

Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs) ...... 609 

Sec. 5602. Negotiated rulemaking for development of methodology and 

criteria for designating medically underserved populations and health 

professions shortage areas ........................................................................... 610 

Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services 

for Children Program .................................................................................... 612 

Sec. 5604. Co-locating primary and specialty care in community-based 

mental health settings .................................................................................. 612 

Sec. 5605. Key National indicators ................................................................ 613 

Sec. 5606. State grants to health care providers who provide services 

to a high percentage of medically underserved populations or other 

special populations ........................................................................................ 617 

Subtitle H—General Provisions 

Sec. 5701. Reports ........................................................................................... 618 

TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY 

Subtitle A—Physician Ownership and Other Transparency 

Sec. 6001. Limitation on Medicare exception to the prohibition on certain 

physician referrals for hospitals .................................................................. 619 

Sec. 6002. Transparency reports and reporting of physician ownership 

or investment interests ................................................................................. 624 

Sec. 6003. Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging 

services ........................................................................................................... 632 

Sec. 6004. Prescription drug sample transparency ...................................... 632 

Sec. 6005. Pharmacy benefit managers transparency requirements .......... 633 

Subtitle B—Nursing Home Transparency and Improvement 

PART 1—IMPROVING TRANSPARENCY OF INFORMATION

Sec. 6101. Required disclosure of ownership and additional disclosable 

parties information ....................................................................................... 635 

Sec. 6102. Accountability requirements for skilled nursing facilities and 

nursing facilities ........................................................................................... 638 

Sec. 6103. Nursing home compare Medicare website .................................. 640 

Sec. 6104. Reporting of expenditures ............................................................ 647 

Sec. 6105. Standardized complaint form ....................................................... 648 

Sec. 6106. Ensuring staffing accountability .................................................. 648 

Sec. 6107. GAO study and report on Five-Star Quality Rating System .... 649 
Page

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PART 2—TARGETING ENFORCEMENT

Sec. 6111. Civil money penalties ................................................................... 649 

Sec. 6112. National independent monitor demonstration project ............... 653 

Sec. 6113. Notification of facility closure ...................................................... 655 

Sec. 6114. National demonstration projects on culture change and use 

of information technology in nursing homes .............................................. 656 

PART 3—IMPROVING STAFF TRAINING

Sec. 6121. Dementia and abuse prevention training ................................... 657 

Subtitle C—Nationwide Program for National and State Background Checks on 

Direct Patient Access Employees of Long-term Care Facilities and Providers 

Sec. 6201. Nationwide program for National and State background 

checks on direct patient access employees of long-term care facilities 

and providers ................................................................................................. 658 

Subtitle D—Patient-Centered Outcomes Research 

Sec. 6301. Patient-Centered Outcomes Research ......................................... 664 

Sec. 6302. Federal coordinating council for comparative effectiveness research ............................................................................................................. 685 

Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions 

Sec. 6401. Provider screening and other enrollment requirements under 

Medicare, Medicaid, and CHIP .................................................................... 685 

Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions ............................................................................................................... 691 

Sec. 6403. Elimination of duplication between the Healthcare Integrity 

and Protection Data Bank and the National Practitioner Data Bank ..... 702 

Sec. 6404. Maximum period for submission of Medicare claims reduced 

to not more than 12 months ......................................................................... 707 

Sec. 6405. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals ....................................... 708 

Sec. 6406. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse ................................. 708 

Sec. 6407. Face to face encounter with patient required before physicians 

may certify eligibility for home health services or durable medical 

equipment under Medicare .......................................................................... 709 

Sec. 6408. Enhanced penalties ....................................................................... 710 

Sec. 6409. Medicare self-referral disclosure protocol ................................... 712 

Sec. 6410. Adjustments to the Medicare durable medical equipment, 

prosthetics, orthotics, and supplies competitive acquisition program ...... 713 

Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program ... 714 

Subtitle F—Additional Medicaid Program Integrity Provisions 

Sec. 6501. Termination of provider participation under Medicaid if terminated under Medicare or other State plan ................................................. 716 

Sec. 6502. Medicaid exclusion from participation relating to certain 

ownership, control, and management affiliations ...................................... 716 

Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid ............................................................... 716 

Sec. 6504. Requirement to report expanded set of data elements under 

MMIS to detect fraud and abuse ................................................................. 717 

Sec. 6505. Prohibition on payments to institutions or entities located 

outside of the United States ........................................................................ 717 

Sec. 6506. Overpayments ............................................................................... 717 

Sec. 6507. Mandatory State use of national correct coding initiative ........ 718 

Sec. 6508. General effective date ................................................................... 719 
Page

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Subtitle G—Additional Program Integrity Provisions 

Sec. 6601. Prohibition on false statements and representations ................ 719 

Sec. 6602. Clarifying definition ...................................................................... 720 

Sec. 6603. Development of model uniform report form ............................... 720 

Sec. 6604. Applicability of State law to combat fraud and abuse ............... 720 

Sec. 6605. Enabling the Department of Labor to issue administrative 

summary cease and desist orders and summary seizures orders against 

plans that are in financially hazardous condition ...................................... 721 

Sec. 6606. MEWA plan registration with Department of Labor ................. 722 

Sec. 6607. Permitting evidentiary privilege and confidential communications ................................................................................................................ 722 

Subtitle H—Elder Justice Act 

Sec. 6701. Short title of subtitle .................................................................... 722 

Sec. 6702. Definitions ..................................................................................... 722 

Sec. 6703. Elder Justice ................................................................................. 722 

Subtitle I—Sense of the Senate Regarding Medical Malpractice 

Sec. 6801. Sense of the Senate regarding medical malpractice .................. 745 

TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES 

Subtitle A—Biologics Price Competition and Innovation 

Sec. 7001. Short title ...................................................................................... 747 

Sec. 7002. Approval pathway for biosimilar biological products ................. 747 

Sec. 7003. Savings ........................................................................................... 764 

Subtitle B—More Affordable Medicines for Children and Underserved 

Communities 

Sec. 7101. Expanded participation in 340B program ................................... 764 

Sec. 7102. Improvements to 340B program integrity .................................. 767 

Sec. 7103. GAO study to make recommendations on improving the 340B 

program .......................................................................................................... 771 

TITLE VIII—CLASS ACT 

Sec. 8001. Short title of title .......................................................................... 772 

Sec. 8002. Establishment of national voluntary insurance program for 

purchasing community living assistance services and support ................. 772 

TITLE IX—REVENUE PROVISIONS 

Subtitle A—Revenue Offset Provisions 

Sec. 9001. Excise tax on high cost employer-sponsored health coverage ... 793 

Sec. 9002. Inclusion of cost of employer-sponsored health coverage on 

W–2 ................................................................................................................ 800 

Sec. 9003. Distributions for medicine qualified only if for prescribed drug 

or insulin ....................................................................................................... 800 

Sec. 9004. Increase in additional tax on distributions from HSAs and 

Archer MSAs not used for qualified medical expenses .............................. 801 

Sec. 9005. Limitation on health flexible spending arrangements under 

cafeteria plans ............................................................................................... 801 

Sec. 9006. Expansion of information reporting requirements ..................... 801 

Sec. 9007. Additional requirements for charitable hospitals ....................... 802 

Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers ........................................................ 806 

Sec. 9009. øImposition of annual fee on medical device manufacturers 

and importers¿ørepealed and replaced¿ ..................................................... 810 
Page

xix 

Sec. 9010. Imposition of annual fee on health insurance providers ........... 811 

Sec. 9011. Study and report of effect on veterans health care .................... 815 

Sec. 9012. Elimination of deduction for expenses allocable to Medicare 

Part D subsidy .............................................................................................. 816 

Sec. 9013. Modification of itemized deduction for medical expenses .......... 816 

Sec. 9014. Limitation on excessive remuneration paid by certain health 

insurance providers ...................................................................................... 816 

Sec. 9015. Additional hospital insurance tax on high-income taxpayers ... 818 

Sec. 9016. Modification of section 833 treatment of certain health organizations ............................................................................................................ 820 

Sec. 9017. øExcise tax on elective cosmetic medical procedures¿ønullified¿ .......................................................................................... 820 

Subtitle B—Other Provisions 

Sec. 9021. Exclusion of health benefits provided by Indian tribal governments ............................................................................................................. 821 

Sec. 9022. Establishment of simple cafeteria plans for small businesses .. 822 

Sec. 9023. Qualifying therapeutic discovery project credit .......................... 825 

TITLE X—STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR 

ALL AMERICANS 

Subtitle A—Provisions Relating to Title I 

Sec. 10101. Amendments to subtitle A øamendments fully incorporated¿ 833 

Sec. 10102. Amendments to subtitle B øamendments fully incorporated¿ 833 

Sec. 10103. Amendments to subtitle C øamendments fully incorporated¿ 833 

Sec. 10104. Amendments to subtitle D ......................................................... 834 

Sec. 10105. Amendments to subtitle E øamendments fully incorporated¿ 834 

Sec. 10106. Amendments to subtitle F øamendments fully incorporated¿ 835 

Sec. 10107. Amendments to subtitle G øamendments fully incorporated¿ 835 

Sec. 10108. Free choice vouchers ................................................................... 835 

Sec. 10109. Development of standards for financial and administrative 

transactions ................................................................................................... 838 

Subtitle B—Provisions Relating to Title II 

PART 1—MEDICAID AND CHIP 

Sec. 10201. Amendments to the Social Security Act and title II of this 

Act .................................................................................................................. 839 

Sec. 10202. Incentives for States to offer home and community-based 

services as a long-term care alternative to nursing homes ....................... 845 

Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and 

other CHIP-related provisions ..................................................................... 849 

PART 2—SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN

Sec. 10211. Definitions ................................................................................... 852 

Sec. 10212. Establishment of pregnancy assistance fund ........................... 853 

Sec. 10213. Permissible uses of Fund ........................................................... 853 

Sec. 10214. Appropriations ............................................................................. 857 

PART 3—INDIAN HEALTH CARE IMPROVEMENT

Sec. 10221. Indian health care improvement ............................................... 857 

Subtitle C—Provisions Relating to Title III 

Sec. 10301. Plans for a Value-Based purchasing program for ambulatory 

surgical centers øamendments fully incorporated¿ .................................... 858 

Sec. 10302. Revision to national strategy for quality improvement in 

health care øamendments fully incorporated¿ ............................................ 858 
Page

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Sec. 10303. Development of outcome measures ........................................... 858 

Sec. 10304. Selection of efficiency measures øamendments fully incorporated¿ ......................................................................................................... 858 

Sec. 10305. Data collection; public reporting øamendments fully incorporated¿ ......................................................................................................... 859 

Sec. 10306. Improvements under the Center for Medicare and Medicaid 

Innovation øamendments fully incorporated¿ ............................................ 859 

Sec. 10307. Improvements to the Medicare shared savings program 

øamendments fully incorporated¿ ............................................................... 859 

Sec. 10308. Revisions to national pilot program on payment bundling 

øamendments fully incorporated¿ ................................................................ 859 

Sec. 10309. Revisions to hospital readmissions reduction program 

øamendments fully incorporated¿ ............................................................... 859 

Sec. 10310. Repeal of physician payment update øamendments fully incorporated¿ .................................................................................................... 859 

Sec. 10311. Revisions to extension of ambulance add-ons øamendments 

fully incorporated¿ ........................................................................................ 859 

Sec. 10312. Certain payment rules for long-term care hospital services 

and moratorium on the establishment of certain hospitals and facilities 

øamendments fully incorporated¿ ................................................................ 860 

Sec. 10313. Revisions to the extension for the rural community hospital 

demonstration program øamendments fully incorporated¿ ....................... 860 

Sec. 10314. Adjustment to low-volume hospital provision øamendments 

fully incorporated¿ ........................................................................................ 860 

Sec. 10315. Revisions to home health care provisions øamendments fully 

incorporated¿ ................................................................................................. 860 

Sec. 10316. Medicare DSH øamendments fully incorporated¿ .................... 860 

Sec. 10317. Revisions to extension of section 508 hospital provisions 

øamendments fully incorporated¿ ............................................................... 860 

Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage øamendments fully incorporated¿ ................................................. 860 

Sec. 10319. Revisions to market basket adjustments øamendments fully 

incorporated¿ ................................................................................................. 860 

Sec. 10320. Expansion of the scope of, and additional improvements to, 

the Independent Medicare Advisory Board ................................................ 861 

Sec. 10321. Revision to community health teams øamendments fully incorporated¿ .................................................................................................... 861 

Sec. 10322. Quality reporting for psychiatric hospitals ............................... 861 

Sec. 10323. Medicare coverage for individuals exposed to environmental 

health hazards ............................................................................................... 863 

Sec. 10324. Protections for frontier States ................................................... 868 

Sec. 10325. Revision to skilled nursing facility prospective ?payment system ................................................................................................................. 870 

Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers ................................................................................................ 870 

Sec. 10327. Improvements to the physician quality reporting system ....... 871 

Sec. 10328. Improvement in part D medication therapy management 

(MTM) programs ........................................................................................... 873 

Sec. 10329. Developing methodology to assess health plan value .............. 874 

Sec. 10330. Modernizing computer and data systems of the Centers for 

Medicare & Medicaid services to support improvements in care delivery .................................................................................................................. 875 

Sec. 10331. Public reporting of performance information ........................... 875 

Sec. 10332. Availability of medicare data for performance measurement . 877 

Sec. 10333. Community-based collaborative care networks ........................ 879 

Sec. 10334. Minority health ........................................................................... 880 

Sec. 10335. Technical correction to the hospital value-based purchasing 

program øamendments fully incorporated¿ ................................................ 883 

Sec. 10336. GAO study and report on Medicare beneficiary access to 

high-quality dialysis services ....................................................................... 884 
Page

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Subtitle D—Provisions Relating to Title IV 

Sec. 10401. Amendments to subtitle A øamendments fully incorporated¿ 884 

Sec. 10402. Amendments to subtitle B øamendments fully incorporated¿ 884 

Sec. 10403. Amendments to subtitle C øamendments fully incorporated¿ 884 

Sec. 10404. Amendments to subtitle D øamendments fully incorporated¿ 885 

Sec. 10405. Amendments to subtitle E øamendments fully incorporated¿ 885 

Sec. 10406. Amendment relating to waiving coinsurance for preventive 

services øamendments fully incorporated¿ ................................................. 885 

Sec. 10407. Better diabetes care .................................................................... 885 

Sec. 10408. Grants for small businesses to provide comprehensive workplace wellness programs ............................................................................... 886 

Sec. 10409. Cures Acceleration Network ...................................................... 887 

Sec. 10410. Centers of Excellence for Depression ........................................ 894 

Sec. 10411. Programs relating to congenital heart disease ......................... 898 

Sec. 10412. Automated Defibrillation in Adam’s Memory Act .................... 900 

Sec. 10413. Young women’s breast health awareness and support of 

young women diagnosed with breast cancer ............................................... 900 

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 ............................................................ 903 

Sec. 10502. Infrastructure to Expand Access to Care .................................. 910 

Sec. 10503. Community Health Centers and the National Health Service 

Corps Fund .................................................................................................... 910 

Sec. 10504. Demonstration project to provide access to affordable care .... 911 

Subtitle F—Provisions Relating to Title VI 

Sec. 10601. Revisions to limitation on medicare exception to the prohibition on certain physician referrals for hospitals øamendments fully 

incorporated¿ ................................................................................................. 911 

Sec. 10602. Clarifications to patient-centered outcomes research øamendments fully incorporated¿ ............................................................................. 912 

Sec. 10603. Striking provisions relating to individual provider application fees øamendments fully incorporated¿ ................................................ 912 

Sec. 10604. Technical correction to section 6405 øamendments fully incorporated¿ .................................................................................................... 912 

Sec. 10605. Certain other providers permitted to conduct face to face 

encounter for home health services øamendments fully incorporated¿ .... 912 

Sec. 10606. Health care fraud enforcement .................................................. 912 

Sec. 10607. State demonstration programs to evaluate alternatives to 

current medical tort litigation ..................................................................... 915 

Sec. 10608. Extension of medical malpractice coverage to free clinics ....... 920 

Sec. 10609. Labeling changes ........................................................................ 920 

Subtitle G—Provisions Relating to Title VIII 

Sec. 10801. Provisions relating to title VIII øamendments fully incorporated¿ ......................................................................................................... 921 

Subtitle H—Provisions Relating to Title IX 

Sec. 10901. Modifications to excise tax on high cost employer-sponsored 

health coverage øamendments fully incorporated¿ .................................... 921 

Sec. 10902. Inflation adjustment of limitation on health flexible spending 

arrangements under cafeteria plans øamendments fully incorporated¿ .. 921 

Sec. 10903. Modification of limitation on charges by charitable hospitals 

øamendments fully incorporated¿ ................................................................ 922 

Sec. 10904. Modification of annual fee on medical device manufacturers 

and importers øamendments fully incorporated¿ ....................................... 922 
Page

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Sec. 10905. Modification of annual fee on health insurance providers 

øamendments fully incorporated¿ ................................................................ 922 

Sec. 10906. Modifications to additional hospital insurance tax on highincome taxpayers øamendments fully incorporated¿ ................................. 922 

Sec. 10907. Excise tax on indoor tanning services in lieu of elective 

cosmetic medical procedures øsubstitutes for section 9017 of PPACA¿ .... 923 

Sec. 10908. Exclusion for assistance provided to participants in State 

student loan repayment programs for certain health professionals ......... 923 

Sec. 10909. Expansion of adoption credit and adoption assistance programs ............................................................................................................. 924 

Health Care and Education Reconciliation Act of 2010 (Public Law 

111–152) 

Sec. 1001. Tax credits øamendments fully incorporated into PPACA¿. ..... 928 

Sec. 1002. Individual responsibility øamendments fully incorporated into 

PPACA¿. ........................................................................................................ 929 

Sec. 1003. Employer responsibility øamendments fully incorporated into 

PPACA¿. ........................................................................................................ 929 

Sec. 1004. Income definitions. ........................................................................ 929 

Sec. 1005. Implementation funding. .............................................................. 931 

Subtitle B—Medicare 

Sec. 1101. Closing the medicare prescription drug ‘‘donut 

hole’’øsubstitutes for section 3315 of PPACA¿. ........................................... 931 

Sec. 1102. Medicare Advantage payments øsubstitutes for sections 3201 

& 3203 of PPACA¿. ....................................................................................... 934 

Sec. 1103. Savings from limits on MA plan administrative costs. .............. 940 

Sec. 1104. Disproportionate share hospital (DSH) payments øamendment 

fully incorporated into PPACA¿. .................................................................. 940 

Sec. 1105. Market basket updates øamendments fully incorporated into 

PPACA¿. ........................................................................................................ 940 

Sec. 1106. Physician ownership-referral øamendments fully incorporated 

into PPACA¿. ................................................................................................. 941 

Sec. 1107. Payment for imaging services øamendments fully incorporated 

into PPACA¿. ................................................................................................. 941 

Sec. 1108. PE GPCI adjustment for 2010 øamendment fully incorporated 

into PPACA¿. ................................................................................................. 941 

Sec. 1109. Payment for qualifying hospitals. ................................................ 941 

Subtitle C—Medicaid 

Sec. 1201. Federal funding for States øamendments fully incorporated 

into PPACA¿. ................................................................................................. 942 

Sec. 1202. Payments to primary care physicians. ........................................ 942 

Sec. 1203. Disproportionate share hospital payments. ................................ 943 

Sec. 1204. Funding for the territories. .......................................................... 944 

Sec. 1205. Delay in Community First Choice option øamendment fully 

incorporated into PPACA¿. .......................................................................... 944 

Sec. 1206. Drug rebates for new formulations of existing drugs øamendment fully incorporated into PPACA¿. ........................................................ 944 

Subtitle D—Reducing Fraud, Waste, and Abuse 

Sec. 1301. Community mental health centers. ............................................. 944 

Sec. 1302. Medicare prepayment medical review limitations. .................... 945 

Sec. 1303. Funding to fight fraud, waste, and abuse. .................................. 945 

Sec. 1304. 90-day period of enhanced oversight for initial claims of DME 

suppliers øamendment fully incorporated into PPACA¿. ........................... 946 
Page

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Subtitle E—Provisions Relating to Revenue 

Sec. 1401. High-cost plan excise tax øamendments fully incorporated into 

PPACA¿. ........................................................................................................ 946 

Sec. 1402. Unearned income Medicare contribution. ................................... 946 

Sec. 1403. Delay of limitation on health flexible spending arrangements 

under cafeteria plans øamendments fully incorporated into PPACA¿. .... 949 

Sec. 1404. Brand name pharmaceuticals øamendments fully incorporated 

into PPACA¿. ................................................................................................. 949 

Sec. 1405. Excise tax on medical device manufacturers øsubstitutes for 

section 9009 of PPACA¿. .............................................................................. 949 

Sec. 1406. Health insurance providers øamendment fully incorporated 

into PPACA¿. ................................................................................................. 950 

Sec. 1407. Delay of elimination of deduction for expenses allocable to 

medicare part D subsidy øamendment fully incorporated in PPACA¿. .... 950 

Sec. 1408. Elimination of unintended application of cellulosic biofuel producer credit. ................................................................................................... 950 

Sec. 1409. Codification of economic substance doctrine and penalties. ...... 951 

Sec. 1410. Time for payment of corporate estimated taxes. ........................ 954 

Subtitle F—Other Provisions 

Sec. 1501. Community college and career training grant program. ........... 954 

TITLE II—EDUCATION AND HEALTH 

Subtitle A—Education øOmitted From This Compilation¿ 

Subtitle B—Health 

Sec. 2301. Insurance reforms øamendment fully incorporated into 

PPACA¿. ........................................................................................................ 954 

Sec. 2302. Drugs purchased by covered entities. ......................................... 954 

Sec. 2303. Community health centers øamendment fully incorporated 

into PPACA¿. ................................................................................................. 955 

1 

PATIENT PROTECTION AND 

AFFORDABLE CARE ACT 

SECTION 1. ø42 U.S.C. 18001 note¿ SHORT TITLE; TABLE OF CONTENTS. 

(a) SHORT TITLE.—This Act may be cited as the ‘‘Patient Protection and Affordable Care Act’’. 

(b) TABLE OF CONTENTS.—The table of contents of this Act is 

as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS 

Subtitle A—Immediate Improvements in Health Care Coverage for All Americans 

Sec. 1001. Amendments to the Public Health Service Act. 

Sec. 1002. Health insurance consumer information. 

Sec. 1003. Ensuring that consumers get value for their dollars. 

Sec. 1004. Effective dates. 

Subtitle B—Immediate Actions to Preserve and Expand Coverage 

Sec. 1101. Immediate access to insurance for uninsured individuals with a preexisting condition. 

Sec. 1102. Reinsurance for early retirees. 

Sec. 1103. Immediate information that allows consumers to identify affordable coverage options. 

Sec. 1104. Administrative simplification. 

Sec. 1105. Effective date. 

Subtitle C—Quality Health Insurance Coverage for All Americans 

PART 1—HEALTH INSURANCE MARKET REFORMS

Sec. 1201. Amendment to the Public Health Service Act. 

PART 2—OTHER PROVISIONS

Sec. 1251. Preservation of right to maintain existing coverage. 

Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and 

group health plans. 

Sec. 1253. Annual report on self-insured plans. 

Sec. 1254. Study of large group market. 

Sec. 1255. Effective dates. 

Subtitle D—Available Coverage Choices for All Americans 

PART 1—ESTABLISHMENT OF QUALIFIED HEALTH PLANS

Sec. 1301. Qualified health plan defined. 

Sec. 1302. Essential health benefits requirements. 

Sec. 1303. Special rules. 

Sec. 1304. Related definitions. 

PART 2—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH

BENEFIT EXCHANGES

Sec. 1311. Affordable choices of health benefit plans. 

Sec. 1312. Consumer choice. 

Sec. 1313. Financial integrity. 
Sec. 1 PPACA (Consolidated) 2 

PART 3—STATE FLEXIBILITY RELATING TO EXCHANGES

Sec. 1321. State flexibility in operation and enforcement of Exchanges and related 

requirements. 

Sec. 1322. Federal program to assist establishment and operation of nonprofit, 

member-run health insurance issuers. 

Sec. 1323. Community health insurance option østricken¿. 

Sec. 1323. Funding for the territories. 

Sec. 1324. Level playing field. 

PART 4—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS

Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid. 

Sec. 1332. Waiver for State innovation. 

Sec. 1333. Provisions relating to offering of plans in more than one State. 

Sec. 1334. Multi-State plans. 

PART 5—REINSURANCE AND RISK ADJUSTMENT

Sec. 1341. Transitional reinsurance program for individual market in each State. 

Sec. 1342. Establishment of risk corridors for plans in individual and small group 

markets. 

Sec. 1343. Risk adjustment. 

Subtitle E—Affordable Coverage Choices for All Americans 

PART I—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS

SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS

Sec. 1401. Refundable tax credit providing premium assistance for coverage under 

a qualified health plan. 

Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans. 

SUBPART B—ELIGIBILITY DETERMINATIONS

Sec. 1411. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility exemptions. 

Sec. 1412. Advance determination and payment of premium tax credits and costsharing reductions. 

Sec. 1413. Streamlining of procedures for enrollment through an exchange and 

State Medicaid, CHIP, and health subsidy programs. 

Sec. 1414. Disclosures to carry out eligibility requirements for certain programs. 

Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for 

Federal and Federally-assisted programs. 

Sec. 1416. Study of geographic variation in application of FPL. 

PART II—SMALL BUSINESS TAX CREDIT

Sec. 1421. Credit for employee health insurance expenses of small businesses. 

Subtitle F—Shared Responsibility for Health Care 

PART I—INDIVIDUAL RESPONSIBILITY

Sec. 1501. Requirement to maintain minimum essential coverage. 

Sec. 1502. Reporting of health insurance coverage. 

PART II—EMPLOYER RESPONSIBILITIES

Sec. 1511. Automatic enrollment for employees of large employers. 

Sec. 1512. Employer requirement to inform employees of coverage options. 

Sec. 1513. Shared responsibility for employers. 

Sec. 1514. Reporting of employer health insurance coverage. 

Sec. 1515. Offering of Exchange-participating qualified health plans through cafeteria plans. 

Subtitle G—Miscellaneous Provisions 

Sec. 1551. Definitions. 

Sec. 1552. Transparency in government. 

Sec. 1553. Prohibition against discrimination on assisted suicide. 

Sec. 1554. Access to therapies. 
3 Sec. 1 PPACA (Consolidated) 

Sec. 1555. Freedom not to participate in Federal health insurance programs. 

Sec. 1556. Equity for certain eligible survivors. 

Sec. 1557. Nondiscrimination. 

Sec. 1558. Protections for employees. 

Sec. 1559. Oversight. 

Sec. 1560. Rules of construction. 

Sec. 1561. Health information technology enrollment standards and protocols. 

Sec. 1562. GAO study regarding the rate of denial of coverage and enrollment by 

health insurance issuers and group health plans. 

Sec. 1563. Small business procurement. 

Sec. 1563 [sic]. Conforming amendments. 

Sec. 1563 [sic]. Sense of the Senate promoting fiscal responsibility. 

TITLE II—ROLE OF PUBLIC PROGRAMS 

Subtitle A—Improved Access to Medicaid 

Sec. 2001. Medicaid coverage for the lowest income populations. 

Sec. 2002. Income eligibility for nonelderly determined using modified gross income. 

Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance. 

Sec. 2004. Medicaid coverage for former foster care children. 

Sec. 2005. Payments to territories. 

Sec. 2006. Special adjustment to FMAP determination for certain States recovering 

from a major disaster. 

Sec. 2007. Medicaid Improvement Fund rescission. 

Subtitle B—Enhanced Support for the Children’s Health Insurance Program 

Sec. 2101. Additional federal financial participation for CHIP. 

Sec. 2102. Technical corrections. 

Subtitle C—Medicaid and CHIP Enrollment Simplification 

Sec. 2201. Enrollment Simplification and coordination with State Health Insurance 

Exchanges. 

Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for 

all Medicaid eligible populations. 

Subtitle D—Improvements to Medicaid Services 

Sec. 2301. Coverage for freestanding birth center services. 

Sec. 2302. Concurrent care for children. 

Sec. 2303. State eligibility option for family planning services. 

Sec. 2304. Clarification of definition of medical assistance. 

Subtitle E—New Options for States to Provide Long-Term Services and Supports 

Sec. 2401. Community First Choice Option. 

Sec. 2402. Removal of barriers to providing home and community-based services. 

Sec. 2403. Money Follows the Person Rebalancing Demonstration. 

Sec. 2404. Protection for recipients of home and community-based services against 

spousal impoverishment. 

Sec. 2405. Funding to expand State Aging and Disability Resource Centers. 

Sec. 2406. Sense of the Senate regarding long-term care. 

Subtitle F—Medicaid Prescription Drug Coverage 

Sec. 2501. Prescription drug rebates. 

Sec. 2502. Elimination of exclusion of coverage of certain drugs. 

Sec. 2503. Providing adequate pharmacy reimbursement. 

Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments 

Sec. 2551. Disproportionate share hospital payments. 

Subtitle H—Improved Coordination for Dual Eligible Beneficiaries 

Sec. 2601. 5-year period for demonstration projects. 

Sec. 2602. Providing Federal coverage and payment coordination for dual eligible 

beneficiaries. 
Sec. 1 PPACA (Consolidated) 4 

Subtitle I—Improving the Quality of Medicaid for Patients and Providers 

Sec. 2701. Adult health quality measures. 

Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions. 

Sec. 2703. State option to provide health homes for enrollees with chronic conditions. 

Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization. 

Sec. 2705. Medicaid Global Payment System Demonstration Project. 

Sec. 2706. Pediatric Accountable Care Organization Demonstration Project. 

Sec. 2707. Medicaid emergency psychiatric demonstration project. 

Subtitle J—Improvements to the Medicaid and CHIP Payment and Access 

Commission (MACPAC) 

Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries. 

Subtitle K—Protections for American Indians and Alaska Natives 

Sec. 2901. Special rules relating to Indians. 

Sec. 2902. Elimination of sunset for reimbursement for all medicare part B services 

furnished by certain indian hospitals and clinics. 

Subtitle L—Maternal and Child Health Services 

Sec. 2951. Maternal, infant, and early childhood home visiting programs. 

Sec. 2952. Support, education, and research for postpartum depression. 

Sec. 2953. Personal responsibility education. 

Sec. 2954. Restoration of funding for abstinence education. 

Sec. 2955. Inclusion of information about the importance of having a health care 

power of attorney in transition planning for children aging out of foster 

care and independent living programs. 

TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE 

Subtitle A—Transforming the Health Care Delivery System 

PART 1—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM

Sec. 3001. Hospital Value-Based purchasing program. 

Sec. 3002. Improvements to the physician quality reporting system. 

Sec. 3003. Improvements to the physician feedback program. 

Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation 

hospitals, and hospice programs. 

Sec. 3005. Quality reporting for PPS-exempt cancer hospitals. 

Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities 

and home health agencies. 

Sec. 3007. Value-based payment modifier under the physician fee schedule. 

Sec. 3008. Payment adjustment for conditions acquired in hospitals. 

PART 2—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY

Sec. 3011. National strategy. 

Sec. 3012. Interagency Working Group on Health Care Quality. 

Sec. 3013. Quality measure development. 

Sec. 3014. Quality measurement. 

Sec. 3015. Data collection; public reporting. 

PART 3—ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS

Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within 

CMS. 

Sec. 3022. Medicare shared savings program. 

Sec. 3023. National pilot program on payment bundling. 

Sec. 3024. Independence at home demonstration program. 

Sec. 3025. Hospital readmissions reduction program. 

Sec. 3026. Community-Based Care Transitions Program. 

Sec. 3027. Extension of gainsharing demonstration. 

Subtitle B—Improving Medicare for Patients and Providers 

PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES

Sec. 3101. øIncrease in the physician payment update¿ørepealed¿. 
5 Sec. 1 PPACA (Consolidated) 

Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee 

schedule. 

Sec. 3103. Extension of exceptions process for Medicare therapy caps. 

Sec. 3104. Extension of payment for technical component of certain physician pathology services. 

Sec. 3105. Extension of ambulance add-ons. 

Sec. 3106. Extension of certain payment rules for long-term care hospital services 

and of moratorium on the establishment of certain hospitals and facilities. 

Sec. 3107. Extension of physician fee schedule mental health add-on. 

Sec. 3108. Permitting physician assistants to order post-Hospital extended care 

services. 

Sec. 3109. Exemption of certain pharmacies from accreditation requirements. 

Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries. 

Sec. 3111. Payment for bone density tests. 

Sec. 3112. Revision to the Medicare Improvement Fund. 

Sec. 3113. Treatment of certain complex diagnostic laboratory tests. 

Sec. 3114. Improved access for certified nurse-midwife services. 

PART II—RURAL PROTECTIONS

Sec. 3121. Extension of outpatient hold harmless provision. 

Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural 

areas. 

Sec. 3123. Extension of the Rural Community Hospital Demonstration Program. 

Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program. 

Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment 

adjustment for low-volume hospitals. 

Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties. 

Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas. 

Sec. 3128. Technical correction related to critical access hospital services. 

Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program. 

PART III—IMPROVING PAYMENT ACCURACY

Sec. 3131. Payment adjustments for home health care. 

Sec. 3132. Hospice reform. 

Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) payments. 

Sec. 3134. Misvalued codes under the physician fee schedule. 

Sec. 3135. Modification of equipment utilization factor for advanced imaging services. 

Sec. 3136. Revision of payment for power-driven wheelchairs. 

Sec. 3137. Hospital wage index improvement. 

Sec. 3138. Treatment of certain cancer hospitals. 

Sec. 3139. Payment for biosimilar biological products. 

Sec. 3140. Medicare hospice concurrent care demonstration program. 

Sec. 3141. Application of budget neutrality on a national basis in the calculation of 

the Medicare hospital wage index floor. 

Sec. 3142. HHS study on urban Medicare-dependent hospitals. 

Sec. 3143. Protecting home health benefits. 

Subtitle C—Provisions Relating to Part C 

Sec. 3201. øMedicare Advantage payment¿ørepealed & replaced¿. 

Sec. 3202. Benefit protection and simplification. 

Sec. 3203. øApplication of coding intensity adjustment during MA payment transition¿ørepealed and replaced¿. 

Sec. 3204. Simplification of annual beneficiary election periods. 

Sec. 3205. Extension for specialized MA plans for special needs individuals. 

Sec. 3206. Extension of reasonable cost contracts. 

Sec. 3207. Technical correction to MA private fee-for-service plans. 

Sec. 3208. Making senior housing facility demonstration permanent. 

Sec. 3209. Authority to deny plan bids. 

Sec. 3210. Development of new standards for certain Medigap plans. 
Sec. 1 PPACA (Consolidated) 6 

Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA– 

PD Plans 

Sec. 3301. Medicare coverage gap discount program. 

Sec. 3302. Improvement in determination of Medicare part D low-income benchmark premium. 

Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under prescription drug plans and MA–PD plans. 

Sec. 3304. Special rule for widows and widowers regarding eligibility for low-income assistance. 

Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA–PD plans. 

Sec. 3306. Funding outreach and assistance for low-income programs. 

Sec. 3307. Improving formulary requirements for prescription drug plans and MA– 

PD plans with respect to certain categories or classes of drugs. 

Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries. 

Sec. 3309. Elimination of cost sharing for certain dual eligible individuals. 

Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in longterm care facilities under prescription drug plans and MA–PD plans. 

Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan complaint 

system. 

Sec. 3312. Uniform exceptions and appeals process for prescription drug plans and 

MA–PD plans. 

Sec. 3313. Office of the Inspector General studies and reports. 

Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian 

Health Service in providing prescription drugs toward the annual outof-pocket threshold under part D. 

Sec. 3315. øImmediate reduction in coverage gap in 2010¿ørepealed and replaced¿. 

Subtitle E—Ensuring Medicare Sustainability 

Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements. 

Sec. 3402. Temporary adjustment to the calculation of part B premiums. 

Sec. 3403. Independent øMedicare¿ Payment Advisory Board. 

Subtitle F—Health Care Quality Improvements 

Sec. 3501. Health care delivery system research; Quality improvement technical assistance. 

Sec. 3502. Establishing community health teams to support the patient-centered 

medical home. 

Sec. 3503. Medication management services in treatment of chronic disease. 

Sec. 3504. Design and implementation of regionalized systems for emergency care. 

Sec. 3505. Trauma care centers and service availability. 

Sec. 3506. Program to facilitate shared decisionmaking. 

Sec. 3507. Presentation of prescription drug benefit and risk information. 

Sec. 3508. Demonstration program to integrate quality improvement and patient 

safety training into clinical education of health professionals. 

Sec. 3509. Improving women’s health. 

Sec. 3510. Patient navigator program. 

Sec. 3511. Authorization of appropriations. 

Sec. 3512. GAO study and report on causes of action. 

Subtitle G—Protecting and Improving Guaranteed Medicare Benefits 

Sec. 3601. Protecting and improving guaranteed Medicare benefits. 

Sec. 3602. No cuts in guaranteed benefits. 

TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC 

HEALTH 

Subtitle A—Modernizing Disease Prevention and Public Health Systems 

Sec. 4001. National Prevention, Health Promotion and Public Health Council. 

Sec. 4002. Prevention and Public Health Fund. 

Sec. 4003. Clinical and community Preventive Services. 

Sec. 4004. Education and outreach campaign regarding preventive benefits. 
7 Sec. 1 PPACA (Consolidated) 

Subtitle B—Increasing Access to Clinical Preventive Services 

Sec. 4101. School-based health centers. 

Sec. 4102. Oral healthcare prevention activities. 

Sec. 4103. Medicare coverage of annual wellness visit providing a personalized prevention plan. 

Sec. 4104. Removal of barriers to preventive services in Medicare. 

Sec. 4105. Evidence-based coverage of preventive services in Medicare. 

Sec. 4106. Improving access to preventive services for eligible adults in Medicaid. 

Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant 

women in Medicaid. 

Sec. 4108. Incentives for prevention of chronic diseases in medicaid. 

Subtitle C—Creating Healthier Communities 

Sec. 4201. Community transformation grants. 

Sec. 4202. Healthy aging, living well; evaluation of community-based prevention 

and wellness programs for Medicare beneficiaries. 

Sec. 4203. Removing barriers and improving access to wellness for individuals with 

disabilities. 

Sec. 4204. Immunizations. 

Sec. 4205. Nutrition labeling of standard menu items at Chain Restaurants. 

Sec. 4206. Demonstration project concerning individualized wellness plan. 

Sec. 4207. Reasonable break time for nursing mothers. 

Subtitle D—Support for Prevention and Public Health Innovation 

Sec. 4301. Research on optimizing the delivery of public health services. 

Sec. 4302. Understanding health disparities: data collection and analysis. 

Sec. 4303. CDC and employer-based wellness programs. 

Sec. 4304. Epidemiology-Laboratory Capacity Grants. 

Sec. 4305. Advancing research and treatment for pain care management. 

Sec. 4306. Funding for Childhood Obesity Demonstration Project. 

Subtitle E—Miscellaneous Provisions 

Sec. 4401. Sense of the Senate concerning CBO scoring. 

Sec. 4402. Effectiveness of Federal health and wellness initiatives. 

TITLE V—HEALTH CARE WORKFORCE 

Subtitle A—Purpose and Definitions 

Sec. 5001. Purpose. 

Sec. 5002. Definitions. 

Subtitle B—Innovations in the Health Care Workforce 

Sec. 5101. National health care workforce commission. 

Sec. 5102. State health care workforce development grants. 

Sec. 5103. Health care workforce assessment. 

Sec. 5104. Interagency task force to assess and improve access to health care in the 

State of Alaska. 

Subtitle C—Increasing the Supply of the Health Care Workforce 

Sec. 5201. Federally supported student loan funds. 

Sec. 5202. Nursing student loan program. 

Sec. 5203. Health care workforce loan repayment programs. 

Sec. 5204. Public health workforce recruitment and retention programs. 

Sec. 5205. Allied health workforce recruitment and retention programs. 

Sec. 5206. Grants for State and local programs. 

Sec. 5207. Funding for National Health Service Corps. 

Sec. 5208. Nurse-managed health clinics. 

Sec. 5209. Elimination of cap on commissioned corps. 

Sec. 5210. Establishing a Ready Reserve Corps. 

Subtitle D—Enhancing Health Care Workforce Education and Training 

Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. 

Sec. 5302. Training opportunities for direct care workers. 

Sec. 5303. Training in general, pediatric, and public health dentistry. 

Sec. 5304. Alternative dental health care providers demonstration project. 
Sec. 1 PPACA (Consolidated) 8 

Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric 

education. 

Sec. 5306. Mental and behavioral health education and training grants. 

Sec. 5307. Cultural competency, prevention, and public health and individuals with 

disabilities training. 

Sec. 5308. Advanced nursing education grants. 

Sec. 5309. Nurse education, practice, and retention grants. 

Sec. 5310. Loan repayment and scholarship program. 

Sec. 5311. Nurse faculty loan program. 

Sec. 5312. Authorization of appropriations for parts B through D of title VIII. 

Sec. 5313. Grants to promote the community health workforce. 

Sec. 5314. Fellowship training in public health. 

Sec. 5315. United States Public Health Sciences Track. 

Sec. 5316. Demonstration grants for family nurse practitioner training programs. 

Subtitle E—Supporting the Existing Health Care Workforce 

Sec. 5401. Centers of excellence. 

Sec. 5402. Health care professionals training for diversity. 

Sec. 5403. Interdisciplinary, community-based linkages. 

Sec. 5404. Workforce diversity grants. 

Sec. 5405. Primary care extension program. 

Subtitle F—Strengthening Primary Care and Other Workforce Improvements 

Sec. 5501. Expanding access to primary care services and general surgery services. 

Sec. 5502. øMedicare Federally qualified health center improvements¿ørepealed¿. 

Sec. 5503. Distribution of additional residency positions. 

Sec. 5504. Counting resident time in nonprovider settings. 

Sec. 5505. Rules for counting resident time for didactic and scholarly activities and 

other activities. 

Sec. 5506. Preservation of resident cap positions from closed hospitals. 

Sec. 5507. Demonstration projects To address health professions workforce needs; 

extension of family-to-family health information centers. 

Sec. 5508. Increasing teaching capacity. 

Sec. 5509. Graduate nurse education demonstration. 

Subtitle G—Improving Access to Health Care Services 

Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs). 

Sec. 5602. Negotiated rulemaking for development of methodology and criteria for 

designating medically underserved populations and health professions 

shortage areas. 

Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for Children Program. 

Sec. 5604. Co-locating primary and specialty care in community-based mental 

health settings. 

Sec. 5605. Key National indicators. 

Sec. 5606. State grants to health care providers who provide services to a high percentage of medically underserved populations or other special populations. 

Subtitle H—General Provisions 

Sec. 5701. Reports. 

TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY 

Subtitle A—Physician Ownership and Other Transparency 

Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician 

referrals for hospitals. 

Sec. 6002. Transparency reports and reporting of physician ownership or investment interests. 

Sec. 6003. Disclosure requirements for in-office ancillary services exception to the 

prohibition on physician self-referral for certain imaging services. 

Sec. 6004. Prescription drug sample transparency. 

Sec. 6005. Pharmacy benefit managers transparency requirements. 
9 Sec. 1 PPACA (Consolidated) 

Subtitle B—Nursing Home Transparency and Improvement 

PART 1—IMPROVING TRANSPARENCY OF INFORMATION

Sec. 6101. Required disclosure of ownership and additional disclosable parties information. 

Sec. 6102. Accountability requirements for skilled nursing facilities and nursing facilities. 

Sec. 6103. Nursing home compare Medicare website. 

Sec. 6104. Reporting of expenditures. 

Sec. 6105. Standardized complaint form. 

Sec. 6106. Ensuring staffing accountability. 

Sec. 6107. GAO study and report on Five-Star Quality Rating System. 

PART 2—TARGETING ENFORCEMENT

Sec. 6111. Civil money penalties. 

Sec. 6112. National independent monitor demonstration project. 

Sec. 6113. Notification of facility closure. 

Sec. 6114. National demonstration projects on culture change and use of information technology in nursing homes. 

PART 3—IMPROVING STAFF TRAINING

Sec. 6121. Dementia and abuse prevention training. 

Subtitle C—Nationwide Program for National and State Background Checks on 

Direct Patient Access Employees of Long-term Care Facilities and Providers 

Sec. 6201. Nationwide program for National and State background checks on direct 

patient access employees of long-term care facilities and providers. 

Subtitle D—Patient-Centered Outcomes Research 

Sec. 6301. Patient-Centered Outcomes Research. 

Sec. 6302. Federal coordinating council for comparative effectiveness research. 

Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions 

Sec. 6401. Provider screening and other enrollment requirements under Medicare, 

Medicaid, and CHIP. 

Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. 

Sec. 6403. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank. 

Sec. 6404. Maximum period for submission of Medicare claims reduced to not more 

than 12 months. 

Sec. 6405. Physicians who order items or services required to be Medicare enrolled 

physicians or eligible professionals. 

Sec. 6406. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse. 

Sec. 6407. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment 

under Medicare. 

Sec. 6408. Enhanced penalties. 

Sec. 6409. Medicare self-referral disclosure protocol. 

Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics, 

orthotics, and supplies competitive acquisition program. 

Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program. 

Subtitle F—Additional Medicaid Program Integrity Provisions 

Sec. 6501. Termination of provider participation under Medicaid if terminated 

under Medicare or other State plan. 

Sec. 6502. Medicaid exclusion from participation relating to certain ownership, 

control, and management affiliations. 

Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid. 

Sec. 6504. Requirement to report expanded set of data elements under MMIS to 

detect fraud and abuse. 

Sec. 6505. Prohibition on payments to institutions or entities located outside of the 

United States. 

Sec. 6506. Overpayments. 
Sec. 1 PPACA (Consolidated) 10 

Sec. 6507. Mandatory State use of national correct coding initiative. 

Sec. 6508. General effective date. 

Subtitle G—Additional Program Integrity Provisions 

Sec. 6601. Prohibition on false statements and representations. 

Sec. 6602. Clarifying definition. 

Sec. 6603. Development of model uniform report form. 

Sec. 6604. Applicability of State law to combat fraud and abuse. 

Sec. 6605. Enabling the Department of Labor to issue administrative summary 

cease and desist orders and summary seizures orders against plans 

that are in financially hazardous condition. 

Sec. 6606. MEWA plan registration with Department of Labor. 

Sec. 6607. Permitting evidentiary privilege and confidential communications. 

Subtitle H—Elder Justice Act 

Sec. 6701. Short title of subtitle. 

Sec. 6702. Definitions. 

Sec. 6703. Elder Justice. 

Subtitle I—Sense of the Senate Regarding Medical Malpractice 

Sec. 6801. Sense of the Senate regarding medical malpractice. 

TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES 

Subtitle A—Biologics Price Competition and Innovation 

Sec. 7001. Short title. 

Sec. 7002. Approval pathway for biosimilar biological products. 

Sec. 7003. Savings. 

Subtitle B—More Affordable Medicines for Children and Underserved Communities 

Sec. 7101. Expanded participation in 340B program. 

Sec. 7102. Improvements to 340B program integrity. 

Sec. 7103. GAO study to make recommendations on improving the 340B program. 

TITLE VIII—CLASS ACT 

Sec. 8001. Short title of title. 

Sec. 8002. Establishment of national voluntary insurance program for purchasing 

community living assistance services and support. 

TITLE IX—REVENUE PROVISIONS 

Subtitle A—Revenue Offset Provisions 

Sec. 9001. Excise tax on high cost employer-sponsored health coverage. 

Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W–2. 

Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin. 

Sec. 9004. Increase in additional tax on distributions from HSAs and Archer MSAs 

not used for qualified medical expenses. 

Sec. 9005. Limitation on health flexible spending arrangements under cafeteria 

plans. 

Sec. 9006. Expansion of information reporting requirements. 

Sec. 9007. Additional requirements for charitable hospitals. 

Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers. 

Sec. 9009. øImposition of annual fee on medical device manufacturers and importers¿ørepealed and replaced¿. 

Sec. 9010. Imposition of annual fee on health insurance providers. 

Sec. 9011. Study and report of effect on veterans health care. 

Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D subsidy. 

Sec. 9013. Modification of itemized deduction for medical expenses. 

Sec. 9014. Limitation on excessive remuneration paid by certain health insurance 

providers. 

Sec. 9015. Additional hospital insurance tax on high-income taxpayers. 

Sec. 9016. Modification of section 833 treatment of certain health organizations. 

Sec. 9017. øExcise tax on elective cosmetic medical procedures¿ønullified¿. 
11 Sec. 1 PPACA (Consolidated) 

Subtitle B—Other Provisions 

Sec. 9021. Exclusion of health benefits provided by Indian tribal governments. 

Sec. 9022. Establishment of simple cafeteria plans for small businesses. 

Sec. 9023. Qualifying therapeutic discovery project credit. 

TITLE X—STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR 

ALL AMERICANS 

Subtitle A—Provisions Relating to Title I 

Sec. 10101. Amendments to subtitle A øamendments fully incorporated above¿. Sec. 10102. Amendments to subtitle B øamendments fully incorporated above¿. Sec. 10103. Amendments to subtitle C øamendments fully incorporated above¿. Sec. 10104. Amendments to subtitle D. 

Sec. 10105. Amendments to subtitle E øamendments fully incorporated above¿. Sec. 10106. Amendments to subtitle F øamendments fully incorporated above¿. Sec. 10107. Amendments to subtitle G øamendments fully incorporated above¿. Sec. 10108. Free choice vouchers. 

Sec. 10109. Development of standards for financial and administrative transactions. 

Subtitle B—Provisions Relating to Title II 

PART 1—MEDICAID AND CHIP 

Sec. 10201. Amendments to the Social Security Act and title II of this Act. 

Sec. 10202. Incentives for States to offer home and community-based services as a 

long-term care alternative to nursing homes. 

Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and other 

CHIP-related provisions. 

PART 2—SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN

Sec. 10211. Definitions. 

Sec. 10212. Establishment of pregnancy assistance fund. 

Sec. 10213. Permissible uses of Fund. 

Sec. 10214. Appropriations. 

PART 3—INDIAN HEALTH CARE IMPROVEMENT

Sec. 10221. Indian health care improvement. 

Subtitle C—Provisions Relating to Title III 

Sec. 10301. Plans for a Value-Based purchasing program for ambulatory surgical 

centers øamendments fully incorporated above¿. Sec. 10302. Revision to national strategy for quality improvement in health care 

øamendments fully incorporated above¿. Sec. 10303. Development of outcome measures. 

Sec. 10304. Selection of efficiency measures øamendments fully incorporated 

above¿. 

Sec. 10305. Data collection; public reporting øamendments fully incorporated 

above¿. 

Sec. 10306. Improvements under the Center for Medicare and Medicaid Innovation 

øamendments fully incorporated above¿. 

Sec. 10307. Improvements to the Medicare shared savings program øamendments 

fully incorporated above¿. 

Sec. 10308. Revisions to national pilot program on payment bundling øamendments 

fully incorporated above¿. 

Sec. 10309. Revisions to hospital readmissions reduction program øamendments 

fully incorporated above¿. 

Sec. 10310. Repeal of physician payment update øamendments fully incorporated 

above¿. 

Sec. 10311. Revisions to extension of ambulance add-ons øamendments fully incorporated above¿. 

Sec. 10312. Certain payment rules for long-term care hospital services and moratorium on the establishment of certain hospitals and facilities øamendments fully incorporated above¿. 

Sec. 10313. Revisions to the extension for the rural community hospital demonstration program øamendments fully incorporated above¿. 

Sec. 10314. Adjustment to low-volume hospital provision øamendments fully incorporated above¿. 
Sec. 1 PPACA (Consolidated) 12 

Sec. 10315. Revisions to home health care provisions øamendments fully incorporated above¿. Sec. 10316. Medicare DSH øamendments fully incorporated above¿. Sec. 10317. Revisions to extension of section 508 hospital provisions øamendments 

fully incorporated above¿. Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage 

øamendments fully incorporated above¿. Sec. 10319. Revisions to market basket adjustments øamendments fully incorporated above¿. Sec. 10320. Expansion of the scope of, and additional improvements to, the Independent Medicare Advisory Board. 

Sec. 10321. Revision to community health teams øamendments fully incorporated 

above¿. Sec. 10322. Quality reporting for psychiatric hospitals. 

Sec. 10323. Medicare coverage for individuals exposed to environmental health hazards. 

Sec. 10324. Protections for frontier States. 

Sec. 10325. Revision to skilled nursing facility prospective payment system. 

Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers. 

Sec. 10327. Improvements to the physician quality reporting system. 

Sec. 10328. Improvement in part D medication therapy management (MTM) programs. 

Sec. 10329. Developing methodology to assess health plan value. 

Sec. 10330. Modernizing computer and data systems of the Centers for Medicare & 

Medicaid services to support improvements in care delivery. 

Sec. 10331. Public reporting of performance information. 

Sec. 10332. Availability of medicare data for performance measurement. 

Sec. 10333. Community-based collaborative care networks. 

Sec. 10334. Minority health. 

Sec. 10335. Technical correction to the hospital value-based purchasing program 

øamendments fully incorporated above¿. 

Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality 

dialysis services. 

Subtitle D—Provisions Relating to Title IV 

Sec. 10401. Amendments to subtitle A øamendments fully incorporated above¿. 

Sec. 10402. Amendments to subtitle B øamendments fully incorporated above¿. 

Sec. 10403. Amendments to subtitle C øamendments fully incorporated above¿. 

Sec. 10404. Amendments to subtitle D øamendments fully incorporated above¿. 

Sec. 10405. Amendments to subtitle E øamendments fully incorporated above¿. 

Sec. 10406. Amendment relating to waiving coinsurance for preventive services 

øamendments fully incorporated above¿. 

Sec. 10407. Better diabetes care. 

Sec. 10408. Grants for small businesses to provide comprehensive workplace 

wellness programs. 

Sec. 10409. Cures Acceleration Network. 

Sec. 10410. Centers of Excellence for Depression. 

Sec. 10411. Programs relating to congenital heart disease. 

Sec. 10412. Automated Defibrillation in Adam’s Memory Act. 

Sec. 10413. Young women’s breast health awareness and support of young women 

diagnosed with breast cancer. 

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. 

Sec. 10502. Infrastructure to Expand Access to Care. 

Sec. 10503. Community Health Centers and the National Health Service Corps 

Fund. 

Sec. 10504. Demonstration project to provide access to affordable care. 

Subtitle F—Provisions Relating to Title VI 

Sec. 10601. Revisions to limitation on medicare exception to the prohibition on certain physician referrals for hospitals øamendments fully incorporated 

above¿. 

Sec. 10602. Clarifications to patient-centered outcomes research øamendments fully 

incorporated above¿. 
13 Sec. 1001 PPACA (Consolidated) 

Sec. 10603. Striking provisions relating to individual provider application fees 

øamendments fully incorporated above¿. 

Sec. 10604. Technical correction to section 6405 øamendments fully incorporated 

above¿. 

Sec. 10605. Certain other providers permitted to conduct face to face encounter for 

home health services øamendments fully incorporated above¿. 

Sec. 10606. Health care fraud enforcement. 

Sec. 10607. State demonstration programs to evaluate alternatives to current medical tort litigation. 

Sec. 10608. Extension of medical malpractice coverage to free clinics. 

Sec. 10609. Labeling changes. 

Subtitle G—Provisions Relating to Title VIII 

Sec. 10801. Provisions relating to title VIII øamendments fully incorporated above¿. 

Subtitle H—Provisions Relating to Title IX 

Sec. 10901. Modifications to excise tax on high cost employer-sponsored health coverage øamendments fully incorporated above¿. 

Sec. 10902. Inflation adjustment of limitation on health flexible spending arrangements under cafeteria plans øamendments fully incorporated above¿. 

Sec. 10903. Modification of limitation on charges by charitable hospitals øamendments fully incorporated above¿. 

Sec. 10904. Modification of annual fee on medical device manufacturers and importers øamendments fully incorporated above¿. 

Sec. 10905. Modification of annual fee on health insurance providers øamendments 

fully incorporated above¿. 

Sec. 10906. Modifications to additional hospital insurance tax on high-income taxpayers øamendments fully incorporated above¿. 

Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic medical procedures øsubstitutes for section 9017 of PPACA¿. 

Sec. 10908. Exclusion for assistance provided to participants in State student loan 

repayment programs for certain health professionals. 

Sec. 10909. Expansion of adoption credit and adoption assistance programs. 

TITLE I—QUALITY, AFFORDABLE 

HEALTH CARE FOR ALL AMERICANS 

Subtitle A—Immediate Improvements in 

Health Care Coverage for All Americans 

SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT. 

Part A of title XXVII of the Public Health Service Act (42 

U.S.C. 300gg et seq.) is amended— 

(1) by striking the part heading and inserting the following: 

‘‘PART A—INDIVIDUAL AND GROUP MARKET 

REFORMS’’; 

(2) by redesignating sections 2704 through 2707 as sections 2725 through 2728, respectively; 

(3) by redesignating sections 2711 through 2713 as sections 2731 through 2733, respectively; 

(4) by redesignating sections 2721 through 2723 as sections 2735 through 2737, respectively; and 

(5) by inserting after section 2702, the following: 
Sec. 1001\2711 PHSA PPACA (Consolidated) 14 

‘‘Subpart II—Improving Coverage 

‘‘SEC. 2711. ø42 U.S.C. 300gg–11¿ NO LIFETIME OR ANNUAL LIMITS. 

øReplaced by section 10101(a)¿ 

‘‘(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. 

‘‘SEC. 2712. ø42 U.S.C. 300gg–12¿ PROHIBITION ON RESCISSIONS. 

‘‘A group health plan and a health insurance issuer offering 

group or individual health insurance coverage shall not rescind 

such plan or coverage with respect to an enrollee once the enrollee 

is covered under such plan or coverage involved, except that this 

section shall not apply to a covered individual who has performed 

an act or practice that constitutes fraud or makes an intentional 

misrepresentation of material fact as prohibited by the terms of the 

plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under 

section 2702(c) or 2742(b). 

‘‘SEC. 2713. ø42 U.S.C. 300gg–13¿ COVERAGE OF PREVENTIVE HEALTH 

SERVICES. 

‘‘(a) IN GENERAL.—A group health plan and a health insurance 

issuer offering group or individual health insurance coverage shall, 

at a minimum provide coverage for and shall not impose any cost 

sharing requirements for— 

‘‘(1) evidence-based items or services that have in effect a 

rating of ‘A’ or ‘B’ in the current recommendations of the 

United States Preventive Services Task Force; 
15 Sec. 1001 PPACA (Consolidated) \2714 PHSA 

‘‘(2) immunizations that have in effect a recommendation 

from the Advisory Committee on Immunization Practices of the 

Centers for Disease Control and Prevention with respect to the 

individual involved; and 

‘‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in 

the comprehensive guidelines supported by the Health Resources and Services Administration. 

‘‘(4) with respect to women, such additional preventive 

care and screenings not described in paragraph (1) as provided 

for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph. 

‘‘(5) for the purposes of this Act, and for the purposes of 

any other provision of law, the current recommendations of the 

United States Preventive Service Task Force regarding breast 

cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around 

November 2009. 

Nothing in this subsection shall be construed to prohibit a plan or 

issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to 

deny coverage for services that are not recommended by such Task 

Force. 

‘‘(b) INTERVAL.— 

‘‘(1) IN GENERAL.—The Secretary shall establish a minimum interval between the date on which a recommendation 

described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which 

the requirement described in subsection (a) is effective with respect to the service described in such recommendation or 

guideline. 

‘‘(2) MINIMUM.—The interval described in paragraph (1) 

shall not be less than 1 year. 

‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Secretary may develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage 

to utilize value-based insurance designs. 

‘‘SEC. 2714. ø42 U.S.C. 300gg–14¿ EXTENSION OF DEPENDENT COVERAGE. 

‘‘(a) IN GENERAL.—A group health plan and a health insurance 

issuer offering group or individual health insurance coverage that 

provides dependent coverage of children shall continue to make 

such coverage available for an adult child until the child turns 26 

years of age. Nothing in this section shall require a health plan or 

a health insurance issuer described in the preceding sentence to 

make coverage available for a child of a child receiving dependent 

coverage. øAs revised by section 2301(b) of HCERA¿ 

‘‘(b) REGULATIONS.—The Secretary shall promulgate regulations to define the dependents to which coverage shall be made 

available under subsection (a). 

‘‘(c) RULE OF CONSTRUCTION.—Nothing in this section shall be 

construed to modify the definition of ‘dependent’ as used in the In-
Sec. 1001\2715 PHSA PPACA (Consolidated) 16 

ternal Revenue Code of 1986 with respect to the tax treatment of 

the cost of coverage. 

‘‘SEC. 2715. ø42 U.S.C. 300gg–15¿ DEVELOPMENT AND UTILIZATION OF 

UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND 

STANDARDIZED DEFINITIONS. 

‘‘(a) IN GENERAL.—Not later than 12 months after the date of 

enactment of the Patient Protection and Affordable Care Act, the 

Secretary shall develop standards for use by a group health plan 

and a health insurance issuer offering group or individual health 

insurance coverage, in compiling and providing to applicants, enrollees, and policyholders or certificate holders a summary of benefits and coverage explanation that accurately describes the benefits 

and coverage under the applicable plan or coverage. In developing 

such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as 

the ‘NAIC’), a working group composed of representatives of health 

insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including 

those representing individuals with limited English proficiency, 

and other qualified individuals. øAs revised by section 10101(b)¿ 

‘‘(b) REQUIREMENTS.—The standards for the summary of benefits and coverage developed under subsection (a) shall provide for 

the following: 

‘‘(1) APPEARANCE.—The standards shall ensure that the 

summary of benefits and coverage is presented in a uniform 

format that does not exceed 4 pages in length and does not include print smaller than 12-point font. 

‘‘(2) LANGUAGE.—The standards shall ensure that the summary is presented in a culturally and linguistically appropriate 

manner and utilizes terminology understandable by the average plan enrollee. 

‘‘(3) CONTENTS.—The standards shall ensure that the summary of benefits and coverage includes— 

‘‘(A) uniform definitions of standard insurance terms 

and medical terms (consistent with subsection (g)) so that 

consumers may compare health insurance coverage and 

understand the terms of coverage (or exception to such 

coverage); 

‘‘(B) a description of the coverage, including cost sharing for— 

‘‘(i) each of the categories of the essential health 

benefits described in subparagraphs (A) through (J) of 

section 1302(b)(1) of the Patient Protection and Affordable Care Act; and 

‘‘(ii) other benefits, as identified by the Secretary; 

‘‘(C) the exceptions, reductions, and limitations on coverage; 

‘‘(D) the cost-sharing provisions, including deductible, 

coinsurance, and co-payment obligations; 

‘‘(E) the renewability and continuation of coverage provisions; 

‘‘(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy 

and serious or chronic medical conditions and related cost 
17 Sec. 1001 PPACA (Consolidated) \2715 PHSA 

sharing, such scenarios to be based on recognized clinical 

practice guidelines; 

‘‘(G) a statement of whether the plan or coverage— 

‘‘(i) provides minimum essential coverage (as defined under section 5000A(f) of the Internal Revenue 

Code 1986); and 

‘‘(ii) ensures that the plan or coverage share of the 

total allowed costs of benefits provided under the plan 

or coverage is not less than 60 percent of such costs; 

‘‘(H) a statement that the outline is a summary of the 

policy or certificate and that the coverage document itself 

should be consulted to determine the governing contractual provisions; and 

‘‘(I) a contact number for the consumer to call with additional questions and an Internet web address where a 

copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained. 

‘‘(c) PERIODIC REVIEW AND UPDATING.—The Secretary shall periodically review and update, as appropriate, the standards developed under this section. 

‘‘(d) REQUIREMENT TO PROVIDE.— ‘‘(1) IN GENERAL.—Not later than 24 months after the date 

of enactment of the Patient Protection and Affordable Care 

Act, each entity described in paragraph (3) shall provide, prior 

to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the 

Secretary under subsection (a) to— 

‘‘(A) an applicant at the time of application; 

‘‘(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and 

‘‘(C) a policyholder or certificate holder at the time of 

issuance of the policy or delivery of the certificate. 

‘‘(2) COMPLIANCE.—An entity described in paragraph (3) is 

deemed to be in compliance with this section if the summary 

of benefits and coverage described in subsection (a) is provided 

in paper or electronic form. 

‘‘(3) ENTITIES IN GENERAL.—An entity described in this 

paragraph is— 

‘‘(A) a health insurance issuer (including a group 

health plan that is not a self-insured plan) offering health 

insurance coverage within the United States; or 

‘‘(B) in the case of a self-insured group health plan, 

the plan sponsor or designated administrator of the plan 

(as such terms are defined in section 3(16) of the Employee 

Retirement Income Security Act of 1974). 

‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan or 

health insurance issuer makes any material modification in 

any of the terms of the plan or coverage involved (as defined 

for purposes of section 102 of the Employee Retirement Income 

Security Act of 1974) that is not reflected in the most recently 

provided summary of benefits and coverage, the plan or issuer 

shall provide notice of such modification to enrollees not later 

than 60 days prior to the date on which such modification will 

become effective. 
Sec. 1001\2715A PHSA PPACA (Consolidated) 18 

‘‘(e) PREEMPTION.—The standards developed under subsection 

(a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to 

consumers than that required to be provided under this section, as 

determined by the Secretary. 

‘‘(f) FAILURE TO PROVIDE.—An entity described in subsection 

(d)(3) that willfully fails to provide the information required under 

this section shall be subject to a fine of not more than $1,000 for 

each such failure. Such failure with respect to each enrollee shall 

constitute a separate offense for purposes of this subsection. 

‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.— 

‘‘(1) IN GENERAL.—The Secretary shall, by regulation, provide for the development of standards for the definitions of 

terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical 

terms described in paragraph (3). 

‘‘(2) INSURANCE-RELATED TERMS.—The insurance-related 

terms described in this paragraph are premium, deductible, coinsurance, co-payment, out-of-pocket limit, preferred provider, 

non-preferred provider, out-of-network co-payments, UCR 

(usual, customary and reasonable) fees, excluded services, 

grievance and appeals, and such other terms as the Secretary 

determines are important to define so that consumers may 

compare health insurance coverage and understand the terms 

of their coverage. 

‘‘(3) MEDICAL TERMS.—The medical terms described in this 

paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled 

nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers 

may compare the medical benefits offered by health insurance 

and understand the extent of those medical benefits (or exceptions to those benefits). 

‘‘SEC. 2715A. ø42 U.S.C. 300gg–15a¿ PROVISION OF ADDITIONAL INFORMATION. 

‘‘øAs added by section 10101(c)¿ 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. 

‘‘SEC. 2716. ø42 U.S.C. 300gg–16¿ PROHIBITION ON DISCRIMINATION IN 

FAVOR OF HIGHLY COMPENSATED INDIVIDUALS. 

øReplaced by section 10101(d)¿ 

‘‘(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— 
19 Sec. 1001 PPACA (Consolidated) \2717 PHSA 

‘‘(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. 

‘‘SEC. 2717. ø42 U.S.C. 300gg–17¿ ENSURING THE QUALITY OF CARE. 

‘‘(a) QUALITY REPORTING.— 

‘‘(1) IN GENERAL.—Not later than 2 years after the date of 

enactment of the Patient Protection and Affordable Care Act, 

the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for 

use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that— 

‘‘(A) improve health outcomes through the implementation of activities such as quality reporting, effective case 

management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection 

and Affordable Care Act, for treatment or services under 

the plan or coverage; 

‘‘(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; 

‘‘(C) implement activities to improve patient safety 

and reduce medical errors through the appropriate use of 

best clinical practices, evidence based medicine, and health 

information technology under the plan or coverage; and 

‘‘(D) implement wellness and health promotion activities. 

‘‘(2) REPORTING REQUIREMENTS.— 

‘‘(A) IN GENERAL.—A group health plan and a health 

insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and 

to enrollees under the plan or coverage, a report on whether the benefits under the plan or coverage satisfy the elements described in subparagraphs (A) through (D) of paragraph (1). 

‘‘(B) TIMING OF REPORTS.—A report under subparagraph (A) shall be made available to an enrollee under the 

plan or coverage during each open enrollment period. 

‘‘(C) AVAILABILITY OF REPORTS.—The Secretary shall 

make reports submitted under subparagraph (A) available 

to the public through an Internet website. 

‘‘(D) PENALTIES.—In developing the reporting requirements under paragraph (1), the Secretary may develop and 
Sec. 1001\2717 PHSA PPACA (Consolidated) 20 

impose appropriate penalties for non-compliance with such 

requirements. 

‘‘(E) EXCEPTIONS.—In developing the reporting requirements under paragraph (1), the Secretary may provide for exceptions to such requirements for group health 

plans and health insurance issuers that substantially meet 

the goals of this section. 

‘‘(b) WELLNESS AND PREVENTION PROGRAMS.—For purposes of 

subsection (a)(1)(D), wellness and health promotion activities may 

include personalized wellness and prevention services, which are 

coordinated, maintained or delivered by a health care provider, a 

wellness and prevention plan manager, or a health, wellness or 

prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which 

may include the following wellness and prevention efforts: 

‘‘(1) Smoking cessation. 

‘‘(2) Weight management. 

‘‘(3) Stress management. 

‘‘(4) Physical fitness. 

‘‘(5) Nutrition. 

‘‘(6) Heart disease prevention. 

‘‘(7) Healthy lifestyle support. 

‘‘(8) Diabetes prevention. 

‘‘(c) PROTECTION OF SECOND AMENDMENT GUN RIGHTS.—øAs 

added by section 10101(e)(2)¿ 

‘‘(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 
21 Sec. 1001 PPACA (Consolidated) \2718 PHSA 

wellness program may not be reduced or withheld under any 

health benefit plan issued pursuant to or in accordance with 

the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon— 

‘‘(A) the lawful ownership or possession of a firearm or 

ammunition; or 

‘‘(B) the lawful use or storage of a firearm or ammunition. 

‘‘(5) LIMITATION ON DATA COLLECTION 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. 

‘‘(d) REGULATIONS.—Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure is described in subsection (a). 

‘‘(e) STUDY AND REPORT.—Not later than 180 days after the 

date on which regulations are promulgated under subsection (c), 

the Government Accountability Office shall review such regulations 

and conduct a study and submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on 

Energy and Commerce of the House of Representatives a report regarding the impact the activities under this section have had on 

the quality and cost of health care. 

‘‘SEC. 2718. ø42 U.S.C. 300gg–18¿ BRINGING DOWN THE COST OF HEALTH 

CARE COVERAGE. 

øReplaced by section 10101(f)¿ 

‘‘(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.— 
Sec. 1001\2718 PHSA PPACA (Consolidated) 22 

‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAY- MENTS.— 

‘‘(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, 
23 Sec. 1001 PPACA (Consolidated) \2719 PHSA 

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. 

‘‘SEC. 2719. ø42 U.S.C. 300gg–19¿ APPEALS PROCESS. 

øReplaced by section 10101(g)¿ 

‘‘(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. 
Sec. 1001\2719A PHSA PPACA (Consolidated) 24 

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. 

‘‘SEC. 2719A. ø42 U.S.C. 300gg–19a¿ PATIENT PROTECTIONS. 

øSection inserted by section 10101(h)¿ 

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group 

health plan, or a health insurance issuer offering group or individual health insurance coverage, requires or provides for designation by a participant, beneficiary, or enrollee of a participating primary care provider, then the plan or issuer shall permit each participant, beneficiary, and enrollee to designate any participating 

primary care provider who is available to accept such individual. 

‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 

‘‘(1) IN GENERAL.—If a group health plan, or a health insurance issuer offering group or individual health insurance 

issuer, provides or covers any benefits with respect to services 

in an emergency department of a hospital, the plan or issuer 

shall cover emergency services (as defined in paragraph 

(2)(B))— 
25 Sec. 1001 PPACA (Consolidated) \2719A PHSA 

‘‘(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. 
Sec. 1001\2719A PHSA PPACA (Consolidated) 26 

‘‘(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. 
27 Sec. 1002 PPACA (Consolidated) \2713 PHSA 

‘‘(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.’’. 

SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION. 

Part C of title XXVII of the Public Health Service Act (42 

U.S.C. 300gg–91 et seq.) is amended by adding at the end the following: 

‘‘SEC. 2793. ø42 U.S.C. 300gg–93¿ HEALTH INSURANCE CONSUMER INFORMATION. 

‘‘(a) IN GENERAL.—The Secretary shall award grants to States 

to enable such States (or the Exchanges operating in such States) 

to establish, expand, or provide support for— 

‘‘(1) offices of health insurance consumer assistance; or 

‘‘(2) health insurance ombudsman programs. 

‘‘(b) ELIGIBILITY.— ‘‘(1) IN GENERAL.—To be eligible to receive a grant, a State 

shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer 

assistance organizations, receives and responds to inquiries 

and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under 

State law. 

‘‘(2) CRITERIA.—A State that receives a grant under this 

section shall comply with criteria established by the Secretary 

for carrying out activities under such grant. 

‘‘(c) DUTIES.—The office of health insurance consumer assistance or health insurance ombudsman shall— 

‘‘(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance 

process of the group health plan or health insurance issuer involved and providing information about the external appeal 

process; 

‘‘(2) collect, track, and quantify problems and inquiries encountered by consumers; 

‘‘(3) educate consumers on their rights and responsibilities 

with respect to group health plans and health insurance coverage; 

‘‘(4) assist consumers with enrollment in a group health 

plan or health insurance coverage by providing information, referral, and assistance; and 

‘‘(5) resolve problems with obtaining premium tax credits 

under section 36B of the Internal Revenue Code of 1986. 

‘‘(d) DATA COLLECTION.—As a condition of receiving a grant 

under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report 
Sec. 1003 PPACA (Consolidated) 28 

data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to 

identify areas where more enforcement action is necessary and 

shall share such information with State insurance regulators, the 

Secretary of Labor, and the Secretary of the Treasury for use in the 

enforcement activities of such agencies. 

‘‘(e) FUNDING.— 

‘‘(1) INITIAL FUNDING.—There is hereby appropriated to the 

Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this 

section applies to carry out this section. Such amount shall remain available without fiscal year limitation. 

‘‘(2) AUTHORIZATION FOR SUBSEQUENT YEARS.—There is authorized to be appropriated to the Secretary for each fiscal year 

following the fiscal year described in paragraph (1), such sums 

as may be necessary to carry out this section.’’. 

SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS. 

Part C of title XXVII of the Public Health Service Act (42 

U.S.C. 300gg–91 et seq.), as amended by section 1002, is further 

amended by adding at the end the following: 

‘‘SEC. 2794. ø42 U.S.C. 300gg–94¿ ENSURING THAT CONSUMERS GET 

VALUE FOR THEIR DOLLARS. 

‘‘(a) INITIAL PREMIUM REVIEW PROCESS.— 

‘‘(1) IN GENERAL.—The Secretary, in conjunction with 

States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection 

(b)(2)(A), of unreasonable increases in premiums for health insurance coverage. 

‘‘(2) JUSTIFICATION AND DISCLOSURE.—The process established under paragraph (1) shall require health insurance 

issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the 

implementation of the increase. Such issuers shall prominently 

post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such 

increases and justifications for all health insurance issuers. 

‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.— 

‘‘(1) INFORMING SECRETARY OF PREMIUM INCREASE PATTERNS.—As a condition of receiving a grant under subsection 

(c)(1), a State, through its Commissioner of Insurance, shall— 

‘‘(A) provide the Secretary with information about 

trends in premium increases in health insurance coverage 

in premium rating areas in the State; and 

‘‘(B) make recommendations, as appropriate, to the 

State Exchange about whether particular health insurance 

issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases. 

‘‘(2) MONITORING BY SECRETARY OF PREMIUM INCREASES.— 

‘‘(A) IN GENERAL.—Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States 

and consistent with the provisions of subsection (a)(2), 
29 Sec. 1003 PPACA (Consolidated) \2794 PHSA 

shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Exchange. 

‘‘(B) CONSIDERATION IN OPENING EXCHANGE.—In determining under section 1312(f)(2)(B) of the Patient Protection and Affordable Care Act whether to offer qualified 

health plans in the large group market through an Exchange, the State shall take into account any excess of premium growth outside of the Exchange as compared to the 

rate of such growth inside the Exchange. 

‘‘(c) GRANTS IN SUPPORT OF PROCESS.— ‘‘(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014.— The Secretary shall carry out a program to award grants to 

States during the 5-year period beginning with fiscal year 2010 

to assist such States in carrying out subsection (a), including— 

‘‘(A) in reviewing and, if appropriate under State law, 

approving premium increases for health insurance coverage; 

‘‘(B) in providing information and recommendations to 

the Secretary under subsection (b)(1); and 

‘‘(C) øAs added by section 10101(i)(1)(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. 

‘‘(2) FUNDING.— 

‘‘(A) IN GENERAL.—Out of all funds in the Treasury not 

otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for 

grants under paragraph (1) and subparagraph (B). 

‘‘(B) FURTHER AVAILABILITY FOR INSURANCE REFORM

AND CONSUMER PROTECTION.—If the amounts appropriated 

under subparagraph (A) are not fully obligated under 

grants under paragraph (1) by the end of fiscal year 2014, 

any remaining funds shall remain available to the Secretary for grants to States for planning and implementing 

the insurance reforms and consumer protections under 

part A. 

‘‘(C) ALLOCATION.—The Secretary shall establish a formula for determining the amount of any grant to a State 

under this subsection. Under such formula— 

‘‘(i) the Secretary shall consider the number of 

plans of health insurance coverage offered in each 

State and the population of the State; and 

‘‘(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more 

than $5,000,000 for a grant year. 

‘‘(d) MEDICAL REIMBURSEMENT DATA CENTERS.—øAs added by 

section 10101(i)(2)¿ 

‘‘(1) FUNCTIONS.—A center established under subsection 

(c)(1)(C) shall— 
Sec. 1004 PPACA (Consolidated) 30 

‘‘(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 bylaws 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. 1004. ø42 U.S.C. 300gg–11 note¿ EFFECTIVE DATES. 

(a) IN GENERAL.—Except as provided for in subsection (b), this 

subtitle (and the amendments made by this subtitle) shall become 

effective for plan years beginning on or after the date that is 6 

months after the date of enactment of this Act, except that the 

amendments made by sections 1002 and 1003 shall become effective for fiscal years beginning with fiscal year 2010. 

(b) SPECIAL RULE.—The amendments made by sections 1002 

and 1003 shall take effect on the date of enactment of this Act. 

Subtitle B—Immediate Actions to Preserve 

and Expand Coverage 

SEC. 1101. ø42 U.S.C. 18001¿ IMMEDIATE ACCESS TO INSURANCE FOR 

UNINSURED INDIVIDUALS WITH A PREEXISTING CONDITION. 

(a) IN GENERAL.—Not later than 90 days after the date of enactment of this Act, the Secretary shall establish a temporary high 

risk health insurance pool program to provide health insurance 

coverage for eligible individuals during the period beginning on the 

date on which such program is established and ending on January 

1, 2014. 

(b) ADMINISTRATION.— 
31 Sec. 1101 PPACA (Consolidated) 

(1) IN GENERAL.—The Secretary may carry out the program under this section directly or through contracts to eligible 

entities. 

(2) ELIGIBLE ENTITIES.—To be eligible for a contract under 

paragraph (1), an entity shall— 

(A) be a State or nonprofit private entity; 

(B) submit to the Secretary an application at such 

time, in such manner, and containing such information as 

the Secretary may require; and 

(C) agree to utilize contract funding to establish and 

administer a qualified high risk pool for eligible individuals. 

(3) MAINTENANCE OF EFFORT.—To be eligible to enter into 

a contract with the Secretary under this subsection, a State 

shall agree not to reduce the annual amount the State expended for the operation of one or more State high risk pools 

during the year preceding the year in which such contract is 

entered into. 

(c) QUALIFIED HIGH RISK POOL.— (1) IN GENERAL.—Amounts made available under this section shall be used to establish a qualified high risk pool that 

meets the requirements of paragraph (2). 

(2) REQUIREMENTS.—A qualified high risk pool meets the 

requirements of this paragraph if such pool— 

(A) provides to all eligible individuals health insurance 

coverage that does not impose any preexisting condition 

exclusion with respect to such coverage; 

(B) provides health insurance coverage— 

(i) in which the issuer’s share of the total allowed 

costs of benefits provided under such coverage is not 

less than 65 percent of such costs; and 

(ii) that has an out of pocket limit not greater 

than the applicable amount described in section 

223(c)(2) of the Internal Revenue Code of 1986 for the 

year involved, except that the Secretary may modify 

such limit if necessary to ensure the pool meets the actuarial value limit under clause (i); 

(C) ensures that with respect to the premium rate 

charged for health insurance coverage offered to eligible 

individuals through the high risk pool, such rate shall— 

(i) except as provided in clause (ii), vary only as 

provided for under section 2701 of the Public Health 

Service Act (as amended by this Act and notwithstanding the date on which such amendments take effect); 

(ii) vary on the basis of age by a factor of not 

greater than 4 to 1; and 

(iii) be established at a standard rate for a standard population; and 

(D) meets any other requirements determined appropriate by the Secretary. 

(d) ELIGIBLE INDIVIDUAL.—An individual shall be deemed to be 

an eligible individual for purposes of this section if such individual— 
Sec. 1101 PPACA (Consolidated) 32 

(1) is a citizen or national of the United States or is lawfully present in the United States (as determined in accordance 

with section 1411); 

(2) has not been covered under creditable coverage (as defined in section 2701(c)(1) of the Public Health Service Act as 

in effect on the date of enactment of this Act) during the 6- 

month period prior to the date on which such individual is applying for coverage through the high risk pool; and 

(3) has a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary. 

(e) PROTECTION AGAINST DUMPING RISK BY INSURERS.— (1) IN GENERAL.—The Secretary shall establish criteria for 

determining whether health insurance issuers and employment-based health plans have discouraged an individual from 

remaining enrolled in prior coverage based on that individual’s 

health status. 

(2) SANCTIONS.—An issuer or employment-based health 

plan shall be responsible for reimbursing the program under 

this section for the medical expenses incurred by the program 

for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to 

disenroll from health benefits coverage prior to enrolling in 

coverage through the program. The criteria shall include at 

least the following circumstances: 

(A) In the case of prior coverage obtained through an 

employer, the provision by the employer, group health 

plan, or the issuer of money or other financial consideration for disenrolling from the coverage. 

(B) In the case of prior coverage obtained directly from 

an issuer or under an employment-based health plan— 

(i) the provision by the issuer or plan of money or 

other financial consideration for disenrolling from the 

coverage; or 

(ii) in the case of an individual whose premium for 

the prior coverage exceeded the premium required by 

the program (adjusted based on the age factors applied 

to the prior coverage)— 

(I) the prior coverage is a policy that is no 

longer being actively marketed (as defined by the 

Secretary) by the issuer; or 

(II) the prior coverage is a policy for which 

duration of coverage form issue or health status 

are factors that can be considered in determining 

premiums at renewal. 

(3) CONSTRUCTION.—Nothing in this subsection shall be 

construed as constituting exclusive remedies for violations of 

criteria established under paragraph (1) or as preventing 

States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers. 

(f) OVERSIGHT.—The Secretary shall establish— 

(1) an appeals process to enable individuals to appeal a determination under this section; and 

(2) procedures to protect against waste, fraud, and abuse. 

(g) FUNDING; TERMINATION OF AUTHORITY.— 
33 Sec. 1102 PPACA (Consolidated) 

(1) IN GENERAL.—There is appropriated to the Secretary, 

out of any moneys in the Treasury not otherwise appropriated, 

$5,000,000,000 to pay claims against (and the administrative 

costs of) the high risk pool under this section that are in excess 

of the amount of premiums collected from eligible individuals 

enrolled in the high risk pool. Such funds shall be available 

without fiscal year limitation. 

(2) INSUFFICIENT FUNDS.—If the Secretary estimates for 

any fiscal year that the aggregate amounts available for the 

payment of the expenses of the high risk pool will be less than 

the actual amount of such expenses, the Secretary shall make 

such adjustments as are necessary to eliminate such deficit. 

(3) TERMINATION OF AUTHORITY.— 

(A) IN GENERAL.—Except as provided in subparagraph 

(B), coverage of eligible individuals under a high risk pool 

in a State shall terminate on January 1, 2014. 

(B) TRANSITION TO EXCHANGE.—The Secretary shall 

develop procedures to provide for the transition of eligible 

individuals enrolled in health insurance coverage offered 

through a high risk pool established under this section into 

qualified health plans offered through an Exchange. Such 

procedures shall ensure that there is no lapse in coverage 

with respect to the individual and may extend coverage 

after the termination of the risk pool involved, if the Secretary determines necessary to avoid such a lapse. 

(4) LIMITATIONS.—The Secretary has the authority to stop 

taking applications for participation in the program under this 

section to comply with the funding limitation provided for in 

paragraph (1). 

(5) RELATION TO STATE LAWS.—The standards established 

under this section shall supersede any State law or regulation 

(other than State licensing laws or State laws relating to plan 

solvency) with respect to qualified high risk pools which are established in accordance with this section. 

SEC. 1102. ø42 U.S.C. 18002¿ REINSURANCE FOR EARLY RETIREES. 

(a) ADMINISTRATION.— 

(1) IN GENERAL.—Not later than 90 days after the date of 

enactment of this Act, the Secretary shall establish a temporary reinsurance program to provide reimbursement to participating employment-based plans for a portion of the cost of 

providing health insurance coverage to early retirees (and to 

the eligible spouses, surviving spouses, and dependents of such 

retirees) during the period beginning on the date on which 

such program is established and ending on January 1, 2014. 

(2) REFERENCE.—In this section: 

(A) HEALTH BENEFITS.—The term ‘‘health benefits’’ 

means medical, surgical, hospital, prescription drug, and 

such other benefits as shall be determined by the Secretary, whether self-funded, or delivered through the purchase of insurance or otherwise. 

(B) EMPLOYMENT-BASED PLAN.—øAs revised by section 

101012(a)¿ The term ‘‘employment-based plan’’ means a 

group benefits plan providing health benefits that— 
Sec. 1102 PPACA (Consolidated) 34 

(i) is— 

(I) maintained by one or more current or 

former employers (including without limitation 

any State or local government or political subdivision thereof or any agency or instrumentality of 

any of the foregoing), employee organization, a 

voluntary employees’ beneficiary association, or a 

committee or board of individuals appointed to administer such plan; or 

(II) a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974); and 

(ii) provides health benefits to early retirees. 

(C) EARLY RETIREES.—The term ‘‘early retirees’’ means 

individuals who are age 55 and older but are not eligible 

for coverage under title XVIII of the Social Security Act, 

and who are not active employees of an employer maintaining, or currently contributing to, the employmentbased plan or of any employer that has made substantial 

contributions to fund such plan. 

(b) PARTICIPATION.— (1) EMPLOYMENT-BASED PLAN ELIGIBILITY.—A participating 

employment-based plan is an employment-based plan that— 

(A) meets the requirements of paragraph (2) with respect to health benefits provided under the plan; and 

(B) submits to the Secretary an application for participation in the program, at such time, in such manner, and 

containing such information as the Secretary shall require. 

(2) EMPLOYMENT-BASED HEALTH BENEFITS.—An employment-based plan meets the requirements of this paragraph if 

the plan— 

(A) implements programs and procedures to generate 

cost-savings with respect to participants with chronic and 

high-cost conditions; 

(B) provides documentation of the actual cost of medical claims involved; and 

(C) is certified by the Secretary. 

(c) PAYMENTS.— 

(1) SUBMISSION OF CLAIMS.— 

(A) IN GENERAL.—A participating employment-based 

plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual 

costs of the items and services for which each claim is 

being submitted. 

(B) BASIS FOR CLAIMS.—Claims submitted under subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the health benefits provided to an early retiree or the spouse, surviving spouse, 

or dependent of such retiree. In determining the amount 

of a claim for purposes of this subsection, the participating 

employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunera-
35 Sec. 1102 PPACA (Consolidated) 

tions) obtained by such plan with respect to such health 

benefit. For purposes of determining the amount of any 

such claim, the costs paid by the early retiree or the retiree’s spouse, surviving spouse, or dependent in the form of 

deductibles, co-payments, or co-insurance shall be included 

in the amounts paid by the participating employmentbased plan. 

(2) PROGRAM PAYMENTS.—If the Secretary determines that 

a participating employment-based plan has submitted a valid 

claim under paragraph (1), the Secretary shall reimburse such 

plan for 80 percent of that portion of the costs attributable to 

such claim that exceed $15,000, subject to the limits contained 

in paragraph (3). 

(3) LIMIT.—To be eligible for reimbursement under the program, a claim submitted by a participating employment-based 

plan shall not be less than $15,000 nor greater than $90,000. 

Such amounts shall be adjusted each fiscal year based on the 

percentage increase in the Medical Care Component of the 

Consumer Price Index for all urban consumers (rounded to the 

nearest multiple of $1,000) for the year involved. 

(4) USE OF PAYMENTS.—Amounts paid to a participating 

employment-based plan under this subsection shall be used to 

lower costs for the plan. Such payments may be used to reduce 

premium costs for an entity described in subsection (a)(2)(B)(i) 

or to reduce premium contributions, co-payments, deductibles, 

co-insurance, or other out-of-pocket costs for plan participants. 

Such payments shall not be used as general revenues for an 

entity described in subsection (a)(2)(B)(i). The Secretary shall 

develop a mechanism to monitor the appropriate use of such 

payments by such entities. 

(5) PAYMENTS NOT TREATED AS INCOME.—Payments received under this subsection shall not be included in determining the gross income of an entity described in subsection 

(a)(2)(B)(i) that is maintaining or currently contributing to a 

participating employment-based plan. 

(6) APPEALS.—The Secretary shall establish— 

(A) an appeals process to permit participating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; 

and 

(B) procedures to protect against fraud, waste, and 

abuse under the program. 

(d) AUDITS.—The Secretary shall conduct annual audits of 

claims data submitted by participating employment-based plans 

under this section to ensure that such plans are in compliance with 

the requirements of this section. 

(e) FUNDING.—There is appropriated to the Secretary, out of 

any moneys in the Treasury not otherwise appropriated, 

$5,000,000,000 to carry out the program under this section. Such 

funds shall be available without fiscal year limitation. 

(f) LIMITATION.—The Secretary has the authority to stop taking 

applications for participation in the program based on the availability of funding under subsection (e). 
Sec. 1103 PPACA (Consolidated) 36 

SEC. 1103. ø42 U.S.C. 18003¿ IMMEDIATE INFORMATION THAT ALLOWS 

CONSUMERS TO IDENTIFY AFFORDABLE COVERAGE OPTIONS. 

(a) INTERNET PORTAL TO AFFORDABLE COVERAGE OPTIONS.— 

(1) IMMEDIATE ESTABLISHMENT.—øAs revised by section 

10102(b)(1)¿ Not later than July 1, 2010, the Secretary, in consultation with the States, shall establish a mechanism, including an Internet website, through which a resident of any, or 

small business in, State may identify affordable health insurance coverage options in that State. 

(2) CONNECTING TO AFFORDABLE COVERAGE.—øReplaced by 

section 10102(b)(2)¿ 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. 

(b) ENHANCING COMPARATIVE PURCHASING OPTIONS.— 

(1) IN GENERAL.—Not later than 60 days after the date of 

enactment of this Act, the Secretary shall develop a standardized format to be used for the presentation of information relating to the coverage options described in subsection (a)(2). 

Such format shall, at a minimum, require the inclusion of information on the percentage of total premium revenue expended on nonclinical costs (as reported under section 2718(a) 

of the Public Health Service Act), eligibility, availability, premium rates, and cost sharing with respect to such coverage options and be consistent with the standards adopted for the uniform explanation of coverage as provided for in section 2715 of 

the Public Health Service Act. 

(2) USE OF FORMAT.—The Secretary shall utilize the format developed under paragraph (1) in compiling information 

concerning coverage options on the Internet website established under subsection (a). 
37 Sec. 1104 PPACA (Consolidated) 

(c) AUTHORITY TO CONTRACT.—The Secretary may carry out 

this section through contracts entered into with qualified entities. 

SEC. 1104. ADMINISTRATIVE SIMPLIFICATION. 

(a) PURPOSE OF ADMINISTRATIVE SIMPLIFICATION.—Section 261 

of the Health Insurance Portability and Accountability Act of 1996 

(42 U.S.C. 1320d note) is amended— 

(1) by inserting ‘‘uniform’’ before ‘‘standards’’; and 

(2) by inserting ‘‘and to reduce the clerical burden on patients, health care providers, and health plans’’ before the period at the end. 

(b) OPERATING RULES FOR HEALTH INFORMATION TRANSACTIONS.— 

(1) DEFINITION OF OPERATING RULES.—Section 1171 of the 

Social Security Act (42 U.S.C. 1320d) is amended by adding at 

the end the following: 

‘‘(9) OPERATING RULES.—The term ‘operating rules’ means 

the necessary business rules and guidelines for the electronic 

exchange of information that are not defined by a standard or 

its implementation specifications as adopted for purposes of 

this part.’’. 

(2) TRANSACTION STANDARDS; OPERATING RULES AND COMPLIANCE.—Section 1173 of the Social Security Act (42 U.S.C. 

1320d–2) is amended— 

(A) in subsection (a)(2), by adding at the end the following new subparagraph: 

‘‘(J) Electronic funds transfers.’’; 

(B) in subsection (a), by adding at the end the following new paragraph: 

‘‘(4) REQUIREMENTS FOR FINANCIAL AND ADMINISTRATIVE

TRANSACTIONS.— 

‘‘(A) IN GENERAL.—The standards and associated operating rules adopted by the Secretary shall— 

‘‘(i) to the extent feasible and appropriate, enable 

determination of an individual’s eligibility and financial responsibility for specific services prior to or at the 

point of care; 

‘‘(ii) be comprehensive, requiring minimal augmentation by paper or other communications; 

‘‘(iii) provide for timely acknowledgment, response, 

and status reporting that supports a transparent 

claims and denial management process (including adjudication and appeals); and 

‘‘(iv) describe all data elements (including reason 

and remark codes) in unambiguous terms, require that 

such data elements be required or conditioned upon 

set values in other fields, and prohibit additional conditions (except where necessary to implement State or 

Federal law, or to protect against fraud and abuse). 

‘‘(B) REDUCTION OF CLERICAL BURDEN.—In adopting 

standards and operating rules for the transactions referred 

to under paragraph (1), the Secretary shall seek to reduce 

the number and complexity of forms (including paper and 
Sec. 1104 PPACA (Consolidated) 38 

electronic forms) and data entry required by patients and 

providers. 

øSection 10109(a), p. 838, added a paragraph (5) relating to 

consideration of standardization of activities and items¿ 

(C) by adding at the end the following new subsections: 

‘‘(g) OPERATING RULES.— ‘‘(1) IN GENERAL.—The Secretary shall adopt a single set of 

operating rules for each transaction referred to under subsection (a)(1) with the goal of creating as much uniformity in 

the implementation of the electronic standards as possible. 

Such operating rules shall be consensus-based and reflect the 

necessary business rules affecting health plans and health care 

providers and the manner in which they operate pursuant to 

standards issued under Health Insurance Portability and Accountability Act of 1996. 

‘‘(2) OPERATING RULES DEVELOPMENT.—In adopting operating rules under this subsection, the Secretary shall consider 

recommendations for operating rules developed by a qualified 

nonprofit entity that meets the following requirements: 

‘‘(A) The entity focuses its mission on administrative 

simplification. 

‘‘(B) The entity demonstrates a multi-stakeholder and 

consensus-based process for development of operating 

rules, including representation by or participation from 

health plans, health care providers, vendors, relevant Federal agencies, and other standard development organizations. 

‘‘(C) The entity has a public set of guiding principles 

that ensure the operating rules and process are open and 

transparent, and supports nondiscrimination and conflict 

of interest policies that demonstrate a commitment to 

open, fair, and nondiscriminatory practices. 

‘‘(D) The entity builds on the transaction standards 

issued under Health Insurance Portability and Accountability Act of 1996. 

‘‘(E) The entity allows for public review and updates of 

the operating rules. 

‘‘(3) REVIEW AND RECOMMENDATIONS.—The National Committee on Vital and Health Statistics shall— 

‘‘(A) advise the Secretary as to whether a nonprofit entity meets the requirements under paragraph (2); 

‘‘(B) review the operating rules developed and recommended by such nonprofit entity; 

‘‘(C) determine whether such operating rules represent 

a consensus view of the health care stakeholders and are 

consistent with and do not conflict with other existing 

standards; 

‘‘(D) evaluate whether such operating rules are consistent with electronic standards adopted for health information technology; and 

‘‘(E) submit to the Secretary a recommendation as to 

whether the Secretary should adopt such operating rules. 

‘‘(4) IMPLEMENTATION.— 
39 Sec. 1104 PPACA (Consolidated) 

‘‘(A) IN GENERAL.—The Secretary shall adopt operating 

rules under this subsection, by regulation in accordance 

with subparagraph (C), following consideration of the operating rules developed by the non-profit entity described in 

paragraph (2) and the recommendation submitted by the 

National Committee on Vital and Health Statistics under 

paragraph (3)(E) and having ensured consultation with 

providers. 

‘‘(B) ADOPTION REQUIREMENTS; EFFECTIVE DATES.— ‘‘(i) ELIGIBILITY FOR A HEALTH PLAN AND HEALTH

CLAIM STATUS.—The set of operating rules for eligibility for a health plan and health claim status transactions shall be adopted not later than July 1, 2011, 

in a manner ensuring that such operating rules are effective not later than January 1, 2013, and may allow 

for the use of a machine readable identification card. 

‘‘(ii) ELECTRONIC FUNDS TRANSFERS AND HEALTH

CARE PAYMENT AND REMITTANCE ADVICE.—The set of 

operating rules for electronic funds transfers and 

health care payment and remittance advice transactions shall— 

‘‘(I) allow for automated reconciliation of the 

electronic payment with the remittance advice; 

and 

‘‘(II) be adopted not later than July 1, 2012, in 

a manner ensuring that such operating rules are 

effective not later than January 1, 2014. 

‘‘(iii) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER

INFORMATION, ENROLLMENT AND DISENROLLMENT IN A

HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, REFERRAL CERTIFICATION AND AUTHORIZATION.—The set 

of operating rules for health claims or equivalent encounter information, enrollment and disenrollment in 

a health plan, health plan premium payments, and referral certification and authorization transactions 

shall be adopted not later than July 1, 2014, in a manner ensuring that such operating rules are effective 

not later than January 1, 2016. 

‘‘(C) EXPEDITED RULEMAKING.—The Secretary shall 

promulgate an interim final rule applying any standard or 

operating rule recommended by the National Committee 

on Vital and Health Statistics pursuant to paragraph (3). 

The Secretary shall accept and consider public comments 

on any interim final rule published under this subparagraph for 60 days after the date of such publication. 

‘‘(h) COMPLIANCE.— 

‘‘(1) HEALTH PLAN CERTIFICATION.— 

‘‘(A) ELIGIBILITY FOR A HEALTH PLAN, HEALTH CLAIM

STATUS, ELECTRONIC FUNDS TRANSFERS, HEALTH CARE PAYMENT AND REMITTANCE ADVICE.—Not later than December 

31, 2013, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan 

are in compliance with any applicable standards (as de-
Sec. 1104 PPACA (Consolidated) 40 

scribed under paragraph (7) of section 1171) and associated operating rules (as described under paragraph (9) of 

such section) for electronic funds transfers, eligibility for a 

health plan, health claim status, and health care payment 

and remittance advice, respectively. 

‘‘(B) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER IN- FORMATION, ENROLLMENT AND DISENROLLMENT IN A

HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, HEALTH

CLAIMS ATTACHMENTS, REFERRAL CERTIFICATION AND AU- THORIZATION.—Not later than December 31, 2015, a health 

plan shall file a statement with the Secretary, in such 

form as the Secretary may require, certifying that the data 

and information systems for such plan are in compliance 

with any applicable standards and associated operating 

rules for health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health 

plan premium payments, health claims attachments, and 

referral certification and authorization, respectively. A 

health plan shall provide the same level of documentation 

to certify compliance with such transactions as is required 

to certify compliance with the transactions specified in 

subparagraph (A). 

‘‘(2) DOCUMENTATION OF COMPLIANCE.—A health plan shall 

provide the Secretary, in such form as the Secretary may require, with adequate documentation of compliance with the 

standards and operating rules described under paragraph (1). 

A health plan shall not be considered to have provided adequate documentation and shall not be certified as being in compliance with such standards, unless the health plan— 

‘‘(A) demonstrates to the Secretary that the plan conducts the electronic transactions specified in paragraph (1) 

in a manner that fully complies with the regulations of the 

Secretary; and 

‘‘(B) provides documentation showing that the plan 

has completed end-to-end testing for such transactions 

with their partners, such as hospitals and physicians. 

‘‘(3) SERVICE CONTRACTS.—A health plan shall be required 

to ensure that any entities that provide services pursuant to a 

contract with such health plan shall comply with any applicable certification and compliance requirements (and provide the 

Secretary with adequate documentation of such compliance) 

under this subsection. 

‘‘(4) CERTIFICATION BY OUTSIDE ENTITY.—The Secretary 

may designate independent, outside entities to certify that a 

health plan has complied with the requirements under this 

subsection, provided that the certification standards employed 

by such entities are in accordance with any standards or operating rules issued by the Secretary. 

‘‘(5) COMPLIANCE WITH REVISED STANDARDS AND OPERATING

RULES.— 

‘‘(A) IN GENERAL.—A health plan (including entities 

described under paragraph (3)) shall file a statement with 

the Secretary, in such form as the Secretary may require, 

certifying that the data and information systems for such 
41 Sec. 1104 PPACA (Consolidated) 

plan are in compliance with any applicable revised standards and associated operating rules under this subsection 

for any interim final rule promulgated by the Secretary 

under subsection (i) that— 

‘‘(i) amends any standard or operating rule described under paragraph (1) of this subsection; or 

‘‘(ii) establishes a standard (as described under 

subsection (a)(1)(B)) or associated operating rules (as 

described under subsection (i)(5)) for any other financial and administrative transactions. 

‘‘(B) DATE OF COMPLIANCE.—A health plan shall comply with such requirements not later than the effective 

date of the applicable standard or operating rule. 

‘‘(6) AUDITS OF HEALTH PLANS.—The Secretary shall conduct periodic audits to ensure that health plans (including entities described under paragraph (3)) are in compliance with 

any standards and operating rules that are described under 

paragraph (1) or subsection (i)(5). 

‘‘(i) REVIEW AND AMENDMENT OF STANDARDS AND OPERATING

RULES.— ‘‘(1) ESTABLISHMENT.—Not later than January 1, 2014, the 

Secretary shall establish a review committee (as described 

under paragraph (4)). 

‘‘(2) EVALUATIONS AND REPORTS.— ‘‘(A) HEARINGS.—Not later than April 1, 2014, and not 

less than biennially thereafter, the Secretary, acting 

through the review committee, shall conduct hearings to 

evaluate and review the adopted standards and operating 

rules established under this section. 

‘‘(B) REPORT.—Not later than July 1, 2014, and not 

less than biennially thereafter, the review committee shall 

provide recommendations for updating and improving such 

standards and operating rules. The review committee shall 

recommend a single set of operating rules per transaction 

standard and maintain the goal of creating as much uniformity as possible in the implementation of the electronic 

standards. 

‘‘(3) INTERIM FINAL RULEMAKING.— 

‘‘(A) IN GENERAL.—Any recommendations to amend 

adopted standards and operating rules that have been approved by the review committee and reported to the Secretary under paragraph (2)(B) shall be adopted by the Secretary through promulgation of an interim final rule not 

later than 90 days after receipt of the committee’s report. 

‘‘(B) PUBLIC COMMENT.— 

‘‘(i) PUBLIC COMMENT PERIOD.—The Secretary 

shall accept and consider public comments on any interim final rule published under this paragraph for 60 

days after the date of such publication. 

‘‘(ii) EFFECTIVE DATE.—The effective date of any 

amendment to existing standards or operating rules 

that is adopted through an interim final rule published under this paragraph shall be 25 months following the close of such public comment period. 
Sec. 1104 PPACA (Consolidated) 42 

‘‘(4) REVIEW COMMITTEE.— 

‘‘(A) DEFINITION.—For the purposes of this subsection, 

the term ‘review committee’ means a committee chartered 

by or within the Department of Health and Human services that has been designated by the Secretary to carry out 

this subsection, including— 

‘‘(i) the National Committee on Vital and Health 

Statistics; or 

‘‘(ii) any appropriate committee as determined by 

the Secretary. 

‘‘(B) COORDINATION OF HIT STANDARDS.—In developing 

recommendations under this subsection, the review committee shall ensure coordination, as appropriate, with the 

standards that support the certified electronic health 

record technology approved by the Office of the National 

Coordinator for Health Information Technology. 

‘‘(5) OPERATING RULES FOR OTHER STANDARDS ADOPTED BY

THE SECRETARY.—The Secretary shall adopt a single set of operating rules (pursuant to the process described under subsection (g)) for any transaction for which a standard had been 

adopted pursuant to subsection (a)(1)(B). 

‘‘(j) PENALTIES.— 

‘‘(1) PENALTY FEE.— 

‘‘(A) IN GENERAL.—Not later than April 1, 2014, and 

annually thereafter, the Secretary shall assess a penalty 

fee (as determined under subparagraph (B)) against a 

health plan that has failed to meet the requirements 

under subsection (h) with respect to certification and documentation of compliance with— 

‘‘(i) the standards and associated operating rules 

described under paragraph (1) of such subsection; and 

‘‘(ii) a standard (as described under subsection 

(a)(1)(B)) and associated operating rules (as described 

under subsection (i)(5)) for any other financial and administrative transactions. 

‘‘(B) FEE AMOUNT.—Subject to subparagraphs (C), (D), 

and (E), the Secretary shall assess a penalty fee against a 

health plan in the amount of $1 per covered life until certification is complete. The penalty shall be assessed per 

person covered by the plan for which its data systems for 

major medical policies are not in compliance and shall be 

imposed against the health plan for each day that the plan 

is not in compliance with the requirements under subsection (h). 

‘‘(C) ADDITIONAL PENALTY FOR MISREPRESENTATION.—A 

health plan that knowingly provides inaccurate or incomplete information in a statement of certification or documentation of compliance under subsection (h) shall be subject to a penalty fee that is double the amount that would 

otherwise be imposed under this subsection. 

‘‘(D) ANNUAL FEE INCREASE.—The amount of the penalty fee imposed under this subsection shall be increased 

on an annual basis by the annual percentage increase in 
43 Sec. 1104 PPACA (Consolidated) 

total national health care expenditures, as determined by 

the Secretary. 

‘‘(E) PENALTY LIMIT.—A penalty fee assessed against a 

health plan under this subsection shall not exceed, on an 

annual basis— 

‘‘(i) an amount equal to $20 per covered life under 

such plan; or 

‘‘(ii) an amount equal to $40 per covered life under 

the plan if such plan has knowingly provided inaccurate or incomplete information (as described under 

subparagraph (C)). 

‘‘(F) DETERMINATION OF COVERED INDIVIDUALS.—The 

Secretary shall determine the number of covered lives 

under a health plan based upon the most recent statements and filings that have been submitted by such plan 

to the Securities and Exchange Commission. 

‘‘(2) NOTICE AND DISPUTE PROCEDURE.—The Secretary shall 

establish a procedure for assessment of penalty fees under this 

subsection that provides a health plan with reasonable notice 

and a dispute resolution procedure prior to provision of a notice of assessment by the Secretary of the Treasury (as described under paragraph (4)(B)). 

‘‘(3) PENALTY FEE REPORT.—Not later than May 1, 2014, 

and annually thereafter, the Secretary shall provide the Secretary of the Treasury with a report identifying those health 

plans that have been assessed a penalty fee under this subsection. 

‘‘(4) COLLECTION OF PENALTY FEE.— 

‘‘(A) IN GENERAL.—The Secretary of the Treasury, acting through the Financial Management Service, shall administer the collection of penalty fees from health plans 

that have been identified by the Secretary in the penalty 

fee report provided under paragraph (3). 

‘‘(B) NOTICE.—Not later than August 1, 2014, and annually thereafter, the Secretary of the Treasury shall provide notice to each health plan that has been assessed a 

penalty fee by the Secretary under this subsection. Such 

notice shall include the amount of the penalty fee assessed 

by the Secretary and the due date for payment of such fee 

to the Secretary of the Treasury (as described in subparagraph (C)). 

‘‘(C) PAYMENT DUE DATE.—Payment by a health plan 

for a penalty fee assessed under this subsection shall be 

made to the Secretary of the Treasury not later than November 1, 2014, and annually thereafter. 

‘‘(D) UNPAID PENALTY FEES.—Any amount of a penalty 

fee assessed against a health plan under this subsection 

for which payment has not been made by the due date provided under subparagraph (C) shall be— 

‘‘(i) increased by the interest accrued on such 

amount, as determined pursuant to the underpayment 

rate established under section 6621 of the Internal 

Revenue Code of 1986; and 
Sec. 1105 PPACA (Consolidated) 44 

‘‘(ii) treated as a past-due, legally enforceable debt 

owed to a Federal agency for purposes of section 

6402(d) of the Internal Revenue Code of 1986. 

‘‘(E) ADMINISTRATIVE FEES.—Any fee charged or allocated for collection activities conducted by the Financial 

Management Service will be passed on to a health plan on 

a pro-rata basis and added to any penalty fee collected 

from the plan.’’. 

(c) PROMULGATION OF RULES.— 

(1) UNIQUE HEALTH PLAN IDENTIFIER.—The Secretary shall 

promulgate a final rule to establish a unique health plan identifier (as described in section 1173(b) of the Social Security Act 

(42 U.S.C. 1320d–2(b))) based on the input of the National 

Committee on Vital and Health Statistics. The Secretary may 

do so on an interim final basis and such rule shall be effective 

not later than October 1, 2012. 

(2) ELECTRONIC FUNDS TRANSFER.—The Secretary shall 

promulgate a final rule to establish a standard for electronic 

funds transfers (as described in section 1173(a)(2)(J) of the Social Security Act, as added by subsection (b)(2)(A)). The Secretary may do so on an interim final basis and shall adopt such 

standard not later than January 1, 2012, in a manner ensuring 

that such standard is effective not later than January 1, 2014. 

(3) HEALTH CLAIMS ATTACHMENTS.—The Secretary shall 

promulgate a final rule to establish a transaction standard and 

a single set of associated operating rules for health claims attachments (as described in section 1173(a)(2)(B) of the Social 

Security Act (42 U.S.C. 1320d–2(a)(2)(B))) that is consistent 

with the X12 Version 5010 transaction standards. The Secretary may do so on an interim final basis and shall adopt a 

transaction standard and a single set of associated operating 

rules not later than January 1, 2014, in a manner ensuring 

that such standard is effective not later than January 1, 2016. 

(d) EXPANSION OF ELECTRONIC TRANSACTIONS IN MEDICARE.— 

Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is 

amended— 

(1) in paragraph (23), by striking the ‘‘or’’ at the end; 

(2) in paragraph (24), by striking the period and inserting 

‘‘; or’’; and 

(3) by inserting after paragraph (24) the following new 

paragraph: 

‘‘(25) not later than January 1, 2014, for which the payment is other than by electronic funds transfer (EFT) or an 

electronic remittance in a form as specified in ASC X12 835 

Health Care Payment and Remittance Advice or subsequent 

standard.’’. 

øSection 10109, p. 838, provided for development of standards 

for financial and administrative transactions¿ 

SEC. 1105. EFFECTIVE DATE. 

This subtitle shall take effect on the date of enactment of this 

Act. 
45 Sec. 1201 PPACA (Consolidated) 

Subtitle C—Quality Health Insurance 

Coverage for All Americans 

PART 1—HEALTH INSURANCE MARKET 

REFORMS 

SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT. 

Part A of title XXVII of the Public Health Service Act (42 

U.S.C. 300gg et seq.), as amended by section 1001, is further 

amended— 

(1) by striking the heading for subpart 1 and inserting the 

following: 

‘‘Subpart I—General Reform’’; 

(2)(A) in section 2701 (42 U.S.C. 300gg), by striking the 

section heading and subsection (a) and inserting the following: 

‘‘SEC. 2704. ø42 U.S.C. 300gg–3¿ PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER DISCRIMINATION BASED 

ON HEALTH STATUS. 

‘‘(a) IN GENERAL.—A group health plan and a health insurance 

issuer offering group or individual health insurance coverage may 

not impose any preexisting condition exclusion with respect to such 

plan or coverage.’’; and 

(B) by transferring such section (as amended by subparagraph (A)) so as to appear after the section 2703 added by 

paragraph (4); 

(3)(A) in section 2702 (42 U.S.C. 300gg–1)— 

(i) by striking the section heading and all that follows 

through subsection (a); 

(ii) in subsection (b)— 

(I) by striking ‘‘health insurance issuer offering 

health insurance coverage in connection with a group 

health plan’’ each place that such appears and inserting ‘‘health insurance issuer offering group or individual health insurance coverage’’; and 

(II) in paragraph (2)(A)— 

(aa) by inserting ‘‘or individual’’ after ‘‘employer’’; and 

(bb) by inserting ‘‘or individual health coverage, as the case may be’’ before the semicolon; 

and 

(iii) in subsection (e)— 

(I) by striking ‘‘(a)(1)(F)’’ and inserting ‘‘(a)(6)’’; 

(II) by striking ‘‘2701’’ and inserting ‘‘2704’’; and 

(III) by striking ‘‘2721(a)’’ and inserting ‘‘2735(a)’’; 

and 

(B) by transferring such section (as amended by subparagraph (A)) to appear after section 2705(a) as added by 

paragraph (4); and 

(4) by inserting after the subpart heading (as added by 

paragraph (1)) the following: 
Sec. 1201\2702 PHSA PPACA (Consolidated) 46 

‘‘SEC. 2701. ø42 U.S.C. 300gg¿ FAIR HEALTH INSURANCE PREMIUMS. 

‘‘(a) PROHIBITING DISCRIMINATORY PREMIUM RATES.— ‘‘(1) IN GENERAL.—With respect to the premium rate 

charged by a health insurance issuer for health insurance coverage offered in the individual or small group market— 

‘‘(A) such rate shall vary with respect to the particular 

plan or coverage involved only by— 

‘‘(i) whether such plan or coverage covers an individual or family; 

‘‘(ii) rating area, as established in accordance with 

paragraph (2); 

‘‘(iii) age, except that such rate shall not vary by 

more than 3 to 1 for adults (consistent with section 

2707(c)); and 

‘‘(iv) tobacco use, except that such rate shall not 

vary by more than 1.5 to 1; and 

‘‘(B) such rate shall not vary with respect to the particular plan or coverage involved by any other factor not 

described in subparagraph (A). 

‘‘(2) RATING AREA.— ‘‘(A) IN GENERAL.—Each State shall establish 1 or 

more rating areas within that State for purposes of applying the requirements of this title. 

‘‘(B) SECRETARIAL REVIEW.—The Secretary shall review 

the rating areas established by each State under subparagraph (A) to ensure the adequacy of such areas for purposes of carrying out the requirements of this title. If the 

Secretary determines a State’s rating areas are not adequate, or that a State does not establish such areas, the 

Secretary may establish rating areas for that State. 

‘‘(3) PERMISSIBLE AGE BANDS.—The Secretary, in consultation with the National Association of Insurance Commissioners, shall define the permissible age bands for rating purposes under paragraph (1)(A)(iii). 

‘‘(4) APPLICATION OF VARIATIONS BASED ON AGE OR TOBACCO USE.—With respect to family coverage under a group 

health plan or health insurance coverage, the rating variations 

permitted under clauses (iii) and (iv) of paragraph (1)(A) shall 

be applied based on the portion of the premium that is attributable to each family member covered under the plan or coverage. 

‘‘(5) SPECIAL RULE FOR LARGE GROUP MARKET.—øAs revised 

by section 10103(a)¿ If a State permits health insurance 

issuers that offer coverage in the large group market in the 

State to offer such coverage through the State Exchange (as 

provided for under section 1312(f)(2)(B) of the Patient Protection and Affordable Care Act), the provisions of this subsection 

shall apply to all coverage offered in such market (other than 

self-insured group health plans offered in such market) in the 

State. 

‘‘SEC. 2702. ø42 U.S.C. 300gg–1¿ GUARANTEED AVAILABILITY OF COVERAGE. 

‘‘(a) GUARANTEED ISSUANCE OF COVERAGE IN THE INDIVIDUAL

AND GROUP MARKET.—Subject to subsections (b) through (e), each 
47 Sec. 1201 PPACA (Consolidated) \2705 PHSA 

health insurance issuer that offers health insurance coverage in the 

individual or group market in a State must accept every employer 

and individual in the State that applies for such coverage. 

‘‘(b) ENROLLMENT.— ‘‘(1) RESTRICTION.—A health insurance issuer described in 

subsection (a) may restrict enrollment in coverage described in 

such subsection to open or special enrollment periods. 

‘‘(2) ESTABLISHMENT.—A health insurance issuer described 

in subsection (a) shall, in accordance with the regulations promulgated under paragraph (3), establish special enrollment periods for qualifying events (under section 603 of the Employee 

Retirement Income Security Act of 1974). 

‘‘(3) REGULATIONS.—The Secretary shall promulgate regulations with respect to enrollment periods under paragraphs 

(1) and (2). 

‘‘SEC. 2703. ø42 U.S.C. 300gg–2¿ GUARANTEED RENEWABILITY OF COVERAGE. 

‘‘(a) IN GENERAL.—Except as provided in this section, if a 

health insurance issuer offers health insurance coverage in the individual or group market, the issuer must renew or continue in 

force such coverage at the option of the plan sponsor or the individual, as applicable. 

‘‘SEC. 2705. ø42 U.S.C. 300gg–4¿ PROHIBITING DISCRIMINATION 

AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH STATUS. 

‘‘(a) IN GENERAL.—A group health plan and a health insurance 

issuer offering group or individual health insurance coverage may 

not establish rules for eligibility (including continued eligibility) of 

any individual to enroll under the terms of the plan or coverage 

based on any of the following health status-related factors in relation to the individual or a dependent of the individual: 

‘‘(1) Health status. 

‘‘(2) Medical condition (including both physical and mental 

illnesses). 

‘‘(3) Claims experience. 

‘‘(4) Receipt of health care. 

‘‘(5) Medical history. 

‘‘(6) Genetic information. 

‘‘(7) Evidence of insurability (including conditions arising 

out of acts of domestic violence). 

‘‘(8) Disability. 

‘‘(9) Any other health status-related factor determined appropriate by the Secretary. 

‘‘(j) PROGRAMS OF HEALTH PROMOTION OR DISEASE PREVENTION.— 

‘‘(1) GENERAL PROVISIONS.— 

‘‘(A) GENERAL RULE.—For purposes of subsection 

(b)(2)(B), a program of health promotion or disease prevention (referred to in this subsection as a ‘wellness program’) 

shall be a program offered by an employer that is designed 

to promote health or prevent disease that meets the applicable requirements of this subsection. 

‘‘(B) NO CONDITIONS BASED ON HEALTH STATUS FACTOR.—If none of the conditions for obtaining a premium 
Sec. 1201\2705 PHSA PPACA (Consolidated) 48 

discount or rebate or other reward for participation in a 

wellness program is based on an individual satisfying a 

standard that is related to a health status factor, such 

wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals and the requirements of paragraph (2) are 

complied with. 

‘‘(C) CONDITIONS BASED ON HEALTH STATUS FACTOR.— If any of the conditions for obtaining a premium discount 

or rebate or other reward for participation in a wellness 

program is based on an individual satisfying a standard 

that is related to a health status factor, such wellness program shall not violate this section if the requirements of 

paragraph (3) are complied with. 

‘‘(2) WELLNESS PROGRAMS NOT SUBJECT TO REQUIRE- MENTS.—If none of the conditions for obtaining a premium discount or rebate or other reward under a wellness program as 

described in paragraph (1)(B) are based on an individual satisfying a standard that is related to a health status factor (or if 

such a wellness program does not provide such a reward), the 

wellness program shall not violate this section if participation 

in the program is made available to all similarly situated individuals. The following programs shall not have to comply with 

the requirements of paragraph (3) if participation in the program is made available to all similarly situated individuals: 

‘‘(A) A program that reimburses all or part of the cost 

for memberships in a fitness center. 

‘‘(B) A diagnostic testing program that provides a reward for participation and does not base any part of the 

reward on outcomes. 

‘‘(C) A program that encourages preventive care related to a health condition through the waiver of the copayment or deductible requirement under group health 

plan for the costs of certain items or services related to a 

health condition (such as prenatal care or well-baby visits). 

‘‘(D) A program that reimburses individuals for the 

costs of smoking cessation programs without regard to 

whether the individual quits smoking. 

‘‘(E) A program that provides a reward to individuals 

for attending a periodic health education seminar. 

‘‘(3) WELLNESS PROGRAMS SUBJECT TO REQUIREMENTS.—If 

any of the conditions for obtaining a premium discount, rebate, 

or reward under a wellness program as described in paragraph 

(1)(C) is based on an individual satisfying a standard that is 

related to a health status factor, the wellness program shall 

not violate this section if the following requirements are complied with: 

‘‘(A) The reward for the wellness program, together 

with the reward for other wellness programs with respect 

to the plan that requires satisfaction of a standard related 

to a health status factor, shall not exceed 30 percent of the 

cost of employee-only coverage under the plan. If, in addition to employees or individuals, any class of dependents 

(such as spouses or spouses and dependent children) may 
49 Sec. 1201 PPACA (Consolidated) \2705 PHSA 

participate fully in the wellness program, such reward 

shall not exceed 30 percent of the cost of the coverage in 

which an employee or individual and any dependents are 

enrolled. For purposes of this paragraph, the cost of coverage shall be determined based on the total amount of 

employer and employee contributions for the benefit package under which the employee is (or the employee and any 

dependents are) receiving coverage. A reward may be in 

the form of a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism 

(such as deductibles, copayments, or coinsurance), the absence of a surcharge, or the value of a benefit that would 

otherwise not be provided under the plan. The Secretaries 

of Labor, Health and Human Services, and the Treasury 

may increase the reward available under this subparagraph to up to 50 percent of the cost of coverage if the Secretaries determine that such an increase is appropriate. 

‘‘(B) The wellness program shall be reasonably designed to promote health or prevent disease. A program 

complies with the preceding sentence if the program has a 

reasonable chance of improving the health of, or preventing disease in, participating individuals and it is not 

overly burdensome, is not a subterfuge for discriminating 

based on a health status factor, and is not highly suspect 

in the method chosen to promote health or prevent disease. 

‘‘(C) The plan shall give individuals eligible for the 

program the opportunity to qualify for the reward under 

the program at least once each year. 

‘‘(D) The full reward under the wellness program shall 

be made available to all similarly situated individuals. For 

such purpose, among other things: 

‘‘(i) The reward is not available to all similarly situated individuals for a period unless the wellness program allows— 

‘‘(I) for a reasonable alternative standard (or 

waiver of the otherwise applicable standard) for 

obtaining the reward for any individual for whom, 

for that period, it is unreasonably difficult due to 

a medical condition to satisfy the otherwise applicable standard; and 

‘‘(II) for a reasonable alternative standard (or 

waiver of the otherwise applicable standard) for 

obtaining the reward for any individual for whom, 

for that period, it is medically inadvisable to attempt to satisfy the otherwise applicable standard. 

‘‘(ii) If reasonable under the circumstances, the 

plan or issuer may seek verification, such as a statement from an individual’s physician, that a health status factor makes it unreasonably difficult or medically 

inadvisable for the individual to satisfy or attempt to 

satisfy the otherwise applicable standard. 

‘‘(E) The plan or issuer involved shall disclose in all 

plan materials describing the terms of the wellness pro-
Sec. 1201\2705 PHSA PPACA (Consolidated) 50 

gram the availability of a reasonable alternative standard 

(or the possibility of waiver of the otherwise applicable 

standard) required under subparagraph (D). If plan materials disclose that such a program is available, without describing its terms, the disclosure under this subparagraph 

shall not be required. 

‘‘(k) EXISTING PROGRAMS.—Nothing in this section shall prohibit a program of health promotion or disease prevention that was 

established prior to the date of enactment of this section and applied with all applicable regulations, and that is operating on such 

date, from continuing to be carried out for as long as such regulations remain in effect. 

‘‘(l) WELLNESS PROGRAM DEMONSTRATION PROJECT.— ‘‘(1) IN GENERAL.—Not later than July 1, 2014, the Secretary, in consultation with the Secretary of the Treasury and 

the Secretary of Labor, shall establish a 10-State demonstration project under which participating States shall apply the 

provisions of subsection (j) to programs of health promotion offered by a health insurance issuer that offers health insurance 

coverage in the individual market in such State. 

‘‘(2) EXPANSION OF DEMONSTRATION PROJECT.—If the Secretary, in consultation with the Secretary of the Treasury and 

the Secretary of Labor, determines that the demonstration 

project described in paragraph (1) is effective, such Secretaries 

may, beginning on July 1, 2017 expand such demonstration 

project to include additional participating States. 

‘‘(3) REQUIREMENTS.— ‘‘(A) MAINTENANCE OF COVERAGE.—The Secretary, in 

consultation with the Secretary of the Treasury and the 

Secretary of Labor, shall not approve the participation of 

a State in the demonstration project under this section unless the Secretaries determine that the State’s project is 

designed in a manner that— 

‘‘(i) will not result in any decrease in coverage; 

and 

‘‘(ii) will not increase the cost to the Federal Government in providing credits under section 36B of the 

Internal Revenue Code of 1986 or cost-sharing assistance under section 1402 of the Patient Protection and 

Affordable Care Act. 

‘‘(B) OTHER REQUIREMENTS.—States that participate in 

the demonstration project under this subsection— 

‘‘(i) may permit premium discounts or rebates or 

the modification of otherwise applicable copayments or 

deductibles for adherence to, or participation in, a reasonably designed program of health promotion and 

disease prevention; 

‘‘(ii) shall ensure that requirements of consumer 

protection are met in programs of health promotion in 

the individual market; 

‘‘(iii) shall require verification from health insurance issuers that offer health insurance coverage in 

the individual market of such State that premium discounts— 
51 Sec. 1201 PPACA (Consolidated) \2706 PHSA 

‘‘(I) do not create undue burdens for individuals insured in the individual market; 

‘‘(II) do not lead to cost shifting; and 

‘‘(III) are not a subterfuge for discrimination; 

‘‘(iv) shall ensure that consumer data is protected 

in accordance with the requirements of section 264(c) 

of the Health Insurance Portability and Accountability 

Act of 1996 (42 U.S.C. 1320d–2 note); and 

‘‘(v) shall ensure and demonstrate to the satisfaction of the Secretary that the discounts or other rewards provided under the project reflect the expected 

level of participation in the wellness program involved 

and the anticipated effect the program will have on 

utilization or medical claim costs. 

‘‘(m) REPORT.— 

‘‘(1) IN GENERAL.—Not later than 3 years after the date of 

enactment of the Patient Protection and Affordable Care Act, 

the Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall submit a report to the 

appropriate committees of Congress concerning— 

‘‘(A) the effectiveness of wellness programs (as defined 

in subsection (j)) in promoting health and preventing disease; 

‘‘(B) the impact of such wellness programs on the access to care and affordability of coverage for participants 

and non-participants of such programs; 

‘‘(C) the impact of premium-based and cost-sharing incentives on participant behavior and the role of such programs in changing behavior; and 

‘‘(D) the effectiveness of different types of rewards. 

‘‘(2) DATA COLLECTION.—In preparing the report described 

in paragraph (1), the Secretaries shall gather relevant information from employers who provide employees with access to 

wellness programs, including State and Federal agencies. 

‘‘(n) REGULATIONS.—Nothing in this section shall be construed 

as prohibiting the Secretaries of Labor, Health and Human Services, or the Treasury from promulgating regulations in connection 

with this section. 

‘‘SEC. 2706. ø42 U.S.C. 300gg–5¿ NON-DISCRIMINATION IN HEALTH CARE. 

‘‘(a) PROVIDERS.—A group health plan and a health insurance 

issuer offering group or individual health insurance coverage shall 

not discriminate with respect to participation under the plan or 

coverage against any health care provider who is acting within the 

scope of that provider’s license or certification under applicable 

State law. This section shall not require that a group health plan 

or health insurance issuer contract with any health care provider 

willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance 

issuer, or the Secretary from establishing varying reimbursement 

rates based on quality or performance measures. 

‘‘(b) INDIVIDUALS.—The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimi-
Sec. 1201\2707 PHSA PPACA (Consolidated) 52 

nation) shall apply with respect to a group health plan or health 

insurance issuer offering group or individual health insurance coverage. 

‘‘SEC. 2707. ø42 U.S.C. 300gg–6¿ COMPREHENSIVE HEALTH INSURANCE 

COVERAGE. 

‘‘(a) COVERAGE FOR ESSENTIAL HEALTH BENEFITS PACKAGE.—A 

health insurance issuer that offers health insurance coverage in the 

individual or small group market shall ensure that such coverage 

includes the essential health benefits package required under section 1302(a) of the Patient Protection and Affordable Care Act. 

‘‘(b) COST-SHARING UNDER GROUP HEALTH PLANS.—A group 

health plan shall ensure that any annual cost-sharing imposed 

under the plan does not exceed the limitations provided for under 

paragraphs (1) and (2) of section 1302(c). 

‘‘(c) CHILD-ONLY PLANS.—If a health insurance issuer offers 

health insurance coverage in any level of coverage specified under 

section 1302(d) of the Patient Protection and Affordable Care Act, 

the issuer shall also offer such coverage in that level as a plan in 

which the only enrollees are individuals who, as of the beginning 

of a plan year, have not attained the age of 21. 

‘‘(d) DENTAL ONLY.—This section shall not apply to a plan described in section 1302(d)(2)(B)(ii)(I). 

‘‘SEC. 2708. ø42 U.S.C. 300gg–7¿ PROHIBITION ON EXCESSIVE WAITING 

PERIODS. 

‘‘øAs revised by section 10103(b)¿ A group health plan and a 

health insurance issuer offering group health insurance coverage 

shall not apply any waiting period (as defined in section 2704(b)(4)) 

that exceeds 90 days. 

‘‘SEC. 2709. ø42 U.S.C. 300gg–8¿ COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CLINICAL TRIALS. 

øSection added by section 10103(c)¿ 

‘‘(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— 
53 Sec. 1201 PPACA (Consolidated) \2709 PHSA 

‘‘(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-ofnetwork 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 
Sec. 1201\2709 PHSA PPACA (Consolidated) 54 

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.’’. 
55 Sec. 1251 PPACA (Consolidated) 

PART 2—OTHER PROVISIONS 

SEC. 1251. ø42 U.S.C. 18011¿ PRESERVATION OF RIGHT TO MAINTAIN 

EXISTING COVERAGE. 

(a) NO CHANGES TO EXISTING COVERAGE.— (1) IN GENERAL.—Nothing in this Act (or an amendment 

made by this Act) shall be construed to require that an individual terminate coverage under a group health plan or health 

insurance coverage in which such individual was enrolled on 

the date of enactment of this Act. 

(2) CONTINUATION OF COVERAGE.—øAs revised by section 

10103(d)(1)¿ Except as provided in paragraph (3), with respect 

to a group health plan or health insurance coverage in which 

an individual was enrolled on the date of enactment of this 

Act, this subtitle and subtitle A (and the amendments made by 

such subtitles) shall not apply to such plan or coverage, regardless of whether the individual renews such coverage after such 

date of enactment. 

(3) APPLICATION OF CERTAIN PROVISIONS.—øAs added by 

section 10103(d)(1)¿ 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. 

(4) APPLICATION OF CERTAIN PROVISIONS.—øAs added by 

section 2301(a) of HCERA¿ 

(A) IN GENERAL.—The following provisions of the Public Health Service Act (as added by this title) shall apply 

to grandfathered health plans for plan years beginning 

with the first plan year to which such provisions would 

otherwise apply: 

(i) Section 2708 (relating to excessive waiting periods). 

(ii) Those provisions of section 2711 relating to 

lifetime limits. 

(iii) Section 2712 (relating to rescissions). 

(iv) Section 2714 (relating to extension of dependent coverage). 

(B) PROVISIONS APPLICABLE ONLY TO GROUP HEALTH

PLANS.— 

(i) PROVISIONS DESCRIBED.—Those provisions of 

section 2711 relating to annual limits and the provisions of section 2704 (relating to pre-existing condition 

exclusions) of the Public Health Service Act (as added 

by this subtitle) shall apply to grandfathered health 

plans that are group health plans for plan years beginning with the first plan year to which such provisions 

otherwise apply. 

(ii) ADULT CHILD COVERAGE.—For plan years beginning before January 1, 2014, the provisions of section 2714 of the Public Health Service Act (as added 

by this subtitle) shall apply in the case of an adult 

child with respect to a grandfathered health plan that 

is a group health plan only if such adult child is not 

eligible to enroll in an eligible employer-sponsored 
Sec. 1252 PPACA (Consolidated) 56 

health plan (as defined in section 5000A(f)(2) of the Internal Revenue Code of 1986) other than such grandfathered health plan. 

(b) ALLOWANCE FOR FAMILY MEMBERS TO JOIN CURRENT COV- ERAGE.—With respect to a group health plan or health insurance 

coverage in which an individual was enrolled on the date of enactment of this Act and which is renewed after such date, family 

members of such individual shall be permitted to enroll in such 

plan or coverage if such enrollment is permitted under the terms 

of the plan in effect as of such date of enactment. 

(c) ALLOWANCE FOR NEW EMPLOYEES TO JOIN CURRENT

PLAN.—A group health plan that provides coverage on the date of 

enactment of this Act may provide for the enrolling of new employees (and their families) in such plan, and this subtitle and subtitle 

A (and the amendments made by such subtitles) shall not apply 

with respect to such plan and such new employees (and their families). 

(d) EFFECT ON COLLECTIVE BARGAINING AGREEMENTS.—In the 

case of health insurance coverage maintained pursuant to one or 

more collective bargaining agreements between employee representatives and one or more employers that was ratified before 

the date of enactment of this Act, the provisions of this subtitle and 

subtitle A (and the amendments made by such subtitles) shall not 

apply until the date on which the last of the collective bargaining 

agreements relating to the coverage terminates. Any coverage 

amendment made pursuant to a collective bargaining agreement 

relating to the coverage which amends the coverage solely to conform to any requirement added by this subtitle or subtitle A (or 

amendments) shall not be treated as a termination of such collective bargaining agreement. 

(e) DEFINITION.—In this title, the term ‘‘grandfathered health 

plan’’ means any group health plan or health insurance coverage 

to which this section applies. 

SEC. 1252. ø42 U.S.C. 18012¿ RATING REFORMS MUST APPLY UNIFORMLY TO ALL HEALTH INSURANCE ISSUERS AND 

GROUP HEALTH PLANS. 

Any standard or requirement adopted by a State pursuant to 

this title, or any amendment made by this title, shall be applied 

uniformly to all health plans in each insurance market to which 

the standard and requirements apply. The preceding sentence shall 

also apply to a State standard or requirement relating to the standard or requirement required by this title (or any such amendment) 

that is not the same as the standard or requirement but that is not 

preempted under section 1321(d). 

SEC. 1253. ø42 U.S.C. 18013¿ 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 (includ-
57 Sec. 1255 PPACA (Consolidated) 

ing information on assets, liabilities, contributions, investments, 

and expenses). The Secretary shall submit such reports to the appropriate committees of Congress. 

øSection 1253 added by section 10103(f)(2)¿ 

SEC. 1254. STUDY OF LARGE GROUP MARKET. 

øSection 1254 added by section 10103(f)(2)¿ 

(a) IN GENERAL.—The Secretary of Health and Human Services shall conduct a study of the fully-insured and self-insured 

group health plan markets to— 

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

(2) determine the extent to which new insurance market 

reforms are likely to cause adverse selection in the large group 

market or to encourage small and midsize employers to self-insure. 

(b) COLLECTION OF INFORMATION.—In conducting the study 

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

(1) the extent to which self-insured group health plans can 

offer less costly coverage and, if so, whether lower costs are 

due to more efficient plan administration and lower overhead 

or to the denial of claims and the offering very limited benefit 

packages; 

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

(3) any potential conflict of interest as it relates to the 

health care needs of self-insured enrollees and self-insured employer’s financial contribution or profit margin, and the impact 

of such conflict on administration of the health plan. 

(c) REPORT.—Not later than 1 year after the date of enactment 

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

SEC. 1255. EFFECTIVE DATES. 

øAs revised by section 10103(e) and redesignated by section 

10103(f)(1)¿ This subtitle (and the amendments made by this subtitle) shall become effective for plan years beginning on or after 

January 1, 2014, 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. 
Sec. 1301 PPACA (Consolidated) 58 

Subtitle D—Available Coverage Choices for 

All Americans 

PART 1—ESTABLISHMENT OF QUALIFIED 

HEALTH PLANS 

SEC. 1301. ø42 U.S.C. 18021¿ QUALIFIED HEALTH PLAN DEFINED. 

(a) QUALIFIED HEALTH PLAN.—In this title: 

(1) IN GENERAL.—The term ‘‘qualified health plan’’ means 

a health plan that— 

(A) has in effect a certification (which may include a 

seal or other indication of approval) that such plan meets 

the criteria for certification described in section 1311(c) 

issued or recognized by each Exchange through which such 

plan is offered; 

(B) provides the essential health benefits package described in section 1302(a); and 

(C) is offered by a health insurance issuer that— 

(i) is licensed and in good standing to offer health 

insurance coverage in each State in which such issuer 

offers health insurance coverage under this title; 

(ii) agrees to offer at least one qualified health 

plan in the silver level and at least one plan in the 

gold level in each such Exchange; 

(iii) agrees to charge the same premium rate for 

each qualified health plan of the issuer without regard 

to whether the plan is offered through an Exchange or 

whether the plan is offered directly from the issuer or 

through an agent; and 

(iv) complies with the regulations developed by 

the Secretary under section 1311(d) and such other requirements as an applicable Exchange may establish. 

øParagraphs (2)-(4) substituted for previous paragraph (2) by 

section 10104(a)¿ 

(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 MED- ICAL 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). 
59 Sec. 1302 PPACA (Consolidated) 

(b) TERMS RELATING TO HEALTH PLANS.—In this title: 

(1) HEALTH PLAN.— (A) IN GENERAL.—The term ‘‘health plan’’ means 

health insurance coverage and a group health plan. 

(B) EXCEPTION FOR SELF-INSURED PLANS AND MEWAS.— Except to the extent specifically provided by this title, the 

term ‘‘health plan’’ shall not include a group health plan 

or multiple employer welfare arrangement to the extent 

the plan or arrangement is not subject to State insurance 

regulation under section 514 of the Employee Retirement 

Income Security Act of 1974. 

(2) HEALTH INSURANCE COVERAGE AND ISSUER.—The terms 

‘‘health insurance coverage’’ and ‘‘health insurance issuer’’ have 

the meanings given such terms by section 2791(b) of the Public 

Health Service Act. 

(3) GROUP HEALTH PLAN.—The term ‘‘group health plan’’ 

has the meaning given such term by section 2791(a) of the 

Public Health Service Act. 

SEC. 1302. ø42 U.S.C. 18022¿ ESSENTIAL HEALTH BENEFITS REQUIREMENTS. 

(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the 

term ‘‘essential health benefits package’’ means, with respect to 

any health plan, coverage that— 

(1) provides for the essential health benefits defined by the 

Secretary under subsection (b); 

(2) limits cost-sharing for such coverage in accordance with 

subsection (c); and 

(3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection 

(d). 

(b) ESSENTIAL HEALTH BENEFITS.— (1) IN GENERAL.—Subject to paragraph (2), the Secretary 

shall define the essential health benefits, except that such benefits shall include at least the following general categories and 

the items and services covered within the categories: 

(A) Ambulatory patient services. 

(B) Emergency services. 

(C) Hospitalization. 

(D) Maternity and newborn care. 

(E) Mental health and substance use disorder services, 

including behavioral health treatment. 

(F) Prescription drugs. 

(G) Rehabilitative and habilitative services and devices. 

(H) Laboratory services. 

(I) Preventive and wellness services and chronic disease management. 

(J) Pediatric services, including oral and vision care. 

(2) LIMITATION.— 

(A) IN GENERAL.—The Secretary shall ensure that the 

scope of the essential health benefits under paragraph (1) 

is equal to the scope of benefits provided under a typical 

employer plan, as determined by the Secretary. To inform 

this determination, the Secretary of Labor shall conduct a 
Sec. 1302 PPACA (Consolidated) 60 

survey of employer-sponsored coverage to determine the 

benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the 

Secretary. 

(B) CERTIFICATION.—In defining the essential health 

benefits described in paragraph (1), and in revising the 

benefits under paragraph (4)(H), the Secretary shall submit a report to the appropriate committees of Congress 

containing a certification from the Chief Actuary of the 

Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2). 

(3) NOTICE AND HEARING.—In defining the essential health 

benefits described in paragraph (1), and in revising the benefits under paragraph (4)(H), the Secretary shall provide notice 

and an opportunity for public comment. 

(4) REQUIRED ELEMENTS FOR CONSIDERATION.—In defining 

the essential health benefits under paragraph (1), the Secretary shall— 

(A) ensure that such essential health benefits reflect 

an appropriate balance among the categories described in 

such subsection, so that benefits are not unduly weighted 

toward any category; 

(B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because 

of their age, disability, or expected length of life; 

(C) take into account the health care needs of diverse 

segments of the population, including women, children, 

persons with disabilities, and other groups; 

(D) ensure that health benefits established as essential not be subject to denial to individuals against their 

wishes on the basis of the individuals’ age or expected 

length of life or of the individuals’ present or predicted disability, degree of medical dependency, or quality of life; 

(E) provide that a qualified health plan shall not be 

treated as providing coverage for the essential health benefits described in paragraph (1) unless the plan provides 

that— 

(i) coverage for emergency department 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; 
61 Sec. 1302 PPACA (Consolidated) 

(F) provide that if a plan described in section 

1311(b)(2)(B)(ii) (relating to stand-alone dental benefits 

plans) is offered through an Exchange, another health plan 

offered through such Exchange shall not fail to be treated 

as a qualified health plan solely because the plan does not 

offer coverage of benefits offered through the stand-alone 

plan that are otherwise required under paragraph (1)(J); 

and 

(G) periodically review the essential health benefits 

under paragraph (1), and provide a report to Congress and 

the public that contains— 

(i) an assessment of whether enrollees are facing 

any difficulty accessing needed services for reasons of 

coverage or cost; 

(ii) an assessment of whether the essential health 

benefits needs to be modified or updated to account for 

changes in medical evidence or scientific advancement; 

(iii) information on how the essential health benefits will be modified to address any such gaps in access 

or changes in the evidence base; 

(iv) an assessment of the potential of additional or 

expanded benefits to increase costs and the interactions between the addition or expansion of benefits 

and reductions in existing benefits to meet actuarial 

limitations described in paragraph (2); and 

(H) periodically update the essential health benefits 

under paragraph (1) to address any gaps in access to coverage or changes in the evidence base the Secretary identifies in the review conducted under subparagraph (G). 

(5) RULE OF CONSTRUCTION.—Nothing in this title shall be 

construed to prohibit a health plan from providing benefits in 

excess of the essential health benefits described in this subsection. 

(c) REQUIREMENTS RELATING TO COST-SHARING.— 

(1) ANNUAL LIMITATION ON COST-SHARING.— 

(A) 2014.—The cost-sharing incurred under a health 

plan with respect to self-only coverage or coverage other 

than self-only coverage for a plan year beginning in 2014 

shall not exceed the dollar amounts in effect under section 

223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for 

self-only and family coverage, respectively, for taxable 

years beginning in 2014. 

(B) 2015 AND LATER.—In the case of any plan year beginning in a calendar year after 2014, the limitation under 

this paragraph shall— 

(i) in the case of self-only coverage, be equal to the 

dollar amount under subparagraph (A) for self-only 

coverage for plan years beginning in 2014, increased 

by an amount equal to the product of that amount and 

the premium adjustment percentage under paragraph 

(4) for the calendar year; and 

(ii) in the case of other coverage, twice the amount 

in effect under clause (i). 
Sec. 1302 PPACA (Consolidated) 62 

If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next 

lowest multiple of $50. 

(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR EMPLOYER- SPONSORED PLANS.— (A) IN GENERAL.—In the case of a health plan offered 

in the small group market, the deductible under the plan 

shall not exceed— 

(i) $2,000 in the case of a plan covering a single 

individual; and (ii) $4,000 in the case of any other plan. 

The amounts under clauses (i) and (ii) may be increased by 

the maximum amount of reimbursement which is reasonably available to a participant under a flexible spending 

arrangement described in section 106(c)(2) of the Internal 

Revenue Code of 1986 (determined without regard to any 

salary reduction arrangement). 

(B) INDEXING OF LIMITS.—In the case of any plan year 

beginning in a calendar year after 2014— 

(i) the dollar amount under subparagraph (A)(i) 

shall be increased by an amount equal to the product 

of that amount and the premium adjustment percentage under paragraph (4) for the calendar year; and 

(ii) the dollar amount under subparagraph (A)(ii) 

shall be increased to an amount equal to twice the 

amount in effect under subparagraph (A)(i) for plan 

years beginning in the calendar year, determined after 

application of clause (i). 

If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next 

lowest multiple of $50. 

(C) ACTUARIAL VALUE.—The limitation under this 

paragraph shall be applied in such a manner so as to not 

affect the actuarial value of any health plan, including a 

plan in the bronze level. 

(D) COORDINATION WITH PREVENTIVE LIMITS.—Nothing 

in this paragraph shall be construed to allow a plan to 

have a deductible under the plan apply to benefits described in section 2713 of the Public Health Service Act. 

(3) COST-SHARING.—In this title— 

(A) IN GENERAL.—The term ‘‘cost-sharing’’ includes— 

(i) deductibles, coinsurance, copayments, or similar charges; and 

(ii) any other expenditure required of an insured 

individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal 

Revenue Code of 1986) with respect to essential health 

benefits covered under the plan. 

(B) EXCEPTIONS.—Such term does not include premiums, balance billing amounts for non-network providers, 

or spending for non-covered services. 

(4) PREMIUM ADJUSTMENT PERCENTAGE.—For purposes of 

paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment percentage for any calendar year is the percentage (if any) by 
63 Sec. 1302 PPACA (Consolidated) 

which the average per capita premium for health insurance 

coverage in the United States for the preceding calendar year 

(as estimated by the Secretary no later than October 1 of such 

preceding calendar year) exceeds such average per capita premium for 2013 (as determined by the Secretary). 

(d) LEVELS OF COVERAGE.— (1) LEVELS OF COVERAGE DEFINED.—The levels of coverage 

described in this subsection are as follows: 

(A) BRONZE LEVEL.—A plan in the bronze level shall 

provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the 

full actuarial value of the benefits provided under the 

plan. 

(B) SILVER LEVEL.—A plan in the silver level shall provide a level of coverage that is designed to provide benefits 

that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan. 

(C) GOLD LEVEL.—A plan in the gold level shall provide a level of coverage that is designed to provide benefits 

that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan. 

(D) PLATINUM LEVEL.—A plan in the platinum level 

shall provide a level of coverage that is designed to provide 

benefits that are actuarially equivalent to 90 percent of 

the full actuarial value of the benefits provided under the 

plan. 

(2) ACTUARIAL VALUE.— (A) IN GENERAL.—Under regulations issued by the Secretary, the level of coverage of a plan shall be determined 

on the basis that the essential health benefits described in 

subsection (b) shall be provided to a standard population 

(and without regard to the population the plan may actually provide benefits to). 

(B) EMPLOYER CONTRIBUTIONS.—øAs revised by section 

10104(b)(1)¿ The Secretary shall issue regulations under 

which employer contributions to a health savings account 

(within the meaning of section 223 of the Internal Revenue 

Code of 1986) may be taken into account in determining 

the level of coverage for a plan of the employer. 

(C) APPLICATION.—In determining under this title, the 

Public Health Service Act, or the Internal Revenue Code 

of 1986 the percentage of the total allowed costs of benefits 

provided under a group health plan or health insurance 

coverage that are provided by such plan or coverage, the 

rules contained in the regulations under this paragraph 

shall apply. 

(3) ALLOWABLE VARIANCE.—The Secretary shall develop 

guidelines to provide for a de minimis variation in the actuarial valuations used in determining the level of coverage of a 

plan to account for differences in actuarial estimates. 

(4) PLAN REFERENCE.—In this title, any reference to a 

bronze, silver, gold, or platinum plan shall be treated as a reference to a qualified health plan providing a bronze, silver, 

gold, or platinum level of coverage, as the case may be. 
Sec. 1303 PPACA (Consolidated) 64 

(e) CATASTROPHIC PLAN.— 

(1) IN GENERAL.—A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as 

meeting the requirements of subsection (d) with respect to any 

plan year if— 

(A) the only individuals who are eligible to enroll in 

the plan are individuals described in paragraph (2); and 

(B) the plan provides— 

(i) except as provided in clause (ii), the essential 

health benefits determined under subsection (b), except that the plan provides no benefits for any plan 

year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in 

effect under subsection (c)(1) for the plan year (except 

as provided for in section 2713); and 

(ii) coverage for at least three primary care visits. 

(2) INDIVIDUALS ELIGIBLE FOR ENROLLMENT.—An individual is described in this paragraph for any plan year if the 

individual— 

(A) has not attained the age of 30 before the beginning 

of the plan year; or 

(B) has a certification in effect for any plan year under 

this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 

1986 by reason of— 

(i) section 5000A(e)(1) of such Code (relating to individuals without affordable coverage); or 

(ii) section 5000A(e)(5) of such Code (relating to 

individuals with hardships). 

(3) RESTRICTION TO INDIVIDUAL MARKET.—If a health insurance issuer offers a health plan described in this subsection, 

the issuer may only offer the plan in the individual market. 

(f) CHILD-ONLY PLANS.—If a qualified health plan is offered 

through the Exchange in any level of coverage specified under subsection (d), the issuer shall also offer that plan through the Exchange in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained 

the age of 21, and such plan shall be treated as a qualified health 

plan. 

(g) PAYMENTS TO FEDERALLY-QUALIFIED HEALTH CENTERS.— 

øAs added by section 10104(b)(2)¿ 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. 

SEC. 1303. ø42 U.S.C. 18023¿ SPECIAL RULES. 

øReplaced by section 10104(c)¿ 

(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 
65 Sec. 1303 PPACA (Consolidated) 

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 SERV- ICES.— (1) VOLUNTARY CHOICE OF COVERAGE OF ABORTION SERV- ICES.— (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 PRO- HIBITED.—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 the Patient 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— 
Sec. 1303 PPACA (Consolidated) 66 

(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. 
67 Sec. 1303 PPACA (Consolidated) 

(E) ENSURING COMPLIANCE WITH SEGREGATION RE- QUIREMENTS.— (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. 
Sec. 1304 PPACA (Consolidated) 68 

(d) APPLICATION OF EMERGENCY SERVICES LAWS.—Nothing in 

this Act shall be construed to relieve any health care provider from 

providing emergency services as required by State or Federal law, 

including section 1867 of the Social Security Act (popularly known 

as ‘‘EMTALA’’). 

SEC. 1304. ø42 U.S.C. 18024¿ RELATED DEFINITIONS. 

(a) DEFINITIONS RELATING TO MARKETS.—In this title: 

(1) GROUP MARKET.—The term ‘‘group market’’ means the 

health insurance market under which individuals obtain 

health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through 

a group health plan maintained by an employer. 

(2) INDIVIDUAL MARKET.—The term ‘‘individual market’’ 

means the market for health insurance coverage offered to individuals other than in connection with a group health plan. 

(3) LARGE AND SMALL GROUP MARKETS.—The terms ‘‘large 

group market’’ and ‘‘small group market’’ mean the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf 

of themselves (and their dependents) through a group health 

plan maintained by a large employer (as defined in subsection 

(b)(1)) or by a small employer (as defined in subsection (b)(2)), 

respectively. 

(b) EMPLOYERS.—In this title: 

(1) LARGE EMPLOYER.—The term ‘‘large employer’’ means, 

in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 101 employees on business days during the 

preceding calendar year and who employs at least 1 employee 

on the first day of the plan year. 

(2) SMALL EMPLOYER.—The term ‘‘small employer’’ means, 

in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs 

at least 1 employee on the first day of the plan year. 

(3) STATE OPTION TO TREAT 50 EMPLOYEES AS SMALL.—In 

the case of plan years beginning before January 1, 2016, a 

State may elect to apply this subsection by substituting ‘‘51 

employees’’ for ‘‘101 employees’’ in paragraph (1) and by substituting ‘‘50 employees’’ for ‘‘100 employees’’ in paragraph (2). 

(4) RULES FOR DETERMINING EMPLOYER SIZE.—For purposes of this subsection— 

(A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS.—All persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal 

Revenue Code of 1986 shall be treated as 1 employer. 

(B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING

YEAR.—In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees 
69 Sec. 1311 PPACA (Consolidated) 

that it is reasonably expected such employer will employ 

on business days in the current calendar year. 

(C) PREDECESSORS.—Any reference in this subsection 

to an employer shall include a reference to any predecessor 

of such employer. 

(D) CONTINUATION OF PARTICIPATION FOR GROWING

SMALL EMPLOYERS.—If— 

(i) a qualified employer that is a small employer 

makes enrollment in qualified health plans offered in 

the small group market available to its employees 

through an Exchange; and 

(ii) the employer ceases to be a small employer by 

reason of an increase in the number of employees of 

such employer; 

the employer shall continue to be treated as a small employer for purposes of this subtitle for the period beginning 

with the increase and ending with the first day on which 

the employer does not make such enrollment available to 

its employees. 

(c) SECRETARY.—In this title, the term ‘‘Secretary’’ means the 

Secretary of Health and Human Services. 

(d) STATE.—In this title, the term ‘‘State’’ means each of the 50 

States and the District of Columbia. 

(e) EDUCATED HEALTH CARE CONSUMERS.—øAs added by section 10104(d)¿ 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. 

PART 2—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH 

BENEFIT EXCHANGES 

SEC. 1311. ø42 U.S.C. 13031¿ AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS. 

(a) ASSISTANCE TO STATES TO ESTABLISH AMERICAN HEALTH

BENEFIT EXCHANGES.— 

(1) PLANNING AND ESTABLISHMENT GRANTS.—There shall 

be appropriated to the Secretary, out of any moneys in the 

Treasury not otherwise appropriated, an amount necessary to 

enable the Secretary to make awards, not later than 1 year 

after the date of enactment of this Act, to States in the amount 

specified in paragraph (2) for the uses described in paragraph 

(3). 

(2) AMOUNT SPECIFIED.—For each fiscal year, the Secretary 

shall determine the total amount that the Secretary will make 

available to each State for grants under this subsection. 

(3) USE OF FUNDS.—A State shall use amounts awarded 

under this subsection for activities (including planning activities) related to establishing an American Health Benefit Exchange, as described in subsection (b). 

(4) RENEWABILITY OF GRANT.— 
Sec. 1311 PPACA (Consolidated) 70 

(A) IN GENERAL.—Subject to subsection (d)(4), the Secretary may renew a grant awarded under paragraph (1) if 

the State recipient of such grant— 

(i) is making progress, as determined by the Secretary, toward— 

(I) establishing an Exchange; and 

(II) implementing the reforms described in 

subtitles A and C (and the amendments made by 

such subtitles); and 

(ii) is meeting such other benchmarks as the Secretary may establish. 

(B) LIMITATION.—No grant shall be awarded under 

this subsection after January 1, 2015. 

(5) TECHNICAL ASSISTANCE TO FACILITATE PARTICIPATION IN

SHOP EXCHANGES.—The Secretary shall provide technical assistance to States to facilitate the participation of qualified 

small businesses in such States in SHOP Exchanges. 

(b) AMERICAN HEALTH BENEFIT EXCHANGES.— (1) IN GENERAL.—Each State shall, not later than January 

1, 2014, establish an American Health Benefit Exchange (referred to in this title as an ‘‘Exchange’’) for the State that— 

(A) facilitates the purchase of qualified health plans; 

(B) provides for the establishment of a Small Business 

Health Options Program (in this title referred to as a 

‘‘SHOP Exchange’’) that is designed to assist qualified employers in the State who are small employers in facilitating the enrollment of their employees in qualified 

health plans offered in the small group market in the 

State; and 

(C) meets the requirements of subsection (d). 

(2) MERGER OF INDIVIDUAL AND SHOP EXCHANGES.—A State 

may elect to provide only one Exchange in the State for providing both Exchange and SHOP Exchange services to both 

qualified individuals and qualified small employers, but only if 

the Exchange has adequate resources to assist such individuals 

and employers. 

(c) RESPONSIBILITIES OF THE SECRETARY.— 

(1) IN GENERAL.—The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified 

health plans. Such criteria shall require that, to be certified, 

a plan shall, at a minimum— 

(A) meet marketing requirements, and not employ 

marketing practices or benefit designs that have the effect 

of discouraging the enrollment in such plan by individuals 

with significant health needs; 

(B) ensure a sufficient choice of providers (in a manner 

consistent with applicable network adequacy provisions 

under section 2702(c) of the Public Health Service Act), 

and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network 

providers; 

(C) include within health insurance plan networks 

those essential community providers, where available, that 

serve predominately low-income, medically-underserved in-
71 Sec. 1311 PPACA (Consolidated) 

dividuals, such as health care providers defined in section 

340B(a)(4) of the Public Health Service Act and providers 

described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set forth by section 221 of Public Law 111–8, 

except that nothing in this subparagraph shall be construed to require any health plan to provide coverage for 

any specific medical procedure; 

(D)(i) be accredited with respect to local performance 

on clinical quality measures such as the Healthcare Effectiveness Data and Information Set, patient experience ratings on a standardized Consumer Assessment of 

Healthcare Providers and Systems survey, as well as consumer access, utilization management, quality assurance, 

provider credentialing, complaints and appeals, network 

adequacy and access, and patient information programs by 

any entity recognized by the Secretary for the accreditation of health insurance issuers or plans (so long as any 

such entity has transparent and rigorous methodological 

and scoring criteria); or 

(ii) receive such accreditation within a period established by an Exchange for such accreditation that is applicable to all qualified health plans; 

(E) implement a quality improvement strategy described in subsection (g)(1); 

(F) utilize a uniform enrollment form that qualified individuals and qualified employers may use (either electronically or on paper) in enrolling in qualified health 

plans offered through such Exchange, and that takes into 

account criteria that the National Association of Insurance 

Commissioners develops and submits to the Secretary; 

(G) utilize the standard format established for presenting health benefits plan options; 

(H) provide information to enrollees and prospective 

enrollees, and to each Exchange in which the plan is offered, on any quality measures for health plan performance endorsed under section 399JJ of the Public Health 

Service Act, as applicable; and 

(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. øAs added by section 10203(a)¿ 

(2) RULE OF CONSTRUCTION.—Nothing in paragraph (1)(C) 

shall be construed to require a qualified health plan to contract 

with a provider described in such paragraph if such provider 

refuses to accept the generally applicable payment rates of 

such plan. 

(3) RATING SYSTEM.—The Secretary shall develop a rating 

system that would rate qualified health plans offered through 

an Exchange in each benefits level on the basis of the relative 

quality and price. The Exchange shall include the quality rating in the information provided to individuals and employers 

through the Internet portal established under paragraph (4). 
Sec. 1311 PPACA (Consolidated) 72 

(4) ENROLLEE SATISFACTION SYSTEM.—The Secretary shall 

develop an enrollee satisfaction survey system that would 

evaluate the level of enrollee satisfaction with qualified health 

plans offered through an Exchange, for each such qualified 

health plan that had more than 500 enrollees in the previous 

year. The Exchange shall include enrollee satisfaction information in the information provided to individuals and employers 

through the Internet portal established under paragraph (5) in 

a manner that allows individuals to easily compare enrollee 

satisfaction levels between comparable plans. 

(5) INTERNET PORTALS.—The Secretary shall— 

(A) continue to operate, maintain, and update the 

Internet portal developed under section 1103(a) and to assist States in developing and maintaining their own such 

portal; and 

(B) make available for use by Exchanges a model template for an Internet portal that may be used to direct 

qualified individuals and qualified employers to qualified 

health plans, to assist such individuals and employers in 

determining whether they are eligible to participate in an 

Exchange or eligible for a premium tax credit or cost-sharing reduction, and to present standardized information (including quality ratings) regarding qualified health plans 

offered through an Exchange to assist consumers in making easy health insurance choices. 

Such template shall include, with respect to each qualified 

health plan offered through the Exchange in each rating area, 

access to the uniform outline of coverage the plan is required 

to provide under section 2716 of the Public Health Service Act 

and to a copy of the plan’s written policy. 

(6) ENROLLMENT PERIODS.—The Secretary shall require an 

Exchange to provide for— 

(A) an initial open enrollment, as determined by the 

Secretary (such determination to be made not later than 

July 1, 2012); 

(B) annual open enrollment periods, as determined by 

the Secretary for calendar years after the initial enrollment period; 

(C) special enrollment periods specified in section 9801 

of the Internal Revenue Code of 1986 and other special enrollment periods under circumstances similar to such periods under part D of title XVIII of the Social Security Act; 

and 

(D) special monthly enrollment periods for Indians (as 

defined in section 4 of the Indian Health Care Improvement Act). 

(d) REQUIREMENTS.— 

(1) IN GENERAL.—An Exchange shall be a governmental 

agency or nonprofit entity that is established by a State. 

(2) OFFERING OF COVERAGE.— 

(A) IN GENERAL.—An Exchange shall make available 

qualified health plans to qualified individuals and qualified employers. 

(B) LIMITATION.— 
73 Sec. 1311 PPACA (Consolidated) 

(i) IN GENERAL.—An Exchange may not make 

available any health plan that is not a qualified health 

plan. 

(ii) OFFERING OF STAND-ALONE DENTAL BENE- FITS.—Each Exchange within a State shall allow an 

issuer of a plan that only provides limited scope dental 

benefits meeting the requirements of section 

9832(c)(2)(A) of the Internal Revenue Code of 1986 to 

offer the plan through the Exchange (either separately 

or in conjunction with a qualified health plan) if the 

plan provides pediatric dental benefits meeting the requirements of section 1302(b)(1)(J)). 

(3) RULES RELATING TO ADDITIONAL REQUIRED BENEFITS.— (A) IN GENERAL.—Except as provided in subparagraph 

(B), an Exchange may make available a qualified health 

plan notwithstanding any provision of law that may require benefits other than the essential health benefits 

specified under section 1302(b). 

(B) STATES MAY REQUIRE ADDITIONAL BENEFITS.— (i) IN GENERAL.—Subject to the requirements of 

clause (ii), a State may require that a qualified health 

plan offered in such State offer benefits in addition to 

the essential health benefits specified under section 

1302(b). 

(ii) STATE MUST ASSUME COST.—øReplaced by section 10104(e)(1)¿ 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). 

(4) FUNCTIONS.—An Exchange shall, at a minimum— 

(A) implement procedures for the certification, recertification, and decertification, consistent with guidelines 

developed by the Secretary under subsection (c), of health 

plans as qualified health plans; 

(B) provide for the operation of a toll-free telephone 

hotline to respond to requests for assistance; 

(C) maintain an Internet website through which enrollees and prospective enrollees of qualified health plans 

may obtain standardized comparative information on such 

plans; 

(D) assign a rating to each qualified health plan offered through such Exchange in accordance with the criteria developed by the Secretary under subsection (c)(3); 

(E) utilize a standardized format for presenting health 

benefits plan options in the Exchange, including the use of 

the uniform outline of coverage established under section 

2715 of the Public Health Service Act; 

(F) in accordance with section 1413, inform individuals 

of eligibility requirements for the medicaid program under 

title XIX of the Social Security Act, the CHIP program 
Sec. 1311 PPACA (Consolidated) 74 

under title XXI of such Act, or any applicable State or local 

public program and if through screening of the application 

by the Exchange, the Exchange determines that such individuals are eligible for any such program, enroll such individuals in such program; 

(G) establish and make available by electronic means 

a calculator to determine the actual cost of coverage after 

the application of any premium tax credit under section 

36B of the Internal Revenue Code of 1986 and any costsharing reduction under section 1402; 

(H) subject to section 1411, grant a certification attesting that, for purposes of the individual responsibility penalty under section 5000A of the Internal Revenue Code of 

1986, an individual is exempt from the individual requirement or from the penalty imposed by such section because— 

(i) there is no affordable qualified health plan 

available through the Exchange, or the individual’s 

employer, covering the individual; or 

(ii) the individual meets the requirements for any 

other such exemption from the individual responsibility requirement or penalty; 

(I) transfer to the Secretary of the Treasury— 

(i) a list of the individuals who are issued a certification under subparagraph (H), including the name 

and taxpayer identification number of each individual; 

(ii) the name and taxpayer identification number 

of each individual who was an employee of an employer but who was determined to be eligible for the 

premium tax credit under section 36B of the Internal 

Revenue Code of 1986 because— 

(I) the employer did not provide minimum essential coverage; or 

(II) the employer provided such minimum essential coverage but it was determined under section 36B(c)(2)(C) of such Code to either be 

unaffordable to the employee or not provide the 

required minimum actuarial value; and 

(iii) the name and taxpayer identification number 

of each individual who notifies the Exchange under 

section 1411(b)(4) that they have changed employers 

and of each individual who ceases coverage under a 

qualified health plan during a plan year (and the effective date of such cessation); 

(J) provide to each employer the name of each employee of the employer described in subparagraph (I)(ii) 

who ceases coverage under a qualified health plan during 

a plan year (and the effective date of such cessation); and 

(K) establish the Navigator program described in subsection (i). 

(5) FUNDING LIMITATIONS.— 

(A) NO FEDERAL FUNDS FOR CONTINUED OPERATIONS.— 

In establishing an Exchange under this section, the State 

shall ensure that such Exchange is self-sustaining begin-
75 Sec. 1311 PPACA (Consolidated) 

ning on January 1, 2015, including allowing the Exchange 

to charge assessments or user fees to participating health 

insurance issuers, or to otherwise generate funding, to 

support its operations. 

(B) PROHIBITING WASTEFUL USE OF FUNDS.—In carrying out activities under this subsection, an Exchange 

shall not utilize any funds intended for the administrative 

and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and 

regulatory modifications. 

(6) CONSULTATION.—An Exchange shall consult with stakeholders relevant to carrying out the activities under this section, including— 

(A) øAs revised by section 10104(e)(2)¿ educated health 

care consumers who are enrollees in qualified health 

plans; 

(B) individuals and entities with experience in facilitating enrollment in qualified health plans; 

(C) representatives of small businesses and self-employed individuals; 

(D) State Medicaid offices; and 

(E) advocates for enrolling hard to reach populations. 

(7) PUBLICATION OF COSTS.—An Exchange shall publish 

the average costs of licensing, regulatory fees, and any other 

payments required by the Exchange, and the administrative 

costs of such Exchange, on an Internet website to educate consumers on such costs. Such information shall also include monies lost to waste, fraud, and abuse. 

(e) CERTIFICATION.— 

(1) IN GENERAL.—An Exchange may certify a health plan 

as a qualified health plan if— 

(A) such health plan meets the requirements for certification as promulgated by the Secretary under subsection (c)(1); and 

(B) the Exchange determines that making available 

such health plan through such Exchange is in the interests 

of qualified individuals and qualified employers in the 

State or States in which such Exchange operates, except 

that the Exchange may not exclude a health plan— 

(i) on the basis that such plan is a fee-for-service 

plan; 

(ii) through the imposition of premium price controls; or 

(iii) on the basis that the plan provides treatments 

necessary to prevent patients’ deaths in circumstances 

the Exchange determines are inappropriate or too 

costly. 

(2) PREMIUM CONSIDERATIONS.—øAs amended by section 

10104(f)(1)¿ The Exchange shall require health plans seeking 

certification as qualified health plans to submit a justification 

for any premium increase prior to implementation of the increase. Such plans shall prominently post such information on 

their websites. The Exchange shall take this information, and 
Sec. 1311 PPACA (Consolidated) 76 

the information and the recommendations provided to the Exchange by the State under section 2794(b)(1) of the Public 

Health Service Act (relating to patterns or practices of excessive or unjustified premium increases), into consideration when 

determining whether to make such health plan available 

through the Exchange. The Exchange shall take into account 

any excess of premium growth outside the Exchange as compared to the rate of such growth inside the Exchange, including information reported by the States. 

(3) TRANSPARENCY IN COVERAGE.—øAs added by section 

10104(f)(2)¿ 

(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 
77 Sec. 1311 PPACA (Consolidated) 

conditions, and periodic financial disclosure with the 

standards established by the Secretary under subparagraph (A). 

(f) FLEXIBILITY.— (1) REGIONAL OR OTHER INTERSTATE EXCHANGES.—An Exchange may operate in more than one State if— 

(A) each State in which such Exchange operates permits such operation; and 

(B) the Secretary approves such regional or interstate 

Exchange. 

(2) SUBSIDIARY EXCHANGES.—A State may establish one or 

more subsidiary Exchanges if— 

(A) each such Exchange serves a geographically distinct area; and 

(B) the area served by each such Exchange is at least 

as large as a rating area described in section 2701(a) of the 

Public Health Service Act. 

(3) AUTHORITY TO CONTRACT.— (A) IN GENERAL.—A State may elect to authorize an 

Exchange established by the State under this section to 

enter into an agreement with an eligible entity to carry 

out 1 or more responsibilities of the Exchange. 

(B) ELIGIBLE ENTITY.—In this paragraph, the term ‘‘eligible entity’’ means— 

(i) a person— 

(I) incorporated under, and subject to the laws 

of, 1 or more States; 

(II) that has demonstrated experience on a 

State or regional basis in the individual and small 

group health insurance markets and in benefits 

coverage; and 

(III) that is not a health insurance issuer or 

that is treated under subsection (a) or (b) of section 52 of the Internal Revenue Code of 1986 as 

a member of the same controlled group of corporations (or under common control with) as a health 

insurance issuer; or 

(ii) the State medicaid agency under title XIX of 

the Social Security Act. 

(g) REWARDING QUALITY THROUGH MARKET-BASED INCENTIVES.— 

(1) STRATEGY DESCRIBED.—A strategy described in this 

paragraph is a payment structure that provides increased reimbursement or other incentives for— 

(A) improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home 

model, for treatment or services under the plan or coverage; 

(B) the implementation of activities to prevent hospital 

readmissions through a comprehensive program for hospital discharge that includes patient-centered education 
Sec. 1311 PPACA (Consolidated) 78 

and counseling, comprehensive discharge planning, and 

post discharge reinforcement by an appropriate health care 

professional; 

(C) the implementation of activities to improve patient 

safety and reduce medical errors through the appropriate 

use of best clinical practices, evidence based medicine, and 

health information technology under the plan or coverage; 

(D) the implementation of wellness and health promotion activities; and 

(E) øAs added by section 10104(g)¿ the implementation of activities to reduce health and health care disparities, including through the use of language services, community outreach, and cultural competency trainings. 

(2) GUIDELINES.—The Secretary, in consultation with experts in health care quality and stakeholders, shall develop 

guidelines concerning the matters described in paragraph (1). 

(3) REQUIREMENTS.—The guidelines developed under paragraph (2) shall require the periodic reporting to the applicable 

Exchange of the activities that a qualified health plan has conducted to implement a strategy described in paragraph (1). 

(h) QUALITY IMPROVEMENT.— 

(1) ENHANCING PATIENT SAFETY.—Beginning on January 1, 

2015, a qualified health plan may contract with— 

(A) a hospital with greater than 50 beds only if such 

hospital— 

(i) utilizes a patient safety evaluation system as 

described in part C of title IX of the Public Health 

Service Act; and 

(ii) implements a mechanism to ensure that each 

patient receives a comprehensive program for hospital 

discharge that includes patient-centered education and 

counseling, comprehensive discharge planning, and 

post discharge reinforcement by an appropriate health 

care professional; or 

(B) a health care provider only if such provider implements such mechanisms to improve health care quality as 

the Secretary may by regulation require. 

(2) EXCEPTIONS.—The Secretary may establish reasonable 

exceptions to the requirements described in paragraph (1). 

(3) ADJUSTMENT.—The Secretary may by regulation adjust 

the number of beds described in paragraph (1)(A). 

(i) NAVIGATORS.— 

(1) IN GENERAL.—An Exchange shall establish a program 

under which it awards grants to entities described in paragraph (2) to carry out the duties described in paragraph (3). 

(2) ELIGIBILITY.— 

(A) IN GENERAL.—To be eligible to receive a grant 

under paragraph (1), an entity shall demonstrate to the 

Exchange involved that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured 

and underinsured consumers), or self-employed individuals 

likely to be qualified to enroll in a qualified health plan. 
79 Sec. 1311 PPACA (Consolidated) 

(B) TYPES.—øAs amended by section 10104(h)¿ Entities described in subparagraph (A) may include trade, industry, and professional associations, commercial fishing 

industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, 

chambers of commerce, unions, resource partners of the 

Small Business Administration, other licensed insurance 

agents and brokers, and other entities that— 

(i) are capable of carrying out the duties described 

in paragraph (3); 

(ii) meet the standards described in paragraph (4); 

and 

(iii) provide information consistent with the standards developed under paragraph (5). 

(3) DUTIES.—An entity that serves as a navigator under a 

grant under this subsection shall— 

(A) conduct public education activities to raise awareness of the availability of qualified health plans; 

(B) distribute fair and impartial information concerning enrollment in qualified health plans, and the 

availability of premium tax credits under section 36B of 

the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402; 

(C) facilitate enrollment in qualified health plans; 

(D) provide referrals to any applicable office of health 

insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public 

Health Service Act, or any other appropriate State agency 

or agencies, for any enrollee with a grievance, complaint, 

or question regarding their health plan, coverage, or a determination under such plan or coverage; and 

(E) provide information in a manner that is culturally 

and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges. 

(4) STANDARDS.— 

(A) IN GENERAL.—The Secretary shall establish standards for navigators under this subsection, including provisions to ensure that any private or public entity that is selected as a navigator is qualified, and licensed if appropriate, to engage in the navigator activities described in 

this subsection and to avoid conflicts of interest. Under 

such standards, a navigator shall not— 

(i) be a health insurance issuer; or 

(ii) receive any consideration directly or indirectly 

from any health insurance issuer in connection with 

the enrollment of any qualified individuals or employees of a qualified employer in a qualified health plan. 

(5) FAIR AND IMPARTIAL INFORMATION AND SERVICES.—The 

Secretary, in collaboration with States, shall develop standards 

to ensure that information made available by navigators is 

fair, accurate, and impartial. 

(6) FUNDING.—Grants under this subsection shall be made 

from the operational funds of the Exchange and not Federal 

funds received by the State to establish the Exchange. 
Sec. 1312 PPACA (Consolidated) 80 

(j) APPLICABILITY OF MENTAL HEALTH PARITY.—Section 2726 of 

the Public Health Service Act shall apply to qualified health plans 

in the same manner and to the same extent as such section applies 

to health insurance issuers and group health plans. 

(k) CONFLICT.—An Exchange may not establish rules that conflict with or prevent the application of regulations promulgated by 

the Secretary under this subtitle. 

SEC. 1312. ø42 U.S.C. 18032¿ CONSUMER CHOICE. 

(a) CHOICE.— 

(1) QUALIFIED INDIVIDUALS.—øAs revised by section 

10104(i)(1)¿ A qualified individual may enroll in any qualified 

health plan available to such individual and for which such individual is eligible. 

(2) QUALIFIED EMPLOYERS.— 

(A) EMPLOYER MAY SPECIFY LEVEL.—A qualified employer may provide support for coverage of employees 

under a qualified health plan by selecting any level of coverage under section 1302(d) to be made available to employees through an Exchange. 

(B) EMPLOYEE MAY CHOOSE PLANS WITHIN A LEVEL.— 

Each employee of a qualified employer that elects a level 

of coverage under subparagraph (A) may choose to enroll 

in a qualified health plan that offers coverage at that level. 

(b) PAYMENT OF PREMIUMS BY QUALIFIED INDIVIDUALS.—A 

qualified individual enrolled in any qualified health plan may pay 

any applicable premium owed by such individual to the health insurance issuer issuing such qualified health plan. 

(c) SINGLE RISK POOL.— 

(1) INDIVIDUAL MARKET.—A health insurance issuer shall 

consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the individual 

market, including those enrollees who do not enroll in such 

plans through the Exchange, to be members of a single risk 

pool. 

(2) SMALL GROUP MARKET.—A health insurance issuer 

shall consider all enrollees in all health plans (other than 

grandfathered health plans) offered by such issuer in the small 

group market, including those enrollees who do not enroll in 

such plans through the Exchange, to be members of a single 

risk pool. 

(3) MERGER OF MARKETS.—A State may require the individual and small group insurance markets within a State to be 

merged if the State determines appropriate. 

(4) STATE LAW.—A State law requiring grandfathered 

health plans to be included in a pool described in paragraph 

(1) or (2) shall not apply. 

(d) EMPOWERING CONSUMER CHOICE.— 

(1) CONTINUED OPERATION OF MARKET OUTSIDE EXCHANGES.—Nothing in this title shall be construed to prohibit— 

(A) a health insurance issuer from offering outside of 

an Exchange a health plan to a qualified individual or 

qualified employer; and 
81 Sec. 1312 PPACA (Consolidated) 

(B) a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health 

plan offered outside of an Exchange. 

(2) CONTINUED OPERATION OF STATE BENEFIT REQUIRE- MENTS.—Nothing in this title shall be construed to terminate, 

abridge, or limit the operation of any requirement under State 

law with respect to any policy or plan that is offered outside 

of an Exchange to offer benefits. 

(3) VOLUNTARY NATURE OF AN EXCHANGE.— (A) CHOICE TO ENROLL OR NOT TO ENROLL.—Nothing 

in this title shall be construed to restrict the choice of a 

qualified individual to enroll or not to enroll in a qualified 

health plan or to participate in an Exchange. 

(B) PROHIBITION AGAINST COMPELLED ENROLLMENT.— Nothing in this title shall be construed to compel an individual to enroll in a qualified health plan or to participate 

in an Exchange. 

(C) INDIVIDUALS ALLOWED TO ENROLL IN ANY PLAN.— A qualified individual may enroll in any qualified health 

plan, except that in the case of a catastrophic plan described in section 1302(e), a qualified individual may enroll 

in the plan only if the individual is eligible to enroll in the 

plan under section 1302(e)(2). 

(D) MEMBERS OF CONGRESS IN THE EXCHANGE.— (i) REQUIREMENT.—Notwithstanding any other 

provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and 

congressional staff with respect to their service as a 

Member of Congress or congressional staff shall be 

health plans that are— 

(I) created under this Act (or an amendment 

made by this Act); or 

(II) offered through an Exchange established 

under this Act (or an amendment made by this 

Act). 

(ii) DEFINITIONS.—In this section: 

(I) MEMBER OF CONGRESS.—The term ‘‘Member of Congress’’ means any member of the House 

of Representatives or the Senate. 

(II) CONGRESSIONAL STAFF.—The term ‘‘congressional staff’’ means all full-time and part-time 

employees employed by the official office of a 

Member of Congress, whether in Washington, DC 

or outside of Washington, DC. 

(4) NO PENALTY FOR TRANSFERRING TO MINIMUM ESSENTIAL

COVERAGE OUTSIDE EXCHANGE.—An Exchange, or a qualified 

health plan offered through an Exchange, shall not impose any 

penalty or other fee on an individual who cancels enrollment 

in a plan because the individual becomes eligible for minimum 

essential coverage (as defined in section 5000A(f) of the Internal Revenue Code of 1986 without regard to paragraph (1)(C) 

or (D) thereof) or such coverage becomes affordable (within the 

meaning of section 36B(c)(2)(C) of such Code). 
Sec. 1312 PPACA (Consolidated) 82 

(e) ENROLLMENT THROUGH AGENTS OR BROKERS.—øAs revised 

by section 10104(i)(2)¿ The Secretary shall establish procedures 

under which a State may allow agents or brokers— 

(1) to enroll individuals and employers in any qualified 

health plans in the individual or small group market as soon 

as the plan is offered through an Exchange in the State; and 

(2) to assist individuals in applying for premium tax credits and cost-sharing reductions for plans sold through an Exchange. 

(f) QUALIFIED INDIVIDUALS AND EMPLOYERS; ACCESS LIMITED

TO CITIZENS AND LAWFUL RESIDENTS.— 

(1) QUALIFIED INDIVIDUALS.—In this title: 

(A) IN GENERAL.—The term ‘‘qualified individual’’ 

means, with respect to an Exchange, an individual who— 

(i) is seeking to enroll in a qualified health plan 

in the individual market offered through the Exchange; and 

(ii) øAs revised by section 10104(i)(3)¿ resides in 

the State that established the Exchange. 

(B) INCARCERATED INDIVIDUALS EXCLUDED.—An individual shall not be treated as a qualified individual if, at 

the time of enrollment, the individual is incarcerated, 

other than incarceration pending the disposition of 

charges. 

(2) QUALIFIED EMPLOYER.—In this title: 

(A) IN GENERAL.—The term ‘‘qualified employer’’ 

means a small employer that elects to make all full-time 

employees of such employer eligible for 1 or more qualified 

health plans offered in the small group market through an 

Exchange that offers qualified health plans. 

(B) EXTENSION TO LARGE GROUPS.— 

(i) IN GENERAL.—Beginning in 2017, each State 

may allow issuers of health insurance coverage in the 

large group market in the State to offer qualified 

health plans in such market through an Exchange. 

Nothing in this subparagraph shall be construed as requiring the issuer to offer such plans through an Exchange. 

(ii) LARGE EMPLOYERS ELIGIBLE.—If a State under 

clause (i) allows issuers to offer qualified health plans 

in the large group market through an Exchange, the 

term ‘‘qualified employer’’ shall include a large employer that elects to make all full-time employees of 

such employer eligible for 1 or more qualified health 

plans offered in the large group market through the 

Exchange. 

(3) ACCESS LIMITED TO LAWFUL RESIDENTS.—If an individual is not, or is not reasonably expected to be for the entire 

period for which enrollment is sought, a citizen or national of 

the United States or an alien lawfully present in the United 

States, the individual shall not be treated as a qualified individual and may not be covered under a qualified health plan 

in the individual market that is offered through an Exchange. 
83 Sec. 1313 PPACA (Consolidated) 

SEC. 1313. ø42 U.S.C. 18033¿ FINANCIAL INTEGRITY. 

(a) ACCOUNTING FOR EXPENDITURES.— 

(1) IN GENERAL.—An Exchange shall keep an accurate accounting of all activities, receipts, and expenditures and shall 

annually submit to the Secretary a report concerning such accountings. 

(2) INVESTIGATIONS.—The Secretary, in coordination with 

the Inspector General of the Department of Health and Human 

Services, may investigate the affairs of an Exchange, may examine the properties and records of an Exchange, and may require periodic reports in relation to activities undertaken by an 

Exchange. An Exchange shall fully cooperate in any investigation conducted under this paragraph. 

(3) AUDITS.—An Exchange shall be subject to annual audits by the Secretary. 

(4) PATTERN OF ABUSE.—If the Secretary determines that 

an Exchange or a State has engaged in serious misconduct 

with respect to compliance with the requirements of, or carrying out of activities required under, this title, the Secretary 

may rescind from payments otherwise due to such State involved under this or any other Act administered by the Secretary an amount not to exceed 1 percent of such payments per 

year until corrective actions are taken by the State that are determined to be adequate by the Secretary. 

(5) PROTECTIONS AGAINST FRAUD AND ABUSE.—With respect to activities carried out under this title, the Secretary 

shall provide for the efficient and non-discriminatory administration of Exchange activities and implement any measure or 

procedure that— 

(A) the Secretary determines is appropriate to reduce 

fraud and abuse in the administration of this title; and 

(B) the Secretary has authority to implement under 

this title or any other Act. 

(6) APPLICATION OF THE FALSE CLAIMS ACT.— 

(A) IN GENERAL.—Payments made by, through, or in 

connection with an Exchange are subject to the False 

Claims Act (31 U.S.C. 3729 et seq.) if those payments include any Federal funds. Compliance with the requirements of this Act concerning eligibility for a health insurance issuer to participate in the Exchange shall be a material condition of an issuer’s entitlement to receive payments, including payments of premium tax credits and 

cost-sharing reductions, through the Exchange. 

øSection 10104(j)(1), p. 834, provides that subparagraph (B) is 

deemed ‘‘null, void, and of no effect’’¿ 

ø(B) DAMAGES.—Notwithstanding paragraph (1) of section 3729(a) of title 31, United States Code, and subject to 

paragraph (2) of such section, the civil penalty assessed 

under the False Claims Act on any person found liable 

under such Act as described in subparagraph (A) shall be 

increased by not less than 3 times and not more than 6 

times the amount of damages which the Government sustains because of the act of that person.¿ 
Sec. 1313 PPACA (Consolidated) 84 

øSection 10104(j)(2),p. 834, replaced paragraph (4) of section 

3730(e) of title 31, United States Code, as follows:¿ 

(2) øsec. 10104(j)(2) of PPACA:¿ 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.’’. 

(b) GAO OVERSIGHT.—Not later than 5 years after the first 

date on which Exchanges are required to be operational under this 

title, the Comptroller General shall conduct an ongoing study of 

Exchange activities and the enrollees in qualified health plans offered through Exchanges. Such study shall review— 

(1) the operations and administration of Exchanges, including surveys and reports of qualified health plans offered 

through Exchanges and on the experience of such plans (including data on enrollees in Exchanges and individuals purchasing health insurance coverage outside of Exchanges), the 

expenses of Exchanges, claims statistics relating to qualified 

health plans, complaints data relating to such plans, and the 

manner in which Exchanges meet their goals; 

(2) any significant observations regarding the utilization 

and adoption of Exchanges; 

(3) where appropriate, recommendations for improvements 

in the operations or policies of Exchanges; 

(4) øAs added by section 10104(k)(3)¿ 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 

(5) how many physicians, by area and specialty, are not 

taking or accepting new patients enrolled in Federal Govern-
85 Sec. 1321 PPACA (Consolidated) 

ment health care programs, and the adequacy of provider networks of Federal Government health care programs. 

PART 3—STATE FLEXIBILITY RELATING TO 

EXCHANGES 

SEC. 1321. ø42 U.S.C. 18041¿ STATE FLEXIBILITY IN OPERATION AND 

ENFORCEMENT OF EXCHANGES AND RELATED REQUIREMENTS. 

(a) ESTABLISHMENT OF STANDARDS.— 

(1) IN GENERAL.—The Secretary shall, as soon as practicable after the date of enactment of this Act, issue regulations setting standards for meeting the requirements under 

this title, and the amendments made by this title, with respect 

to— 

(A) the establishment and operation of Exchanges (including SHOP Exchanges); 

(B) the offering of qualified health plans through such 

Exchanges; 

(C) the establishment of the reinsurance and risk adjustment programs under part V; and 

(D) such other requirements as the Secretary determines appropriate. 

The preceding sentence shall not apply to standards for requirements under subtitles A and C (and the amendments 

made by such subtitles) for which the Secretary issues regulations under the Public Health Service Act. 

(2) CONSULTATION.—In issuing the regulations under paragraph (1), the Secretary shall consult with the National Association of Insurance Commissioners and its members and with 

health insurance issuers, consumer organizations, and such 

other individuals as the Secretary selects in a manner designed to ensure balanced representation among interested 

parties. 

(b) STATE ACTION.—Each State that elects, at such time and in 

such manner as the Secretary may prescribe, to apply the requirements described in subsection (a) shall, not later than January 1, 

2014, adopt and have in effect— 

(1) the Federal standards established under subsection (a); 

or 

(2) a State law or regulation that the Secretary determines 

implements the standards within the State. 

(c) FAILURE TO ESTABLISH EXCHANGE OR IMPLEMENT REQUIREMENTS.— 

(1) IN GENERAL.—If— 

(A) a State is not an electing State under subsection 

(b); or 

(B) the Secretary determines, on or before January 1, 

2013, that an electing State— 

(i) will not have any required Exchange operational by January 1, 2014; or 

(ii) has not taken the actions the Secretary determines necessary to implement— 
Sec. 1322 PPACA (Consolidated) 86 

(I) the other requirements set forth in the 

standards under subsection (a); or 

(II) the requirements set forth in subtitles A 

and C and the amendments made by such subtitles; 

the Secretary shall (directly or through agreement with a notfor-profit entity) establish and operate such Exchange within 

the State and the Secretary shall take such actions as are necessary to implement such other requirements. 

(2) ENFORCEMENT AUTHORITY.—The provisions of section 

2736(b) of the Public Health Services Act shall apply to the enforcement under paragraph (1) of requirements of subsection 

(a)(1) (without regard to any limitation on the application of 

those provisions to group health plans). 

(d) NO INTERFERENCE WITH STATE REGULATORY AUTHORITY.— Nothing in this title shall be construed to preempt any State law 

that does not prevent the application of the provisions of this title. 

(e) PRESUMPTION FOR CERTAIN STATE-OPERATED EXCHANGES.— (1) IN GENERAL.—In the case of a State operating an Exchange before January 1, 2010, and which has insured a percentage of its population not less than the percentage of the 

population projected to be covered nationally after the implementation of this Act, that seeks to operate an Exchange under 

this section, the Secretary shall presume that such Exchange 

meets the standards under this section unless the Secretary 

determines, after completion of the process established under 

paragraph (2), that the Exchange does not comply with such 

standards. 

(2) PROCESS.—The Secretary shall establish a process to 

work with a State described in paragraph (1) to provide assistance necessary to assist the State’s Exchange in coming into 

compliance with the standards for approval under this section. 

SEC. 1322. ø42 U.S.C. 18042¿ FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND OPERATION OF NONPROFIT, MEMBER-RUN 

HEALTH INSURANCE ISSUERS. 

(a) ESTABLISHMENT OF PROGRAM.— 

(1) IN GENERAL.—The Secretary shall establish a program 

to carry out the purposes of this section to be known as the 

Consumer Operated and Oriented Plan (CO-OP) program. 

(2) PURPOSE.—It is the purpose of the CO-OP program to 

foster the creation of qualified nonprofit health insurance 

issuers to offer qualified health plans in the individual and 

small group markets in the States in which the issuers are licensed to offer such plans. 

(b) LOANS AND GRANTS UNDER THE CO-OP PROGRAM.— 

(1) IN GENERAL.—The Secretary shall provide through the 

CO-OP program for the awarding to persons applying to become qualified nonprofit health insurance issuers of— 

(A) loans to provide assistance to such person in meeting its start-up costs; and 

(B) grants to provide assistance to such person in 

meeting any solvency requirements of States in which the 

person seeks to be licensed to issue qualified health plans. 

(2) REQUIREMENTS FOR AWARDING LOANS AND GRANTS.— 
87 Sec. 1322 PPACA (Consolidated) 

(A) IN GENERAL.—In awarding loans and grants under 

the CO-OP program, the Secretary shall— 

(i) take into account the recommendations of the 

advisory board established under paragraph (3); 

(ii) give priority to applicants that will offer qualified health plans on a Statewide basis, will utilize integrated care models, and have significant private support; and 

(iii) ensure that there is sufficient funding to establish at least 1 qualified nonprofit health insurance 

issuer in each State, except that nothing in this clause 

shall prohibit the Secretary from funding the establishment of multiple qualified nonprofit health insurance issuers in any State if the funding is sufficient to 

do so. 

(B) STATES WITHOUT ISSUERS IN PROGRAM.—If no 

health insurance issuer applies to be a qualified nonprofit 

health insurance issuer within a State, the Secretary may 

use amounts appropriated under this section for the 

awarding of grants to encourage the establishment of a 

qualified nonprofit health insurance issuer within the 

State or the expansion of a qualified nonprofit health insurance issuer from another State to the State. 

(C) AGREEMENT.— 

(i) IN GENERAL.—The Secretary shall require any 

person receiving a loan or grant under the CO-OP program to enter into an agreement with the Secretary 

which requires such person to meet (and to continue 

to meet)— 

(I) any requirement under this section for 

such person to be treated as a qualified nonprofit 

health insurance issuer; and 

(II) any requirements contained in the agreement for such person to receive such loan or 

grant. 

(ii) RESTRICTIONS ON USE OF FEDERAL FUNDS.— 

The agreement shall include a requirement that no 

portion of the funds made available by any loan or 

grant under this section may be used— 

(I) for carrying on propaganda, or otherwise 

attempting, to influence legislation; or 

(II) for marketing. 

Nothing in this clause shall be construed to allow a 

person to take any action prohibited by section 

501(c)(29) of the Internal Revenue Code of 1986. 

(iii) FAILURE TO MEET REQUIREMENTS.—If the Secretary determines that a person has failed to meet any 

requirement described in clause (i) or (ii) and has 

failed to correct such failure within a reasonable period of time of when the person first knows (or reasonably should have known) of such failure, such person 

shall repay to the Secretary an amount equal to the 

sum of— 
Sec. 1322 PPACA (Consolidated) 88 

(I) 110 percent of the aggregate amount of 

loans and grants received under this section; plus 

(II) interest on the aggregate amount of loans 

and grants received under this section for the period the loans or grants were outstanding. 

The Secretary shall notify the Secretary of the Treasury of any determination under this section of a failure that results in the termination of an issuer’s taxexempt status under section 501(c)(29) of such Code. 

(D) TIME FOR AWARDING LOANS AND GRANTS.—The Secretary shall not later than July 1, 2013, award the loans 

and grants under the CO-OP program and begin the distribution of amounts awarded under such loans and 

grants. 

(3) REPAYMENT OF LOANS AND GRANTS.—øAs added by section 10104(l)(2)¿ 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. 

(4) ADVISORY BOARD.—øAs redesignated by section 

10104(l)(1)¿ 

(A) IN GENERAL.—The advisory board under this paragraph shall consist of 15 members appointed by the Comptroller General of the United States from among individuals with qualifications described in section 1805(c)(2) of 

the Social Security Act. 

(B) RULES RELATING TO APPOINTMENTS.— 

(i) STANDARDS.—Any individual appointed under 

subparagraph (A) shall meet ethics and conflict of interest standards protecting against insurance industry 

involvement and interference. 

(ii) ORIGINAL APPOINTMENTS.—The original appointment of board members under subparagraph 

(A)(ii) shall be made no later than 3 months after the 

date of enactment of this Act. 

(C) VACANCY.—Any vacancy on the advisory board 

shall be filled in the same manner as the original appointment. 

(D) PAY AND REIMBURSEMENT.— 

(i) NO COMPENSATION FOR MEMBERS OF ADVISORY

BOARD.—Except as provided in clause (ii), a member of 

the advisory board may not receive pay, allowances, or 

benefits by reason of their service on the board. 

(ii) TRAVEL EXPENSES.—Each member shall receive travel expenses, including per diem in lieu of 
89 Sec. 1322 PPACA (Consolidated) 

subsistence under subchapter I of chapter 57 of title 5, 

United States Code. 

(E) APPLICATION OF FACA.—The Federal Advisory 

Committee Act (5 U.S.C. App.) shall apply to the advisory 

board, except that section 14 of such Act shall not apply. 

(F) TERMINATION.—The advisory board shall terminate 

on the earlier of the date that it completes its duties under 

this section or December 31, 2015. 

(c) QUALIFIED NONPROFIT HEALTH INSURANCE ISSUER.—For 

purposes of this section— 

(1) IN GENERAL.—The term ‘‘qualified nonprofit health insurance issuer’’ means a health insurance issuer that is an organization— 

(A) that is organized under State law as a nonprofit, 

member corporation; 

(B) substantially all of the activities of which consist 

of the issuance of qualified health plans in the individual 

and small group markets in each State in which it is licensed to issue such plans; and 

(C) that meets the other requirements of this subsection. 

(2) CERTAIN ORGANIZATIONS PROHIBITED.—An organization 

shall not be treated as a qualified nonprofit health insurance 

issuer if— 

(A) the organization or a related entity (or any predecessor of either) was a health insurance issuer on July 16, 

2009; or 

(B) the organization is sponsored by a State or local 

government, any political subdivision thereof, or any instrumentality of such government or political subdivision. 

(3) GOVERNANCE REQUIREMENTS.—An organization shall 

not be treated as a qualified nonprofit health insurance issuer 

unless— 

(A) the governance of the organization is subject to a 

majority vote of its members; 

(B) its governing documents incorporate ethics and 

conflict of interest standards protecting against insurance 

industry involvement and interference; and 

(C) as provided in regulations promulgated by the Secretary, the organization is required to operate with a 

strong consumer focus, including timeliness, responsiveness, and accountability to members. 

(4) PROFITS INURE TO BENEFIT OF MEMBERS.—An organization shall not be treated as a qualified nonprofit health insurance issuer unless any profits made by the organization are required to be used to lower premiums, to improve benefits, or 

for other programs intended to improve the quality of health 

care delivered to its members. 

(5) COMPLIANCE WITH STATE INSURANCE LAWS.—An organization shall not be treated as a qualified nonprofit health insurance issuer unless the organization meets all the requirements that other issuers of qualified health plans are required 

to meet in any State where the issuer offers a qualified health 

plan, including solvency and licensure requirements, rules on 
Sec. 1322 PPACA (Consolidated) 90 

payments to providers, and compliance with network adequacy 

rules, rate and form filing rules, any applicable State premium 

assessments and any other State law described in section 

1324(b). 

(6) COORDINATION WITH STATE INSURANCE REFORMS.—An 

organization shall not be treated as a qualified nonprofit 

health insurance issuer unless the organization does not offer 

a health plan in a State until that State has in effect (or the 

Secretary has implemented for the State) the market reforms 

required by part A of title XXVII of the Public Health Service 

Act (as amended by subtitles A and C of this Act). 

(d) ESTABLISHMENT OF PRIVATE PURCHASING COUNCIL.— (1) IN GENERAL.—Qualified nonprofit health insurance 

issuers participating in the CO-OP program under this section 

may establish a private purchasing council to enter into collective purchasing arrangements for items and services that increase administrative and other cost efficiencies, including 

claims administration, administrative services, health information technology, and actuarial services. 

(2) COUNCIL MAY NOT SET PAYMENT RATES.—The private 

purchasing council established under paragraph (1) shall not 

set payment rates for health care facilities or providers participating in health insurance coverage provided by qualified nonprofit health insurance issuers. 

(3) CONTINUED APPLICATION OF ANTITRUST LAWS.— (A) IN GENERAL.—Nothing in this section shall be construed to limit the application of the antitrust laws to any 

private purchasing council (whether or not established 

under this subsection) or to any qualified nonprofit health 

insurance issuer participating in such a council. 

(B) ANTITRUST LAWS.—For purposes of this subparagraph, the term ‘‘antitrust laws’’ has the meaning given 

the term in subsection (a) of the first section of the Clayton Act (15 U.S.C. 12(a)). Such term also includes section 

5 of the Federal Trade Commission Act (15 U.S.C. 45) to 

the extent that such section 5 applies to unfair methods of 

competition. 

(e) LIMITATION ON PARTICIPATION.—No representative of any 

Federal, State, or local government (or of any political subdivision 

or instrumentality thereof), and no representative of a person described in subsection (c)(2)(A), may serve on the board of directors 

of a qualified nonprofit health insurance issuer or with a private 

purchasing council established under subsection (d). 

(f) LIMITATIONS ON SECRETARY.— 

(1) IN GENERAL.—The Secretary shall not— 

(A) participate in any negotiations between 1 or more 

qualified nonprofit health insurance issuers (or a private 

purchasing council established under subsection (d)) and 

any health care facilities or providers, including any drug 

manufacturer, pharmacy, or hospital; and 

(B) establish or maintain a price structure for reimbursement of any health benefits covered by such issuers. 

(2) COMPETITION.—Nothing in this section shall be construed as authorizing the Secretary to interfere with the com-
91 Sec. 1322 PPACA (Consolidated) 

petitive nature of providing health benefits through qualified 

nonprofit health insurance issuers. 

(g) APPROPRIATIONS.—There are hereby appropriated, out of 

any funds in the Treasury not otherwise appropriated, 

$6,000,000,000 to carry out this section. 

(h) TAX EXEMPTION FOR QUALIFIED NONPROFIT HEALTH INSUR- ANCE ISSUER.— (1) IN GENERAL.—Section 501(c) of the Internal Revenue 

Code of 1986 (relating to list of exempt organizations) is 

amended by adding at the end the following: 

‘‘(29) CO-OP HEALTH INSURANCE ISSUERS.— ‘‘(A) IN GENERAL.—A qualified nonprofit health insurance issuer (within the meaning of section 1322 of the Patient Protection and Affordable Care Act) which has received a loan or grant under the CO-OP program under 

such section, but only with respect to periods for which the 

issuer is in compliance with the requirements of such section and any agreement with respect to the loan or grant. 

‘‘(B) CONDITIONS FOR EXEMPTION.—Subparagraph (A) 

shall apply to an organization only if— 

‘‘(i) the organization has given notice to the Secretary, in such manner as the Secretary may by regulations prescribe, that it is applying for recognition of 

its status under this paragraph, 

‘‘(ii) except as provided in section 1322(c)(4) of the 

Patient Protection and Affordable Care Act, no part of 

the net earnings of which inures to the benefit of any 

private shareholder or individual, 

‘‘(iii) no substantial part of the activities of which 

is carrying on propaganda, or otherwise attempting, to 

influence legislation, and 

‘‘(iv) the organization does not participate in, or 

intervene in (including the publishing or distributing 

of statements), any political campaign on behalf of (or 

in opposition to) any candidate for public office.’’. 

(2) ADDITIONAL REPORTING REQUIREMENT.—Section 6033 of 

such Code (relating to returns by exempt organizations) is 

amended by redesignating subsection (m) as subsection (n) and 

by inserting after subsection (l) the following: 

‘‘(m) ADDITIONAL INFORMATION REQUIRED FROM CO-OP INSURERS.—An organization described in section 501(c)(29) shall include 

on the return required under subsection (a) the following information: 

‘‘(1) The amount of the reserves required by each State in 

which the organization is licensed to issue qualified health 

plans. 

‘‘(2) The amount of reserves on hand.’’. 

(3) APPLICATION OF TAX ON EXCESS BENEFIT TRANSACTIONS.—Section 4958(e)(1) of such Code (defining applicable 

tax-exempt organization) is amended by striking ‘‘paragraph 

(3) or (4)’’ and inserting ‘‘paragraph (3), (4), or (29)’’. 

(i) GAO STUDY AND REPORT.— 

(1) STUDY.—The Comptroller General of the General Accountability Office shall conduct an ongoing study on competi-
Sec. 1323 PPACA (Consolidated) 92 

tion and market concentration in the health insurance market 

in the United States after the implementation of the reforms 

in such market under the provisions of, and the amendments 

made by, this Act. Such study shall include an analysis of new 

issuers of health insurance in such market. 

(2) REPORT.—The Comptroller General shall, not later 

than December 31 of each even-numbered year (beginning with 

2014), report to the appropriate committees of the Congress 

the results of the study conducted under paragraph (1), including any recommendations for administrative or legislative 

changes the Comptroller General determines necessary or appropriate to increase competition in the health insurance market. 

SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION øSTRICKEN¿. 

øSection stricken by section 10104(m)¿ 

SEC. 1323. ø42 U.S.C. 18043¿ FUNDING FOR THE TERRITORIES. 

øNew section 1323 inserted by section 1204(a) of HCERA¿ 

(a) IN GENERAL.—A territory that— 

(1) elects consistent with subsection (b) to establish an Exchange in accordance with part II of this subtitle and establishes such an Exchange in accordance with such part shall be 

treated as a State for purposes of such part and shall be entitled to payment from the amount allocated to the territory 

under subsection (c); or 

(2) does not make such election shall be entitled to an increase in the dollar limitation applicable to the territory under 

subsections (f) and (g) of section 1108 of the Social Security Act 

(42 U.S.C. 1308) for such period in such amount for such territory and such increase shall not be taken into account in computing any other amount under such subsections. 

(b) TERMS AND CONDITIONS.—An election under subsection 

(a)(1) shall— 

(1) not be effective unless the election is consistent with 

section 1321 and is received not later than October 1, 2013; 

and 

(2) be contingent upon entering into an agreement between 

the territory and the Secretary that requires that— 

(A) funds provided under the agreement shall be used 

only to provide premium and cost-sharing assistance to 

residents of the territory obtaining health insurance coverage through the Exchange; and 

(B) the premium and cost-sharing assistance provided 

under such agreement shall be structured in such a manner so as to prevent any gap in assistance for individuals 

between the income level at which medical assistance is 

available through the territory’s Medicaid plan under title 

XIX of the Social Security Act and the income level at 

which premium and cost-sharing assistance is available 

under the agreement. 

(c) APPROPRIATION AND ALLOCATION.— 

(1) APPROPRIATION.—Out of any funds in the Treasury not 

otherwise appropriated, there is appropriated for purposes of 

payment pursuant to subsection (a) $1,000,000,000, to be avail-
93 Sec. 1331 PPACA (Consolidated) 

able during the period beginning with 2014 and ending with 

2019. 

(2) ALLOCATION.—The Secretary shall allocate the amount 

appropriated under paragraph (1) among the territories for 

purposes of carrying out this section as follows: 

(A) For Puerto Rico, $925,000,000. 

(B) For another territory, the portion of $75,000,000 

specified by the Secretary. 

SEC. 1324. ø42 U.S.C. 18044¿ LEVEL PLAYING FIELD. 

(a) IN GENERAL.—øAs revised by section 10104(n)¿ Notwithstanding any other provision of law, any health insurance coverage 

offered by a private health insurance issuer shall not be subject to 

any Federal or State law described in subsection (b) if a qualified 

health plan offered under the Consumer Operated and Oriented 

Plan program under section 1322, or a multi-State qualified health 

plan under section 1334, is not subject to such law. 

(b) LAWS DESCRIBED.—The Federal and State laws described in 

this subsection are those Federal and State laws relating to— 

(1) guaranteed renewal; 

(2) rating; 

(3) preexisting conditions; 

(4) non-discrimination; 

(5) quality improvement and reporting; 

(6) fraud and abuse; 

(7) solvency and financial requirements; 

(8) market conduct; 

(9) prompt payment; 

(10) appeals and grievances; 

(11) privacy and confidentiality; 

(12) licensure; and 

(13) benefit plan material or information. 

PART 4—STATE FLEXIBILITY TO ESTABLISH 

ALTERNATIVE PROGRAMS 

SEC. 1331. ø42 U.S.C. 18051¿ STATE FLEXIBILITY TO ESTABLISH BASIC 

HEALTH PROGRAMS FOR LOW-INCOME INDIVIDUALS NOT 

ELIGIBLE FOR MEDICAID. 

(a) ESTABLISHMENT OF PROGRAM.— 

(1) IN GENERAL.—The Secretary shall establish a basic 

health program meeting the requirements of this section under 

which a State may enter into contracts to offer 1 or more 

standard health plans providing at least the essential health 

benefits described in section 1302(b) to eligible individuals in 

lieu of offering such individuals coverage through an Exchange. 

(2) CERTIFICATIONS AS TO BENEFIT COVERAGE AND COSTS.— 

Such program shall provide that a State may not establish a 

basic health program under this section unless the State establishes to the satisfaction of the Secretary, and the Secretary 

certifies, that— 

(A) in the case of an eligible individual enrolled in a 

standard health plan offered through the program, the 

State provides— 
Sec. 1331 PPACA (Consolidated) 94 

(i) that the amount of the monthly premium an eligible individual is required to pay for coverage under 

the standard health plan for the individual and the individual’s dependents does not exceed the amount of 

the monthly premium that the eligible individual 

would have been required to pay (in the rating area in 

which the individual resides) if the individual had enrolled in the applicable second lowest cost silver plan 

(as defined in section 36B(b)(3)(B) of the Internal Revenue Code of 1986) offered to the individual through 

an Exchange; and 

(ii) that the cost-sharing an eligible individual is 

required to pay under the standard health plan does 

not exceed— 

(I) the cost-sharing required under a platinum 

plan in the case of an eligible individual with 

household income not in excess of 150 percent of 

the poverty line for the size of the family involved; 

and 

(II) the cost-sharing required under a gold 

plan in the case of an eligible individual not described in subclause (I); and 

(B) the benefits provided under the standard health 

plans offered through the program cover at least the essential health benefits described in section 1302(b). 

For purposes of subparagraph (A)(i), the amount of the monthly premium an individual is required to pay under either the 

standard health plan or the applicable second lowest cost silver 

plan shall be determined after reduction for any premium tax 

credits and cost-sharing reductions allowable with respect to 

either plan. 

(b) STANDARD HEALTH PLAN.—In this section, the term ‘‘standard heath plan’’ means a health benefits plan that the State contracts with under this section— 

(1) under which the only individuals eligible to enroll are 

eligible individuals; 

(2) that provides at least the essential health benefits described in section 1302(b); and 

(3) in the case of a plan that provides health insurance 

coverage offered by a health insurance issuer, that has a medical loss ratio of at least 85 percent. 

(c) CONTRACTING PROCESS.— 

(1) IN GENERAL.—A State basic health program shall establish a competitive process for entering into contracts with 

standard health plans under subsection (a), including negotiation of premiums and cost-sharing and negotiation of benefits 

in addition to the essential health benefits described in section 

1302(b). 

(2) SPECIFIC ITEMS TO BE CONSIDERED.—A State shall, as 

part of its competitive process under paragraph (1), include at 

least the following: 

(A) INNOVATION.—Negotiation with offerors of a standard health plan for the inclusion of innovative features in 

the plan, including— 
95 Sec. 1331 PPACA (Consolidated) 

(i) care coordination and care management for enrollees, especially for those with chronic health conditions; 

(ii) incentives for use of preventive services; and 

(iii) the establishment of relationships between 

providers and patients that maximize patient involvement in health care decision-making, including providing incentives for appropriate utilization under the 

plan. 

(B) HEALTH AND RESOURCE DIFFERENCES.—Consideration of, and the making of suitable allowances for, differences in health care needs of enrollees and differences 

in local availability of, and access to, health care providers. 

Nothing in this subparagraph shall be construed as allowing discrimination on the basis of pre-existing conditions 

or other health status-related factors. 

(C) MANAGED CARE.—Contracting with managed care 

systems, or with systems that offer as many of the attributes of managed care as are feasible in the local health 

care market. 

(D) PERFORMANCE MEASURES.—Establishing specific 

performance measures and standards for issuers of standard health plans that focus on quality of care and improved health outcomes, requiring such plans to report to 

the State with respect to the measures and standards, and 

making the performance and quality information available 

to enrollees in a useful form. 

(3) ENHANCED AVAILABILITY.— (A) MULTIPLE PLANS.—A State shall, to the maximum 

extent feasible, seek to make multiple standard health 

plans available to eligible individuals within a State to ensure individuals have a choice of such plans. 

(B) REGIONAL COMPACTS.—A State may negotiate a regional compact with other States to include coverage of eligible individuals in all such States in agreements with 

issuers of standard health plans. 

(4) COORDINATION WITH OTHER STATE PROGRAMS.—A State 

shall seek to coordinate the administration of, and provision of 

benefits under, its program under this section with the State 

medicaid program under title XIX of the Social Security Act, 

the State child health plan under title XXI of such Act, and 

other State-administered health programs to maximize the efficiency of such programs and to improve the continuity of care. 

(d) TRANSFER OF FUNDS TO STATES.— 

(1) IN GENERAL.—If the Secretary determines that a State 

electing the application of this section meets the requirements 

of the program established under subsection (a), the Secretary 

shall transfer to the State for each fiscal year for which 1 or 

more standard health plans are operating within the State the 

amount determined under paragraph (3). 

(2) USE OF FUNDS.—A State shall establish a trust for the 

deposit of the amounts received under paragraph (1) and 

amounts in the trust fund shall only be used to reduce the premiums and cost-sharing of, or to provide additional benefits 
Sec. 1331 PPACA (Consolidated) 96 

for, eligible individuals enrolled in standard health plans within the State. Amounts in the trust fund, and expenditures of 

such amounts, shall not be included in determining the 

amount of any non-Federal funds for purposes of meeting any 

matching or expenditure requirement of any federally-funded 

program. 

(3) AMOUNT OF PAYMENT.— 

(A) SECRETARIAL DETERMINATION.— 

(i) IN GENERAL.—øAs revised by section 

10104(o)(1)¿ The amount determined under this paragraph for any fiscal year is the amount the Secretary 

determines is equal to 95 percent of the premium tax 

credits under section 36B of the Internal Revenue 

Code of 1986, and the cost-sharing reductions under 

section 1402, that would have been provided for the 

fiscal year to eligible individuals enrolled in standard 

health plans in the State if such eligible individuals 

were allowed to enroll in qualified health plans 

through an Exchange established under this subtitle. 

(ii) SPECIFIC REQUIREMENTS.—The Secretary shall 

make the determination under clause (i) on a per enrollee basis and shall take into account all relevant 

factors necessary to determine the value of the premium tax credits and cost-sharing reductions that 

would have been provided to eligible individuals described in clause (i), including the age and income of 

the enrollee, whether the enrollment is for self-only or 

family coverage, geographic differences in average 

spending for health care across rating areas, the 

health status of the enrollee for purposes of determining risk adjustment payments and reinsurance 

payments that would have been made if the enrollee 

had enrolled in a qualified health plan through an Exchange, and whether any reconciliation of the credit or 

cost-sharing reductions would have occurred if the enrollee had been so enrolled. This determination shall 

take into consideration the experience of other States 

with respect to participation in an Exchange and such 

credits and reductions provided to residents of the 

other States, with a special focus on enrollees with income below 200 percent of poverty. 

(iii) CERTIFICATION.—The Chief Actuary of the 

Centers for Medicare & Medicaid Services, in consultation with the Office of Tax Analysis of the Department 

of the Treasury, shall certify whether the methodology 

used to make determinations under this subparagraph, and such determinations, meet the requirements of clause (ii). Such certifications shall be based 

on sufficient data from the State and from comparable 

States about their experience with programs created 

by this Act. 

(B) CORRECTIONS.—The Secretary shall adjust the 

payment for any fiscal year to reflect any error in the de-
97 Sec. 1331 PPACA (Consolidated) 

terminations under subparagraph (A) for any preceding 

fiscal year. 

(4) APPLICATION OF SPECIAL RULES.—The provisions of section 1303 shall apply to a State basic health program, and to 

standard health plans offered through such program, in the 

same manner as such rules apply to qualified health plans. 

(e) ELIGIBLE INDIVIDUAL.— (1) IN GENERAL.—In this section, the term ‘‘eligible individual’’ means, with respect to any State, an individual— 

(A) who a resident of the State who is not eligible to 

enroll in the State’s medicaid program under title XIX of 

the Social Security Act for benefits that at a minimum consist of the essential health benefits described in section 

1302(b); 

(B) øAs revised by section 10104(o)(2)¿ whose household income exceeds 133 percent but does not exceed 200 

percent of the poverty line for the size of the family involved, 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; 

(C) who is not eligible for minimum essential coverage 

(as defined in section 5000A(f) of the Internal Revenue 

Code of 1986) or is eligible for an employer-sponsored plan 

that is not affordable coverage (as determined under section 5000A(e)(2) of such Code); and 

(D) who has not attained age 65 as of the beginning 

of the plan year. 

Such term shall not include any individual who is not a qualified individual under section 1312 who is eligible to be covered 

by a qualified health plan offered through an Exchange. 

(2) ELIGIBLE INDIVIDUALS MAY NOT USE EXCHANGE.—An eligible individual shall not be treated as a qualified individual 

under section 1312 eligible for enrollment in a qualified health 

plan offered through an Exchange established under section 

1311. 

(f) SECRETARIAL OVERSIGHT.—The Secretary shall each year 

conduct a review of each State program to ensure compliance with 

the requirements of this section, including ensuring that the State 

program meets— 

(1) eligibility verification requirements for participation in 

the program; 

(2) the requirements for use of Federal funds received by 

the program; and 

(3) the quality and performance standards under this section. 

(g) STANDARD HEALTH PLAN OFFERORS.—A State may provide 

that persons eligible to offer standard health plans under a basic 

health program established under this section may include a licensed health maintenance organization, a licensed health insurance insurer, or a network of health care providers established to 

offer services under the program. 
Sec. 1332 PPACA (Consolidated) 98 

(h) DEFINITIONS.—Any term used in this section which is also 

used in section 36B of the Internal Revenue Code of 1986 shall 

have the meaning given such term by such section. 

SEC. 1332. ø42 U.S.C. 18052¿ WAIVER FOR STATE INNOVATION. 

(a) APPLICATION.— 

(1) IN GENERAL.—A State may apply to the Secretary for 

the waiver of all or any requirements described in paragraph 

(2) with respect to health insurance coverage within that State 

for plan years beginning on or after January 1, 2017. Such application shall— 

(A) be filed at such time and in such manner as the 

Secretary may require; 

(B) contain such information as the Secretary may require, including— 

(i) a comprehensive description of the State legislation and program to implement a plan meeting the 

requirements for a waiver under this section; and 

(ii) a 10-year budget plan for such plan that is 

budget neutral for the Federal Government; and 

(C) provide an assurance that the State has enacted 

the law described in subsection (b)(2). 

(2) REQUIREMENTS.—The requirements described in this 

paragraph with respect to health insurance coverage within 

the State for plan years beginning on or after January 1, 2014, 

are as follows: 

(A) Part I of subtitle D. 

(B) Part II of subtitle D. 

(C) Section 1402. 

(D) Sections 36B, 4980H, and 5000A of the Internal 

Revenue Code of 1986. 

(3) PASS THROUGH OF FUNDING.—With respect to a State 

waiver under paragraph (1), under which, due to the structure 

of the State plan, individuals and small employers in the State 

would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the 

Internal Revenue Code of 1986 or under part I of subtitle E for 

which they would otherwise be eligible, the Secretary shall provide for an alternative means by which the aggregate amount 

of such credits or reductions that would have been paid on behalf of participants in the Exchanges established under this 

title had the State not received such waiver, shall be paid to 

the State for purposes of implementing the State plan under 

the waiver. Such amount shall be determined annually by the 

Secretary, taking into consideration the experience of other 

States with respect to participation in an Exchange and credits 

and reductions provided under such provisions to residents of 

the other States. 

(4) WAIVER CONSIDERATION AND TRANSPARENCY.— 

(A) IN GENERAL.—An application for a waiver under 

this section shall be considered by the Secretary in accordance with the regulations described in subparagraph (B). 

(B) REGULATIONS.—Not later than 180 days after the 

date of enactment of this Act, the Secretary shall promul-
99 Sec. 1332 PPACA (Consolidated) 

gate regulations relating to waivers under this section that 

provide— 

(i) a process for public notice and comment at the 

State level, including public hearings, sufficient to ensure a meaningful level of public input; 

(ii) a process for the submission of an application 

that ensures the disclosure of— 

(I) the provisions of law that the State involved seeks to waive; and 

(II) the specific plans of the State to ensure 

that the waiver will be in compliance with subsection (b); 

(iii) 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 and that does not impose requirements 

that are in addition to, or duplicative of, requirements 

imposed under the Administrative Procedures Act, or 

requirements that are unreasonable or unnecessarily 

burdensome with respect to State compliance; 

(iv) a process for the submission to the Secretary 

of periodic reports by the State concerning the implementation of the program under the waiver; and 

(v) a process for the periodic evaluation by the 

Secretary of the program under the waiver. 

(C) REPORT.—The Secretary shall annually report to 

Congress concerning actions taken by the Secretary with 

respect to applications for waivers under this section. 

(5) COORDINATED WAIVER PROCESS.—The Secretary shall 

develop a process for coordinating and consolidating the State 

waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under titles 

XVIII, XIX, and XXI of the Social Security Act, and any other 

Federal law relating to the provision of health care items or 

services. Such process shall permit a State to submit a single 

application for a waiver under any or all of such provisions. 

(6) DEFINITION.—In this section, the term ‘‘Secretary’’ 

means— 

(A) the Secretary of Health and Human Services with 

respect to waivers relating to the provisions described in 

subparagraph (A) through (C) of paragraph (2); and 

(B) the Secretary of the Treasury with respect to waivers relating to the provisions described in paragraph 

(2)(D). 

(b) GRANTING OF WAIVERS.— 

(1) IN GENERAL.—The Secretary may grant a request for a 

waiver under subsection (a)(1) only if the Secretary determines 

that the State plan— 

(A) will provide coverage that is at least as comprehensive as the coverage defined in section 1302(b) and 

offered through Exchanges established under this title as 

certified by Office of the Actuary of the Centers for Medicare & Medicaid Services based on sufficient data from the 

State and from comparable States about their experience 
Sec. 1333 PPACA (Consolidated) 100 

with programs created by this Act and the provisions of 

this Act that would be waived; 

(B) will provide coverage and cost sharing protections 

against excessive out-of-pocket spending that are at least 

as affordable as the provisions of this title would provide; 

(C) will provide coverage to at least a comparable 

number of its residents as the provisions of this title would 

provide; and 

(D) will not increase the Federal deficit. 

(2) REQUIREMENT TO ENACT A LAW.— (A) IN GENERAL.—A law described in this paragraph is 

a State law that provides for State actions under a waiver 

under this section, including the implementation of the 

State plan under subsection (a)(1)(B). 

(B) TERMINATION OF OPT OUT.—A State may repeal a 

law described in subparagraph (A) and terminate the authority provided under the waiver with respect to the 

State. 

(c) SCOPE OF WAIVER.— (1) IN GENERAL.—The Secretary shall determine the scope 

of a waiver of a requirement described in subsection (a)(2) 

granted to a State under subsection (a)(1). 

(2) LIMITATION.—The Secretary may not waive under this 

section any Federal law or requirement that is not within the 

authority of the Secretary. 

(d) DETERMINATIONS BY SECRETARY.— (1) TIME FOR DETERMINATION.—The Secretary shall make 

a determination under subsection (a)(1) not later than 180 

days after the receipt of an application from a State under 

such subsection. 

(2) EFFECT OF DETERMINATION.— (A) GRANTING OF WAIVERS.—If the Secretary determines to grant a waiver under subsection (a)(1), the Secretary shall notify the State involved of such determination and the terms and effectiveness of such waiver. 

(B) DENIAL OF WAIVER.—If the Secretary determines a 

waiver should not be granted under subsection (a)(1), the 

Secretary shall notify the State involved, and the appropriate committees of Congress of such determination and 

the reasons therefore. 

(e) TERM OF WAIVER.—No waiver under this section may extend over a period of longer than 5 years unless the State requests 

continuation of such waiver, and such request shall be deemed 

granted unless the Secretary, within 90 days after the date of its 

submission to the Secretary, either denies such request in writing 

or informs the State in writing with respect to any additional information which is needed in order to make a final determination 

with respect to the request. 

SEC. 1333. ø42 U.S.C. 18053¿ PROVISIONS RELATING TO OFFERING OF 

PLANS IN MORE THAN ONE STATE. 

(a) HEALTH CARE CHOICE COMPACTS.— 

(1) IN GENERAL.—Not later than July 1, 2013, the Secretary shall, in consultation with the National Association of 

Insurance Commissioners, issue regulations for the creation of 
101 Sec. 1334 PPACA (Consolidated) 

health care choice compacts under which 2 or more States may 

enter into an agreement under which— 

(A) 1 or more qualified health plans could be offered 

in the individual markets in all such States but, except as 

provided in subparagraph (B), only be subject to the laws 

and regulations of the State in which the plan was written 

or issued; 

(B) the issuer of any qualified health plan to which the 

compact applies— 

(i) would continue to be subject to market conduct, 

unfair trade practices, network adequacy, and consumer protection standards (including standards relating to rating), including addressing disputes as to the 

performance of the contract, of the State in which the 

purchaser resides; 

(ii) would be required to be licensed in each State 

in which it offers the plan under the compact or to 

submit to the jurisdiction of each such State with regard to the standards described in clause (i) (including 

allowing access to records as if the insurer were licensed in the State); and 

(iii) must clearly notify consumers that the policy 

may not be subject to all the laws and regulations of 

the State in which the purchaser resides. 

(2) STATE AUTHORITY.—A State may not enter into an 

agreement under this subsection unless the State enacts a law 

after the date of the enactment of this title that specifically authorizes the State to enter into such agreements. 

(3) APPROVAL OF COMPACTS.—The Secretary may approve 

interstate health care choice compacts under paragraph (1) 

only if the Secretary determines that such health care choice 

compact— 

(A) will provide coverage that is at least as comprehensive as the coverage defined in section 1302(b) and 

offered through Exchanges established under this title; 

(B) will provide coverage and cost sharing protections 

against excessive out-of-pocket spending that are at least 

as affordable as the provisions of this title would provide; 

(C) will provide coverage to at least a comparable 

number of its residents as the provisions of this title would 

provide; 

(D) will not increase the Federal deficit; and 

(E) will not weaken enforcement of laws and regulations described in paragraph (1)(B)(i) in any State that is 

included in such compact. 

(4) EFFECTIVE DATE.—A health care choice compact described in paragraph (1) shall not take effect before January 1, 

2016. 

øSubsection (b) stricken by section 10104(p)¿ 

SEC. 1334. ø42 U.S.C. 18054¿ MULTI-STATE PLANS. 

øSection added by section 10104(q)¿ 

(a) OVERSIGHT BY THE OFFICE OF PERSONNEL MANAGEMENT.— 
Sec. 1334 PPACA (Consolidated) 102 

(1) IN GENERAL.—The Director of the Office of Personnel 

Management (referred to in this section as the ‘‘Director’’) shall 

enter into contracts with health insurance issuers (which may 

include a group of health insurance issuers affiliated either by 

common ownership and control or by the common use of a nationally licensed service mark), without regard to section 5 of 

title 41, United States Code, or other statutes requiring competitive bidding, to offer at least 2 multi-State qualified health 

plans through each Exchange in each State. Such plans shall 

provide individual, or in the case of small employers, group 

coverage. 

(2) TERMS.—Each contract entered into under paragraph 

(1) shall be for a uniform term of at least 1 year, but may be 

made automatically renewable from term to term in the absence of notice of termination by either party. In entering into 

such contracts, the Director shall ensure that health benefits 

coverage is provided in accordance with the types of coverage 

provided for under section 2701(a)(1)(A)(i) of the Public Health 

Service Act. 

(3) NON-PROFIT ENTITIES.—In entering into contracts under 

paragraph (1), the Director shall ensure that at least one contract is entered into with a non-profit entity. 

(4) ADMINISTRATION.—The Director shall implement this 

subsection in a manner similar to the manner in which the Director implements the contracting provisions with respect to 

carriers under the Federal employees health benefit program 

under chapter 89 of title 5, United States Code, including 

(through negotiating with each multi-state plan)— 

(A) a medical loss ratio; 

(B) a profit margin; 

(C) the premiums to be charged; and 

(D) such other terms and conditions of coverage as are 

in the interests of enrollees in such plans. 

(5) AUTHORITY TO PROTECT CONSUMERS.—The Director may 

prohibit the offering of any multi-State health plan that does 

not meet the terms and conditions defined by the Director with 

respect to the elements described in subparagraphs (A) 

through (D) of paragraph (4). 

(6) ASSURED AVAILABILITY OF VARIED 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; 
103 Sec. 1334 PPACA (Consolidated) 

(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 multiState 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— 
Sec. 1334 PPACA (Consolidated) 104 

(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 REQUIRE- MENTS.—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 
105 Sec. 1341 PPACA (Consolidated) 

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 multiState 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. 

PART 5—REINSURANCE AND RISK 

ADJUSTMENT 

SEC. 1341. ø42 U.S.C. 18061¿ TRANSITIONAL REINSURANCE PROGRAM 

FOR INDIVIDUAL MARKET IN EACH STATE. 

øSection heading amended by section 10104(r)(1)¿ 

(a) IN GENERAL.—Each State shall, not later than January 1, 

2014— 

(1) include in the Federal standards or State law or regulation the State adopts and has in effect under section 1321(b) 

the provisions described in subsection (b); and 

(2) establish (or enter into a contract with) 1 or more applicable reinsurance entities to carry out the reinsurance program under this section. 

(b) MODEL REGULATION.— (1) IN GENERAL.—In establishing the Federal standards 

under section 1321(a), the Secretary, in consultation with the 

National Association of Insurance Commissioners (the ‘‘NAIC’’), 

shall include provisions that enable States to establish and 

maintain a program under which— 

(A) health insurance issuers, and third party administrators on behalf of group health plans, are required to 

make payments to an applicable reinsurance entity for any 

plan year beginning in the 3-year period beginning January 1, 2014 (as specified in paragraph (3); and 

(B) the applicable reinsurance entity collects payments 

under subparagraph (A) and uses amounts so collected to 

make reinsurance payments to health insurance issuers 
Sec. 1341 PPACA (Consolidated) 106 

described in subparagraph (A) that cover high risk individuals in the individual market (excluding grandfathered 

health plans) for any plan year beginning in such 3-year 

period. 

(2) HIGH-RISK INDIVIDUAL; PAYMENT AMOUNTS.—The Secretary shall include the following in the provisions under paragraph (1): 

(A) DETERMINATION OF HIGH-RISK INDIVIDUALS.—The 

method by which individuals will be identified as high risk 

individuals for purposes of the reinsurance program established under this section. Such method shall provide for 

identification of individuals as high-risk individuals on the 

basis of— 

(i) a list of at least 50 but not more than 100 medical conditions that are identified as high-risk conditions and that may be based on the identification of diagnostic and procedure codes that are indicative of individuals with pre-existing, high-risk conditions; or 

(ii) any other comparable objective method of identification recommended by the American Academy of 

Actuaries. 

(B) PAYMENT AMOUNT.—øAs revised by section 

10104(r)(2)¿ The formula for determining the amount of 

payments that will be paid to health insurance issuers described in paragraph (1)(B) that insure high-risk individuals. Such formula shall provide for the equitable allocation of available funds through reconciliation and may be 

designed— 

(i) to provide a schedule of payments that specifies 

the amount that will be paid for each of the conditions 

identified under subparagraph (A); or 

(ii) to use any other comparable method for determining payment amounts that is recommended by the 

American Academy of Actuaries and that encourages 

the use of care coordination and care management 

programs for high risk conditions. 

(3) DETERMINATION OF REQUIRED CONTRIBUTIONS.— 

(A) IN GENERAL.—The Secretary shall include in the 

provisions under paragraph (1) the method for determining 

the amount each health insurance issuer and group health 

plan described in paragraph (1)(A) contributing to the reinsurance program under this section is required to contribute under such paragraph for each plan year beginning 

in the 36-month period beginning January 1, 2014. The 

contribution amount for any plan year may be based on 

the percentage of revenue of each issuer and the total costs 

of providing benefits to enrollees in self-insured plans or 

on a specified amount per enrollee and may be required to 

be paid in advance or periodically throughout the plan 

year. 

(B) SPECIFIC REQUIREMENTS.—The method under this 

paragraph shall be designed so that— 

(i) the contribution amount for each issuer proportionally reflects each issuer’s fully insured commercial 
107 Sec. 1341 PPACA (Consolidated) 

book of business for all major medical products and 

the total value of all fees charged by the issuer and 

the costs of coverage administered by the issuer as a 

third party administrator; 

(ii) the contribution amount can include an additional amount to fund the administrative expenses of 

the applicable reinsurance entity; 

(iii) the aggregate contribution amounts for all 

States shall, based on the best estimates of the NAIC 

and without regard to amounts described in clause (ii), 

equal $10,000,000,000 for plan years beginning in 

2014, $6,000,000,000 for plan years beginning 2015, 

and $4,000,000,000 for plan years beginning in 2016; 

and 

(iv) in addition to the aggregate contribution 

amounts under clause (iii), each issuer’s contribution 

amount for any calendar year under clause (iii) reflects its proportionate share of an additional 

$2,000,000,000 for 2014, an additional $2,000,000,000 

for 2015, and an additional $1,000,000,000 for 2016. 

Nothing in this subparagraph shall be construed to preclude a State from collecting additional amounts from 

issuers on a voluntary basis. 

(4) EXPENDITURE OF FUNDS.—The provisions under paragraph (1) shall provide that— 

(A) the contribution amounts collected for any calendar year may be allocated and used in any of the three 

calendar years for which amounts are collected based on 

the reinsurance needs of a particular period or to reflect 

experience in a prior period; and 

(B) amounts remaining unexpended as of December, 

2016, may be used to make payments under any reinsurance program of a State in the individual market in effect 

in the 2-year period beginning on January 1, 2017. 

Notwithstanding the preceding sentence, any contribution 

amounts described in paragraph (3)(B)(iv) shall be deposited 

into the general fund of the Treasury of the United States and 

may not be used for the program established under this section. 

(c) APPLICABLE REINSURANCE ENTITY.—For purposes of this 

section— 

(1) IN GENERAL.—The term ‘‘applicable reinsurance entity’’ 

means a not-for-profit organization— 

(A) øAs revised by section 10104(r)(3)¿ the purpose of 

which is to help stabilize premiums for coverage in the individual market in a State during the first 3 years of operation of an Exchange for such markets within the State 

when the risk of adverse selection related to new rating 

rules and market changes is greatest; and 

(B) the duties of which shall be to carry out the reinsurance program under this section by coordinating the 

funding and operation of the risk-spreading mechanisms 

designed to implement the reinsurance program. 
Sec. 1342 PPACA (Consolidated) 108 

(2) STATE DISCRETION.—A State may have more than 1 applicable reinsurance entity to carry out the reinsurance program under this section within the State and 2 or more States 

may enter into agreements to provide for an applicable reinsurance entity to carry out such program in all such States. 

(3) ENTITIES ARE TAX-EXEMPT.—An applicable reinsurance 

entity established under this section shall be exempt from taxation under chapter 1 of the Internal Revenue Code of 1986. 

The preceding sentence shall not apply to the tax imposed by 

section 511 such Code (relating to tax on unrelated business 

taxable income of an exempt organization). 

(d) COORDINATION WITH STATE HIGH-RISK POOLS.—The State 

shall eliminate or modify any State high-risk pool to the extent 

necessary to carry out the reinsurance program established under 

this section. The State may coordinate the State high-risk pool with 

such program to the extent not inconsistent with the provisions of 

this section. 

SEC. 1342. ø42 U.S.C. 18062¿ ESTABLISHMENT OF RISK CORRIDORS FOR 

PLANS IN INDIVIDUAL AND SMALL GROUP MARKETS. 

(a) IN GENERAL.—The Secretary shall establish and administer 

a program of risk corridors for calendar years 2014, 2015, and 2016 

under which a qualified health plan offered in the individual or 

small group market shall participate in a payment adjustment system based on the ratio of the allowable costs of the plan to the 

plan’s aggregate premiums. Such program shall be based on the 

program for regional participating provider organizations under 

part D of title XVIII of the Social Security Act. 

(b) PAYMENT METHODOLOGY.— (1) PAYMENTS OUT.—The Secretary shall provide under the 

program established under subsection (a) that if— 

(A) a participating plan’s allowable costs for any plan 

year are more than 103 percent but not more than 108 

percent of the target amount, the Secretary shall pay to 

the plan an amount equal to 50 percent of the target 

amount in excess of 103 percent of the target amount; and 

(B) a participating plan’s allowable costs for any plan 

year are more than 108 percent of the target amount, the 

Secretary shall pay to the plan an amount equal to the 

sum of 2.5 percent of the target amount plus 80 percent 

of allowable costs in excess of 108 percent of the target 

amount. 

(2) PAYMENTS IN.—The Secretary shall provide under the 

program established under subsection (a) that if— 

(A) a participating plan’s allowable costs for any plan 

year are less than 97 percent but not less than 92 percent 

of the target amount, the plan shall pay to the Secretary 

an amount equal to 50 percent of the excess of 97 percent 

of the target amount over the allowable costs; and 

(B) a participating plan’s allowable costs for any plan 

year are less than 92 percent of the target amount, the 

plan shall pay to the Secretary an amount equal to the 

sum of 2.5 percent of the target amount plus 80 percent 

of the excess of 92 percent of the target amount over the 

allowable costs. 
109 Sec. 1343 PPACA (Consolidated) 

(c) DEFINITIONS.—In this section: 

(1) ALLOWABLE COSTS.— 

(A) IN GENERAL.—The amount of allowable costs of a 

plan for any year is an amount equal to the total costs 

(other than administrative costs) of the plan in providing 

benefits covered by the plan. 

(B) REDUCTION FOR RISK ADJUSTMENT AND REINSURANCE PAYMENTS.—Allowable costs shall reduced by any 

risk adjustment and reinsurance payments received under 

section 1341 and 1343. 

(2) TARGET AMOUNT.—The target amount of a plan for any 

year is an amount equal to the total premiums (including any 

premium subsidies under any governmental program), reduced 

by the administrative costs of the plan. 

SEC. 1343. ø42 U.S.C. 18063¿ RISK ADJUSTMENT. 

(a) IN GENERAL.— 

(1) LOW ACTUARIAL RISK PLANS.—Using the criteria and 

methods developed under subsection (b), each State shall assess a charge on health plans and health insurance issuers 

(with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans 

or coverage for a year is less than the average actuarial risk 

of all enrollees in all plans or coverage in such State for such 

year that are not self-insured group health plans (which are 

subject to the provisions of the Employee Retirement Income 

Security Act of 1974). 

(2) HIGH ACTUARIAL RISK PLANS.—Using the criteria and 

methods developed under subsection (b), each State shall provide a payment to health plans and health insurance issuers 

(with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans 

or coverage for a year is greater than the average actuarial 

risk of all enrollees in all plans and coverage in such State for 

such year that are not self-insured group health plans (which 

are subject to the provisions of the Employee Retirement Income Security Act of 1974). 

(b) CRITERIA AND METHODS.—The Secretary, in consultation 

with States, shall establish criteria and methods to be used in carrying out the risk adjustment activities under this section. The Secretary may utilize criteria and methods similar to the criteria and 

methods utilized under part C or D of title XVIII of the Social Security Act. Such criteria and methods shall be included in the 

standards and requirements the Secretary prescribes under section 

1321. 

(c) SCOPE.—A health plan or a health insurance issuer is described in this subsection if such health plan or health insurance 

issuer provides coverage in the individual or small group market 

within the State. This subsection shall not apply to a grandfathered health plan or the issuer of a grandfathered health plan 

with respect to that plan. 
Sec. 1401 PPACA (Consolidated) 110 

Subtitle E—Affordable Coverage Choices 

for All Americans 

PART I—PREMIUM TAX CREDITS AND COSTSHARING REDUCTIONS 

Subpart A—Premium Tax Credits and Costsharing Reductions 

SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSISTANCE FOR COVERAGE UNDER A QUALIFIED HEALTH 

PLAN. 

(a) IN GENERAL.—Subpart C of part IV of subchapter A of 

chapter 1 of the Internal Revenue Code of 1986 (relating to refundable credits) is amended by inserting after section 36A the following new section: 

‘‘SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED HEALTH PLAN. 

‘‘(a) IN GENERAL.—In the case of an applicable taxpayer, there 

shall be allowed as a credit against the tax imposed by this subtitle 

for any taxable year an amount equal to the premium assistance 

credit amount of the taxpayer for the taxable year. 

‘‘(b) PREMIUM ASSISTANCE CREDIT AMOUNT.—For purposes of 

this section— 

‘‘(1) IN GENERAL.—The term ‘premium assistance credit 

amount’ means, with respect to any taxable year, the sum of 

the premium assistance amounts determined under paragraph 

(2) with respect to all coverage months of the taxpayer occurring during the taxable year. 

‘‘(2) PREMIUM ASSISTANCE AMOUNT.—The premium assistance amount determined under this subsection with respect to 

any coverage month is the amount equal to the lesser of— 

‘‘(A) the monthly premiums for such month for 1 or 

more qualified health plans offered in the individual market within a State which cover the taxpayer, the taxpayer’s spouse, or any dependent (as defined in section 

152) of the taxpayer and which were enrolled in through 

an Exchange established by the State under 1311 of the 

Patient Protection and Affordable Care Act, or 

‘‘(B) the excess (if any) of— 

‘‘(i) the adjusted monthly premium for such month 

for the applicable second lowest cost silver plan with 

respect to the taxpayer, over 

‘‘(ii) an amount equal to 1/12 of the product of the 

applicable percentage and the taxpayer’s household income for the taxable year. 

‘‘(3) OTHER TERMS AND RULES RELATING TO PREMIUM ASSISTANCE AMOUNTS.—For purposes of paragraph (2)— 

‘‘(A) APPLICABLE PERCENTAGE.— 

‘‘(i) IN GENERAL.—øAs revised by section 

1001(a)(1)(A) of HCERA¿ Except as provided in clause 

(ii), the applicable percentage for any taxable year 
111 Sec. 1401 PPACA (Consolidated) \36B IRC 

shall be the percentage such that the applicable percentage for any taxpayer whose household income is 

within an income tier specified in the following table 

shall increase, on a sliding scale in a linear manner, 

from the initial premium percentage to the final premium percentage specified in such table for such income tier: 

‘‘In the case of household income (expressed as a percent of poverty line) 

within the following income tier: 

The initial premium percentage is— The final premium percentage is— 

Up to 133% 2.0% 2.0% 

133% up to 150% 3.0% 4.0% 

150% up to 200% 4.0% 6.3% 

200% up to 250% 6.3% 8.05% 

250% up to 300% 8.05% 9.5% 

300% up to 400% 9.5% 9.5% 

‘‘(ii) INDEXING.—øAs added by section 

1001(a)(1)(B) of HCERA instead of clauses (ii) and (iii) 

previously here¿ 

‘‘(I) IN GENERAL.—Subject to subclause (II), in 

the case of taxable years beginning in any calendar year after 2014, the initial and final applicable percentages under clause (i) (as in effect for 

the preceding calendar year after application of 

this clause) shall be adjusted to reflect the excess 

of the rate of premium growth for the preceding 

calendar year over the rate of income growth for 

the preceding calendar year. 

‘‘(II) ADDITIONAL ADJUSTMENT.—Except as 

provided in subclause (III), in the case of any calendar year after 2018, the percentages described 

in subclause (I) shall, in addition to the adjustment under subclause (I), be adjusted to reflect 

the excess (if any) of the rate of premium growth 

estimated under subclause (I) for the preceding 

calendar year over the rate of growth in the consumer price index for the preceding calendar year. 

‘‘(III) FAILSAFE.—Subclause (II) shall apply for 

any calendar year only if the aggregate amount of 

premium tax credits under this section and costsharing reductions under section 1402 of the Patient Protection and Affordable Care Act for the 

preceding calendar year exceeds an amount equal 

to 0.504 percent of the gross domestic product for 

the preceding calendar year. 

‘‘(B) APPLICABLE SECOND LOWEST COST SILVER PLAN.— 

The applicable second lowest cost silver plan with respect 

to any applicable taxpayer is the second lowest cost silver 

plan of the individual market in the rating area in which 

the taxpayer resides which— 
Sec. 1401\36B IRC PPACA (Consolidated) 112 

‘‘(i) is offered through the same Exchange through 

which the qualified health plans taken into account 

under paragraph (2)(A) were offered, and 

‘‘(ii) provides— 

‘‘(I) self-only coverage in the case of an applicable taxpayer— 

‘‘(aa) whose tax for the taxable year is determined under section 1(c) (relating to unmarried individuals other than surviving 

spouses and heads of households) and who is 

not allowed a deduction under section 151 for 

the taxable year with respect to a dependent, 

or 

‘‘(bb) who is not described in item (aa) but 

who purchases only self-only coverage, and 

‘‘(II) family coverage in the case of any other 

applicable taxpayer. 

If a taxpayer files a joint return and no credit is allowed 

under this section with respect to 1 of the spouses by reason of subsection (e), the taxpayer shall be treated as described in clause (ii)(I) unless a deduction is allowed under 

section 151 for the taxable year with respect to a dependent other than either spouse and subsection (e) does not 

apply to the dependent. 

‘‘(C) ADJUSTED MONTHLY PREMIUM.—The adjusted 

monthly premium for an applicable second lowest cost silver plan is the monthly premium which would have been 

charged (for the rating area with respect to which the premiums under paragraph (2)(A) were determined) for the 

plan if each individual covered under a qualified health 

plan taken into account under paragraph (2)(A) were covered by such silver plan and the premium was adjusted 

only for the age of each such individual in the manner allowed under section 2701 of the Public Health Service Act. 

In the case of a State participating in the wellness discount demonstration project under section 2705(d) of the 

Public Health Service Act, the adjusted monthly premium 

shall be determined without regard to any premium discount or rebate under such project. 

‘‘(D) ADDITIONAL BENEFITS.—If— 

‘‘(i) a qualified health plan under section 

1302(b)(5) of the Patient Protection and Affordable 

Care Act offers benefits in addition to the essential 

health benefits required to be provided by the plan, or 

‘‘(ii) a State requires a qualified health plan under 

section 1311(d)(3)(B) of such Act to cover benefits in 

addition to the essential health benefits required to be 

provided by the plan, 

the portion of the premium for the plan properly allocable 

(under rules prescribed by the Secretary of Health and 

Human Services) to such additional benefits shall not be 

taken into account in determining either the monthly premium or the adjusted monthly premium under paragraph 

(2). 
113 Sec. 1401 PPACA (Consolidated) \36B IRC 

‘‘(E) SPECIAL RULE FOR PEDIATRIC DENTAL COVERAGE.— For purposes of determining the amount of any monthly 

premium, if an individual enrolls in both a qualified health 

plan and a plan described in section 1311(d)(2)(B)(ii)(I) of 

the Patient Protection and Affordable Care Act for any 

plan year, the portion of the premium for the plan described in such section that (under regulations prescribed 

by the Secretary) is properly allocable to pediatric dental 

benefits which are included in the essential health benefits 

required to be provided by a qualified health plan under 

section 1302(b)(1)(J) of such Act shall be treated as a premium payable for a qualified health plan. 

‘‘(c) DEFINITION AND RULES RELATING TO APPLICABLE TAX- PAYERS, COVERAGE MONTHS, AND QUALIFIED HEALTH PLAN.—For 

purposes of this section— 

‘‘(1) APPLICABLE TAXPAYER.— ‘‘(A) IN GENERAL.—øAs revised by section 10105(b)¿ 

The term ‘applicable taxpayer’ means, with respect to any 

taxable year, a taxpayer whose household income for the 

taxable year equals or exceeds 100 percent but does not exceed 400 percent of an amount equal to the poverty line for 

a family of the size involved. 

‘‘(B) SPECIAL RULE FOR CERTAIN INDIVIDUALS LAW- FULLY PRESENT IN THE UNITED STATES.—If— 

‘‘(i) a taxpayer has a household income which is 

not greater than 100 percent of an amount equal to 

the poverty line for a family of the size involved, and 

‘‘(ii) the taxpayer is an alien lawfully present in 

the United States, but is not eligible for the medicaid 

program under title XIX of the Social Security Act by 

reason of such alien status, 

the taxpayer shall, for purposes of the credit under this 

section, be treated as an applicable taxpayer with a household income which is equal to 100 percent of the poverty 

line for a family of the size involved. 

‘‘(C) MARRIED COUPLES MUST FILE JOINT RETURN.—If 

the taxpayer is married (within the meaning of section 

7703) at the close of the taxable year, the taxpayer shall 

be treated as an applicable taxpayer only if the taxpayer 

and the taxpayer’s spouse file a joint return for the taxable 

year. 

‘‘(D) 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. 

‘‘(2) COVERAGE MONTH.—For purposes of this subsection— 

‘‘(A) IN GENERAL.—The term ‘coverage month’ means, 

with respect to an applicable taxpayer, any month if— 

‘‘(i) as of the first day of such month the taxpayer, 

the taxpayer’s spouse, or any dependent of the taxpayer is covered by a qualified health plan described 

in subsection (b)(2)(A) that was enrolled in through an 
Sec. 1401\36B IRC PPACA (Consolidated) 114 

Exchange established by the State under section 1311 

of the Patient Protection and Affordable Care Act, and 

‘‘(ii) the premium for coverage under such plan for 

such month is paid by the taxpayer (or through advance payment of the credit under subsection (a) 

under section 1412 of the Patient Protection and Affordable Care Act). 

‘‘(B) EXCEPTION FOR MINIMUM ESSENTIAL COVERAGE.— ‘‘(i) IN GENERAL.—The term ‘coverage month’ shall 

not include any month with respect to an individual if 

for such month the individual is eligible for minimum 

essential coverage other than eligibility for coverage 

described in section 5000A(f)(1)(C) (relating to coverage in the individual market). 

‘‘(ii) MINIMUM ESSENTIAL COVERAGE.—The term 

‘minimum essential coverage’ has the meaning given 

such term by section 5000A(f). 

‘‘(C) SPECIAL RULE FOR EMPLOYER-SPONSORED MINIMUM

ESSENTIAL COVERAGE.—For purposes of subparagraph 

(B)— 

‘‘(i) COVERAGE MUST BE AFFORDABLE.—Except as 

provided in clause (iii), an employee shall not be treated as eligible for minimum essential coverage if such 

coverage— 

‘‘(I) consists of an eligible employer-sponsored 

plan (as defined in section 5000A(f)(2)), and 

‘‘(II) the employee’s required contribution 

(within the meaning of section 5000A(e)(1)(B)) 

with respect to the plan exceeds 9.5 percent of the 

applicable taxpayer’s household income. øAs revised by section 1001(a)(2)(A) of HCERA¿ 

This clause shall also apply to an individual who is eligible to enroll in the plan by reason of a relationship 

the individual bears to the employee. 

‘‘(ii) COVERAGE MUST PROVIDE MINIMUM VALUE.— 

Except as provided in clause (iii), an employee shall 

not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employersponsored plan (as defined in section 5000A(f)(2)) and 

the plan’s share of the total allowed costs of benefits 

provided under the plan is less than 60 percent of 

such costs. 

‘‘(iii) EMPLOYEE OR FAMILY MUST NOT BE COVERED

UNDER EMPLOYER PLAN.—Clauses (i) and (ii) shall not 

apply if the employee (or any individual described in 

the last sentence of clause (i)) is covered under the eligible employer-sponsored plan or the grandfathered 

health plan. 

‘‘(iv) INDEXING.—øAs revised by section 10105(c) 

and sections 1001(a)(2)(A) and (B) of HCERA¿ In the 

case of plan years beginning in any calendar year after 

2014, the Secretary shall adjust the 9.5 percent under 

clause (i)(II) in the same manner as the percentages 

are adjusted under subsection (b)(3)(A)(ii). 
115 Sec. 1401 PPACA (Consolidated) \36B IRC 

‘‘(D) EXCEPTION FOR INDIVIDUAL RECEIVING FREE

CHOICE VOUCHERS.—øAs added by section 10107(h)(1), effective for taxable year beginning after December 31, 2013¿ 

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. 

‘‘(3) DEFINITIONS AND OTHER RULES.— ‘‘(A) QUALIFIED HEALTH PLAN.—The term ‘qualified 

health plan’ has the meaning given such term by section 

1301(a) of the Patient Protection and Affordable Care Act, 

except that such term shall not include a qualified health 

plan which is a catastrophic plan described in section 

1302(e) of such Act. 

‘‘(B) GRANDFATHERED HEALTH PLAN.—The term ‘grandfathered health plan’ has the meaning given such term by 

section 1251 of the Patient Protection and Affordable Care 

Act. 

‘‘(d) TERMS RELATING TO INCOME AND FAMILIES.—For purposes 

of this section— 

‘‘(1) FAMILY SIZE.—The family size involved with respect to 

any taxpayer shall be equal to the number of individuals for 

whom the taxpayer is allowed a deduction under section 151 

(relating to allowance of deduction for personal exemptions) for 

the taxable year. 

‘‘(2) HOUSEHOLD INCOME.— ‘‘(A) HOUSEHOLD INCOME.—The term ‘household income’ means, with respect to any taxpayer, an amount 

equal to the sum of—øClauses (i) and (ii) revised by section 

1004(a)(1)(A) of HCERA¿ 

‘‘(i) the modified adjusted gross income of the taxpayer, plus 

‘‘(ii) the aggregate modified adjusted gross incomes of all other individuals who— 

‘‘(I) were taken into account in determining 

the taxpayer’s family size under paragraph (1), 

and 

‘‘(II) were required to file a return of tax imposed by section 1 for the taxable year. 

‘‘(B) MODIFIED ADJUSTED GROSS INCOME.—øReplaced 

by section 1004(a)(2) of HCERA¿ The term ‘modified adjusted gross income’ means adjusted gross income increased by— 

‘‘(i) any amount excluded from gross income under 

section 911, and 

‘‘(ii) any amount of interest received or accrued by 

the taxpayer during the taxable year which is exempt 

from tax. 

‘‘(3) POVERTY LINE.— 

‘‘(A) IN GENERAL.—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)). 

‘‘(B) POVERTY LINE USED.—In the case of any qualified 

health plan offered through an Exchange for coverage dur-
Sec. 1401\36B IRC PPACA (Consolidated) 116 

ing a taxable year beginning in a calendar year, the poverty line used shall be the most recently published poverty 

line as of the 1st day of the regular enrollment period for 

coverage during such calendar year. 

‘‘(e) RULES FOR INDIVIDUALS NOT LAWFULLY PRESENT.— ‘‘(1) IN GENERAL.—If 1 or more individuals for whom a taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable 

year (including the taxpayer or his spouse) are individuals who 

are not lawfully present— 

‘‘(A) the aggregate amount of premiums otherwise 

taken into account under clauses (i) and (ii) of subsection 

(b)(2)(A) shall be reduced by the portion (if any) of such 

premiums which is attributable to such individuals, and 

‘‘(B) for purposes of applying this section, the determination as to what percentage a taxpayer’s household income bears to the poverty level for a family of the size involved shall be made under one of the following methods: 

‘‘(i) A method under which— 

‘‘(I) the taxpayer’s family size is determined 

by not taking such individuals into account, and 

‘‘(II) the taxpayer’s household income is equal 

to the product of the taxpayer’s household income 

(determined without regard to this subsection) 

and a fraction— 

‘‘(aa) the numerator of which is the poverty line for the taxpayer’s family size determined after application of subclause (I), and 

‘‘(bb) the denominator of which is the poverty line for the taxpayer’s family size determined without regard to subclause (I). 

‘‘(ii) A comparable method reaching the same result as the method under clause (i). 

‘‘(2) LAWFULLY PRESENT.—For purposes of this section, an 

individual shall be treated as lawfully present only if the individual is, and is reasonably expected to be for the entire period 

of enrollment for which the credit under this section is being 

claimed, a citizen or national of the United States or an alien 

lawfully present in the United States. 

‘‘(3) SECRETARIAL AUTHORITY.—The Secretary of Health 

and Human Services, in consultation with the Secretary, shall 

prescribe rules setting forth the methods by which calculations 

of family size and household income are made for purposes of 

this subsection. Such rules shall be designed to ensure that the 

least burden is placed on individuals enrolling in qualified 

health plans through an Exchange and taxpayers eligible for 

the credit allowable under this section. 

‘‘(f) RECONCILIATION OF CREDIT AND ADVANCE CREDIT.— 

‘‘(1) IN GENERAL.—The amount of the credit allowed under 

this section for any taxable year shall be reduced (but not 

below zero) by the amount of any advance payment of such 

credit under section 1412 of the Patient Protection and Affordable Care Act. 

‘‘(2) EXCESS ADVANCE PAYMENTS.— 
117 Sec. 1401 PPACA (Consolidated) \36B IRC 

‘‘(A) IN GENERAL.—If the advance payments to a taxpayer under section 1412 of the Patient Protection and Affordable Care Act for a taxable year exceed the credit allowed by this section (determined without regard to paragraph (1)), the tax imposed by this chapter for the taxable 

year shall be increased by the amount of such excess. 

‘‘(B) LIMITATION ON INCREASE WHERE INCOME LESS

THAN 400 PERCENT OF POVERTY LINE.— 

‘‘(i) IN GENERAL.—In the case of an applicable taxpayer whose household income is less than 400 percent of the poverty line for the size of the family involved for the taxable year, the amount of the increase 

under subparagraph (A) shall in no event exceed $400 

($250 in the case of a taxpayer whose tax is determined under section 1(c) for the taxable year). 

‘‘(ii) INDEXING OF AMOUNT.—In the case of any calendar year beginning after 2014, each of the dollar 

amounts under clause (i) shall be increased by an 

amount equal to— 

‘‘(I) such dollar amount, multiplied by 

‘‘(II) the cost-of-living adjustment determined 

under section 1(f)(3) for the calendar year, determined by substituting ‘calendar year 2013’ for ‘calendar year 1992’ in subparagraph (B) thereof. 

If the amount of any increase under clause (i) is not 

a multiple of $50, such increase shall be rounded to 

the next lowest multiple of $50. 

‘‘(3) INFORMATION REQUIREMENT.—øAs revised by section 

1004(c) of HCERA¿ Each Exchange (or any person carrying out 

1 or more responsibilities of an Exchange under section 

1311(f)(3) or 1321(c) of the Patient Protection and Affordable 

Care Act) shall provide the following information to the Secretary and to the taxpayer with respect to any health plan provided through the Exchange: 

‘‘(A) The level of coverage described in section 1302(d) 

of the Patient Protection and Affordable Care Act and the 

period such coverage was in effect. 

‘‘(B) The total premium for the coverage without regard to the credit under this section or cost-sharing reductions under section 1402 of such Act. 

‘‘(C) The aggregate amount of any advance payment of 

such credit or reductions under section 1412 of such Act. 

‘‘(D) The name, address, and TIN of the primary insured and the name and TIN of each other individual obtaining coverage under the policy. 

‘‘(E) Any information provided to the Exchange, including any change of circumstances, necessary to determine eligibility for, and the amount of, such credit. 

‘‘(F) Information necessary to determine whether a 

taxpayer has received excess advance payments. 

‘‘(g) REGULATIONS.—The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section, including regulations which provide for— 
Sec. 1401 PPACA (Consolidated) 118 

‘‘(1) the coordination of the credit allowed under this section with the program for advance payment of the credit under 

section 1412 of the Patient Protection and Affordable Care Act, 

and 

‘‘(2) the application of subsection (f) where the filing status 

of the taxpayer for a taxable year is different from such status 

used for determining the advance payment of the credit.’’. 

(b) DISALLOWANCE OF DEDUCTION.—Section 280C of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: 

‘‘(g) CREDIT FOR HEALTH INSURANCE PREMIUMS.—No deduction 

shall be allowed for the portion of the premiums paid by the taxpayer for coverage of 1 or more individuals under a qualified health 

plan which is equal to the amount of the credit determined for the 

taxable year under section 36B(a) with respect to such premiums.’’. 

(c) STUDY ON AFFORDABLE COVERAGE.— (1) STUDY AND REPORT.— (A) IN GENERAL.—Not later than 5 years after the date 

of the enactment of this Act, the Comptroller General shall 

conduct a study on the affordability of health insurance 

coverage, including— 

(i) the impact of the tax credit for qualified health 

insurance coverage of individuals under section 36B of 

the Internal Revenue Code of 1986 and the tax credit 

for employee health insurance expenses of small employers under section 45R of such Code on maintaining and expanding the health insurance coverage of individuals; 

(ii) the availability of affordable health benefits 

plans, including a study of whether the percentage of 

household income used for purposes of section 

36B(c)(2)(C) of the Internal Revenue Code of 1986 (as 

added by this section) is the appropriate level for determining whether employer-provided coverage is affordable for an employee and whether such level may 

be lowered without significantly increasing the costs to 

the Federal Government and reducing employer-provided coverage; and 

(iii) the ability of individuals to maintain essential 

health benefits coverage (as defined in section 

5000A(f) of the Internal Revenue Code of 1986). 

(B) REPORT.—The Comptroller General shall submit to 

the appropriate committees of Congress a report on the 

study conducted under subparagraph (A), together with 

legislative recommendations relating to the matters studied under such subparagraph. 

(2) APPROPRIATE COMMITTEES OF CONGRESS.—In this subsection, the term ‘‘appropriate committees of Congress’’ means 

the Committee on Ways and Means, the Committee on Education and Labor, and the Committee on Energy and Commerce of the House of Representatives and the Committee on 

Finance and the Committee on Health, Education, Labor and 

Pensions of the Senate. 

(d) CONFORMING AMENDMENTS.— 
119 Sec. 1402 PPACA (Consolidated) 

(1) Paragraph (2) of section 1324(b) of title 31, United 

States Code, is amended by inserting ‘‘36B,’’ after ‘‘36A,’’. 

(2) The table of sections for subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 

is amended by inserting after the item relating to section 36A 

the following new item: 

‘‘Sec. 36B. Refundable credit for coverage under a qualified health plan.’’. 

(3) øAs revised by section 10105(d)¿ Section 6211(b)(4)(A) 

of the Internal Revenue Code of 1986 is amended by inserting 

‘‘36B,’’ after ‘‘36A,’’. 

(e) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years ending after December 31, 2013. 

SEC. 1402. ø42 U.S.C. 18071¿ REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN QUALIFIED HEALTH PLANS. 

(a) IN GENERAL.—In the case of an eligible insured enrolled in 

a qualified health plan— 

(1) the Secretary shall notify the issuer of the plan of such 

eligibility; and 

(2) the issuer shall reduce the cost-sharing under the plan 

at the level and in the manner specified in subsection (c). 

(b) ELIGIBLE INSURED.—In this section, the term ‘‘eligible insured’’ means an individual— 

(1) who enrolls in a qualified health plan in the silver level 

of coverage in the individual market offered through an Exchange; and 

(2) whose household income exceeds 100 percent but does 

not exceed 400 percent of the poverty line for a family of the 

size involved. 

In the case of an individual described in section 36B(c)(1)(B) of the 

Internal Revenue Code of 1986, the individual shall be treated as 

having household income equal to 100 percent for purposes of applying this section. 

(c) DETERMINATION OF REDUCTION IN COST-SHARING.— 

(1) REDUCTION IN OUT-OF-POCKET LIMIT.— 

(A) IN GENERAL.—The reduction in cost-sharing under 

this subsection shall first be achieved by reducing the applicable out-of pocket limit under section 1302(c)(1) in the 

case of— 

(i) an eligible insured whose household income is 

more than 100 percent but not more than 200 percent 

of the poverty line for a family of the size involved, by 

two-thirds; 

(ii) an eligible insured whose household income is 

more than 200 percent but not more than 300 percent 

of the poverty line for a family of the size involved, by 

one-half; and 

(iii) an eligible insured whose household income is 

more than 300 percent but not more than 400 percent 

of the poverty line for a family of the size involved, by 

one-third. 

(B) COORDINATION WITH ACTUARIAL VALUE LIMITS.— 

(i) IN GENERAL.—The Secretary shall ensure the 

reduction under this paragraph shall not result in an 
Sec. 1402 PPACA (Consolidated) 120 

increase in the plan’s share of the total allowed costs 

of benefits provided under the plan above— 

(I) 94 percent in the case of an eligible insured described in paragraph (2)(A); øAs revised 

by section 1001(b)(1)(A) of HCERA¿ 

(II) 87 percent in the case of an eligible insured described in paragraph (2)(B); 

øsection 1001(a)(1)(C) of HCERA struck subclause (III) and inserted new subclauses (III) and (IV)¿ 

(III) 73 percent in the case of an eligible insured whose household income is more than 200 

percent but not more than 250 percent of the poverty line for a family of the size involved; and 

(IV) 70 percent in the case of an eligible insured whose household income is more than 250 

percent but not more than 400 percent of the poverty line for a family of the size involved. 

(ii) ADJUSTMENT.—The Secretary shall adjust the 

out-of pocket limits under paragraph (1) if necessary 

to ensure that such limits do not cause the respective 

actuarial values to exceed the levels specified in clause 

(i). 

(2) ADDITIONAL REDUCTION FOR LOWER INCOME IN- SUREDS.—The Secretary shall establish procedures under 

which the issuer of a qualified health plan to which this section applies shall further reduce cost-sharing under the plan in 

a manner sufficient to— 

(A) in the case of an eligible insured whose household 

income is not less than 100 percent but not more than 150 

percent of the poverty line for a family of the size involved, 

increase the plan’s share of the total allowed costs of benefits provided under the plan to 94 percent of such costs; 

øAs revised by section 1001(a)(2)(A) of HCERA¿ 

(B) in the case of an eligible insured whose household 

income is more than 150 percent but not more than 200 

percent of the poverty line for a family of the size involved, 

increase the plan’s share of the total allowed costs of benefits provided under the plan to 87 percent of such costs; 

and øAs revised by section 1001(a)(2)(B) of HCERA¿ 

(C) in the case of an eligible insured whose household 

income is more than 200 percent but not more than 250 

percent of the poverty line for a family of the size involved, 

increase the plan’s share of the total allowed costs of benefits provided under the plan to 73 percent of such costs. 

øAs added by section 1001(a)(2)(C) of HCERA¿ 

(3) METHODS FOR REDUCING COST-SHARING.— 

(A) IN GENERAL.—An issuer of a qualified health plan 

making reductions under this subsection shall notify the 

Secretary of such reductions and the Secretary shall make 

periodic and timely payments to the issuer equal to the 

value of the reductions. 

(B) CAPITATED PAYMENTS.—The Secretary may establish a capitated payment system to carry out the payment 

of cost-sharing reductions under this section. Any such sys-
121 Sec. 1402 PPACA (Consolidated) 

tem shall take into account the value of the reductions and 

make appropriate risk adjustments to such payments. 

(4) ADDITIONAL BENEFITS.—If a qualified health plan under 

section 1302(b)(5) offers benefits in addition to the essential 

health benefits required to be provided by the plan, or a State 

requires a qualified health plan under section 1311(d)(3)(B) to 

cover benefits in addition to the essential health benefits required to be provided by the plan, the reductions in cost-sharing under this section shall not apply to such additional benefits. 

(5) SPECIAL RULE FOR PEDIATRIC DENTAL PLANS.—If an individual enrolls in both a qualified health plan and a plan described in section 1311(d)(2)(B)(ii)(I) for any plan year, subsection (a) shall not apply to that portion of any reduction in 

cost-sharing under subsection (c) that (under regulations prescribed by the Secretary) is properly allocable to pediatric dental benefits which are included in the essential health benefits 

required to be provided by a qualified health plan under section 1302(b)(1)(J). 

(d) SPECIAL RULES FOR INDIANS.— (1) INDIANS UNDER 300 PERCENT OF POVERTY.—If an individual enrolled in any qualified health plan in the individual 

market through an Exchange is an Indian (as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(d))) whose household income is 

not more than 300 percent of the poverty line for a family of 

the size involved, then, for purposes of this section— 

(A) such individual shall be treated as an eligible insured; and 

(B) the issuer of the plan shall eliminate any costsharing under the plan. 

(2) ITEMS OR SERVICES FURNISHED THROUGH INDIAN

HEALTH PROVIDERS.—If an Indian (as so defined) enrolled in a 

qualified health plan is furnished an item or service directly by 

the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under 

contract health services— 

(A) no cost-sharing under the plan shall be imposed 

under the plan for such item or service; and 

(B) the issuer of the plan shall not reduce the payment 

to any such entity for such item or service by the amount 

of any cost-sharing that would be due from the Indian but 

for subparagraph (A). 

(3) PAYMENT.—The Secretary shall pay to the issuer of a 

qualified health plan the amount necessary to reflect the increase in actuarial value of the plan required by reason of this 

subsection. 

(e) RULES FOR INDIVIDUALS NOT LAWFULLY PRESENT.— 

(1) IN GENERAL.—If an individual who is an eligible insured is not lawfully present— 

(A) no cost-sharing reduction under this section shall 

apply with respect to the individual; and 

(B) for purposes of applying this section, the determination as to what percentage a taxpayer’s household in-
Sec. 1402 PPACA (Consolidated) 122 

come bears to the poverty level for a family of the size involved shall be made under one of the following methods: 

(i) A method under which— 

(I) the taxpayer’s family size is determined by 

not taking such individuals into account, and 

(II) the taxpayer’s household income is equal 

to the product of the taxpayer’s household income 

(determined without regard to this subsection) 

and a fraction— 

(aa) the numerator of which is the poverty line for the taxpayer’s family size determined after application of subclause (I), and 

(bb) the denominator of which is the poverty line for the taxpayer’s family size determined without regard to subclause (I). 

(ii) A comparable method reaching the same result 

as the method under clause (i). 

(2) LAWFULLY PRESENT.—For purposes of this section, an 

individual shall be treated as lawfully present only if the individual is, and is reasonably expected to be for the entire period 

of enrollment for which the cost-sharing reduction under this 

section is being claimed, a citizen or national of the United 

States or an alien lawfully present in the United States. 

(3) SECRETARIAL AUTHORITY.—The Secretary, in consultation with the Secretary of the Treasury, shall prescribe rules 

setting forth the methods by which calculations of family size 

and household income are made for purposes of this subsection. Such rules shall be designed to ensure that the least 

burden is placed on individuals enrolling in qualified health 

plans through an Exchange and taxpayers eligible for the credit allowable under this section. 

(f) DEFINITIONS AND SPECIAL RULES.—In this section: 

(1) IN GENERAL.—Any term used in this section which is 

also used in section 36B of the Internal Revenue Code of 1986 

shall have the meaning given such term by such section. 

(2) LIMITATIONS ON REDUCTION.—No cost-sharing reduction 

shall be allowed under this section with respect to coverage for 

any month unless the month is a coverage month with respect 

to which a credit is allowed to the insured (or an applicable 

taxpayer on behalf of the insured) under section 36B of such 

Code. 

(3) DATA USED FOR ELIGIBILITY.—Any determination under 

this section shall be made on the basis of the taxable year for 

which the advance determination is made under section 1412 

and not the taxable year for which the credit under section 

36B of such Code is allowed. 
123 Sec. 1411 PPACA (Consolidated) 

Subpart B—Eligibility Determinations 

SEC. 1411. ø42 U.S.C. 18081¿ PROCEDURES FOR DETERMINING ELIGIBILITY FOR EXCHANGE PARTICIPATION, PREMIUM TAX 

CREDITS AND REDUCED COST-SHARING, AND INDIVIDUAL 

RESPONSIBILITY EXEMPTIONS. 

(a) ESTABLISHMENT OF PROGRAM.—The Secretary shall establish a program meeting the requirements of this section for determining— 

(1) whether an individual who is to be covered in the individual market by a qualified health plan offered through an 

Exchange, or who is claiming a premium tax credit or reduced 

cost-sharing, meets the requirements of sections 1312(f)(3), 

1402(e), and 1412(d) of this title and section 36B(e) of the Internal Revenue Code of 1986 that the individual be a citizen 

or national of the United States or an alien lawfully present 

in the United States; 

(2) in the case of an individual claiming a premium tax 

credit or reduced cost-sharing under section 36B of such Code 

or section 1402— 

(A) whether the individual meets the income and coverage requirements of such sections; and 

(B) the amount of the tax credit or reduced cost-sharing; 

(3) whether an individual’s coverage under an employersponsored health benefits plan is treated as unaffordable under 

sections 36B(c)(2)(C) and 5000A(e)(2); and 

(4) whether to grant a certification under section 

1311(d)(4)(H) attesting that, for purposes of the individual responsibility requirement under section 5000A of the Internal 

Revenue Code of 1986, an individual is entitled to an exemption from either the individual responsibility requirement or 

the penalty imposed by such section. 

(b) INFORMATION REQUIRED TO BE PROVIDED BY APPLICANTS.— 

(1) IN GENERAL.—An applicant for enrollment in a qualified health plan offered through an Exchange in the individual 

market shall provide— 

(A) the name, address, and date of birth of each individual who is to be covered by the plan (in this subsection 

referred to as an ‘‘enrollee’’); and 

(B) the information required by any of the following 

paragraphs that is applicable to an enrollee. 

(2) CITIZENSHIP OR IMMIGRATION STATUS.—The following 

information shall be provided with respect to every enrollee: 

(A) In the case of an enrollee whose eligibility is based 

on an attestation of citizenship of the enrollee, the enrollee’s social security number. 

(B) In the case of an individual whose eligibility is 

based on an attestation of the enrollee’s immigration status, the enrollee’s social security number (if applicable) 

and such identifying information with respect to the enrollee’s immigration status as the Secretary, after consultation with the Secretary of Homeland Security, determines appropriate. 
Sec. 1411 PPACA (Consolidated) 124 

(3) ELIGIBILITY AND AMOUNT OF TAX CREDIT OR REDUCED

COST-SHARING.—In the case of an enrollee with respect to 

whom a premium tax credit or reduced cost-sharing under section 36B of such Code or section 1402 is being claimed, the following information: 

(A) INFORMATION REGARDING INCOME AND FAMILY

SIZE.—The information described in section 6103(l)(21) for 

the taxable year ending with or within the second calendar 

year preceding the calendar year in which the plan year 

begins. 

(B) CHANGES IN CIRCUMSTANCES.—The information described in section 1412(b)(2), including information with 

respect to individuals who were not required to file an income tax return for the taxable year described in subparagraph (A) or individuals who experienced changes in marital status or family size or significant reductions in income. 

(4) EMPLOYER-SPONSORED COVERAGE.—In the case of an 

enrollee with respect to whom eligibility for a premium tax 

credit under section 36B of such Code or cost-sharing reduction 

under section 1402 is being established on the basis that the 

enrollee’s (or related individual’s) employer is not treated 

under section 36B(c)(2)(C) of such Code as providing minimum 

essential coverage or affordable minimum essential coverage, 

the following information: 

(A) The name, address, and employer identification 

number (if available) of the employer. 

(B) Whether the enrollee or individual is a full-time 

employee and whether the employer provides such minimum essential coverage. 

(C) If the employer provides such minimum essential 

coverage, the lowest cost option for the enrollee’s or individual’s enrollment status and the enrollee’s or individual’s 

required contribution (within the meaning of section 

5000A(e)(1)(B) of such Code) under the employer-sponsored 

plan. 

(D) If an enrollee claims an employer’s minimum essential coverage is unaffordable, the information described 

in paragraph (3). 

If an enrollee changes employment or obtains additional employment while enrolled in a qualified health plan for which 

such credit or reduction is allowed, the enrollee shall notify the 

Exchange of such change or additional employment and provide the information described in this paragraph with respect 

to the new employer. 

(5) EXEMPTIONS FROM INDIVIDUAL RESPONSIBILITY REQUIREMENTS.—In the case of an individual who is seeking an exemption certificate under section 1311(d)(4)(H) from any requirement or penalty imposed by section 5000A, the following information: 

(A) In the case of an individual seeking exemption 

based on the individual’s status as a member of an exempt 

religious sect or division, as a member of a health care 

sharing ministry, as an Indian, or as an individual eligible 
125 Sec. 1411 PPACA (Consolidated) 

for a hardship exemption, such information as the Secretary shall prescribe. 

(B) In the case of an individual seeking exemption 

based on the lack of affordable coverage or the individual’s 

status as a taxpayer with household income less than 100 

percent of the poverty line, the information described in 

paragraphs (3) and (4), as applicable. 

(c) VERIFICATION OF INFORMATION CONTAINED IN RECORDS OF

SPECIFIC FEDERAL OFFICIALS.— 

(1) INFORMATION TRANSFERRED TO SECRETARY.—An Exchange shall submit the information provided by an applicant 

under subsection (b) to the Secretary for verification in accordance with the requirements of this subsection and subsection 

(d). 

(2) CITIZENSHIP OR IMMIGRATION STATUS.— 

(A) COMMISSIONER OF SOCIAL SECURITY.—The Secretary shall submit to the Commissioner of Social Security 

the following information for a determination as to whether the information provided is consistent with the information in the records of the Commissioner: 

(i) The name, date of birth, and social security 

number of each individual for whom such information 

was provided under subsection (b)(2). 

(ii) The attestation of an individual that the individual is a citizen. 

(B) SECRETARY OF HOMELAND SECURITY.— 

(i) IN GENERAL.—In the case of an individual— 

(I) who attests that the individual is an alien 

lawfully present in the United States; or 

(II) who attests that the individual is a citizen 

but with respect to whom the Commissioner of Social Security has notified the Secretary under subsection (e)(3) that the attestation is inconsistent 

with information in the records maintained by the 

Commissioner; 

the Secretary shall submit to the Secretary of Homeland Security the information described in clause (ii) 

for a determination as to whether the information provided is consistent with the information in the records 

of the Secretary of Homeland Security. 

(ii) INFORMATION.—The information described in 

clause (ii) is the following: 

(I) The name, date of birth, and any identifying information with respect to the individual’s 

immigration status provided under subsection 

(b)(2). 

(II) The attestation that the individual is an 

alien lawfully present in the United States or in 

the case of an individual described in clause (i)(II), 

the attestation that the individual is a citizen. 

(3) ELIGIBILITY FOR TAX CREDIT AND COST-SHARING REDUCTION.—The Secretary shall submit the information described in 

subsection (b)(3)(A) provided under paragraph (3), (4), or (5) of 
Sec. 1411 PPACA (Consolidated) 126 

subsection (b) to the Secretary of the Treasury for verification 

of household income and family size for purposes of eligibility. 

(4) METHODS.— 

(A) IN GENERAL.—The Secretary, in consultation with 

the Secretary of the Treasury, the Secretary of Homeland 

Security, and the Commissioner of Social Security, shall 

provide that verifications and determinations under this 

subsection shall be done— 

(i) through use of an on-line system or otherwise 

for the electronic submission of, and response to, the 

information submitted under this subsection with respect to an applicant; or 

(ii) by determining the consistency of the information submitted with the information maintained in the 

records of the Secretary of the Treasury, the Secretary 

of Homeland Security, or the Commissioner of Social 

Security through such other method as is approved by 

the Secretary. 

(B) FLEXIBILITY.—The Secretary may modify the methods used under the program established by this section for 

the Exchange and verification of information if the Secretary determines such modifications would reduce the administrative costs and burdens on the applicant, including 

allowing an applicant to request the Secretary of the 

Treasury to provide the information described in paragraph (3) directly to the Exchange or to the Secretary. The 

Secretary shall not make any such modification unless the 

Secretary determines that any applicable requirements 

under this section and section 6103 of the Internal Revenue Code of 1986 with respect to the confidentiality, disclosure, maintenance, or use of information will be met. 

(d) VERIFICATION BY SECRETARY.—In the case of information 

provided under subsection (b) that is not required under subsection 

(c) to be submitted to another person for verification, the Secretary 

shall verify the accuracy of such information in such manner as the 

Secretary determines appropriate, including delegating responsibility for verification to the Exchange. 

(e) ACTIONS RELATING TO VERIFICATION.— 

(1) IN GENERAL.—Each person to whom the Secretary provided information under subsection (c) shall report to the Secretary under the method established under subsection (c)(4) 

the results of its verification and the Secretary shall notify the 

Exchange of such results. Each person to whom the Secretary 

provided information under subsection (d) shall report to the 

Secretary in such manner as the Secretary determines appropriate. 

(2) VERIFICATION.— 

(A) ELIGIBILITY FOR ENROLLMENT AND PREMIUM TAX

CREDITS AND COST-SHARING REDUCTIONS.—If information 

provided by an applicant under paragraphs (1), (2), (3), 

and (4) of subsection (b) is verified under subsections (c) 

and (d)— 
127 Sec. 1411 PPACA (Consolidated) 

(i) the individual’s eligibility to enroll through the 

Exchange and to apply for premium tax credits and 

cost-sharing reductions shall be satisfied; and 

(ii) the Secretary shall, if applicable, notify the 

Secretary of the Treasury under section 1412(c) of the 

amount of any advance payment to be made. 

(B) EXEMPTION FROM INDIVIDUAL RESPONSIBILITY.—If 

information provided by an applicant under subsection 

(b)(5) is verified under subsections (c) and (d), the Secretary shall issue the certification of exemption described 

in section 1311(d)(4)(H). 

(3) INCONSISTENCIES INVOLVING ATTESTATION OF CITIZEN- SHIP OR LAWFUL PRESENCE.—If the information provided by 

any applicant under subsection (b)(2) is inconsistent with information in the records maintained by the Commissioner of Social Security or Secretary of Homeland Security, whichever is 

applicable, the applicant’s eligibility will be determined in the 

same manner as an individual’s eligibility under the medicaid 

program is determined under section 1902(ee) of the Social Security Act (as in effect on January 1, 2010). 

(4) INCONSISTENCIES INVOLVING OTHER INFORMATION.— (A) IN GENERAL.—If the information provided by an 

applicant under subsection (b) (other than subsection 

(b)(2)) is inconsistent with information in the records 

maintained by persons under subsection (c) or is not 

verified under subsection (d), the Secretary shall notify the 

Exchange and the Exchange shall take the following actions: 

(i) REASONABLE EFFORT.—The Exchange shall 

make a reasonable effort to identify and address the 

causes of such inconsistency, including through typographical or other clerical errors, by contacting the applicant to confirm the accuracy of the information, and 

by taking such additional actions as the Secretary, 

through regulation or other guidance, may identify. 

(ii) NOTICE AND OPPORTUNITY TO CORRECT.—In the 

case the inconsistency or inability to verify is not resolved under subparagraph (A), the Exchange shall— 

(I) notify the applicant of such fact; 

(II) provide the applicant an opportunity to either present satisfactory documentary evidence or 

resolve the inconsistency with the person verifying 

the information under subsection (c) or (d) during 

the 90-day period beginning the date on which the 

notice required under subclause (I) is sent to the 

applicant. 

The Secretary may extend the 90-day period under 

subclause (II) for enrollments occurring during 2014. 

(B) SPECIFIC ACTIONS NOT INVOLVING CITIZENSHIP OR

LAWFUL PRESENCE.— 

(i) IN GENERAL.—Except as provided in paragraph 

(3), the Exchange shall, during any period before the 

close of the period under subparagraph (A)(ii)(II), 

make any determination under paragraphs (2), (3), 
Sec. 1411 PPACA (Consolidated) 128 

and (4) of subsection (a) on the basis of the information contained on the application. 

(ii) ELIGIBILITY OR AMOUNT OF CREDIT OR REDUCTION.—If an inconsistency involving the eligibility for, 

or amount of, any premium tax credit or cost-sharing 

reduction is unresolved under this subsection as of the 

close of the period under subparagraph (A)(ii)(II), the 

Exchange shall notify the applicant of the amount (if 

any) of the credit or reduction that is determined on 

the basis of the records maintained by persons under 

subsection (c). 

(iii) EMPLOYER AFFORDABILITY.—If the Secretary 

notifies an Exchange that an enrollee is eligible for a 

premium tax credit under section 36B of such Code or 

cost-sharing reduction under section 1402 because the 

enrollee’s (or related individual’s) employer does not 

provide minimum essential coverage through an employer-sponsored plan or that the employer does provide that coverage but it is not affordable coverage, 

the Exchange shall notify the employer of such fact 

and that the employer may be liable for the payment 

assessed under section 4980H of such Code. 

(iv) EXEMPTION.—In any case where the inconsistency involving, or inability to verify, information provided under subsection (b)(5) is not resolved as of the 

close of the period under subparagraph (A)(ii)(II), the 

Exchange shall notify an applicant that no certification of exemption from any requirement or payment 

under section 5000A of such Code will be issued. 

(C) APPEALS PROCESS.—The Exchange shall also notify 

each person receiving notice under this paragraph of the 

appeals processes established under subsection (f). 

(f) APPEALS AND REDETERMINATIONS.— 

(1) IN GENERAL.—The Secretary, in consultation with the 

Secretary of the Treasury, the Secretary of Homeland Security, 

and the Commissioner of Social Security, shall establish procedures by which the Secretary or one of such other Federal officers— 

(A) hears and makes decisions with respect to appeals 

of any determination under subsection (e); and 

(B) redetermines eligibility on a periodic basis in appropriate circumstances. 

(2) EMPLOYER LIABILITY.— 

(A) IN GENERAL.—The Secretary shall establish a separate appeals process for employers who are notified under 

subsection (e)(4)(C) that the employer may be liable for a 

tax imposed by section 4980H of the Internal Revenue 

Code of 1986 with respect to an employee because of a determination that the employer does not provide minimum 

essential coverage through an employer-sponsored plan or 

that the employer does provide that coverage but it is not 

affordable coverage with respect to an employee. Such 

process shall provide an employer the opportunity to— 
129 Sec. 1411 PPACA (Consolidated) 

(i) present information to the Exchange for review 

of the determination either by the Exchange or the 

person making the determination, including evidence 

of the employer-sponsored plan and employer contributions to the plan; and 

(ii) have access to the data used to make the determination to the extent allowable by law. 

Such process shall be in addition to any rights of appeal 

the employer may have under subtitle F of such Code. 

(B) CONFIDENTIALITY.—Notwithstanding any provision 

of this title (or the amendments made by this title) or section 6103 of the Internal Revenue Code of 1986, an employer shall not be entitled to any taxpayer return information with respect to an employee for purposes of determining whether the employer is subject to the penalty 

under section 4980H of such Code with respect to the employee, except that— 

(i) the employer may be notified as to the name of 

an employee and whether or not the employee’s income is above or below the threshold by which the affordability of an employer’s health insurance coverage 

is measured; and 

(ii) this subparagraph shall not apply to an employee who provides a waiver (at such time and in 

such manner as the Secretary may prescribe) authorizing an employer to have access to the employee’s taxpayer return information. 

(g) CONFIDENTIALITY OF APPLICANT INFORMATION.— 

(1) IN GENERAL.—An applicant for insurance coverage or 

for a premium tax credit or cost-sharing reduction shall be required to provide only the information strictly necessary to authenticate identity, determine eligibility, and determine the 

amount of the credit or reduction. 

(2) RECEIPT OF INFORMATION.—Any person who receives 

information provided by an applicant under subsection (b) 

(whether directly or by another person at the request of the applicant), or receives information from a Federal agency under 

subsection (c), (d), or (e), shall— 

(A) use the information only for the purposes of, and 

to the extent necessary in, ensuring the efficient operation 

of the Exchange, including verifying the eligibility of an individual to enroll through an Exchange or to claim a premium tax credit or cost-sharing reduction or the amount 

of the credit or reduction; and 

(B) not disclose the information to any other person 

except as provided in this section. 

(h) PENALTIES.— 

(1) FALSE OR FRAUDULENT INFORMATION.— 

(A) CIVIL PENALTY.— 

(i) IN GENERAL.—If— 

(I) any person fails to provides correct information under subsection (b); and 
Sec. 1411 PPACA (Consolidated) 130 

(II) such failure is attributable to negligence 

or disregard of any rules or regulations of the Secretary, 

such person shall be subject, in addition to any other 

penalties that may be prescribed by law, to a civil penalty of not more than $25,000 with respect to any failures involving an application for a plan year. For purposes of this subparagraph, the terms ‘‘negligence’’ and 

‘‘disregard’’ shall have the same meanings as when 

used in section 6662 of the Internal Revenue Code of 

1986. 

(ii) REASONABLE CAUSE EXCEPTION.—No penalty 

shall be imposed under clause (i) if the Secretary determines that there was a reasonable cause for the 

failure and that the person acted in good faith. 

(B) KNOWING AND WILLFUL VIOLATIONS.—Any person 

who knowingly and willfully provides false or fraudulent 

information under subsection (b) shall be subject, in addition to any other penalties that may be prescribed by law, 

to a civil penalty of not more than $250,000. 

(2) IMPROPER USE OR DISCLOSURE OF INFORMATION.—Any 

person who knowingly and willfully uses or discloses information in violation of subsection (g) shall be subject, in addition 

to any other penalties that may be prescribed by law, to a civil 

penalty of not more than $25,000. 

(3) LIMITATIONS ON LIENS AND LEVIES.—The Secretary (or, 

if applicable, the Attorney General of the United States) shall 

not— 

(A) file notice of lien with respect to any property of 

a person by reason of any failure to pay the penalty imposed by this subsection; or 

(B) levy on any such property with respect to such failure. 

(i) STUDY OF ADMINISTRATION OF EMPLOYER RESPONSIBILITY.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services shall, in consultation with the Secretary of the Treasury, conduct a study of the procedures that are necessary to 

ensure that in the administration of this title and section 

4980H of the Internal Revenue Code of 1986 (as added by section 1513) that the following rights are protected: 

(A) The rights of employees to preserve their right to 

confidentiality of their taxpayer return information and 

their right to enroll in a qualified health plan through an 

Exchange if an employer does not provide affordable coverage. 

(B) The rights of employers to adequate due process 

and access to information necessary to accurately determine any payment assessed on employers. 

(2) REPORT.—Not later than January 1, 2013, the Secretary of Health and Human Services shall report the results 

of the study conducted under paragraph (1), including any recommendations for legislative changes, to the Committees on 

Finance and Health, Education, Labor and Pensions of the 
131 Sec. 1412 PPACA (Consolidated) 

Senate and the Committees of Education and Labor and Ways 

and Means of the House of Representatives. 

SEC. 1412. ø42 U.S.C. 18082¿ ADVANCE DETERMINATION AND PAYMENT 

OF PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS. 

(a) IN GENERAL.—The Secretary, in consultation with the Secretary of the Treasury, shall establish a program under which— 

(1) upon request of an Exchange, advance determinations 

are made under section 1411 with respect to the income eligibility of individuals enrolling in a qualified health plan in the 

individual market through the Exchange for the premium tax 

credit allowable under section 36B of the Internal Revenue 

Code of 1986 and the cost-sharing reductions under section 

1402; 

(2) the Secretary notifies— 

(A) the Exchange and the Secretary of the Treasury of 

the advance determinations; and 

(B) the Secretary of the Treasury of the name and employer identification number of each employer with respect 

to whom 1 or more employee of the employer were determined to be eligible for the premium tax credit under section 36B of the Internal Revenue Code of 1986 and the 

cost-sharing reductions under section 1402 because— 

(i) the employer did not provide minimum essential coverage; or 

(ii) the employer provided such minimum essential coverage but it was determined under section 

36B(c)(2)(C) of such Code to either be unaffordable to 

the employee or not provide the required minimum actuarial value; and 

(3) the Secretary of the Treasury makes advance payments 

of such credit or reductions to the issuers of the qualified 

health plans in order to reduce the premiums payable by individuals eligible for such credit. 

(b) ADVANCE DETERMINATIONS.— 

(1) IN GENERAL.—The Secretary shall provide under the 

program established under subsection (a) that advance determination of eligibility with respect to any individual shall be 

made— 

(A) during the annual open enrollment period applicable to the individual (or such other enrollment period as 

may be specified by the Secretary); and 

(B) on the basis of the individual’s household income 

for the most recent taxable year for which the Secretary, 

after consultation with the Secretary of the Treasury, determines information is available. 

(2) CHANGES IN CIRCUMSTANCES.—The Secretary shall provide procedures for making advance determinations on the 

basis of information other than that described in paragraph 

(1)(B) in cases where information included with an application 

form demonstrates substantial changes in income, changes in 

family size or other household circumstances, change in filing 

status, the filing of an application for unemployment benefits, 

or other significant changes affecting eligibility, including— 
Sec. 1412 PPACA (Consolidated) 132 

(A) allowing an individual claiming a decrease of 20 

percent or more in income, or filing an application for unemployment benefits, to have eligibility for the credit determined on the basis of household income for a later period or on the basis of the individual’s estimate of such income for the taxable year; and 

(B) the determination of household income in cases 

where the taxpayer was not required to file a return of tax 

imposed by this chapter for the second preceding taxable 

year. 

(c) PAYMENT OF PREMIUM TAX CREDITS AND COST-SHARING RE- DUCTIONS.— 

(1) IN GENERAL.—The Secretary shall notify the Secretary 

of the Treasury and the Exchange through which the individual is enrolling of the advance determination under section 

1411. 

(2) PREMIUM TAX CREDIT.— (A) IN GENERAL.—The Secretary of the Treasury shall 

make the advance payment under this section of any premium tax credit allowed under section 36B of the Internal 

Revenue Code of 1986 to the issuer of a qualified health 

plan on a monthly basis (or such other periodic basis as 

the Secretary may provide). 

(B) ISSUER RESPONSIBILITIES.—An issuer of a qualified 

health plan receiving an advance payment with respect to 

an individual enrolled in the plan shall— 

(i) reduce the premium charged the insured for 

any period by the amount of the advance payment for 

the period; 

(ii) notify the Exchange and the Secretary of such 

reduction; 

(iii) include with each billing statement the 

amount by which the premium for the plan has been 

reduced by reason of the advance payment; and 

(iv) in the case of any nonpayment of premiums by 

the insured— 

(I) notify the Secretary of such nonpayment; 

and 

(II) allow a 3-month grace period for nonpayment of premiums before discontinuing coverage. 

(3) COST-SHARING REDUCTIONS.—The Secretary shall also 

notify the Secretary of the Treasury and the Exchange under 

paragraph (1) if an advance payment of the cost-sharing reductions under section 1402 is to be made to the issuer of any 

qualified health plan with respect to any individual enrolled in 

the plan. The Secretary of the Treasury shall make such advance payment at such time and in such amount as the Secretary specifies in the notice. 

(d) NO FEDERAL PAYMENTS FOR INDIVIDUALS NOT LAWFULLY

PRESENT.—Nothing in this subtitle or the amendments made by 

this subtitle allows Federal payments, credits, or cost-sharing reductions for individuals who are not lawfully present in the United 

States. 
133 Sec. 1413 PPACA (Consolidated) 

(e) STATE FLEXIBILITY.—Nothing in this subtitle or the amendments made by this subtitle shall be construed to prohibit a State 

from making payments to or on behalf of an individual for coverage 

under a qualified health plan offered through an Exchange that are 

in addition to any credits or cost-sharing reductions allowable to 

the individual under this subtitle and such amendments. 

SEC. 1413. ø42 U.S.C. 18083¿ STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH AN EXCHANGE AND STATE MEDICAID, CHIP, AND HEALTH SUBSIDY PROGRAMS. 

(a) IN GENERAL.—The Secretary shall establish a system meeting the requirements of this section under which residents of each 

State may apply for enrollment in, receive a determination of eligibility for participation in, and continue participation in, applicable 

State health subsidy programs. Such system shall ensure that if an 

individual applying to an Exchange is found through screening to 

be eligible for medical assistance under the State medicaid plan 

under title XIX, or eligible for enrollment under a State children’s 

health insurance program (CHIP) under title XXI of such Act, the 

individual is enrolled for assistance under such plan or program. 

(b) REQUIREMENTS RELATING TO FORMS AND NOTICE.— 

(1) REQUIREMENTS RELATING TO FORMS.— 

(A) IN GENERAL.—The Secretary shall develop and provide to each State a single, streamlined form that— 

(i) may be used to apply for all applicable State 

health subsidy programs within the State; 

(ii) may be filed online, in person, by mail, or by 

telephone; 

(iii) may be filed with an Exchange or with State 

officials operating one of the other applicable State 

health subsidy programs; and 

(iv) is structured to maximize an applicant’s ability to complete the form satisfactorily, taking into account the characteristics of individuals who qualify for 

applicable State health subsidy programs. 

(B) STATE AUTHORITY TO ESTABLISH FORM.—A State 

may develop and use its own single, streamlined form as 

an alternative to the form developed under subparagraph 

(A) if the alternative form is consistent with standards 

promulgated by the Secretary under this section. 

(C) SUPPLEMENTAL ELIGIBILITY FORMS.—The Secretary 

may allow a State to use a supplemental or alternative 

form in the case of individuals who apply for eligibility 

that is not determined on the basis of the household income (as defined in section 36B of the Internal Revenue 

Code of 1986). 

(2) NOTICE.—The Secretary shall provide that an applicant 

filing a form under paragraph (1) shall receive notice of eligibility for an applicable State health subsidy program without 

any need to provide additional information or paperwork unless such information or paperwork is specifically required by 

law when information provided on the form is inconsistent 

with data used for the electronic verification under paragraph 

(3) or is otherwise insufficient to determine eligibility. 
Sec. 1413 PPACA (Consolidated) 134 

(c) REQUIREMENTS RELATING TO ELIGIBILITY BASED ON DATA

EXCHANGES.— 

(1) DEVELOPMENT OF SECURE INTERFACES.—Each State 

shall develop for all applicable State health subsidy programs 

a secure, electronic interface allowing an exchange of data (including information contained in the application forms described in subsection (b)) that allows a determination of eligibility for all such programs based on a single application. Such 

interface shall be compatible with the method established for 

data verification under section 1411(c)(4). 

(2) DATA MATCHING PROGRAM.—Each applicable State 

health subsidy program shall participate in a data matching 

arrangement for determining eligibility for participation in the 

program under paragraph (3) that— 

(A) provides access to data described in paragraph (3); 

(B) applies only to individuals who— 

(i) receive assistance from an applicable State 

health subsidy program; or 

(ii) apply for such assistance— 

(I) by filing a form described in subsection (b); 

or 

(II) by requesting a determination of eligibility and authorizing disclosure of the information described in paragraph (3) to applicable State 

health coverage subsidy programs for purposes of 

determining and establishing eligibility; and 

(C) consistent with standards promulgated by the Secretary, including the privacy and data security safeguards 

described in section 1942 of the Social Security Act or that 

are otherwise applicable to such programs. 

(3) DETERMINATION OF ELIGIBILITY.— 

(A) IN GENERAL.—Each applicable State health subsidy program shall, to the maximum extent practicable— 

(i) establish, verify, and update eligibility for participation in the program using the data matching arrangement under paragraph (2); and 

(ii) determine such eligibility on the basis of reliable, third party data, including information described 

in sections 1137, 453(i), and 1942(a) of the Social Security Act, obtained through such arrangement. 

(B) EXCEPTION.—This paragraph shall not apply in circumstances with respect to which the Secretary determines that the administrative and other costs of use of the 

data matching arrangement under paragraph (2) outweigh 

its expected gains in accuracy, efficiency, and program participation. 

(4) SECRETARIAL STANDARDS.—The Secretary shall, after 

consultation with persons in possession of the data to be 

matched and representatives of applicable State health subsidy 

programs, promulgate standards governing the timing, contents, and procedures for data matching described in this subsection. Such standards shall take into account administrative 

and other costs and the value of data matching to the estab-
135 Sec. 1414 PPACA (Consolidated) 

lishment, verification, and updating of eligibility for applicable 

State health subsidy programs. 

(d) ADMINISTRATIVE AUTHORITY.— 

(1) AGREEMENTS.—Subject to section 1411 and section 

6103(l)(21) of the Internal Revenue Code of 1986 and any other 

requirement providing safeguards of privacy and data integrity, the Secretary may establish model agreements, and enter 

into agreements, for the sharing of data under this section. 

(2) AUTHORITY OF EXCHANGE TO CONTRACT OUT.—Nothing 

in this section shall be construed to— 

(A) prohibit contractual arrangements through which 

a State medicaid agency determines eligibility for all applicable State health subsidy programs, but only if such 

agency complies with the Secretary’s requirements ensuring reduced administrative costs, eligibility errors, and disruptions in coverage; or 

(B) change any requirement under title XIX that eligibility for participation in a State’s medicaid program must 

be determined by a public agency. 

(e) APPLICABLE STATE HEALTH SUBSIDY PROGRAM.—In this section, the term ‘‘applicable State health subsidy program’’ means— 

(1) the program under this title for the enrollment in 

qualified health plans offered through an Exchange, including 

the premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 

1402; 

(2) a State medicaid program under title XIX of the Social 

Security Act; 

(3) a State children’s health insurance program (CHIP) 

under title XXI of such Act; and 

(4) a State program under section 1331 establishing qualified basic health plans. 

SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS 

FOR CERTAIN PROGRAMS. 

(a) DISCLOSURE OF TAXPAYER RETURN INFORMATION AND SOCIAL SECURITY NUMBERS.— 

(1) TAXPAYER RETURN INFORMATION.—Subsection (l) of section 6103 of the Internal Revenue Code of 1986 is amended by 

adding at the end the following new paragraph: 

‘‘(21) DISCLOSURE OF RETURN INFORMATION TO CARRY OUT

ELIGIBILITY REQUIREMENTS FOR CERTAIN PROGRAMS.— 

‘‘(A) IN GENERAL.—The Secretary, upon written request from the Secretary of Health and Human Services, 

shall disclose to officers, employees, and contractors of the 

Department of Health and Human Services return information of any taxpayer whose income is relevant in determining any premium tax credit under section 36B or any 

cost-sharing reduction under section 1402 of the Patient 

Protection and Affordable Care Act or eligibility for participation in a State medicaid program under title XIX of the 

Social Security Act, a State’s children’s health insurance 

program under title XXI of the Social Security Act, or a 

basic health program under section 1331 of Patient Protec-
Sec. 1414 PPACA (Consolidated) 136 

tion and Affordable Care Act. Such return information 

shall be limited to— 

‘‘(i) taxpayer identity information with respect to 

such taxpayer, 

‘‘(ii) the filing status of such taxpayer, 

‘‘(iii) the number of individuals for whom a deduction is allowed under section 151 with respect to the 

taxpayer (including the taxpayer and the taxpayer’s 

spouse), 

‘‘(iv) the modified adjusted gross income (as defined in section 36B) of such taxpayer and each of the 

other individuals included under clause (iii) who are 

required to file a return of tax imposed by chapter 1 

for the taxable year, øAs revised by section 

1004(a)(1)(B) of HCERA¿ 

‘‘(v) such other information as is prescribed by the 

Secretary by regulation as might indicate whether the 

taxpayer is eligible for such credit or reduction (and 

the amount thereof), and 

‘‘(vi) the taxable year with respect to which the 

preceding information relates or, if applicable, the fact 

that such information is not available. 

‘‘(B) INFORMATION TO EXCHANGE AND STATE AGENCIES.—The Secretary of Health and Human Services may 

disclose to an Exchange established under the Patient Protection and Affordable Care Act or its contractors, or to a 

State agency administering a State program described in 

subparagraph (A) or its contractors, any inconsistency between the information provided by the Exchange or State 

agency to the Secretary and the information provided to 

the Secretary under subparagraph (A). 

‘‘(C) RESTRICTION ON USE OF DISCLOSED INFORMATION.—Return information disclosed under subparagraph 

(A) or (B) may be used by officers, employees, and contractors of the Department of Health and Human Services, an 

Exchange, or a State agency only for the purposes of, and 

to the extent necessary in— 

‘‘(i) establishing eligibility for participation in the 

Exchange, and verifying the appropriate amount of, 

any credit or reduction described in subparagraph (A), 

‘‘(ii) determining eligibility for participation in the 

State programs described in subparagraph (A).’’. 

(2) SOCIAL SECURITY NUMBERS.—Section 205(c)(2)(C) of the 

Social Security Act is amended by adding at the end the following new clause: 

‘‘(x) The Secretary of Health and Human Services, 

and the Exchanges established under section 1311 of 

the Patient Protection and Affordable Care Act, are 

authorized to collect and use the names and social security account numbers of individuals as required to 

administer the provisions of, and the amendments 

made by, the such Act.’’. 
137 Sec. 1416 PPACA (Consolidated) 

(b) CONFIDENTIALITY AND DISCLOSURE.—Paragraph (3) of section 6103(a) of such Code is amended by striking ‘‘or (20)’’ and inserting ‘‘(20), or (21)’’. 

(c) PROCEDURES AND RECORDKEEPING RELATED TO DISCLO- SURES.—Paragraph (4) of section 6103(p) of such Code is amended— 

(1) by inserting ‘‘, or any entity described in subsection 

(l)(21),’’ after ‘‘or (20)’’ in the matter preceding subparagraph 

(A), 

(2) by inserting ‘‘or any entity described in subsection 

(l)(21),’’ after ‘‘or (o)(1)(A)’’ in subparagraph (F)(ii), and 

(3) by inserting ‘‘or any entity described in subsection 

(l)(21),’’ after ‘‘or (20)’’ both places it appears in the matter 

after subparagraph (F). 

(d) UNAUTHORIZED DISCLOSURE OR INSPECTION.—Paragraph (2) 

of section 7213(a) of such Code is amended by striking ‘‘or (20)’’ and 

inserting ‘‘(20), or (21)’’. 

SEC. 1415. ø42 U.S.C. 18084¿ PREMIUM TAX CREDIT AND COST-SHARING 

REDUCTION PAYMENTS DISREGARDED FOR FEDERAL 

AND FEDERALLY-ASSISTED PROGRAMS. 

For purposes of determining the eligibility of any individual for 

benefits or assistance, or the amount or extent of benefits or assistance, under any Federal program or under any State or local program financed in whole or in part with Federal funds— 

(1) any credit or refund allowed or made to any individual 

by reason of section 36B of the Internal Revenue Code of 1986 

(as added by section 1401) shall not be taken into account as 

income and shall not be taken into account as resources for the 

month of receipt and the following 2 months; and 

(2) any cost-sharing reduction payment or advance payment of the credit allowed under such section 36B that is made 

under section 1402 or 1412 shall be treated as made to the 

qualified health plan in which an individual is enrolled and not 

to that individual. 

SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF 

FPL. 

øSection added by section 10105(f)¿ 

(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. 
Sec. 1421 PPACA (Consolidated) 138 

(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. 

PART II—SMALL BUSINESS TAX CREDIT 

SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF 

SMALL BUSINESSES. 

(a) IN GENERAL.—Subpart D of part IV of subchapter A of 

chapter 1 of the Internal Revenue Code of 1986 (relating to business-related credits) is amended by inserting after section 45Q the 

following: 

‘‘SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL EMPLOYERS. 

‘‘(a) GENERAL RULE.—For purposes of section 38, in the case of 

an eligible small employer, the small employer health insurance 

credit determined under this section for any taxable year in the 

credit period is the amount determined under subsection (b). 

‘‘(b) HEALTH INSURANCE CREDIT AMOUNT.—Subject to subsection (c), the amount determined under this subsection with respect to any eligible small employer is equal to 50 percent (35 percent in the case of a tax-exempt eligible small employer) of the lesser of— 

‘‘(1) the aggregate amount of nonelective contributions the 

employer made on behalf of its employees during the taxable 

year under the arrangement described in subsection (d)(4) for 

premiums for qualified health plans offered by the employer to 

its employees through an Exchange, or 

‘‘(2) the aggregate amount of nonelective contributions 

which the employer would have made during the taxable year 

under the arrangement if each employee taken into account 

under paragraph (1) had enrolled in a qualified health plan 

which had a premium equal to the average premium (as determined by the Secretary of Health and Human Services) for the 

small group market in the rating area in which the employee 

enrolls for coverage. 

‘‘(c) PHASEOUT OF CREDIT AMOUNT BASED ON NUMBER OF EMPLOYEES AND AVERAGE WAGES.—The amount of the credit determined under subsection (b) without regard to this subsection shall 

be reduced (but not below zero) by the sum of the following 

amounts: 

‘‘(1) Such amount multiplied by a fraction the numerator 

of which is the total number of full-time equivalent employees 

of the employer in excess of 10 and the denominator of which 

is 15. 

‘‘(2) Such amount multiplied by a fraction the numerator 

of which is the average annual wages of the employer in excess 

of the dollar amount in effect under subsection (d)(3)(B) and 

the denominator of which is such dollar amount. 

‘‘(d) ELIGIBLE SMALL EMPLOYER.—For purposes of this section— 
139 Sec. 1421 PPACA (Consolidated) \45R IRC 

‘‘(1) IN GENERAL.—The term ‘eligible small employer’ 

means, with respect to any taxable year, an employer— 

‘‘(A) which has no more than 25 full-time equivalent 

employees for the taxable year, 

‘‘(B) the average annual wages of which do not exceed 

an amount equal to twice the dollar amount in effect under 

paragraph (3)(B) for the taxable year, and 

‘‘(C) which has in effect an arrangement described in 

paragraph (4). 

‘‘(2) FULL-TIME EQUIVALENT EMPLOYEES.— ‘‘(A) IN GENERAL.—The term ‘full-time equivalent employees’ means a number of employees equal to the number determined by dividing— 

‘‘(i) the total number of hours of service for which 

wages were paid by the employer to employees during 

the taxable year, by 

‘‘(ii) 2,080. 

Such number shall be rounded to the next lowest whole 

number if not otherwise a whole number. 

‘‘(B) EXCESS HOURS NOT COUNTED.—If an employee 

works in excess of 2,080 hours of service during any taxable year, such excess shall not be taken into account 

under subparagraph (A). 

‘‘(C) HOURS OF SERVICE.—The Secretary, in consultation with the Secretary of Labor, shall prescribe such regulations, rules, and guidance as may be necessary to determine the hours of service of an employee, including rules 

for the application of this paragraph to employees who are 

not compensated on an hourly basis. 

‘‘(3) AVERAGE ANNUAL WAGES.— 

‘‘(A) IN GENERAL.—The average annual wages of an eligible small employer for any taxable year is the amount 

determined by dividing— 

‘‘(i) the aggregate amount of wages which were 

paid by the employer to employees during the taxable 

year, by 

‘‘(ii) the number of full-time equivalent employees 

of the employee determined under paragraph (2) for 

the taxable year. 

Such amount shall be rounded to the next lowest multiple 

of $1,000 if not otherwise such a multiple. 

‘‘(B) DOLLAR AMOUNT.—øReplaced by section 

10105(e)(1)¿ 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. 
Sec. 1421\45R IRC PPACA (Consolidated) 140 

‘‘(4) CONTRIBUTION ARRANGEMENT.—An arrangement is described in this paragraph if it requires an eligible small employer to make a nonelective contribution on behalf of each employee who enrolls in a qualified health plan offered to employees by the employer through an exchange in an amount equal 

to a uniform percentage (not less than 50 percent) of the premium cost of the qualified health plan. 

‘‘(5) SEASONAL WORKER HOURS AND WAGES NOT COUNTED.— For purposes of this subsection— 

‘‘(A) IN GENERAL.—The number of hours of service 

worked by, and wages paid to, a seasonal worker of an employer shall not be taken into account in determining the 

full-time equivalent employees and average annual wages 

of the employer unless the worker works for the employer 

on more than 120 days during the taxable year. 

‘‘(B) DEFINITION OF SEASONAL WORKER.—The term 

‘seasonal worker’ means a worker who performs labor or 

services on a seasonal basis as defined by the Secretary of 

Labor, including workers covered by section 500.20(s)(1) of 

title 29, Code of Federal Regulations and retail workers 

employed exclusively during holiday seasons. 

‘‘(e) OTHER RULES AND DEFINITIONS.—For purposes of this section— 

‘‘(1) EMPLOYEE.— ‘‘(A) CERTAIN EMPLOYEES EXCLUDED.—The term ‘employee’ shall not include— 

‘‘(i) an employee within the meaning of section 

401(c)(1), 

‘‘(ii) any 2-percent shareholder (as defined in section 1372(b)) of an eligible small business which is an 

S corporation, 

‘‘(iii) any 5-percent owner (as defined in section 

416(i)(1)(B)(i)) of an eligible small business, or 

‘‘(iv) any individual who bears any of the relationships described in subparagraphs (A) through (G) of 

section 152(d)(2) to, or is a dependent described in section 152(d)(2)(H) of, an individual described in clause 

(i), (ii), or (iii). 

‘‘(B) LEASED EMPLOYEES.—The term ‘employee’ shall 

include a leased employee within the meaning of section 

414(n). 

‘‘(2) CREDIT PERIOD.—The term ‘credit period’ means, with 

respect to any eligible small employer, the 2-consecutive-taxable year period beginning with the 1st taxable year in which 

the employer (or any predecessor) offers 1 or more qualified 

health plans to its employees through an Exchange. 

‘‘(3) NONELECTIVE CONTRIBUTION.—The term ‘nonelective 

contribution’ means an employer contribution other than an 

employer contribution pursuant to a salary reduction arrangement. 

‘‘(4) WAGES.—The term ‘wages’ has the meaning given 

such term by section 3121(a) (determined without regard to 

any dollar limitation contained in such section). 

‘‘(5) AGGREGATION AND OTHER RULES MADE APPLICABLE.— 
141 Sec. 1421 PPACA (Consolidated) \45R IRC 

‘‘(A) AGGREGATION RULES.—All employers treated as a 

single employer under subsection (b), (c), (m), or (o) of section 414 shall be treated as a single employer for purposes 

of this section. 

‘‘(B) OTHER RULES.—Rules similar to the rules of subsections (c), (d), and (e) of section 52 shall apply. 

‘‘(f) CREDIT MADE AVAILABLE TO TAX-EXEMPT ELIGIBLE SMALL

EMPLOYERS.— 

‘‘(1) IN GENERAL.—In the case of a tax-exempt eligible 

small employer, there shall be treated as a credit allowable 

under subpart C (and not allowable under this subpart) the 

lesser of— 

‘‘(A) the amount of the credit determined under this 

section with respect to such employer, or 

‘‘(B) the amount of the payroll taxes of the employer 

during the calendar year in which the taxable year begins. 

‘‘(2) TAX-EXEMPT ELIGIBLE SMALL EMPLOYER.—For purposes 

of this section, the term ‘tax-exempt eligible small employer’ 

means an eligible small employer which is any organization described in section 501(c) which is exempt from taxation under 

section 501(a). 

‘‘(3) PAYROLL TAXES.—For purposes of this subsection— 

‘‘(A) IN GENERAL.—The term ‘payroll taxes’ means— 

‘‘(i) amounts required to be withheld from the employees of the tax-exempt eligible small employer 

under section 3401(a), 

‘‘(ii) amounts required to be withheld from such 

employees under section 3101(b), and 

‘‘(iii) amounts of the taxes imposed on the tax-exempt eligible small employer under section 3111(b). 

‘‘(B) SPECIAL RULE.—A rule similar to the rule of section 24(d)(2)(C) shall apply for purposes of subparagraph 

(A). 

‘‘(g) APPLICATION OF SECTION FOR CALENDAR YEARS 2010, 2011, 

2012, AND 2013.—øAs revised by section 10105(e)(2)¿ In the case of 

any taxable year beginning in 2010, 2011, 2012, or 2013, the following modifications to this section shall apply in determining the 

amount of the credit under subsection (a): 

‘‘(1) NO CREDIT PERIOD REQUIRED.—The credit shall be determined without regard to whether the taxable year is in a 

credit period and for purposes of applying this section to taxable years beginning after 2013, no credit period shall be treated as beginning with a taxable year beginning before 2014. 

‘‘(2) AMOUNT OF CREDIT.—The amount of the credit determined under subsection (b) shall be determined— 

‘‘(A) by substituting ‘35 percent (25 percent in the case 

of a tax-exempt eligible small employer)’ for ‘50 percent (35 

percent in the case of a tax-exempt eligible small employer)’, 

‘‘(B) by reference to an eligible small employer’s nonelective contributions for premiums paid for health insurance coverage (within the meaning of section 9832(b)(1)) of 

an employee, and 
Sec. 1421 PPACA (Consolidated) 142 

‘‘(C) by substituting for the average premium determined under subsection (b)(2) the amount the Secretary of 

Health and Human Services determines is the average 

premium for the small group market in the State in which 

the employer is offering health insurance coverage (or for 

such area within the State as is specified by the Secretary). 

‘‘(3) CONTRIBUTION ARRANGEMENT.—An arrangement shall 

not fail to meet the requirements of subsection (d)(4) solely because it provides for the offering of insurance outside of an Exchange. 

‘‘(h) INSURANCE DEFINITIONS.—Any term used in this section 

which is also used in the Public Health Service Act or subtitle A 

of title I of the Patient Protection and Affordable Care Act shall 

have the meaning given such term by such Act or subtitle. 

‘‘(i) REGULATIONS.—The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section, including regulations to prevent the avoidance of the 2-year 

limit on the credit period through the use of successor entities and 

the avoidance of the limitations under subsection (c) through the 

use of multiple entities.’’. 

(b) CREDIT TO BE PART OF GENERAL BUSINESS CREDIT.—Section 38(b) of the Internal Revenue Code of 1986 (relating to current 

year business credit) is amended by striking ‘‘plus’’ at the end of 

paragraph (34), by striking the period at the end of paragraph (35) 

and inserting ‘‘, plus’’, and by inserting after paragraph (35) the following: 

‘‘(36) the small employer health insurance credit determined under section 45R.’’. 

(c) CREDIT ALLOWED AGAINST ALTERNATIVE MINIMUM TAX.— 

Section 38(c)(4)(B) of the Internal Revenue Code of 1986 (defining 

specified credits) is amended by redesignating clauses (vi), (vii), 

and (viii) as clauses (vii), (viii), and (ix), respectively, and by inserting after clause (v) the following new clause: 

‘‘(vi) the credit determined under section 45R,’’. 

(d) DISALLOWANCE OF DEDUCTION FOR CERTAIN EXPENSES FOR

WHICH CREDIT ALLOWED.— 

(1) IN GENERAL.—Section 280C of the Internal Revenue 

Code of 1986 (relating to disallowance of deduction for certain 

expenses for which credit allowed), as amended by section 

1401(b), is amended by adding at the end the following new 

subsection: 

‘‘(h) CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF

SMALL EMPLOYERS.—øAs revised by section 10105(e)(3)¿ No deduction shall be allowed for that portion of the premiums for qualified 

health plans (as defined in section 1301(a) of the Patient Protection 

and Affordable Care Act), or for health insurance coverage in the 

case of taxable years beginning in 2010, 2011, 2012, or 2013, paid 

by an employer which is equal to the amount of the credit determined under section 45R(a) with respect to the premiums.’’. 

(2) DEDUCTION FOR EXPIRING CREDITS.—Section 196(c) of 

such Code is amended by striking ‘‘and’’ at the end of paragraph (12), by striking the period at the end of paragraph (13) 
143 Sec. 1501 PPACA (Consolidated) 

and inserting ‘‘, and’’, and by adding at the end the following 

new paragraph: 

‘‘(14) the small employer health insurance credit determined under section 45R(a).’’. 

(e) CLERICAL AMENDMENT.—The table of sections for subpart D 

of part IV of subchapter A of chapter 1 of the Internal Revenue 

Code of 1986 is amended by adding at the end the following: 

‘‘Sec. 45R. Employee health insurance expenses of small employers.’’. 

(f) EFFECTIVE DATES.—øAs revised by section 10105(e)(4)¿ 

(1) IN GENERAL.—The amendments made by this section 

shall apply to amounts paid or incurred in taxable years beginning after December 31, 2009. 

(2) MINIMUM TAX.—The amendments made by subsection 

(c) shall apply to credits determined under section 45R of the 

Internal Revenue Code of 1986 in taxable years beginning after 

December 31, 2009, and to carrybacks of such credits. 

Subtitle F—Shared Responsibility for 

Health Care 

PART I—INDIVIDUAL RESPONSIBILITY 

SEC. 1501. ø42 U.S.C. 18091¿ REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE. 

(a) FINDINGS.—Congress makes the following findings: 

(1) IN GENERAL.—The individual responsibility requirement provided for in this section (in this subsection referred to 

as the ‘‘requirement’’) is commercial and economic in nature, 

and substantially affects interstate commerce, as a result of 

the effects described in paragraph (2). 

(2) EFFECTS ON THE NATIONAL ECONOMY AND INTERSTATE

COMMERCE.—øReplaced by section 10106(a)¿ 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. 
Sec. 1501 PPACA (Consolidated) 144 

(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 employerbased 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. 
145 Sec. 1501 PPACA (Consolidated) 

(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. 

(3) SUPREME COURT RULING.—In United States v. SouthEastern Underwriters Association (322 U.S. 533 (1944)), the 

Supreme Court of the United States ruled that insurance is 

interstate commerce subject to Federal regulation. 

(b) IN GENERAL.—Subtitle D of the Internal Revenue Code of 

1986 is amended by adding at the end the following new chapter: 

‘‘CHAPTER 48—MAINTENANCE OF MINIMUM ESSENTIAL 

COVERAGE 

Sec. 1501\5000A IRC 

‘‘Sec. 5000A. Requirement to maintain minimum essential coverage. 

‘‘SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE. 

‘‘(a) REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.—An applicable individual shall for each month beginning 

after 2013 ensure that the individual, and any dependent of the individual who is an applicable individual, is covered under minimum essential coverage for such month. 

‘‘(b) SHARED RESPONSIBILITY PAYMENT.— 

‘‘(1) IN GENERAL.—øReplaced by section 10106(b)¿ 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) INCLUSION WITH RETURN.—Any penalty imposed by 

this section with respect to any month shall be included with 

a taxpayer’s return under chapter 1 for the taxable year which 

includes such month. 

‘‘(3) PAYMENT OF PENALTY.—If an individual with respect 

to whom a penalty is imposed by this section for any month— 

‘‘(A) is a dependent (as defined in section 152) of another taxpayer for the other taxpayer’s taxable year including such month, such other taxpayer shall be liable for 

such penalty, or 

‘‘(B) files a joint return for the taxable year including 

such month, such individual and the spouse of such individual shall be jointly liable for such penalty. 

‘‘(c) AMOUNT OF PENALTY.—øParagraphs (1) and (2) were revised in their entirety by section 10106(b)(2)¿ 
Sec. 1501 PPACA (Consolidated) 146 

‘‘(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.—øAs revised by section 

1002(a)(1) of HCERA¿ An amount equal to the following 

percentage of the excess of the taxpayer’s household income for the taxable year over the amount of gross income 

specified in section 6012(a)(1) with respect to the taxpayer 

for the taxable year: 

‘‘(i) 1.0 percent for taxable years beginning in 

2014. 

‘‘(ii) 2.0 percent for taxable years beginning in 

2015. 

‘‘(iii) 2.5 percent for taxable years beginning after 

2015. 

‘‘(3) APPLICABLE DOLLAR AMOUNT.—øAs revised by section 

10106(b)(3) and by section 1002(a)(2) of HCERA¿ For purposes 

of paragraph (1)— 

‘‘(A) IN GENERAL.—Except as provided in subparagraphs (B) and (C), the applicable dollar amount is $695. 

‘‘(B) PHASE IN.—The applicable dollar amount is $95 

for 2014 and $325 for 2015. 

‘‘(C) SPECIAL RULE FOR INDIVIDUALS UNDER AGE 18.— 

If an applicable individual has not attained the age of 18 

as of the beginning of a month, the applicable dollar 

amount with respect to such individual for the month shall 

be equal to one-half of the applicable dollar amount for the 

calendar year in which the month occurs. 

‘‘(D) INDEXING OF AMOUNT.—In the case of any calendar year beginning after 2016, the applicable dollar 
147 Sec. 1501 PPACA (Consolidated) 

amount shall be equal to $695, increased by an amount 

equal to— 

‘‘(i) $695, multiplied by 

‘‘(ii) the cost-of-living adjustment determined 

under section 1(f)(3) for the calendar year, determined 

by substituting ‘calendar year 2015’ for ‘calendar year 

1992’ in subparagraph (B) thereof. 

If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next 

lowest multiple of $50. 

‘‘(4) TERMS RELATING TO INCOME AND FAMILIES.—For purposes of this section— 

‘‘(A) FAMILY SIZE.—The family size involved with respect to any taxpayer shall be equal to the number of individuals for whom the taxpayer is allowed a deduction 

under section 151 (relating to allowance of deduction for 

personal exemptions) for the taxable year. 

‘‘(B) HOUSEHOLD INCOME.—The term ‘household income’ means, with respect to any taxpayer for any taxable 

year, an amount equal to the sum of—øshown to reflect 

probable amendment made by section 1004(a)(1)(C) of 

HCERA¿ 

‘‘(i) the modified adjusted gross income of the taxpayer, plus 

‘‘(ii) the aggregate modified adjusted gross incomes of all other individuals who— 

‘‘(I) were taken into account in determining 

the taxpayer’s family size under paragraph (1), 

and 

‘‘(II) were required to file a return of tax imposed by section 1 for the taxable year. 

‘‘(C) MODIFIED ADJUSTED GROSS INCOME.—øReplaced 

by section 1004(a)(2)(B)¿ The term ‘modified adjusted gross 

income’ means adjusted gross income increased by— 

‘‘(i) any amount excluded from gross income under 

section 911, and 

‘‘(ii) any amount of interest received or accrued by 

the taxpayer during the taxable year which is exempt 

from tax. 

‘‘(d) APPLICABLE INDIVIDUAL.—For purposes of this section— 

‘‘(1) IN GENERAL.—The term ‘applicable individual’ means, 

with respect to any month, an individual other than an individual described in paragraph (2), (3), or (4). 

‘‘(2) RELIGIOUS EXEMPTIONS.— 

‘‘(A) RELIGIOUS CONSCIENCE EXEMPTION.—øReplaced 

by section 10106(c)¿ 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 
Sec. 1501 PPACA (Consolidated) 148 

‘‘(ii) an adherent of established tenets or teachings 

of such sect or division as described in such section. 

‘‘(B) HEALTH CARE SHARING MINISTRY.— ‘‘(i) IN GENERAL.—Such term shall not include any 

individual for any month if such individual is a member of a health care sharing ministry for the month. 

‘‘(ii) HEALTH CARE SHARING MINISTRY.—The term 

‘health care sharing ministry’ means an organization— 

‘‘(I) which is described in section 501(c)(3) and 

is exempt from taxation under section 501(a), 

‘‘(II) members of which share a common set of 

ethical or religious beliefs and share medical expenses among members in accordance with those 

beliefs and without regard to the State in which 

a member resides or is employed, 

‘‘(III) members of which retain membership 

even after they develop a medical condition, 

‘‘(IV) which (or a predecessor of which) has 

been in existence at all times since December 31, 

1999, and medical expenses of its members have 

been shared continuously and without interruption since at least December 31, 1999, and 

‘‘(V) which conducts an annual audit which is 

performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request. 

‘‘(3) INDIVIDUALS NOT LAWFULLY PRESENT.—Such term 

shall not include an individual for any month if for the month 

the individual is not a citizen or national of the United States 

or an alien lawfully present in the United States. 

‘‘(4) INCARCERATED INDIVIDUALS.—Such term shall not include an individual for any month if for the month the individual is incarcerated, other than incarceration pending the 

disposition of charges. 

‘‘(e) EXEMPTIONS.—No penalty shall be imposed under subsection (a) with respect to— 

‘‘(1) INDIVIDUALS WHO CANNOT AFFORD COVERAGE.— 

‘‘(A) IN GENERAL.—Any applicable individual for any 

month if the applicable individual’s required contribution 

(determined on an annual basis) for coverage for the 

month exceeds 8 percent of such individual’s household income for the taxable year described in section 1412(b)(1)(B) 

of the Patient Protection and Affordable Care Act. For purposes of applying this subparagraph, the taxpayer’s household income shall be increased by any exclusion from gross 

income for any portion of the required contribution made 

through a salary reduction arrangement. 

‘‘(B) REQUIRED CONTRIBUTION.—For purposes of this 

paragraph, the term ‘required contribution’ means— 

‘‘(i) in the case of an individual eligible to purchase minimum essential coverage consisting of coverage through an eligible-employer-sponsored plan, the 
149 Sec. 1501 PPACA (Consolidated) 

portion of the annual premium which would be paid 

by the individual (without regard to whether paid 

through salary reduction or otherwise) for self-only 

coverage, or 

‘‘(ii) in the case of an individual eligible only to 

purchase minimum essential coverage described in 

subsection (f)(1)(C), the annual premium for the lowest 

cost bronze plan available in the individual market 

through the Exchange in the State in the rating area 

in which the individual resides (without regard to 

whether the individual purchased a qualified health 

plan through the Exchange), reduced by the amount of 

the credit allowable under section 36B for the taxable 

year (determined as if the individual was covered by 

a qualified health plan offered through the Exchange 

for the entire taxable year). 

‘‘(C) SPECIAL RULES FOR INDIVIDUALS RELATED TO EM- PLOYEES.—øReplaced by section 10106(d)¿ 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. 

‘‘(D) INDEXING.—In the case of plan years beginning in 

any calendar year after 2014, subparagraph (A) shall be 

applied by substituting for ‘8 percent’ the percentage the 

Secretary of Health and Human Services determines reflects the excess of the rate of premium growth between 

the preceding calendar year and 2013 over the rate of income growth for such period. 

‘‘(2) TAXPAYERS WITH INCOME BELOW FILING THRESHOLD.— 

øAs revised by section 1002(b)(2) of HCERA¿ Any applicable individual for any month during a calendar year if the individual’s household income for the taxable year described in section 

1412(b)(1)(B) of the Patient Protection and Affordable Care Act 

is less than the amount of gross income specified in section 

6012(a)(1) with respect to the taxpayer. 

‘‘(3) MEMBERS OF INDIAN TRIBES.—Any applicable individual for any month during which the individual is a member 

of an Indian tribe (as defined in section 45A(c)(6)). 

‘‘(4) MONTHS DURING SHORT COVERAGE GAPS.— 

‘‘(A) IN GENERAL.—Any month the last day of which 

occurred during a period in which the applicable individual 

was not covered by minimum essential coverage for a continuous period of less than 3 months. 

‘‘(B) SPECIAL RULES.—For purposes of applying this 

paragraph— 

‘‘(i) the length of a continuous period shall be determined without regard to the calendar years in 

which months in such period occur, 

‘‘(ii) if a continuous period is greater than the period allowed under subparagraph (A), no exception 

shall be provided under this paragraph for any month 

in the period, and 
Sec. 1501 PPACA (Consolidated) 150 

‘‘(iii) if there is more than 1 continuous period described in subparagraph (A) covering months in a calendar year, the exception provided by this paragraph 

shall only apply to months in the first of such periods. 

The Secretary shall prescribe rules for the collection of the 

penalty imposed by this section in cases where continuous 

periods include months in more than 1 taxable year. 

‘‘(5) HARDSHIPS.—Any applicable individual who for any 

month is determined by the Secretary of Health and Human 

Services under section 1311(d)(4)(H) to have suffered a hardship with respect to the capability to obtain coverage under a 

qualified health plan. 

‘‘(f) MINIMUM ESSENTIAL COVERAGE.—For purposes of this section— 

‘‘(1) IN GENERAL.—The term ‘minimum essential coverage’ 

means any of the following: 

‘‘(A) GOVERNMENT SPONSORED PROGRAMS.—øreflects 

amendments by Public Laws 111–159 and 111–173¿ Coverage under— 

‘‘(i) the Medicare program under part A of title 

XVIII of the Social Security Act, 

‘‘(ii) the Medicaid program under title XIX of the 

Social Security Act, 

‘‘(iii) the CHIP program under title XXI of the Social Security Act, 

‘‘(iv) medical coverage under chapter 55 of title 10, 

United States Code, including coverage under the 

TRICARE program; øsic¿ 

‘‘(v) a health care program under chapter 17 of 

title 38, United States Code, as determined by the Secretary of Veterans Affairs, in coordination with the 

Secretary of Health and Human Services and the Secretary, 

‘‘(vi) a health plan under section 2504(e) of title 

22, United States Code (relating to Peace Corps volunteers); øsic¿ or 

‘‘(vii) the Nonappropriated Fund Health Benefits 

Program of the Department of Defense, established 

under section 349 of the National Defense Authorization Act for Fiscal Year 1995 (Public Law 103–337; 10 

U.S.C. 1587 note). 

‘‘(B) EMPLOYER-SPONSORED PLAN.—Coverage under an 

eligible employer-sponsored plan. 

‘‘(C) PLANS IN THE INDIVIDUAL MARKET.—Coverage 

under a health plan offered in the individual market within a State. 

‘‘(D) GRANDFATHERED HEALTH PLAN.—Coverage under 

a grandfathered health plan. 

‘‘(E) OTHER COVERAGE.—Such other health benefits 

coverage, such as a State health benefits risk pool, as the 

Secretary of Health and Human Services, in coordination 

with the Secretary, recognizes for purposes of this subsection. 
151 Sec. 1501 PPACA (Consolidated) 

‘‘(2) ELIGIBLE EMPLOYER-SPONSORED PLAN.—The term ‘eligible employer-sponsored plan’ means, with respect to any employee, a group health plan or group health insurance coverage 

offered by an employer to the employee which is— 

‘‘(A) a governmental plan (within the meaning of section 2791(d)(8) of the Public Health Service Act), or 

‘‘(B) any other plan or coverage offered in the small or 

large group market within a State. 

Such term shall include a grandfathered health plan described 

in paragraph (1)(D) offered in a group market. 

‘‘(3) EXCEPTED BENEFITS NOT TREATED AS MINIMUM ESSENTIAL COVERAGE.—The term ‘minimum essential coverage’ shall 

not include health insurance coverage which consists of coverage of excepted benefits— 

‘‘(A) described in paragraph (1) of subsection (c) of section 2791 of the Public Health Service Act; or 

‘‘(B) described in paragraph (2), (3), or (4) of such subsection if the benefits are provided under a separate policy, 

certificate, or contract of insurance. 

‘‘(4) INDIVIDUALS RESIDING OUTSIDE UNITED STATES OR

RESIDENTS OF TERRITORIES.—Any applicable individual shall be 

treated as having minimum essential coverage for any 

month— 

‘‘(A) if such month occurs during any period described 

in subparagraph (A) or (B) of section 911(d)(1) which is applicable to the individual, or 

‘‘(B) if such individual is a bona fide resident of any 

possession of the United States (as determined under section 937(a)) for such month. 

‘‘(5) INSURANCE-RELATED TERMS.—Any term used in this 

section which is also used in title I of the Patient Protection 

and Affordable Care Act shall have the same meaning as when 

used in such title. 

‘‘(g) ADMINISTRATION AND PROCEDURE.— 

‘‘(1) IN GENERAL.—The penalty provided by this section 

shall be paid upon notice and demand by the Secretary, and 

except as provided in paragraph (2), shall be assessed and collected in the same manner as an assessable penalty under subchapter B of chapter 68. 

‘‘(2) SPECIAL RULES.—Notwithstanding any other provision 

of law— 

‘‘(A) WAIVER OF CRIMINAL PENALTIES.—In the case of 

any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to 

any criminal prosecution or penalty with respect to such 

failure. 

‘‘(B) LIMITATIONS ON LIENS AND LEVIES.—The Secretary shall not— 

‘‘(i) file notice of lien with respect to any property 

of a taxpayer by reason of any failure to pay the penalty imposed by this section, or 

‘‘(ii) levy on any such property with respect to 

such failure.’’. 
Sec. 1501 PPACA (Consolidated) 152 

(c) CLERICAL AMENDMENT.—The table of chapters for subtitle 

D of the Internal Revenue Code of 1986 is amended by inserting 

after the item relating to chapter 47 the following new item: 

‘‘CHAPTER 48—MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE.’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years ending after December 31, 2013. 

SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE. 

(a) IN GENERAL.—Part III of subchapter A of chapter 61 of the 

Internal Revenue Code of 1986 is amended by inserting after subpart C the following new subpart: 

‘‘Subpart D—Information Regarding Health 

Insurance Coverage 

‘‘Sec. 6055. Reporting of health insurance coverage. 

‘‘SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE. 

‘‘(a) IN GENERAL.—Every person who provides minimum essential coverage to an individual during a calendar year shall, at such 

time as the Secretary may prescribe, make a return described in 

subsection (b). 

‘‘(b) FORM AND MANNER OF RETURN.— ‘‘(1) IN GENERAL.—A return is described in this subsection 

if such return— 

‘‘(A) is in such form as the Secretary may prescribe, 

and 

‘‘(B) contains— 

‘‘(i) the name, address and TIN of the primary insured and the name and TIN of each other individual 

obtaining coverage under the policy, 

‘‘(ii) the dates during which such individual was 

covered under minimum essential coverage during the 

calendar year, 

‘‘(iii) in the case of minimum essential coverage 

which consists of health insurance coverage, information concerning— 

‘‘(I) whether or not the coverage is a qualified 

health plan offered through an Exchange established under section 1311 of the Patient Protection 

and Affordable Care Act, and 

‘‘(II) in the case of a qualified health plan, the 

amount (if any) of any advance payment under 

section 1412 of the Patient Protection and Affordable Care Act of any cost-sharing reduction under 

section 1402 of such Act or of any premium tax 

credit under section 36B with respect to such coverage, and 

‘‘(iv) such other information as the Secretary may 

require. 

‘‘(2) INFORMATION RELATING TO EMPLOYER-PROVIDED COVERAGE.—If minimum essential coverage provided to an individual under subsection (a) consists of health insurance coverage of a health insurance issuer provided through a group 
153 Sec. 1502 PPACA (Consolidated) 

health plan of an employer, a return described in this subsection shall include— 

‘‘(A) the name, address, and employer identification 

number of the employer maintaining the plan, 

‘‘(B) the portion of the premium (if any) required to be 

paid by the employer, and 

‘‘(C) if the health insurance coverage is a qualified 

health plan in the small group market offered through an 

Exchange, such other information as the Secretary may require for administration of the credit under section 45R 

(relating to credit for employee health insurance expenses 

of small employers). 

‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVIDUALS WITH RESPECT TO WHOM INFORMATION IS REPORTED.— 

‘‘(1) IN GENERAL.—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— 

‘‘(A) the name and address of the person required to 

make such return and the phone number of the information contact for such person, and 

‘‘(B) the information required to be shown on the return with respect to such individual. 

‘‘(2) TIME FOR FURNISHING STATEMENTS.—The written 

statement required under paragraph (1) shall be furnished on 

or before January 31 of the year following the calendar year 

for which the return under subsection (a) was required to be 

made. 

‘‘(d) COVERAGE PROVIDED BY GOVERNMENTAL UNITS.—In the 

case of coverage provided by any governmental unit or any agency 

or instrumentality thereof, the officer or employee who enters into 

the agreement to provide such coverage (or the person appropriately designated for purposes of this section) shall make the returns and statements required by this section. 

‘‘(e) MINIMUM ESSENTIAL COVERAGE.—For purposes of this section, the term ‘minimum essential coverage’ has the meaning given 

such term by section 5000A(f).’’. 

(b) ASSESSABLE PENALTIES.— 

(1) Subparagraph (B) of section 6724(d)(1) of the Internal 

Revenue Code of 1986 (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 6055 (relating to returns relating to 

information regarding health insurance coverage), 

and’’. 

(2) Paragraph (2) of section 6724(d) of such Code is amended by striking ‘‘or’’ at the end of subparagraph (EE), by striking the period at the end of subparagraph (FF) and inserting 

‘‘, or’’ and by inserting after subparagraph (FF) the following 

new subparagraph: 

‘‘(GG) section 6055(c) (relating to statements relating 

to information regarding health insurance coverage).’’. 
Sec. 1511 PPACA (Consolidated) 154 

(c) NOTIFICATION OF NONENROLLMENT.—Not later than June 

30 of each year, the Secretary of the Treasury, acting through the 

Internal Revenue Service and in consultation with the Secretary of 

Health and Human Services, shall send a notification to each individual who files an individual income tax return and who is not enrolled in minimum essential coverage (as defined in section 5000A 

of the Internal Revenue Code of 1986). Such notification shall contain information on the services available through the Exchange 

operating in the State in which such individual resides. 

(d) CONFORMING AMENDMENT.—The table of subparts for part 

III of subchapter A of chapter 61 of such Code is amended by inserting after the item relating to subpart C the following new item: 

‘‘SUBPART D—INFORMATION REGARDING HEALTH INSURANCE COVERAGE’’. 

(e) EFFECTIVE DATE.—The amendments made by this section 

shall apply to calendar years beginning after 2013. 

PART II—EMPLOYER RESPONSIBILITIES 

SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE EMPLOYERS. 

The Fair Labor Standards Act of 1938 is amended by inserting 

after section 18 (29 U.S.C. 218) the following: 

‘‘SEC. 18A. ø29 U.S.C. 218a¿ AUTOMATIC ENROLLMENT FOR EMPLOYEES 

OF LARGE EMPLOYERS. 

‘‘In accordance with regulations promulgated by the Secretary, 

an employer to which this Act applies that has more than 200 fulltime employees and that offers employees enrollment in 1 or more 

health benefits plans shall automatically enroll new full-time employees in one of the plans offered (subject to any waiting period 

authorized by law) and to continue the enrollment of current employees in a health benefits plan offered through the employer. Any 

automatic enrollment program shall include adequate notice and 

the opportunity for an employee to opt out of any coverage the individual or employee were automatically enrolled in. Nothing in this 

section shall be construed to supersede any State law which establishes, implements, or continues in effect any standard or requirement relating to employers in connection with payroll except to the 

extent that such standard or requirement prevents an employer 

from instituting the automatic enrollment program under this section.’’. 

SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF 

COVERAGE OPTIONS. 

The Fair Labor Standards Act of 1938 is amended by inserting 

after section 18A (as added by section 1513) the following: 

‘‘SEC. 18B. ø29 U.S.C. 218b¿ NOTICE TO EMPLOYEES. 

‘‘(a) IN GENERAL.—In accordance with regulations promulgated 

by the Secretary, an employer to which this Act applies, shall provide to each employee at the time of hiring (or with respect to current employees, not later than March 1, 2013), written notice— 

‘‘(1) informing the employee of the existence of an Exchange, including a description of the services provided by such 
155 Sec. 1513 PPACA (Consolidated) \4980H IRC 

Exchange, and the manner in which the employee may contact 

the Exchange to request assistance; 

‘‘(2) if the employer plan’s share of the total allowed costs 

of benefits provided under the plan is less than 60 percent of 

such costs, that the employee may be eligible for a premium 

tax credit under section 36B of the Internal Revenue Code of 

1986 and a cost sharing reduction under section 1402 of the 

Patient Protection and Affordable Care Act if the employee 

purchases a qualified health plan through the Exchange; and 

‘‘(3) øAs revised by section 10108(i)(2)¿ if the employee purchases a qualified health plan through the Exchange and the 

employer does not offer a free choice voucher, the employee 

may lose the employer contribution (if any) to any health benefits plan offered by the employer and that all or a portion of 

such contribution may be excludable from income for Federal 

income tax purposes. 

‘‘(b) EFFECTIVE DATE.—Subsection (a) shall take effect with respect to employers in a State beginning on March 1, 2013.’’. 

SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS. 

(a) IN GENERAL.—Chapter 43 of the Internal Revenue Code of 

1986 is amended by adding at the end the following: 

‘‘SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING 

HEALTH COVERAGE. 

‘‘(a) LARGE EMPLOYERS NOT OFFERING HEALTH COVERAGE.— If— 

‘‘(1) any applicable large employer fails to offer to its fulltime employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employersponsored plan (as defined in section 5000A(f)(2)) for any 

month, and 

‘‘(2) at least one full-time employee of the applicable large 

employer has been certified to the employer under section 1411 

of the Patient Protection and Affordable Care Act as having enrolled for such month in a qualified health plan with respect 

to which an applicable premium tax credit or cost-sharing reduction is allowed or paid with respect to the employee, 

then there is hereby imposed on the employer an assessable payment equal to the product of the applicable payment amount and 

the number of individuals employed by the employer as full-time 

employees during such month. 

ø‘‘(b) LARGE EMPLOYERS WITH WAITING PERIODS EXCEEDING 60 

DAYS.—øReplaced first by section 10106(e) and stricken by section 

1003(d) of HCERA and succeeding subsections were redesignated 

accordingly¿¿ 

‘‘(b) LARGE EMPLOYERS OFFERING COVERAGE WITH EMPLOYEES

WHO QUALIFY FOR PREMIUM TAX CREDITS OR COST-SHARING RE- DUCTIONS.— 

‘‘(1) IN GENERAL.—If— 

‘‘(A) an applicable large employer offers to its full-time 

employees (and their dependents) the opportunity to enroll 

in minimum essential coverage under an eligible employersponsored plan (as defined in section 5000A(f)(2)) for any 

month, and 
Sec. 1513\4980H IRC PPACA (Consolidated) 156 

‘‘(B) 1 or more full-time employees of the applicable 

large employer has been certified to the employer under 

section 1411 of the Patient Protection and Affordable Care 

Act as having enrolled for such month in a qualified health 

plan with respect to which an applicable premium tax 

credit or cost-sharing reduction is allowed or paid with respect to the employee, 

then there is hereby imposed on the employer an assessable 

payment equal to the product of the number of full-time employees of the applicable large employer described in subparagraph (B) for such month and an amount equal to 1⁄12 of 

$3,000. øAs revised by section 1003(b)(1) of HCERA¿ 

‘‘(2) OVERALL LIMITATION.—The aggregate amount of tax 

determined under paragraph (1) with respect to all employees 

of an applicable large employer for any month shall not exceed 

the product of the applicable payment amount and the number 

of individuals employed by the employer as full-time employees 

during such month. 

‘‘(3) SPECIAL RULES FOR EMPLOYERS PROVIDING FREE

CHOICE VOUCHERS.—øAs added by section 10108(i)(1)¿ 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. 

‘‘(c) DEFINITIONS AND SPECIAL RULES.—For purposes of this 

section— 

‘‘(1) APPLICABLE PAYMENT AMOUNT.—The term ‘applicable 

payment amount’ means, with respect to any month, 1⁄12 of 

$2,000. øAs revised by section 1003(b)(2) of HCERA¿ 

‘‘(2) APPLICABLE LARGE EMPLOYER.— 

‘‘(A) IN GENERAL.—The term ‘applicable large employer’ means, with respect to a calendar year, an employer who employed an average of at least 50 full-time 

employees on business days during the preceding calendar 

year. 

‘‘(B) EXEMPTION FOR CERTAIN EMPLOYERS.— 

‘‘(i) IN GENERAL.—An employer shall not be considered to employ more than 50 full-time employees if— 

‘‘(I) the employer’s workforce exceeds 50 fulltime employees for 120 days or fewer during the 

calendar year, and 

‘‘(II) the employees in excess of 50 employed 

during such 120-day period were seasonal workers. 

‘‘(ii) DEFINITION OF SEASONAL WORKERS.—The 

term ‘seasonal worker’ means a worker who performs 

labor or services on a seasonal basis as defined by the 

Secretary of Labor, including workers covered by section 500.20(s)(1) of title 29, Code of Federal Regulations and retail workers employed exclusively during 

holiday seasons. 

‘‘(C) RULES FOR DETERMINING EMPLOYER SIZE.—For 

purposes of this paragraph— 
157 Sec. 1513 PPACA (Consolidated) \4980H IRC 

‘‘(i) APPLICATION OF AGGREGATION RULE FOR EM- PLOYERS.—All persons treated as a single employer 

under subsection (b), (c), (m), or (o) of section 414 of 

the Internal Revenue Code of 1986 shall be treated as 

1 employer. 

‘‘(ii) EMPLOYERS NOT IN EXISTENCE IN PRECEDING

YEAR.—In the case of an employer which was not in 

existence throughout the preceding calendar year, the 

determination of whether such employer is an applicable large employer shall be based on the average number of employees that it is reasonably expected such 

employer will employ on business days in the current 

calendar year. 

‘‘(iii) PREDECESSORS.—Any reference in this subsection to an employer shall include a reference to any 

predecessor of such employer. 

øPrevious subparagraph (D), relating to application to construction industry employers, added by section 10106 but replaced, as 

shown below, by section 1003(a) of HCERA¿ 

‘‘(D) APPLICATION OF EMPLOYER SIZE TO ASSESSABLE

PENALTIES.— 

‘‘(i) IN GENERAL.—The number of individuals employed by an applicable large employer as full-time 

employees during any month shall be reduced by 30 

solely for purposes of calculating— 

‘‘(I) the assessable payment under subsection 

(a), or 

‘‘(II) the overall limitation under subsection 

(b)(2). 

‘‘(ii) AGGREGATION.—In the case of persons treated 

as 1 employer under subparagraph (C)(i), only 1 reduction under subclause (I) or (II) shall be allowed with 

respect to such persons and such reduction shall be allocated among such persons ratably on the basis of the 

number of full-time employees employed by each such 

person. 

‘‘(E) FULL-TIME EQUIVALENTS TREATED AS FULL-TIME

EMPLOYEES.—øAs added by section 1003(c) of HCERA¿ 

Solely for purposes of determining whether an employer is 

an applicable large employer under this paragraph, an employer shall, in addition to the number of full-time employees for any month otherwise determined, include for such 

month a number of full-time employees determined by dividing the aggregate number of hours of service of employees who are not full-time employees for the month by 120. 

‘‘(3) APPLICABLE PREMIUM TAX CREDIT AND COST-SHARING

REDUCTION.—The term ‘applicable premium tax credit and 

cost-sharing reduction’ means— 

‘‘(A) any premium tax credit allowed under section 

36B, 

‘‘(B) any cost-sharing reduction under section 1402 of 

the Patient Protection and Affordable Care Act, and 

‘‘(C) any advance payment of such credit or reduction 

under section 1412 of such Act. 
Sec. 1513 PPACA (Consolidated) 158 

‘‘(4) FULL-TIME EMPLOYEE.— 

‘‘(A) IN GENERAL.—øAs revised by section 10106(f)(1)¿ 

The term ‘full-time employee’ means, with respect to any 

month, an employee who is employed on average at least 

30 hours of service per week. 

‘‘(B) HOURS OF SERVICE.—The Secretary, in consultation with the Secretary of Labor, shall prescribe such regulations, rules, and guidance as may be necessary to determine the hours of service of an employee, including rules 

for the application of this paragraph to employees who are 

not compensated on an hourly basis. 

‘‘(5) INFLATION ADJUSTMENT.— 

‘‘(A) IN GENERAL.—In the case of any calendar year 

after 2014, each of the dollar amounts in subsection (b) 

and paragraph (1) shall be increased by an amount equal 

to the product of—øAs revised by section 1003(a)(3) of 

HCERA¿ 

‘‘(i) such dollar amount, and 

‘‘(ii) the premium adjustment percentage (as defined in section 1302(c)(4) of the Patient Protection 

and Affordable Care Act) for the calendar year. 

‘‘(B) ROUNDING.—If the amount of any increase under 

subparagraph (A) is not a multiple of $10, such increase 

shall be rounded to the next lowest multiple of $10. 

‘‘(6) OTHER DEFINITIONS.—Any term used in this section 

which is also used in the Patient Protection and Affordable 

Care Act shall have the same meaning as when used in such 

Act. 

‘‘(7) TAX NONDEDUCTIBLE.—For denial of deduction for the 

tax imposed by this section, see section 275(a)(6). 

‘‘(d) ADMINISTRATION AND PROCEDURE.— 

‘‘(1) IN GENERAL.—Any assessable payment provided by 

this section shall be paid upon notice and demand by the Secretary, and shall be assessed and collected in the same manner 

as an assessable penalty under subchapter B of chapter 68. 

‘‘(2) TIME FOR PAYMENT.—The Secretary may provide for 

the payment of any assessable payment provided by this section on an annual, monthly, or other periodic basis as the Secretary may prescribe. 

‘‘(3) COORDINATION WITH CREDITS, ETC..—The Secretary 

shall prescribe rules, regulations, or guidance for the repayment of any assessable payment (including interest) if such 

payment is based on the allowance or payment of an applicable 

premium tax credit or cost-sharing reduction with respect to an 

employee, such allowance or payment is subsequently disallowed, and the assessable payment would not have been required to be made but for such allowance or payment.’’. 

(b) CLERICAL AMENDMENT.—The table of sections for chapter 

43 of such Code is amended by adding at the end the following new 

item: 

‘‘Sec. 4980H. Shared responsibility for employers regarding health coverage.’’. 

(c) STUDY AND REPORT OF EFFECT OF TAX ON WORKERS’ 

WAGES.— 
159 Sec. 1514 PPACA (Consolidated) \6056 IRC 

(1) IN GENERAL.—The Secretary of Labor shall conduct a 

study to determine whether employees’ wages are reduced by 

reason of the application of the assessable payments under section 4980H of the Internal Revenue Code of 1986 (as added by 

the amendments made by this section). The Secretary shall 

make such determination on the basis of the National Compensation Survey published by the Bureau of Labor Statistics. 

(2) REPORT.—The Secretary shall report the results of the 

study under paragraph (1) to the Committee on Ways and 

Means of the House of Representatives and to the Committee 

on Finance of the Senate. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to months beginning after December 31, 2013. 

SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE. 

(a) IN GENERAL.—Subpart D of part III of subchapter A of 

chapter 61 of the Internal Revenue Code of 1986, as added by section 1502, is amended by inserting after section 6055 the following 

new section: 

‘‘SEC. 6056. CERTAIN EMPLOYERS REQUIRED TO REPORT ON HEALTH 

INSURANCE COVERAGE. 

øHeading revised by section 10108(j)(3)(A)¿ 

‘‘(a) IN GENERAL.—øAs revised by section 10108(j)(1)¿ Every applicable large employer required to meet the requirements of section 4980H with respect to its full-time employees during a calendar year and every offering employer shall, at such time as the 

Secretary may prescribe, make a return described in subsection (b). 

‘‘(b) FORM AND MANNER OF RETURN.—A return is described in 

this subsection if such return— 

‘‘(1) is in such form as the Secretary may prescribe, and 

‘‘(2) contains— 

‘‘(A) the name, date, and employer identification number of the employer, 

‘‘(B) a certification as to whether the employer offers 

to its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under 

an eligible employer-sponsored plan (as defined in section 

5000A(f)(2)), 

‘‘(C) øAs revised by section 10108(j)(3)(B), including 

addition of clause (v)¿ if the employer certifies that the 

employer did offer to its full-time employees (and their dependents) the opportunity to so enroll— 

‘‘(i) in the case of an applicable large employer, 

the length of any waiting period (as defined in section 

2701(b)(4) of the Public Health Service Act) with respect to such coverage, 

‘‘(ii) the months during the calendar year for 

which coverage under the plan was available, 

‘‘(iii) the monthly premium for the lowest cost option in each of the enrollment categories under the 

plan, 

‘‘(iv) the employer’s share of the total allowed 

costs of benefits provided under the plan, and 
Sec. 1514\6056 IRC PPACA (Consolidated) 160 

‘‘(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, 

‘‘(D) the number of full-time employees for each month 

during the calendar year, 

‘‘(E) the name, address, and TIN of each full-time employee during the calendar year and the months (if any) 

during which such employee (and any dependents) were 

covered under any such health benefits plans, and 

‘‘(F) such other information as the Secretary may require. 

øSentence added by section 10106(g)¿ 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). 

‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVIDUALS WITH RESPECT TO WHOM INFORMATION IS REPORTED.— 

‘‘(1) IN GENERAL.—Every person required to make a return 

under subsection (a) shall furnish to each full-time employee 

whose name is required to be set forth in such return under 

subsection (b)(2)(E) a written statement showing— 

‘‘(A) the name and address of the person required to 

make such return and the phone number of the information contact for such person, and 

‘‘(B) the information required to be shown on the return with respect to such individual. 

‘‘(2) TIME FOR FURNISHING STATEMENTS.—The written 

statement required under paragraph (1) shall be furnished on 

or before January 31 of the year following the calendar year 

for which the return under subsection (a) was required to be 

made. 

‘‘(d) COORDINATION WITH OTHER REQUIREMENTS.—To the maximum extent feasible, the Secretary may provide that— 

‘‘(1) any return or statement required to be provided under 

this section may be provided as part of any return or statement required under section 6051 or 6055, and 

‘‘(2) øAs revised by section 10108(j)(3)(C)¿ in the case of an 

applicable large employer or offering employer offering health 

insurance coverage of a health insurance issuer, the employer 

may enter into an agreement with the issuer to include information required under this section with the return and statement required to be provided by the issuer under section 6055. 

‘‘(e) COVERAGE PROVIDED BY GOVERNMENTAL UNITS.—øAs revised by section 10108(j)(3)(D)¿ In the case of any applicable large 

employer or offering employer which is a governmental unit or any 

agency or instrumentality thereof, the person appropriately designated for purposes of this section shall make the returns and 

statements required by this section. 

‘‘(f) DEFINITIONS.—øReplaced by section 10108(j)(2)¿ For purposes of this section— 

‘‘(1) OFFERING EMPLOYER.— 
161 Sec. 1515 PPACA (Consolidated) 

‘‘(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.’’. 

(b) ASSESSABLE PENALTIES.— 

(1) Subparagraph (B) of section 6724(d)(1) of the Internal 

Revenue Code of 1986 (relating to definitions), as amended by 

section 1502, is amended by striking ‘‘or’’ at the end of clause 

(xxiii), by striking ‘‘and’’ at the end of clause (xxiv) and inserting ‘‘or’’, and by inserting after clause (xxiv) the following new 

clause: øClause revised by section 10108(j)(3)(E)¿ 

‘‘(xxv) section 6056 (relating to returns relating to 

certain employers required to report on health insurance coverage), and’’. 

(2) Paragraph (2) of section 6724(d) of such Code, as so 

amended, is amended by striking ‘‘or’’ at the end of subparagraph (FF), by striking the period at the end of subparagraph 

(GG) and inserting ‘‘, or’’ and by inserting after subparagraph 

(GG) the following new subparagraph: øAs revised by section 

10108(j)(3)(F)¿ 

‘‘(HH) section 6056(c) (relating to statements relating 

to certain employers required to report on health insurance coverage).’’. 

(c) CONFORMING AMENDMENT.—The table of sections for subpart D of part III of subchapter A of chapter 61 of such Code, as 

added by section 1502, is amended by adding at the end the following new item: øAs revised by section 10108(j)(3)(G)¿ 

‘‘Sec. 6056. Certain employers required to report on health insurance coverage.’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to periods beginning after December 31, 2013. 

SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED 

HEALTH PLANS THROUGH CAFETERIA PLANS. 

(a) IN GENERAL.—Subsection (f) of section 125 of the Internal 

Revenue Code of 1986 is amended by adding at the end the following new paragraph: 

‘‘(3) CERTAIN EXCHANGE-PARTICIPATING QUALIFIED HEALTH

PLANS NOT QUALIFIED.— 

‘‘(A) IN GENERAL.—The term ‘qualified benefit’ shall 

not include any qualified health plan (as defined in section 

1301(a) of the Patient Protection and Affordable Care Act) 

offered through an Exchange established under section 

1311 of such Act. 
Sec. 10108 PPACA (Consolidated) 162 

‘‘(B) EXCEPTION FOR EXCHANGE-ELIGIBLE EMPLOYERS.— 

Subparagraph (A) shall not apply with respect to any employee if such employee’s employer is a qualified employer 

(as defined in section 1312(f)(2) of the Patient Protection 

and Affordable Care Act) offering the employee the opportunity to enroll through such an Exchange in a qualified 

health plan in a group market.’’. 

(b) CONFORMING AMENDMENTS.—Subsection (f) of section 125 

of such Code is amended— 

(1) by striking ‘‘For purposes of this section, the term’’ and 

inserting ‘‘For purposes of this section— 

‘‘(1) IN GENERAL.—The term’’, and 

(2) by striking ‘‘Such term shall not include’’ and inserting 

the following: 

‘‘(2) LONG-TERM CARE INSURANCE NOT QUALIFIED.—The 

term ‘qualified benefit’ shall not include’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2013. 

øNote: Section 10108 provides for Free Choice Vouchers as follows:¿ 

SEC. 10108. ƒ42 U.S.C. 18101≈ FREE CHOICE VOUCHERS 

ƒcopied from title Xx and shown here for information purposes 

only≈. 

(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 
163 Sec. 10108 PPACA (Consolidated) 

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.— 
Sec. 1551 PPACA (Consolidated) 164 

(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) ƒAdded a subparagraph (D) to section 36(c)(2) of the 

IRC, added by section 1401≈ 

(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) ƒAdded a paragraph (3) to section 4980H(c) of the 

IRC, added by section 1513≈ 

(B) EFFECTIVE DATE.—The amendment made by this 

paragraph shall apply to months beginning after December 

31, 2013. 

(2) ƒAmended section 18B(a)(3) of FLSA, added by section 

1512≈ 

(j) EMPLOYER REPORTING.— 

(1) ƒAmended section 6056(a) of the IRC, added by section 

1514≈ 

(2) ƒReplaced subsection (f) of section 6056 of the IRC, 

added by section 1514≈ 

(3) ƒMade miscellaneous conforming amendments to sections 6056 and 6724(d) of the IRC, added by section 1514, as 

well as a table of sections amendment≈ 

(4) EFFECTIVE DATE.—The amendments made by this subsection shall apply to periods beginning after December 31, 

2013. 

Subtitle G—Miscellaneous Provisions 

SEC. 1551. ø42 U.S.C. 18111¿ DEFINITIONS. 

Unless specifically provided for otherwise, the definitions contained in section 2791 of the Public Health Service Act (42 U.S.C. 

300gg–91) shall apply with respect to this title. 

SEC. 1552. ø42 U.S.C. 18112¿ TRANSPARENCY IN GOVERNMENT. 

Not later than 30 days after the date of enactment of this Act, 

the Secretary of Health and Human Services shall publish on the 

Internet website of the Department of Health and Human Services, 

a list of all of the authorities provided to the Secretary under this 

Act (and the amendments made by this Act). 
165 Sec. 1555 PPACA (Consolidated) 

SEC. 1553. ø42 U.S.C. 18113¿ PROHIBITION AGAINST DISCRIMINATION 

ON ASSISTED SUICIDE. 

(a) IN GENERAL.—The Federal Government, and any State or 

local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made 

by this Act) or any health plan created under this Act (or under 

an amendment made by this Act), may not subject an individual 

or institutional health care entity to discrimination on the basis 

that the entity does not provide any health care item or service furnished for the purpose of causing, or for the purpose of assisting 

in causing, the death of any individual, such as by assisted suicide, 

euthanasia, or mercy killing. 

(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, or any other kind of 

health care facility, organization, or plan. 

(c) CONSTRUCTION AND TREATMENT OF CERTAIN SERVICES.— Nothing in subsection (a) shall be construed to apply to, or to affect, any limitation relating to— 

(1) the withholding or withdrawing of medical treatment 

or medical care; 

(2) the withholding or withdrawing of nutrition or hydration; 

(3) abortion; or 

(4) the use of an item, good, benefit, or service furnished 

for the purpose of alleviating pain or discomfort, even if such 

use may increase the risk of death, so long as such item, good, 

benefit, or service is not also furnished for the purpose of causing, or the purpose of assisting in causing, death, for any reason. 

(d) 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. 

SEC. 1554. ø42 U.S.C. 18114¿ ACCESS TO THERAPIES. 

Notwithstanding any other provision of this Act, the Secretary 

of Health and Human Services shall not promulgate any regulation 

that— 

(1) creates any unreasonable barriers to the ability of individuals to obtain appropriate medical care; 

(2) impedes timely access to health care services; 

(3) interferes with communications regarding a full range 

of treatment options between the patient and the provider; 

(4) restricts the ability of health care providers to provide 

full disclosure of all relevant information to patients making 

health care decisions; 

(5) violates the principles of informed consent and the ethical standards of health care professionals; or 

(6) limits the availability of health care treatment for the 

full duration of a patient’s medical needs. 

SEC. 1555. ø42 U.S.C. 18115¿ FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH INSURANCE PROGRAMS. 

No individual, company, business, nonprofit entity, or health 

insurance issuer offering group or individual health insurance cov-
Sec. 1556 PPACA (Consolidated) 166 

erage shall be required to participate in any Federal health insurance program created under this Act (or any amendments made by 

this Act), or in any Federal health insurance program expanded by 

this Act (or any such amendments), and there shall be no penalty 

or fine imposed upon any such issuer for choosing not to participate 

in such programs. 

SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS. 

(a) REBUTTABLE PRESUMPTION.—Section 411(c)(4) of the Black 

Lung Benefits Act (30 U.S.C. 921(c)(4)) is amended by striking the 

last sentence. 

(b) CONTINUATION OF BENEFITS.—Section 422(l) of the Black 

Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking ‘‘, except with respect to a claim filed under this part on or after the 

effective date of the Black Lung Benefits Amendments of 1981’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply with respect to claims filed under part B or part C of 

the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931 et seq.) 

after January 1, 2005, that are pending on or after the date of enactment of this Act. 

SEC. 1557. ø42 U.S.C. 18116¿ NONDISCRIMINATION. 

(a) IN GENERAL.—Except as otherwise provided for in this title 

(or an amendment made by this title), an individual shall not, on 

the ground prohibited under title VI of the Civil Rights Act of 1964 

(42 U.S.C. 2000d et seq.), title IX of the Education Amendments of 

1972 (20 U.S.C. 1681 et seq.), the Age Discrimination Act of 1975 

(42 U.S.C. 6101 et seq.), or section 504 of the Rehabilitation Act of 

1973 (29 U.S.C. 794), be excluded from participation in, be denied 

the benefits of, or be subjected to discrimination under, any health 

program or activity, any part of which is receiving Federal financial 

assistance, including credits, subsidies, or contracts of insurance, or 

under any program or activity that is administered by an Executive 

Agency or any entity established under this title (or amendments). 

The enforcement mechanisms provided for and available under 

such title VI, title IX, section 504, or such Age Discrimination Act 

shall apply for purposes of violations of this subsection. 

(b) CONTINUED APPLICATION OF LAWS.—Nothing in this title (or 

an amendment made by this title) shall be construed to invalidate 

or limit the rights, remedies, procedures, or legal standards available to individuals aggrieved under title VI of the Civil Rights Act 

of 1964 (42 U.S.C. 2000d et seq.), title VII of the Civil Rights Act 

of 1964 (42 U.S.C. 2000e et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act 

of 1975 (42 U.S.C. 611 et seq.), or to supersede State laws that provide additional protections against discrimination on any basis described in subsection (a). 

(c) REGULATIONS.—The Secretary may promulgate regulations 

to implement this section. 

SEC. 1558. PROTECTIONS FOR EMPLOYEES. 

The Fair Labor Standards Act of 1938 is amended by inserting 

after section 18B (as added by section 1512) the following: 
167 Sec. 1560 PPACA (Consolidated) 

‘‘SEC. 18C. ø29 U.S.C. 218c¿ PROTECTIONS FOR EMPLOYEES. 

‘‘(a) PROHIBITION.—No employer shall discharge or in any manner discriminate against any employee with respect to his or her 

compensation, terms, conditions, or other privileges of employment 

because the employee (or an individual acting at the request of the 

employee) has— 

‘‘(1) received a credit under section 36B of the Internal 

Revenue Code of 1986 or a subsidy under section 1402 of this 

Act; 

‘‘(2) provided, caused to be provided, or is about to provide 

or cause to be provided to the employer, the Federal Government, or the attorney general of a State information relating 

to any violation of, or any act or omission the employee reasonably believes to be a violation of, any provision of this title (or 

an amendment made by this title); 

‘‘(3) testified or is about to testify in a proceeding concerning such violation; 

‘‘(4) assisted or participated, or is about to assist or participate, in such a proceeding; or 

‘‘(5) objected to, or refused to participate in, any activity, 

policy, practice, or assigned task that the employee (or other 

such person) reasonably believed to be in violation of any provision of this title (or amendment), or any order, rule, regulation, standard, or ban under this title (or amendment). 

‘‘(b) COMPLAINT PROCEDURE.— 

‘‘(1) IN GENERAL.—An employee who believes that he or 

she has been discharged or otherwise discriminated against by 

any employer in violation of this section may seek relief in accordance with the procedures, notifications, burdens of proof, 

remedies, and statutes of limitation set forth in section 2087(b) 

of title 15, United States Code. 

‘‘(2) NO LIMITATION ON RIGHTS.—Nothing in this section 

shall be deemed to diminish the rights, privileges, or remedies 

of any employee under any Federal or State law or under any 

collective bargaining agreement. The rights and remedies in 

this section may not be waived by any agreement, policy, form, 

or condition of employment.’’. 

SEC. 1559. ø42 U.S.C. 18117¿ OVERSIGHT. 

The Inspector General of the Department of Health and 

Human Services shall have oversight authority with respect to the 

administration and implementation of this title as it relates to such 

Department. 

SEC. 1560. ø42 U.S.C. 18118¿ RULES OF CONSTRUCTION. 

(a) NO EFFECT ON ANTITRUST LAWS.—Nothing in this title (or 

an amendment made by this title) shall be construed to modify, impair, or supersede the operation of any of the antitrust laws. For 

the purposes of this section, the term ‘‘antitrust laws’’ has the 

meaning given such term in subsection (a) of the first section of the 

Clayton Act, except that such term includes section 5 of the Federal Trade Commission Act to the extent that such section 5 applies to unfair methods of competition. 

(b) RULE OF CONSTRUCTION REGARDING HAWAII’S PREPAID

HEALTH CARE ACT.—Nothing in this title (or an amendment made 
Sec. 1561 PPACA (Consolidated) 168 

by this title) shall be construed to modify or limit the application 

of the exemption for Hawaii’s Prepaid Health Care Act (Haw. Rev. 

Stat. §§ 393–1 et seq.) as provided for under section 514(b)(5) of the 

Employee Retirement Income Security Act of 1974 (29 U.S.C. 

1144(b)(5)). 

(c) STUDENT HEALTH INSURANCE PLANS.—Nothing in this title 

(or an amendment made by this title) shall be construed to prohibit 

an institution of higher education (as such term is defined for purposes of the Higher Education Act of 1965) from offering a student 

health insurance plan, to the extent that such requirement is otherwise permitted under applicable Federal, State or local law. 

(d) NO EFFECT ON EXISTING REQUIREMENTS.—Nothing in this 

title (or an amendment made by this title, unless specified by direct statutory reference) shall be construed to modify any existing 

Federal requirement concerning the State agency responsible for 

determining eligibility for programs identified in section 1413. 

SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT 

STANDARDS AND PROTOCOLS. 

Title XXX of the Public Health Service Act (42 U.S.C. 300jj et 

seq.) is amended by adding at the end the following: 

‘‘Subtitle C—Other Provisions 

‘‘SEC. 3021. ø42 U.S.C. 300jj–51¿ HEALTH INFORMATION TECHNOLOGY 

ENROLLMENT STANDARDS AND PROTOCOLS. 

‘‘(a) IN GENERAL.— 

‘‘(1) STANDARDS AND PROTOCOLS.—Not later than 180 days 

after the date of enactment of this title, the Secretary, in consultation with the HIT Policy Committee and the HIT Standards Committee, shall develop interoperable and secure standards and protocols that facilitate enrollment of individuals in 

Federal and State health and human services programs, as determined by the Secretary. 

‘‘(2) METHODS.—The Secretary shall facilitate enrollment 

in such programs through methods determined appropriate by 

the Secretary, which shall include providing individuals and 

third parties authorized by such individuals and their designees notification of eligibility and verification of eligibility required under such programs. 

‘‘(b) CONTENT.—The standards and protocols for electronic enrollment in the Federal and State programs described in subsection 

(a) shall allow for the following: 

‘‘(1) Electronic matching against existing Federal and 

State data, including vital records, employment history, enrollment systems, tax records, and other data determined appropriate by the Secretary to serve as evidence of eligibility and 

in lieu of paper-based documentation. 

‘‘(2) Simplification and submission of electronic documentation, digitization of documents, and systems verification of eligibility. 

‘‘(3) Reuse of stored eligibility information (including documentation) to assist with retention of eligible individuals. 
169 Sec. 1561 PPACA (Consolidated) \3021 PHSA 

‘‘(4) Capability for individuals to apply, recertify and manage their eligibility information online, including at home, at 

points of service, and other community-based locations. 

‘‘(5) Ability to expand the enrollment system to integrate 

new programs, rules, and functionalities, to operate at increased volume, and to apply streamlined verification and eligibility processes to other Federal and State programs, as appropriate. 

‘‘(6) Notification of eligibility, recertification, and other 

needed communication regarding eligibility, which may include 

communication via email and cellular phones. 

‘‘(7) Other functionalities necessary to provide eligibles 

with streamlined enrollment process. 

‘‘(c) APPROVAL AND NOTIFICATION.—With respect to any standard or protocol developed under subsection (a) that has been approved by the HIT Policy Committee and the HIT Standards Committee, the Secretary— 

‘‘(1) shall notify States of such standards or protocols; and 

‘‘(2) may require, as a condition of receiving Federal funds 

for the health information technology investments, that States 

or other entities incorporate such standards and protocols into 

such investments. 

‘‘(d) GRANTS FOR IMPLEMENTATION OF APPROPRIATE ENROLL- MENT HIT.— 

‘‘(1) IN GENERAL.—The Secretary shall award grant to eligible entities to develop new, and adapt existing, technology 

systems to implement the HIT enrollment standards and protocols developed under subsection (a) (referred to in this subsection as ‘appropriate HIT technology’). 

‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a grant under 

this subsection, an entity shall— 

‘‘(A) be a State, political subdivision of a State, or a 

local governmental entity; and 

‘‘(B) submit to the Secretary an application at such 

time, in such manner, and containing— 

‘‘(i) a plan to adopt and implement appropriate enrollment technology that includes— 

‘‘(I) proposed reduction in maintenance costs 

of technology systems; 

‘‘(II) elimination or updating of legacy systems; and 

‘‘(III) demonstrated collaboration with other 

entities that may receive a grant under this section that are located in the same State, political 

subdivision, or locality; 

‘‘(ii) an assurance that the entity will share such 

appropriate enrollment technology in accordance with 

paragraph (4); and 

‘‘(iii) such other information as the Secretary may 

require. 

‘‘(3) SHARING.— 

‘‘(A) IN GENERAL.—The Secretary shall ensure that appropriate enrollment HIT adopted under grants under this 

subsection is made available to other qualified State, 
Sec. 1562 PPACA (Consolidated) 170 

qualified political subdivisions of a State, or other appropriate qualified entities (as described in subparagraph (B)) 

at no cost. 

‘‘(B) QUALIFIED ENTITIES.—The Secretary shall determine what entities are qualified to receive enrollment HIT 

under subparagraph (A), taking into consideration the recommendations of the HIT Policy Committee and the HIT 

Standards Committee.’’. 

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

ISSUERS AND GROUP HEALTH PLANS. 

øSection inserted by section 10107(b)(2)¿ 

(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. 

øThe following section 1563 (relating to small business procurement) inserted by section 10107(b)(2)¿ 
171 Sec. 1563 PPACA (Consolidated) 

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. 

øThe following section 1563 (relating to conforming amendments) redesignated from section 1562 by section 10107(b)(1)¿ 

SEC. 1563 [sic]. CONFORMING AMENDMENTS. 

(a) APPLICABILITY.—Section 2735 of the Public Health Service 

Act (42 U.S.C. 300gg–21), as so redesignated by section 1001(4), is 

amended— 

(1) by striking subsection (a); 

(2) in subsection (b)— 

(A) in paragraph (1), by striking ‘‘1 through 3’’ and inserting ‘‘1 and 2’’; and 

(B) in paragraph (2)— 

(i) in subparagraph (A), by striking ‘‘subparagraph 

(D)’’ and inserting ‘‘subparagraph (D) or (E)’’; 

(ii) by striking ‘‘1 through 3’’ and inserting ‘‘1 and 

2’’; and 

(iii) by adding at the end the following: øProvision 

likely amended by section 10107(a)¿ 

‘‘(E) ELECTION NOT APPLICABLE.—The election described in subparagraph (A) shall not be available with respect to the provisions of subparts I and II.’’; 

(3) in subsection (c), by striking ‘‘1 through 3 shall not 

apply to any group’’ and inserting ‘‘1 and 2 shall not apply to 

any individual coverage or any group’’; and 

(4) in subsection (d)— 

(A) in paragraph (1), by striking ‘‘1 through 3 shall not 

apply to any group’’ and inserting ‘‘1 and 2 shall not apply 

to any individual coverage or any group’’; 

(B) in paragraph (2)— 

(i) in the matter preceding subparagraph (A), by 

striking ‘‘1 through 3 shall not apply to any group’’ 

and inserting ‘‘1 and 2 shall not apply to any individual coverage or any group’’; and 

(ii) in subparagraph (C), by inserting ‘‘or, with respect to individual coverage, under any health insurance coverage maintained by the same health insurance issuer’’; and 

(C) in paragraph (3), by striking ‘‘any group’’ and inserting ‘‘any individual coverage or any group’’. 

(b) DEFINITIONS.—Section 2791(d) of the Public Health Service 

Act (42 U.S.C. 300gg–91(d)) is amended by adding at the end the 

following: 

‘‘(20) QUALIFIED HEALTH PLAN.—The term ‘qualified health 

plan’ has the meaning given such term in section 1301(a) of 

the Patient Protection and Affordable Care Act. 
Sec. 1563 PPACA (Consolidated) 172 

‘‘(21) EXCHANGE.—The term ‘Exchange’ means an American Health Benefit Exchange established under section 1311 

of the Patient Protection and Affordable Care Act.’’. 

(c) TECHNICAL AND CONFORMING AMENDMENTS.—Title XXVII of 

the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended— 

(1) in section 2704 (42 U.S.C. 300gg), as so redesignated by 

section 1201(2)— 

(A) in subsection (c)— 

(i) in paragraph (2), by striking ‘‘group health 

plan’’ each place that such term appears and inserting 

‘‘group or individual health plan’’; and 

(ii) in paragraph (3)— 

(I) by striking ‘‘group health insurance’’ each 

place that such term appears and inserting ‘‘group 

or individual health insurance’’; and 

(II) in subparagraph (D), by striking ‘‘small or 

large’’ and inserting ‘‘individual or group’’; 

(B) in subsection (d), by striking ‘‘group health insurance’’ each place that such term appears and inserting 

‘‘group or individual health insurance’’; and 

(C) in subsection (e)(1)(A), by striking ‘‘group health 

insurance’’ and inserting ‘‘group or individual health insurance’’; 

(2) by striking the second heading for subpart 2 of part A 

(relating to other requirements); 

(3) in section 2725 (42 U.S.C. 300gg–4), as so redesignated 

by section 1001(2)— 

(A) in subsection (a), by striking ‘‘health insurance 

issuer offering group health insurance coverage’’ and inserting ‘‘health insurance issuer offering group or individual health insurance coverage’’; 

(B) in subsection (b)— 

(i) by striking ‘‘health insurance issuer offering 

group health insurance coverage in connection with a 

group health plan’’ in the matter preceding paragraph 

(1) and inserting ‘‘health insurance issuer offering 

group or individual health insurance coverage’’; and 

(ii) in paragraph (1), by striking ‘‘plan’’ and inserting ‘‘plan or coverage’’; 

(C) in subsection (c)— 

(i) in paragraph (2), by striking ‘‘group health insurance coverage offered by a health insurance issuer’’ 

and inserting ‘‘health insurance issuer offering group 

or individual health insurance coverage’’; and 

(ii) in paragraph (3), by striking ‘‘issuer’’ and inserting ‘‘health insurance issuer’’; and 

(D) in subsection (e), by striking ‘‘health insurance 

issuer offering group health insurance coverage’’ and inserting ‘‘health insurance issuer offering group or individual health insurance coverage’’; 

(4) in section 2726 (42 U.S.C. 300gg–5), as so redesignated 

by section 1001(2)— 
173 Sec. 1563 PPACA (Consolidated) 

(A) in subsection (a), by striking ‘‘(or health insurance 

coverage offered in connection with such a plan)’’ each 

place that such term appears and inserting ‘‘or a health insurance issuer offering group or individual health insurance coverage’’; 

(B) in subsection (b), by striking ‘‘(or health insurance 

coverage offered in connection with such a plan)’’ each 

place that such term appears and inserting ‘‘or a health insurance issuer offering group or individual health insurance coverage’’; and 

(C) in subsection (c)— 

(i) in paragraph (1), by striking ‘‘(and group health 

insurance coverage offered in connection with a group 

health plan)’’ and inserting ‘‘and a health insurance 

issuer offering group or individual health insurance 

coverage’’; 

(ii) in paragraph (2), by striking ‘‘(or health insurance coverage offered in connection with such a plan)’’ 

each place that such term appears and inserting ‘‘or a 

health insurance issuer offering group or individual 

health insurance coverage’’; 

(5) in section 2727 (42 U.S.C. 300gg–6), as so redesignated 

by section 1001(2), by striking ‘‘health insurance issuers providing health insurance coverage in connection with group 

health plans’’ and inserting ‘‘and health insurance issuers offering group or individual health insurance coverage’’; 

(6) in section 2728 (42 U.S.C. 300gg–7), as so redesignated 

by section 1001(2)— 

(A) in subsection (a), by striking ‘‘health insurance 

coverage offered in connection with such plan’’ and inserting ‘‘individual health insurance coverage’’; 

(B) in subsection (b)— 

(i) in paragraph (1), by striking ‘‘or a health insurance issuer that provides health insurance coverage in 

connection with a group health plan’’ and inserting ‘‘or 

a health insurance issuer that offers group or individual health insurance coverage’’; 

(ii) in paragraph (2), by striking ‘‘health insurance 

coverage offered in connection with the plan’’ and inserting ‘‘individual health insurance coverage’’; and 

(iii) in paragraph (3), by striking ‘‘health insurance coverage offered by an issuer in connection with 

such plan’’ and inserting ‘‘individual health insurance 

coverage’’; 

(C) in subsection (c), by striking ‘‘health insurance 

issuer providing health insurance coverage in connection 

with a group health plan’’ and inserting ‘‘health insurance 

issuer that offers group or individual health insurance coverage’’; and 

(D) in subsection (e)(1), by striking ‘‘health insurance 

coverage offered in connection with such a plan’’ and inserting ‘‘individual health insurance coverage’’; 

(7) by striking the heading for subpart 3; 
Sec. 1563 PPACA (Consolidated) 174 

(8) in section 2731 (42 U.S.C. 300gg–11), as so redesignated by section 1001(3)— 

(A) by striking the section heading and all that follows 

through subsection (b); 

(B) in subsection (c)— 

(i) in paragraph (1)— 

(I) in the matter preceding subparagraph (A), 

by striking ‘‘small group’’ and inserting ‘‘group 

and individual’’; and 

(II) in subparagraph (B)— 

(aa) in the matter preceding clause (i), by 

inserting ‘‘and individuals’’ after ‘‘employers’’; 

(bb) in clause (i), by inserting ‘‘or any additional individuals’’ after ‘‘additional groups’’; 

and 

(cc) in clause (ii), by striking ‘‘without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such’’ and inserting ‘‘and individuals 

without regard to the claims experience of 

those individuals, employers and their employees (and their dependents) or any health 

status-related factor relating to such individuals’’; and 

(ii) in paragraph (2), by striking ‘‘small group’’ and 

inserting ‘‘group or individual’’; 

(C) in subsection (d)— 

(i) by striking ‘‘small group’’ each place that such 

appears and inserting ‘‘group or individual’’; and 

(ii) in paragraph (1)(B)— 

(I) by striking ‘‘all employers’’ and inserting 

‘‘all employers and individuals’’; 

(II) by striking ‘‘those employers’’ and inserting ‘‘those individuals, employers’’; and 

(III) by striking ‘‘such employees’’ and inserting ‘‘such individuals, employees’’; 

(D) by striking subsection (e); 

(E) by striking subsection (f); and 

(F) by transferring such section (as amended by this 

paragraph) to appear at the end of section 2702 (as added 

by section 1001(4)); 

(9) in section 2732 (42 U.S.C. 300gg–12), as so redesignated by section 1001(3)— 

(A) by striking the section heading and all that follows 

through subsection (a); 

(B) in subsection (b)— 

(i) in the matter preceding paragraph (1), by striking ‘‘group health plan in the small or large group 

market’’ and inserting ‘‘health insurance coverage offered in the group or individual market’’; 

(ii) in paragraph (1), by inserting ‘‘, or individual, 

as applicable,’’ after ‘‘plan sponsor’’; 
175 Sec. 1563 PPACA (Consolidated) 

(iii) in paragraph (2), by inserting ‘‘, or individual, 

as applicable,’’ after ‘‘plan sponsor’’; and 

(iv) by striking paragraph (3) and inserting the 

following: 

‘‘(3) VIOLATION OF PARTICIPATION OR CONTRIBUTION

RATES.—In the case of a group health plan, the plan sponsor 

has failed to comply with a material plan provision relating to 

employer contribution or group participation rules, pursuant to 

applicable State law.’’; 

(C) in subsection (c)— 

(i) in paragraph (1)— 

(I) in the matter preceding subparagraph (A), 

by striking ‘‘group health insurance coverage offered in the small or large group market’’ and inserting ‘‘group or individual health insurance coverage’’; 

(II) in subparagraph (A), by inserting ‘‘or individual, as applicable,’’ after ‘‘plan sponsor’’; 

(III) in subparagraph (B)— 

(aa) by inserting ‘‘or individual, as applicable,’’ after ‘‘plan sponsor’’; and 

(bb) by inserting ‘‘or individual health insurance coverage’’; and 

(IV) in subparagraph (C), by inserting ‘‘or individuals, as applicable,’’ after ‘‘those sponsors’’; 

and 

(ii) in paragraph (2)(A)— 

(I) in the matter preceding clause (i), by striking ‘‘small group market or the large group market, or both markets,’’ and inserting ‘‘individual or 

group market, or all markets,’’; and 

(II) in clause (i), by inserting ‘‘or individual, 

as applicable,’’ after ‘‘plan sponsor’’; and 

(D) by transferring such section (as amended by this 

paragraph) to appear at the end of section 2703 (as added 

by section 1001(4)); 

(10) in section 2733 (42 U.S.C. 300gg–13), as so redesignated by section 1001(4)— 

(A) in subsection (a)— 

(i) in the matter preceding paragraph (1), by striking ‘‘small employer’’ and inserting ‘‘small employer or 

an individual’’; 

(ii) in paragraph (1), by inserting ‘‘, or individual, 

as applicable,’’ after ‘‘employer’’ each place that such 

appears; and 

(iii) in paragraph (2), by striking ‘‘small employer’’ 

and inserting ‘‘employer, or individual, as applicable,’’; 

(B) in subsection (b)— 

(i) in paragraph (1)— 

(I) in the matter preceding subparagraph (A), 

by striking ‘‘small employer’’ and inserting ‘‘employer, or individual, as applicable,’’; 

(II) in subparagraph (A), by adding ‘‘and’’ at 

the end; 
Sec. 1563 PPACA (Consolidated) 176 

(III) by striking subparagraphs (B) and (C); 

and 

(IV) in subparagraph (D)— 

(aa) by inserting ‘‘, or individual, as applicable,’’ after ‘‘employer’’; and 

(bb) by redesignating such subparagraph 

as subparagraph (B); 

(ii) in paragraph (2)— 

(I) by striking ‘‘small employers’’ each place 

that such term appears and inserting ‘‘employers, 

or individuals, as applicable,’’; and 

(II) by striking ‘‘small employer’’ and inserting 

‘‘employer, or individual, as applicable,’’; and 

(C) by redesignating such section (as amended by this 

paragraph) as section 2709 and transferring such section 

to appear after section 2708 (as added by section 1001(5)); 

(11) by redesignating subpart 4 as subpart 2; 

(12) in section 2735 (42 U.S.C. 300gg–21), as so redesignated by section 1001(4)— 

(A) by striking subsection (a); 

(B) by striking ‘‘subparts 1 through 3’’ each place that 

such appears and inserting ‘‘subpart 1’’; 

(C) by redesignating subsections (b) through (e) as 

subsections (a) through (d), respectively; and 

(D) by redesignating such section (as amended by this 

paragraph) as section 2722; 

(13) in section 2736 (42 U.S.C. 300gg–22), as so redesignated by section 1001(4)— 

(A) in subsection (a)— 

(i) in paragraph (1), by striking ‘‘small or large 

group markets’’ and inserting ‘‘individual or group 

market’’; and 

(ii) in paragraph (2), by inserting ‘‘or individual 

health insurance coverage’’ after ‘‘group health plans’’; 

(B) in subsection (b)(1)(B), by inserting ‘‘individual 

health insurance coverage or’’ after ‘‘respect to’’; and 

(C) by redesignating such section (as amended by this 

paragraph) as section 2723; 

(14) in section 2737(a)(1) (42 U.S.C. 300gg–23), as so redesignated by section 1001(4)— 

(A) by inserting ‘‘individual or’’ before ‘‘group health 

insurance’’; and 

(B) by redesignating such section(as amended by this 

paragraph) as section 2724; 

(15) in section 2762 (42 U.S.C. 300gg–62)— 

(A) in the section heading by inserting ‘‘AND APPLICATION’’ before the period; and 

(B) by adding at the end the following: 

‘‘(c) APPLICATION OF PART A PROVISIONS.— 

‘‘(1) IN GENERAL.—The provisions of part A shall apply to 

health insurance issuers providing health insurance coverage 

in the individual market in a State as provided for in such 

part. 
177 Sec. 1563 PPACA (Consolidated) \9815 IRC 

‘‘(2) CLARIFICATION.—To the extent that any provision of 

this part conflicts with a provision of part A with respect to 

health insurance issuers providing health insurance coverage 

in the individual market in a State, the provisions of such part 

A shall apply.’’; and 

(16) in section 2791(e) (42 U.S.C. 300gg–91(e))— 

(A) in paragraph (2), by striking ‘‘51’’ and inserting 

‘‘101’’; and 

(B) in paragraph (4)— 

(i) by striking ‘‘at least 2’’ each place that such appears and inserting ‘‘at least 1’’; and 

(ii) by striking ‘‘50’’ and inserting ‘‘100’’. 

(d) APPLICATION.—ø42 U.S.C. 18120¿ Notwithstanding any 

other provision of the Patient Protection and Affordable Care Act, 

nothing in such Act (or an amendment made by such Act) shall be 

construed to— 

(1) prohibit (or authorize the Secretary of Health and 

Human Services to promulgate regulations that prohibit) a 

group health plan or health insurance issuer from carrying out 

utilization management techniques that are commonly used as 

of the date of enactment of this Act; or 

(2) restrict the application of the amendments made by 

this subtitle. 

(e) TECHNICAL AMENDMENT TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.—Subpart B of part 7 of subtitle A 

of title I of the Employee Retirement Income Security Act of 1974 

(29 U.S.C. 1181 et. seq.) is amended, by adding at the end the following: 

‘‘SEC. 715. ø29 U.S.C. 1185d¿ ADDITIONAL MARKET REFORMS. 

‘‘(a) GENERAL RULE.—Except as provided in subsection (b)— 

‘‘(1) the provisions of part A of title XXVII of the Public 

Health Service Act (as amended by the Patient Protection and 

Affordable Care Act) shall apply to group health plans, and 

health insurance issuers providing health insurance coverage 

in connection with group health plans, as if included in this 

subpart; and 

‘‘(2) to the extent that any provision of this part conflicts 

with a provision of such part A with respect to group health 

plans, or health insurance issuers providing health insurance 

coverage in connection with group health plans, the provisions 

of such part A shall apply. 

‘‘(b) EXCEPTION.—Notwithstanding subsection (a), the provisions of sections 2716 and 2718 of title XXVII of the Public Health 

Service Act (as amended by the Patient Protection and Affordable 

Care Act) shall not apply with respect to self-insured group health 

plans, and the provisions of this part shall continue to apply to 

such plans as if such sections of the Public Health Service Act (as 

so amended) had not been enacted.’’. 

(f) TECHNICAL AMENDMENT TO THE INTERNAL REVENUE CODE

OF 1986.—Subchapter B of chapter 100 of the Internal Revenue 

Code of 1986 is amended by adding at the end the following: 

‘‘SEC. 9815. ADDITIONAL MARKET REFORMS. 

‘‘(a) GENERAL RULE.—Except as provided in subsection (b)— 
Sec. 1563 PPACA (Consolidated) 178 

‘‘(1) the provisions of part A of title XXVII of the Public 

Health Service Act (as amended by the Patient Protection and 

Affordable Care Act) shall apply to group health plans, and 

health insurance issuers providing health insurance coverage 

in connection with group health plans, as if included in this 

subchapter; and 

‘‘(2) to the extent that any provision of this subchapter conflicts with a provision of such part A with respect to group 

health plans, or health insurance issuers providing health insurance coverage in connection with group health plans, the 

provisions of such part A shall apply. 

‘‘(b) EXCEPTION.—Notwithstanding subsection (a), the provisions of sections 2716 and 2718 of title XXVII of the Public Health 

Service Act (as amended by the Patient Protection and Affordable 

Care Act) shall not apply with respect to self-insured group health 

plans, and the provisions of this subchapter shall continue to apply 

to such plans as if such sections of the Public Health Service Act 

(as so amended) had not been enacted.’’. 

øThe following section 1563 (relating to Sense of the Senate 

promoting fiscal responsibility) was the original section 1563¿ 

SEC. 1563 [sic]. SENSE OF THE SENATE PROMOTING FISCAL RESPONSIBILITY. 

(a) FINDINGS.—The Senate makes the following findings: 

(1) Based on Congressional Budget Office (CBO) estimates, 

this Act will reduce the Federal deficit between 2010 and 2019. 

(2) CBO projects this Act will continue to reduce budget 

deficits after 2019. 

(3) Based on CBO estimates, this Act will extend the solvency of the Medicare HI Trust Fund. 

(4) This Act will increase the surplus in the Social Security 

Trust Fund, which should be reserved to strengthen the finances of Social Security. 

(5) The initial net savings generated by the Community 

Living Assistance Services and Supports (CLASS) program are 

necessary to ensure the long-term solvency of that program. 

(b) SENSE OF THE SENATE.—It is the sense of the Senate that— 

(1) the additional surplus in the Social Security Trust 

Fund generated by this Act should be reserved for Social Security and not spent in this Act for other purposes; and 

(2) the net savings generated by the CLASS program 

should be reserved for the CLASS program and not spent in 

this Act for other purposes. 

øNote section 10108, p. 835, provides for free choice vouchers¿ 
179 Sec. 2001 PPACA (Consolidated) 

TITLE II—ROLE OF PUBLIC PROGRAMS 

Subtitle A—Improved Access to Medicaid 

SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPULATIONS. 

(a) COVERAGE FOR INDIVIDUALS WITH INCOME AT OR BELOW

133 PERCENT OF THE POVERTY LINE.— 

(1) BEGINNING 2014.—Section 1902(a)(10)(A)(i) of the Social 

Security Act (42 U.S.C. 1396a) is amended— 

(A) by striking ‘‘or’’ at the end of subclause (VI); 

(B) by adding ‘‘or’’ at the end of subclause (VII); and 

(C) by inserting after subclause (VII) the following: 

‘‘(VIII) beginning January 1, 2014, who are 

under 65 years of age, not pregnant, not entitled 

to, or enrolled for, benefits under part A of title 

XVIII, or enrolled for benefits under part B of title 

XVIII, and are not described in a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) does not exceed 

133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size 

involved, subject to subsection (k);’’. 

(2) PROVISION OF AT LEAST MINIMUM ESSENTIAL COVERAGE.— 

(A) IN GENERAL.—Section 1902 of such Act (42 U.S.C. 

1396a) is amended by inserting after subsection (j) the following: 

‘‘(k)(1) The medical assistance provided to an individual described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of 

benchmark coverage described in section 1937(b)(1) or benchmark 

equivalent coverage described in section 1937(b)(2). Such medical 

assistance shall be provided subject to the requirements of section 

1937, without regard to whether a State otherwise has elected the 

option to provide medical assistance through coverage under that 

section, unless an individual described in subclause (VIII) of subsection (a)(10)(A)(i) is also an individual for whom, under subparagraph (B) of section 1937(a)(2), the State may not require enrollment in benchmark coverage described in subsection (b)(1) of section 1937 or benchmark equivalent coverage described in subsection (b)(2) of that section.’’. 

(B) CONFORMING AMENDMENT.—Section 1903(i) of the 

Social Security Act, as amended by section 6402(c), is 

amended— 

(i) in paragraph (24), by striking ‘‘or’’ at the end; 

(ii) in paragraph (25), by striking the period and 

inserting ‘‘; or’’; and 

(iii) by adding at the end the following: 

‘‘(26) with respect to any amounts expended for medical assistance for individuals described in subclause (VIII) of subsection (a)(10)(A)(i) other than medical assistance provided 

through benchmark coverage described in section 1937(b)(1) or 
Sec. 2001 PPACA (Consolidated) 180 

benchmark equivalent coverage described in section 

1937(b)(2).’’. 

(3) FEDERAL FUNDING FOR COST OF COVERING NEWLY ELIGIBLE INDIVIDUALS.—Section 1905 of the Social Security Act (42 

U.S.C. 1396d), is amended— 

(A) in subsection (b), in the first sentence, by inserting 

‘‘subsection (y) and’’ before ‘‘section 1933(d)’’; and 

(B) by adding at the end the following new subsection: 

‘‘(y) INCREASED FMAP FOR MEDICAL ASSISTANCE FOR NEWLY

ELIGIBLE MANDATORY INDIVIDUALS.— 

‘‘(1) AMOUNT OF INCREASE.—øReplaced by section 

1201(1)(B) of HCERA¿ Notwithstanding subsection (b), the 

Federal medical assistance percentage for a State that is one 

of the 50 States or the District of Columbia, with respect to 

amounts expended by such State for medical assistance for 

newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), shall be equal to— 

‘‘(A) 100 percent for calendar quarters in 2014, 2015, 

and 2016; 

‘‘(B) 95 percent for calendar quarters in 2017; 

‘‘(C) 94 percent for calendar quarters in 2018; 

‘‘(D) 93 percent for calendar quarters in 2019; and 

‘‘(E) 90 percent for calendar quarters in 2020 and each 

year thereafter. 

‘‘(2) DEFINITIONS.—In this subsection: 

‘‘(A) NEWLY ELIGIBLE.—The term ‘newly eligible’ 

means, with respect to an individual described in subclause (VIII) of section 1902(a)(10)(A)(i), an individual who 

is not under 19 years of age (or such higher age as the 

State may have elected) and who, as of December 1, 2009, 

is not eligible under the State plan or under a waiver of 

the plan for full benefits or for benchmark coverage described in subparagraph (A), (B), or (C) of section 

1937(b)(1) or benchmark equivalent coverage described in 

section 1937(b)(2) that has an aggregate actuarial value 

that is at least actuarially equivalent to benchmark coverage described in subparagraph (A), (B), or (C) of section 

1937(b)(1), or is eligible but not enrolled (or is on a waiting 

list) for such benefits or coverage through a waiver under 

the plan that has a capped or limited enrollment that is 

full. øAs revised by section 10201(c)(3)(B)¿ 

‘‘(B) FULL BENEFITS.—The term ‘full benefits’ means, 

with respect to an individual, medical assistance for all 

services covered under the State plan under this title that 

is not less in amount, duration, or scope, or is determined 

by the Secretary to be substantially equivalent, to the 

medical assistance available for an individual described in 

section 1902(a)(10)(A)(i). 

øDrafting note: subclause (II) of paragraph (1)(B)(ii), as originally added by section 2001(a)(3) and as amended by section 

10201(c)(3)(A), was redesignated as paragraph (5) of subsection (z) 

and is shown in subsection (z), p. 841, as added by section 

10201(c)(4)¿ 
181 Sec. 2001 PPACA (Consolidated) 

(4) STATE OPTIONS TO OFFER COVERAGE EARLIER AND PRESUMPTIVE ELIGIBILITY; CHILDREN REQUIRED TO HAVE COVERAGE

FOR PARENTS TO BE ELIGIBLE.— 

(A) IN GENERAL.—Subsection (k) of section 1902 of the 

Social Security Act (as added by paragraph (2)), is amended by inserting after paragraph (1) the following: 

‘‘(2) øAs revised by section 10201(b)¿ Beginning with the first 

day of any fiscal year quarter that begins on or after April 1, 2010, 

and before January 1, 2014, a State may elect through a State plan 

amendment to provide medical assistance to individuals who would 

be described in subclause (VIII) of subsection (a)(10)(A)(i) if that 

subclause were effective before January 1, 2014. A State may elect 

to phase-in the extension of eligibility for medical assistance to 

such individuals based on income, so long as the State does not extend such eligibility to individuals described in such subclause with 

higher income before making individuals described in such subclause with lower income eligible for medical assistance. 

‘‘(3) If an individual described in subclause (VIII) of subsection 

(a)(10)(A)(i) is the parent of a child who is under 19 years of age 

(or such higher age as the State may have elected) who is eligible 

for medical assistance under the State plan or under a waiver of 

such plan (under that subclause or under a State plan amendment 

under paragraph (2), the individual may not be enrolled under the 

State plan unless the individual’s child is enrolled under the State 

plan or under a waiver of the plan or is enrolled in other health 

insurance coverage. For purposes of the preceding sentence, the 

term ‘parent’ includes an individual treated as a caretaker relative 

for purposes of carrying out section 1931.’’. 

(B) PRESUMPTIVE ELIGIBILITY.—Section 1920 of the Social Security Act (42 U.S.C. 1396r–1) is amended by adding at the end the following: 

‘‘(e) If the State has elected the option to provide a presumptive eligibility period under this section or section 1920A, the State 

may elect to provide a presumptive eligibility period (as defined in 

subsection (b)(1)) for individuals who are eligible for medical assistance under clause (i)(VIII) of subsection (a)(10)(A) or section 1931 

in the same manner as the State provides for such a period under 

this section or section 1920A, subject to such guidance as the Secretary shall establish.’’. 

(5) CONFORMING AMENDMENTS.— 

(A) Section 1902(a)(10) of such Act (42 U.S.C. 

1396a(a)(10)) is amended in the matter following subparagraph (G), by striking ‘‘and (XIV)’’ and inserting ‘‘(XIV)’’ 

and by inserting ‘‘and (XV) the medical assistance made 

available to an individual described in subparagraph 

(A)(i)(VIII) shall be limited to medical assistance described 

in subsection (k)(1)’’ before the semicolon. øNote that section 10201(a)(2) made an additional conforming amendment to reflect overlap with subparagraph (A)(i)(IX), added 

by section 2004(a)¿ 

(B) Section 1902(l)(2)(C) of such Act (42 U.S.C. 

1396a(l)(2)(C)) is amended by striking ‘‘100’’ and inserting 

‘‘133’’. 
Sec. 2001 PPACA (Consolidated) 182 

(C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is 

amended in the matter preceding paragraph (1)— 

(i) by striking ‘‘or’’ at the end of clause (xii); 

(ii) by inserting ‘‘or’’ at the end of clause (xiii); and 

(iii) by inserting after clause (xiii) the following: 

‘‘(xiv) individuals described in section 

1902(a)(10)(A)(i)(VIII),’’. 

(D) Section 1903(f)(4) of such Act (42 U.S.C. 

1396b(f)(4)) is amended by inserting 

‘‘1902(a)(10)(A)(i)(VIII),’’ after ‘‘1902(a)(10)(A)(i)(VII),’’. 

(E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 

1396u–7(a)(1)(B)) is amended by inserting ‘‘subclause 

(VIII) of section 1902(a)(10)(A)(i) or under’’ after ‘‘eligible 

under’’. 

(b) MAINTENANCE OF MEDICAID INCOME ELIGIBILITY.—Section 

1902 of the Social Security Act (42 U.S.C. 1396a) is amended— 

(1) in subsection (a)— 

(A) by striking ‘‘and’’ at the end of paragraph (72); 

(B) by striking the period at the end of paragraph (73) 

and inserting ‘‘; and’’; and 

(C) by inserting after paragraph (73) the following new 

paragraph: 

‘‘(74) provide for maintenance of effort under the State 

plan or under any waiver of the plan in accordance with subsection (gg).’’; and 

(2) by adding at the end the following new subsection: 

‘‘(gg) MAINTENANCE OF EFFORT.— 

‘‘(1) GENERAL REQUIREMENT TO MAINTAIN ELIGIBILITY

STANDARDS UNTIL STATE EXCHANGE IS FULLY OPERATIONAL.— 

Subject to the succeeding paragraphs of this subsection, during 

the period that begins on the date of enactment of the Patient 

Protection and Affordable Care Act and ends on the date on 

which the Secretary determines that an Exchange established 

by the State under section 1311 of the Patient Protection and 

Affordable Care Act is fully operational, as a condition for receiving any Federal payments under section 1903(a) for calendar quarters occurring during such period, a State shall not 

have in effect eligibility standards, methodologies, or procedures under the State plan under this title or under any waiver of such plan that is in effect during that period, that are 

more restrictive than the eligibility standards, methodologies, 

or procedures, respectively, under the plan or waiver that are 

in effect on the date of enactment of the Patient Protection and 

Affordable Care Act. 

‘‘(2) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.—The requirement under paragraph (1) shall continue to apply to a State through September 

30, 2019, with respect to the eligibility standards, methodologies, and procedures under the State plan under this title or 

under any waiver of such plan that are applicable to determining the eligibility for medical assistance of any child who 

is under 19 years of age (or such higher age as the State may 

have elected). 
183 Sec. 2001 PPACA (Consolidated) 

‘‘(3) NONAPPLICATION.—During the period that begins on 

January 1, 2011, and ends on December 31, 2013, the requirement under paragraph (1) shall not apply to a State with respect to nonpregnant, nondisabled adults who are eligible for 

medical assistance under the State plan or under a waiver of 

the plan at the option of the State and whose income exceeds 

133 percent of the poverty line (as defined in section 2110(c)(5)) 

applicable to a family of the size involved if, on or after December 31, 2010, the State certifies to the Secretary that, with respect to the State fiscal year during which the certification is 

made, the State has a budget deficit, or with respect to the 

succeeding State fiscal year, the State is projected to have a 

budget deficit. Upon submission of such a certification to the 

Secretary, the requirement under paragraph (1) shall not apply 

to the State with respect to any remaining portion of the period described in the preceding sentence. 

‘‘(4) DETERMINATION OF COMPLIANCE.— ‘‘(A) STATES SHALL APPLY MODIFIED ADJUSTED GROSS

INCOME.—A State’s determination of income in accordance 

with subsection (e)(14) shall not be considered to be eligibility standards, methodologies, or procedures that are 

more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver 

of the plan on the date of enactment of the Patient Protection and Affordable Care Act for purposes of determining 

compliance with the requirements of paragraph (1), (2), or 

(3). øAs revised by section 1004(b)(1)(B) of HCERA¿ 

‘‘(B) STATES MAY EXPAND ELIGIBILITY OR MOVE

WAIVERED POPULATIONS INTO COVERAGE UNDER THE STATE

PLAN.—With respect to any period applicable under paragraph (1), (2), or (3), a State that applies eligibility standards, methodologies, or procedures under the State plan 

under this title or under any waiver of the plan that are 

less restrictive than the eligibility standards, methodologies, or procedures, applied under the State plan or under 

a waiver of the plan on the date of enactment of the Patient Protection and Affordable Care Act, or that makes individuals who, on such date of enactment, are eligible for 

medical assistance under a waiver of the State plan, after 

such date of enactment eligible for medical assistance 

through a State plan amendment with an income eligibility level that is not less than the income eligibility level 

that applied under the waiver, or as a result of the application of subclause (VIII) of section 1902(a)(10)(A)(i), shall 

not be considered to have in effect eligibility standards, 

methodologies, or procedures that are more restrictive 

than the standards, methodologies, or procedures in effect 

under the State plan or under a waiver of the plan on the 

date of enactment of the Patient Protection and Affordable 

Care Act for purposes of determining compliance with the 

requirements of paragraph (1), (2), or (3).’’. 

(c) MEDICAID BENCHMARK BENEFITS MUST CONSIST OF AT

LEAST MINIMUM ESSENTIAL COVERAGE.—Section 1937(b) of such 

Act (42 U.S.C. 1396u–7(b)) is amended— 
Sec. 2001 PPACA (Consolidated) 184 

(1) in paragraph (1), in the matter preceding subparagraph 

(A), by inserting ‘‘subject to paragraphs (5) and (6),’’ before 

‘‘each’’; 

(2) in paragraph (2)— 

(A) in the matter preceding subparagraph (A), by inserting ‘‘subject to paragraphs (5) and (6)’’ after ‘‘subsection (a)(1),’’; 

(B) in subparagraph (A)— 

(i) by redesignating clauses (iv) and (v) as clauses 

(vi) and (vii), respectively; and 

(ii) by inserting after clause (iii), the following: 

‘‘(iv) Coverage of prescription drugs. 

‘‘(v) Mental health services.’’; and 

(C) in subparagraph (C)— 

(i) by striking clauses (i) and (ii); and 

(ii) by redesignating clauses (iii) and (iv) as 

clauses (i) and (ii), respectively; and 

(3) by adding at the end the following new paragraphs: 

‘‘(5) MINIMUM STANDARDS.—Effective January 1, 2014, any 

benchmark benefit package under paragraph (1) or benchmark 

equivalent coverage under paragraph (2) must provide at least 

essential health benefits as described in section 1302(b) of the 

Patient Protection and Affordable Care Act. 

‘‘(6) MENTAL HEALTH SERVICES PARITY.— 

‘‘(A) IN GENERAL.—In the case of any benchmark benefit package under paragraph (1) or benchmark equivalent 

coverage under paragraph (2) that is offered by an entity 

that is not a medicaid managed care organization and that 

provides both medical and surgical benefits and mental 

health or substance use disorder benefits, the entity shall 

ensure that the financial requirements and treatment limitations applicable to such mental health or substance use 

disorder benefits comply with the requirements of section 

2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan. 

‘‘(B) DEEMED COMPLIANCE.—Coverage provided with 

respect to an individual described in section 1905(a)(4)(B) 

and covered under the State plan under section 

1902(a)(10)(A) of the services described in section 

1905(a)(4)(B) (relating to early and periodic screening, diagnostic, and treatment services defined in section 1905(r)) 

and provided in accordance with section 1902(a)(43), shall 

be deemed to satisfy the requirements of subparagraph 

(A).’’. 

(d) ANNUAL REPORTS ON MEDICAID ENROLLMENT.— 

(1) STATE REPORTS.—Section 1902(a) of the Social Security 

Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is 

amended— 

(A) by striking ‘‘and’’ at the end of paragraph (73); 

(B) by striking the period at the end of paragraph (74) 

and inserting ‘‘; and’’; and 

(C) by inserting after paragraph (74) the following new 

paragraph: 
185 Sec. 2001 PPACA (Consolidated) 

‘‘(75) provide that, beginning January 2015, and annually 

thereafter, the State shall submit a report to the Secretary 

that contains— 

‘‘(A) the total number of enrolled and newly enrolled 

individuals in the State plan or under a waiver of the plan 

for the fiscal year ending on September 30 of the preceding 

calendar year, disaggregated by population, including children, parents, nonpregnant childless adults, disabled individuals, elderly individuals, and such other categories or 

sub-categories of individuals eligible for medical assistance 

under the State plan or under a waiver of the plan as the 

Secretary may require; 

‘‘(B) a description, which may be specified by population, of the outreach and enrollment processes used by 

the State during such fiscal year; and 

‘‘(C) any other data reporting determined necessary by 

the Secretary to monitor enrollment and retention of individuals eligible for medical assistance under the State plan 

or under a waiver of the plan.’’. 

(2) REPORTS TO CONGRESS.—Beginning April 2015, and annually thereafter, the Secretary of Health and Human Services 

shall submit a report to the appropriate committees of Congress on the total enrollment and new enrollment in Medicaid 

for the fiscal year ending on September 30 of the preceding calendar year on a national and State-by-State basis, and shall 

include in each such report such recommendations for administrative or legislative changes to improve enrollment in the 

Medicaid program as the Secretary determines appropriate. 

(e) STATE OPTION FOR COVERAGE FOR INDIVIDUALS WITH INCOME THAT EXCEEDS 133 PERCENT OF THE POVERTY LINE.— 

(1) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY

GROUP.—Section 1902 of the Social Security Act (42 U.S.C. 

1396a) is amended— 

(A) in subsection (a)(10)(A)(ii)— 

(i) in subclause (XVIII), by striking ‘‘or’’ at the 

end; 

(ii) in subclause (XIX), by adding ‘‘or’’ at the end; 

and 

(iii) by adding at the end the following new subclause: 

‘‘(XX) beginning January 1, 2014, who are 

under 65 years of age and are not described in or 

enrolled under a previous subclause of this clause, 

and whose income (as determined under subsection (e)(14)) exceeds 133 percent of the poverty 

line (as defined in section 2110(c)(5)) applicable to 

a family of the size involved but does not exceed 

the highest income eligibility level established 

under the State plan or under a waiver of the 

plan, subject to subsection (hh);’’ and 

(B) by adding at the end the following new subsection: 

‘‘(hh)(1) A State may elect to phase-in the extension of eligibility for medical assistance to individuals described in subclause 

(XX) of subsection (a)(10)(A)(ii) based on the categorical group (in-
Sec. 2002 PPACA (Consolidated) 186 

cluding nonpregnant childless adults) or income, so long as the 

State does not extend such eligibility to individuals described in 

such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance. 

‘‘(2) If an individual described in subclause (XX) of subsection 

(a)(10)(A)(ii) is the parent of a child who is under 19 years of age 

(or such higher age as the State may have elected) who is eligible 

for medical assistance under the State plan or under a waiver of 

such plan, the individual may not be enrolled under the State plan 

unless the individual’s child is enrolled under the State plan or 

under a waiver of the plan or is enrolled in other health insurance 

coverage. For purposes of the preceding sentence, the term ‘parent’ 

includes an individual treated as a caretaker relative for purposes 

of carrying out section 1931.’’. 

(2) CONFORMING AMENDMENTS.— (A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as 

amended by subsection (a)(5)(C), is amended in the matter 

preceding paragraph (1)— 

(i) by striking ‘‘or’’ at the end of clause (xiii); 

(ii) by inserting ‘‘or’’ at the end of clause (xiv); and 

(iii) by inserting after clause (xiv) the following: 

‘‘(xv) individuals described in section 

1902(a)(10)(A)(ii)(XX),’’. 

(B) Section 1903(f)(4) of such Act (42 U.S.C. 

1396b(f)(4)) is amended by inserting 

‘‘1902(a)(10)(A)(ii)(XX),’’ after ‘‘1902(a)(10)(A)(ii)(XIX),’’. 

(C) Section 1920(e) of such Act (42 U.S.C. 1396r–1(e)), 

as added by subsection (a)(4)(B), is amended by inserting 

‘‘or clause (ii)(XX)’’ after ‘‘clause (i)(VIII)’’. 

SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED 

USING MODIFIED GROSS INCOME. 

(a) IN GENERAL.—Section 1902(e) of the Social Security Act (42 

U.S.C. 1396a(e)) is amended by adding at the end the following: 

‘‘(14) INCOME DETERMINED USING MODIFIED ADJUSTED

GROSS INCOME.—øAs revised by section 1004(b)(1)(A) & 1004(e) 

of HCERA¿ 

‘‘(A) IN GENERAL.—Notwithstanding subsection (r) or 

any other provision of this title, except as provided in subparagraph (D), for purposes of determining income eligibility for medical assistance under the State plan or under 

any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of 

income is required, including with respect to the imposition of premiums and cost-sharing, a State shall use the 

modified adjusted gross income of an individual and, in the 

case of an individual in a family greater than 1, the household income of such family. A State shall establish income 

eligibility thresholds for populations to be eligible for medical assistance under the State plan or a waiver of the plan 

using modified adjusted gross income and household income that are not less than the effective income eligibility 

levels that applied under the State plan or waiver on the 

date of enactment of the Patient Protection and Affordable 
187 Sec. 2002 PPACA (Consolidated) 

Care Act. For purposes of complying with the maintenance 

of effort requirements under subsection (gg) during the 

transition to modified adjusted gross income and household income, a State shall, working with the Secretary, establish an equivalent income test that ensures individuals 

eligible for medical assistance under the State plan or 

under a waiver of the plan on the date of enactment of the 

Patient Protection and Affordable Care Act, do not lose 

coverage under the State plan or under a waiver of the 

plan. The Secretary may waive such provisions of this title 

and title XXI as are necessary to ensure that States establish income and eligibility determination systems that protect beneficiaries. 

‘‘(B) NO INCOME OR EXPENSE DISREGARDS.—Subject to 

subparagraph (I), no type of expense, block, or other income disregard shall be applied by a State to determine income eligibility for medical assistance under the State plan 

or under any waiver of such plan or for any other purpose 

applicable under the plan or waiver for which a determination of income is required. 

‘‘(C) NO ASSETS TEST.—A State shall not apply any assets or resources test for purposes of determining eligibility for medical assistance under the State plan or under 

a waiver of the plan. 

‘‘(D) EXCEPTIONS.— ‘‘(i) INDIVIDUALS ELIGIBLE BECAUSE OF OTHER AID

OR ASSISTANCE, ELDERLY INDIVIDUALS, MEDICALLY

NEEDY INDIVIDUALS, AND INDIVIDUALS ELIGIBLE FOR

MEDICARE COST-SHARING.—Subparagraphs (A), (B), 

and (C) shall not apply to the determination of eligibility under the State plan or under a waiver for medical assistance for the following: 

‘‘(I) Individuals who are eligible for medical 

assistance under the State plan or under a waiver 

of the plan on a basis that does not require a determination of income by the State agency administering the State plan or waiver, including as a 

result of eligibility for, or receipt of, other Federal 

or State aid or assistance, individuals who are eligible on the basis of receiving (or being treated as 

if receiving) supplemental security income benefits 

under title XVI, and individuals who are eligible 

as a result of being or being deemed to be a child 

in foster care under the responsibility of the State. 

‘‘(II) Individuals who have attained age 65. 

‘‘(III) Individuals who qualify for medical assistance under the State plan or under any waiver 

of such plan on the basis of being blind or disabled 

(or being treated as being blind or disabled) without regard to whether the individual is eligible for 

supplemental security income benefits under title 

XVI on the basis of being blind or disabled and including an individual who is eligible for medical 

assistance on the basis of section 1902(e)(3). 
Sec. 2002 PPACA (Consolidated) 188 

‘‘(IV) Individuals described in subsection 

(a)(10)(C). 

‘‘(V) Individuals described in any clause of 

subsection (a)(10)(E). 

‘‘(ii) EXPRESS LANE AGENCY FINDINGS.—In the case 

of a State that elects the Express Lane option under 

paragraph (13), notwithstanding subparagraphs (A), 

(B), and (C), the State may rely on a finding made by 

an Express Lane agency in accordance with that paragraph relating to the income of an individual for purposes of determining the individual’s eligibility for 

medical assistance under the State plan or under a 

waiver of the plan. 

‘‘(iii) MEDICARE PRESCRIPTION DRUG SUBSIDIES DE- TERMINATIONS.—Subparagraphs (A), (B), and (C) shall 

not apply to any determinations of eligibility for premium and cost-sharing subsidies under and in accordance with section 1860D–14 made by the State pursuant to section 1935(a)(2). 

‘‘(iv) LONG-TERM CARE.—Subparagraphs (A), (B), 

and (C) shall not apply to any determinations of eligibility of individuals for purposes of medical assistance 

for nursing facility services, a level of care in any institution equivalent to that of nursing facility services, 

home or community-based services furnished under a 

waiver or State plan amendment under section 1915 

or a waiver under section 1115, and services described 

in section 1917(c)(1)(C)(ii). 

‘‘(v) GRANDFATHER OF CURRENT ENROLLEES UNTIL

DATE OF NEXT REGULAR REDETERMINATION.—An individual who, on January 1, 2014, is enrolled in the 

State plan or under a waiver of the plan and who 

would be determined ineligible for medical assistance 

solely because of the application of the modified adjusted gross income or household income standard described in subparagraph (A), shall remain eligible for 

medical assistance under the State plan or waiver 

(and subject to the same premiums and cost-sharing 

as applied to the individual on that date) through 

March 31, 2014, or the date on which the individual’s 

next regularly scheduled redetermination of eligibility 

is to occur, whichever is later. 

‘‘(E) TRANSITION PLANNING AND OVERSIGHT.—Each 

State shall submit to the Secretary for the Secretary’s approval the income eligibility thresholds proposed to be established using modified adjusted gross income and household income, the methodologies and procedures to be used 

to determine income eligibility using modified adjusted 

gross income and household income and, if applicable, a 

State plan amendment establishing an optional eligibility 

category under subsection (a)(10)(A)(ii)(XX). To the extent 

practicable, the State shall use the same methodologies 

and procedures for purposes of making such determinations as the State used on the date of enactment of the Pa-
189 Sec. 2002 PPACA (Consolidated) 

tient Protection and Affordable Care Act. The Secretary 

shall ensure that the income eligibility thresholds proposed to be established using modified adjusted gross income and household income, including under the eligibility 

category established under subsection (a)(10)(A)(ii)(XX), 

and the methodologies and procedures proposed to be used 

to determine income eligibility, will not result in children 

who would have been eligible for medical assistance under 

the State plan or under a waiver of the plan on the date 

of enactment of the Patient Protection and Affordable Care 

Act no longer being eligible for such assistance. 

‘‘(F) LIMITATION ON SECRETARIAL AUTHORITY.—The 

Secretary shall not waive compliance with the requirements of this paragraph except to the extent necessary to 

permit a State to coordinate eligibility requirements for 

dual eligible individuals (as defined in section 

1915(h)(2)(B)) under the State plan or under a waiver of 

the plan and under title XVIII and individuals who require 

the level of care provided in a hospital, a nursing facility, 

or an intermediate care facility for the mentally retarded. 

‘‘(G) DEFINITIONS OF MODIFIED ADJUSTED GROSS IN- COME AND HOUSEHOLD INCOME.—In this paragraph, the 

terms ‘modified adjusted gross income’ and ‘household income’ have the meanings given such terms in section 

36B(d)(2) of the Internal Revenue Code of 1986. 

‘‘(H) CONTINUED APPLICATION OF MEDICAID RULES RE- GARDING POINT-IN-TIME INCOME AND SOURCES OF IN- COME.—The requirement under this paragraph for States 

to use modified adjusted gross income and household income to determine income eligibility for medical assistance 

under the State plan or under any waiver of such plan and 

for any other purpose applicable under the plan or waiver 

for which a determination of income is required shall not 

be construed as affecting or limiting the application of— 

‘‘(i) the requirement under this title and under the 

State plan or a waiver of the plan to determine an individual’s income as of the point in time at which an 

application for medical assistance under the State 

plan or a waiver of the plan is processed; or 

‘‘(ii) any rules established under this title or under 

the State plan or a waiver of the plan regarding 

sources of countable income. 

‘‘(I) TREATMENT OF PORTION OF MODIFIED ADJUSTED

GROSS INCOME.—øAs added by section 1004(e)(2) of 

HCERA¿ For purposes of determining the income eligibility of an individual for medical assistance whose eligibility is determined based on the application of modified 

adjusted gross income under subparagraph (A), the State 

shall— 

‘‘(i) determine the dollar equivalent of the difference between the upper income limit on eligibility 

for such an individual (expressed as a percentage of 

the poverty line) and such upper income limit increased by 5 percentage points; and 
Sec. 2003 PPACA (Consolidated) 190 

‘‘(ii) notwithstanding the requirement in subparagraph (A) with respect to use of modified adjusted 

gross income, utilize as the applicable income of such 

individual, in determining such income eligibility, an 

amount equal to the modified adjusted gross income 

applicable to such individual reduced by such dollar 

equivalent amount.’’. 

(b) CONFORMING AMENDMENT.—Section 1902(a)(17) of such Act 

(42 U.S.C. 1396a(a)(17)) is amended by inserting ‘‘(e)(14),’’ before 

‘‘(l)(3)’’. 

(c) EFFECTIVE DATE.—The amendments made by subsections 

(a) and (b) take effect on January 1, 2014. 

SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR EMPLOYER-SPONSORED INSURANCE. 

(a) IN GENERAL.—Section 1906A of such Act (42 U.S.C. 1396e– 

1) is amended— 

(1) in subsection (a)— 

(A) by striking ‘‘may elect to’’ and inserting ‘‘shall’’; 

øSubparagraph (B) of section 10203(b)(2), p. 849, provides: 

‘‘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.’’¿ 

(B) by striking ‘‘under age 19’’; and 

(C) by inserting ‘‘, in the case of an individual under 

age 19,’’ after ‘‘(and’’; 

(2) in subsection (c), in the first sentence, by striking 

‘‘under age 19’’; and 

(3) in subsection (d)— 

(A) in paragraph (2)— 

(i) in the first sentence, by striking ‘‘under age 

19’’; and 

(ii) by striking the third sentence and inserting ‘‘A 

State may not require, as a condition of an individual 

(or the individual’s parent) being or remaining eligible 

for medical assistance under this title, that the individual (or the individual’s parent) apply for enrollment 

in qualified employer-sponsored coverage under this 

section.’’; and 

(B) in paragraph (3), by striking ‘‘the parent of an individual under age 19’’ and inserting ‘‘an individual (or the 

parent of an individual)’’; and 

(4) in subsection (e), by striking ‘‘under age 19’’ each place 

it appears. 

(b) CONFORMING AMENDMENT.—The heading for section 1906A 

of such Act (42 U.S.C. 1396e–1) is amended by striking ‘‘OPTION

FOR CHILDREN’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

take effect on January 1, 2014. 
191 Sec. 2005 PPACA (Consolidated) 

SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN. 

(a) IN GENERAL.—Section 1902(a)(10)(A)(i) of the Social Security Act (42 U.S.C. 1396a), as amended by section 2001(a)(1), is 

amended— 

(1) by striking ‘‘or’’ at the end of subclause (VII); 

(2) by adding ‘‘or’’ at the end of subclause (VIII); and 

(3) by inserting after subclause (VIII) the following: 

‘‘(IX) øReplaced by section 10201(a)(1)¿ 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;’’. 

øSection 10201(a)(2), p. 839, provides a related amendment to 

section 1902(a)(10) of the SSA¿ 

(b) OPTION TO PROVIDE PRESUMPTIVE ELIGIBILITY.—Section 

1920(e) of such Act (42 U.S.C. 1396r–1(e)), as added by section 

2001(a)(4)(B) and amended by section 2001(e)(2)(C), is amended by 

inserting ‘‘, clause (i)(IX),’’ after ‘‘clause (i)(VIII)’’. 

(c) CONFORMING AMENDMENTS.— (1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), as 

amended by section 2001(a)(5)(D), is amended by inserting 

‘‘1902(a)(10)(A)(i)(IX),’’ after ‘‘1902(a)(10)(A)(i)(VIII),’’. 

(2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C. 

1396u–7(a)(2)(B)(viii)) is amended by inserting ‘‘, or the individual qualifies for medical assistance on the basis of section 

1902(a)(10)(A)(i)(IX)’’ before the period. 

øAdditional conforming amendments relating to section 

1902(a)(10)(A)(i)(IX) are in section 10201(c)(1), p. 840¿ 

(d) EFFECTIVE DATE.—The amendments made by this section 

take effect on January 1, 2014. øAs revised by section 10201(a)(3)¿ 

SEC. 2005. PAYMENTS TO TERRITORIES. 

(a) INCREASE IN LIMIT ON PAYMENTS.—Section 1108(g) of the 

Social Security Act (42 U.S.C. 1308(g)) is amended— 

(1) in paragraph (2), in the matter preceding subparagraph 

(A), by striking ‘‘paragraph (3)’’ and inserting ‘‘paragraphs (3) 

and (5)’’; 

(2) in paragraph (4), by striking ‘‘and (3)’’ and inserting 

‘‘(3), and (4)’’; and 

(3) by adding at the end the following paragraph: 

‘‘(5) ADDITIONAL INCREASE.—øReplaced by section 

1204(b)(1)(B) of HCERA¿ The Secretary shall increase the 
Sec. 2006 PPACA (Consolidated) 192 

amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa (after the application of subsection 

(f) and the preceding paragraphs of this subsection) for the period beginning July 1, 2011, and ending on September 30, 

2019, by such amounts that the total additional payments 

under title XIX to such territories equals $6,300,000,000 for 

such period. The Secretary shall increase such amounts in proportion to the amounts applicable to such territories under this 

subsection and subsection (f) on the date of enactment of this 

paragraph.’’. 

øSubsection (b) repealed by section 1204(b)(2)(A) of HCERA¿ 

(c) INCREASED FMAP.— 

(1) IN GENERAL.—The first sentence of section 1905(b) of 

the Social Security Act (42 U.S.C. 1396d(b)) is amended by 

striking ‘‘shall be 50 per centum’’ and inserting ‘‘shall be 55 

percent’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) takes effect on July 1, 2011. øAs revised by section 

1204(b)(2)(B)of HCERA¿ 

SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR 

CERTAIN STATES RECOVERING FROM A MAJOR DISASTER. 

Section 1905 of the Social Security Act (42 U.S.C. 1396d), as 

amended by sections 2001(a)(3) and 2001(b)(2), is amended— 

(1) in subsection (b), in the first sentence, by striking ‘‘subsection (y)’’ and inserting ‘‘subsections (y) and (aa)’’; and 

(2) by adding at the end the following new subsection: 

‘‘(aa)(1) Notwithstanding subsection (b), beginning January 1, 

2011, the Federal medical assistance percentage for a fiscal year 

for a disaster-recovery FMAP adjustment State shall be equal to 

the following: 

‘‘(A) In the case of the first fiscal year (or part of a fiscal 

year) for which this subsection applies to the State, the Federal medical assistance percentage determined for the fiscal 

year without regard to this subsection, subsection (y), subsection (z), and section 10202 of the Patient Protection and Affordable Care Act, increased by 50 percent of the number of 

percentage points by which the Federal medical assistance percentage determined for the State for the fiscal year without regard to this subsection and subsection (y), is less than the Federal medical assistance percentage determined for the State for 

the preceding fiscal year after the application of only subsection (a) of section 5001 of Public Law 111–5 (if applicable 

to the preceding fiscal year) and without regard to this subsection, subsection (y), and subsections (b) and (c) of section 

5001 of Public Law 111–5. 

‘‘(B) In the case of the second or any succeeding fiscal year 

for which this subsection applies to the State, the Federal medical assistance percentage determined for the preceding fiscal 

year under this subsection for the State, increased by 25 percent of the number of percentage points by which the Federal 

medical assistance percentage determined for the State for the 

fiscal year without regard to this subsection, subsection (y), 
193 Sec. 2007 PPACA (Consolidated) 

subsection (z), and section 10202 of the Patient Protection and 

Affordable Care Act, is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year under this subsection. 

‘‘(2) In this subsection, the term ‘disaster-recovery FMAP adjustment State’ means a State that is one of the 50 States or the 

District of Columbia, for which, at any time during the preceding 

7 fiscal years, the President has declared a major disaster under 

section 401 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act and determined as a result of such disaster 

that every county or parish in the State warrant individual and 

public assistance or public assistance from the Federal Government 

under such Act and for which— 

‘‘(A) in the case of the first fiscal year (or part of a fiscal 

year) for which this subsection applies to the State, the Federal medical assistance percentage determined for the State for 

the fiscal year without regard to this subsection, subsection (y), 

subsection (z), and section 10202 of the Patient Protection and 

Affordable Care Act, is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year after the application of only subsection (a) of section 

5001 of Public Law 111–5 (if applicable to the preceding fiscal 

year) and without regard to this subsection, subsection (y), and 

subsections (b) and (c) of section 5001 of Public Law 111–5, by 

at least 3 percentage points; and 

‘‘(B) in the case of the second or any succeeding fiscal year 

for which this subsection applies to the State, the Federal medical assistance percentage determined for the State for the fiscal year without regard to this subsection, subsection (y), subsection (z), and section 10202 of the Patient Protection and Affordable Care Act, is less than the Federal medical assistance 

percentage determined for the State for the preceding fiscal 

year under this subsection by at least 3 percentage points. 

‘‘(3) The Federal medical assistance percentage determined for 

a disaster-recovery FMAP adjustment State under paragraph (1) 

shall apply for purposes of this title (other than with respect to disproportionate share hospital payments described in section 1923 

and payments under this title that are based on the enhanced 

FMAP described in 2105(b)) and shall not apply with respect to 

payments under title IV (other than under part E of title IV) or 

payments under title XXI.’’. 

SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION. 

(a) RESCISSION.—Any amounts available to the Medicaid Improvement Fund established under section 1941 of the Social Security Act (42 U.S.C. 1396w–1) for any of fiscal years 2014 through 

2018 that are available for expenditure from the Fund and that are 

not so obligated as of the date of the enactment of this Act are rescinded. 

(b) CONFORMING AMENDMENTS.—Section 1941(b)(1) of the Social Security Act (42 U.S.C. 1396w–1(b)(1)) is amended— 

(1) in subparagraph (A), by striking ‘‘$100,000,000’’ and inserting ‘‘$0’’; and 
Sec. 2101 PPACA (Consolidated) 194 

(2) in subparagraph (B), by striking ‘‘$150,000,000’’ and inserting ‘‘$0’’. 

Subtitle B—Enhanced Support for the 

Children’s Health Insurance Program 

SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR 

CHIP. 

(a) IN GENERAL.—Section 2105(b) of the Social Security Act (42 

U.S.C. 1397ee(b)) is amended by adding at the end the following: 

øAs revised by section 10203(c)(1)¿ ‘‘Notwithstanding the preceding 

sentence, during the period that begins on October 1, 2015, and 

ends on September 30, 2019, the enhanced FMAP determined for 

a State for a fiscal year (or for any portion of a fiscal year occurring 

during such period) shall be increased by 23 percentage points, but 

in no case shall exceed 100 percent. The increase in the enhanced 

FMAP under the preceding sentence shall not apply with respect 

to determining the payment to a State under subsection (a)(1) for 

expenditures described in subparagraph (D)(iv), paragraphs (8), (9), 

(11) of subsection (c), or clause (4) of the first sentence of section 

1905(b).’’. 

(b) MAINTENANCE OF EFFORT.— 

(1) IN GENERAL.—Section 2105(d) of the Social Security Act 

(42 U.S.C. 1397ee(d)) is amended by adding at the end the following: 

‘‘(3) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.— 

‘‘(A) IN GENERAL.—øAs revised by section 

10203(c)(2)(A)(i)¿ During the period that begins on the 

date of enactment of the Patient Protection and Affordable 

Care Act and ends on September 30, 2019, as a condition 

of receiving payments under section 1903(a), a State shall 

not have in effect eligibility standards, methodologies, or 

procedures under its State child health plan (including any 

waiver under such plan) for children (including children 

provided medical assistance for which payment is made 

under section 2105(a)(1)(A)) that are more restrictive than 

the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) as in effect on the 

date of enactment of that Act. The preceding sentence 

shall not be construed as preventing a State during such 

period from— 

‘‘(i) applying eligibility standards, methodologies, 

or procedures for children under the State child health 

plan or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, 

or procedures, respectively, for children under the plan 

or waiver that are in effect on the date of enactment 

of such Act; øAs revised by section 10203(c)(2)(A)(ii)¿ 

‘‘(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 
195 Sec. 2101 PPACA (Consolidated) 

has been certified by the Secretary under subparagraph (C); or øAs added by section 10203(c)(2)(A)(iv)¿ 

‘‘(iii) imposing a limitation described in section 

2112(b)(7) for a fiscal year in order to limit expenditures under the State child health plan to those for 

which Federal financial participation is available 

under this section for the fiscal year. 

‘‘(B) ASSURANCE OF EXCHANGE COVERAGE FOR TAR- GETED LOW-INCOME CHILDREN UNABLE TO BE PROVIDED

CHILD HEALTH ASSISTANCE AS A RESULT OF FUNDING SHORT- FALLS.—In the event that allotments provided under section 2104 are insufficient to provide coverage to all children who are eligible to be targeted low-income children 

under the State child health plan under this title, a State 

shall establish procedures to ensure that such children are 

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 

through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care 

Act. 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 costsharing 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. øAs revised by sections 

10201(g) and 10203(c)(2)(B)¿ 

‘‘(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. øAs added by section 10203(c)(2)(C)¿’’. 

(2) CONFORMING AMENDMENT TO TITLE XXI MEDICAID MAINTENANCE OF EFFORT.—Section 2105(d)(1) of the Social Security 

Act (42 U.S.C. 1397ee(d)(1)) is amended by adding before the 

period ‘‘, except as required under section 1902(e)(14)’’. 

(c) NO ENROLLMENT BONUS PAYMENTS FOR CHILDREN ENROLLED AFTER FISCAL YEAR 2013.—Section 2105(a)(3)(F)(iii) of the 

Social Security Act (42 U.S.C. 1397ee(a)(3)(F)(iii)) is amended by 
Sec. 2101 PPACA (Consolidated) 196 

inserting ‘‘or any children enrolled on or after October 1, 2013’’ before the period. 

(d) INCOME ELIGIBILITY DETERMINED USING MODIFIED GROSS

INCOME.— 

(1) STATE PLAN REQUIREMENT.—Section 2102(b)(1)(B) of 

the Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended— 

(A) in clause (iii), by striking ‘‘and’’ after the semicolon; 

(B) in clause (iv), by striking the period and inserting 

‘‘; and’’; and 

(C) by adding at the end the following: øAs revised by 

section 1004(b)(2)(A) of HCERA¿ 

‘‘(v) shall, beginning January 1, 2014, use modified adjusted gross income and household income (as 

defined in section 36B(d)(2) of the Internal Revenue 

Code of 1986) to determine eligibility for child health 

assistance under the State child health plan or under 

any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required, including with respect 

to the imposition of premiums and cost-sharing, consistent with section 1902(e)(14).’’. 

(2) CONFORMING AMENDMENT.—Section 2107(e)(1) of the 

Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended— 

(A) by redesignating subparagraphs (E) through (L) as 

subparagraphs (F) through (M), respectively; and 

(B) by inserting after subparagraph (D), the following: 

‘‘(E) Section 1902(e)(14) (relating to income determined 

using modified adjusted gross income and household income). øAs revised by section 1004(b)(2)(B) of HCERA; reflecting probable intent¿’’. 

(e) APPLICATION OF STREAMLINED ENROLLMENT SYSTEM.—Section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)), 

as amended by subsection (d)(2), is amended by adding at the end 

the following: 

‘‘(N) Section 1943(b) (relating to coordination with 

State Exchanges and the State Medicaid agency).’’. 

(f) CHIP ELIGIBILITY FOR CHILDREN INELIGIBLE FOR MEDICAID

AS A RESULT OF ELIMINATION OF DISREGARDS.—Notwithstanding 

any other provision of law, a State shall treat any child who is determined to be ineligible for medical assistance under the State 

Medicaid plan or under a waiver of the plan as a result of the 

elimination of the application of an income disregard based on expense or type of income, as required under section 1902(e)(14) of 

the Social Security Act (as added by this Act), as a targeted lowincome child under section 2110(b) (unless the child is excluded 

under paragraph (2) of that section) and shall provide child health 

assistance to the child under the State child health plan (whether 

implemented under title XIX or XXI, or both, of the Social Security 

Act). 

øAdditional CHIP amendments made by section 10203, p. 848¿ 
197 Sec. 2102 PPACA (Consolidated) 

SEC. 2102. TECHNICAL CORRECTIONS. 

(a) CHIPRA.—Effective as if included in the enactment of the 

Children’s Health Insurance Program Reauthorization Act of 2009 

(Public Law 111–3) (in this section referred to as ‘‘CHIPRA’’): 

(1) Section 2104(m) of the Social Security Act, as added by 

section 102 of CHIPRA, is amended— 

(A) by redesignating paragraph (7) as paragraph (8); 

and 

(B) by inserting after paragraph (6), the following: 

‘‘(7) ADJUSTMENT OF FISCAL YEAR 2010 ALLOTMENTS TO ACCOUNT FOR CHANGES IN PROJECTED SPENDING FOR CERTAIN PREVIOUSLY APPROVED EXPANSION PROGRAMS.—For purposes of recalculating the fiscal year 2010 allotment, in the case of one of 

the 50 States or the District of Columbia that has an approved 

State plan amendment effective January 1, 2006, to provide 

child health assistance through the provision of benefits under 

the State plan under title XIX for children from birth through 

age 5 whose family income does not exceed 200 percent of the 

poverty line, the Secretary shall increase the allotment by an 

amount that would be equal to the Federal share of expenditures that would have been claimed at the enhanced FMAP 

rate rather than the Federal medical assistance percentage 

matching rate for such population.’’. 

øAdditional amendments to section 2104(m) of the SSA made 

by section 10203(d)(2), p. 849¿ 

(2) Section 605 of CHIPRA is amended by striking ‘‘legal 

residents’’ and insert ‘‘lawfully residing in the United States’’. 

(3) Subclauses (I) and (II) of paragraph (3)(C)(i) of section 

2105(a) of the Social Security Act (42 U.S.C. 1397ee(a)(3)(ii)), 

as added by section 104 of CHIPRA, are each amended by 

striking ‘‘, respectively’’. 

(4) Section 2105(a)(3)(E)(ii) of the Social Security Act (42 

U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of CHIPRA, 

is amended by striking subclause (IV). 

(5) Section 2105(c)(9)(B) of the Social Security Act (42 

U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of 

CHIPRA, is amended by striking ‘‘section 1903(a)(3)(F)’’ and inserting ‘‘section 1903(a)(3)(G)’’. 

(6) Section 2109(b)(2)(B) of the Social Security Act (42 

U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, is 

amended by striking ‘‘the child population growth factor under 

section 2104(m)(5)(B)’’ and inserting ‘‘a high-performing State 

under section 2111(b)(3)(B)’’. 

(7) Section 2110(c)(9)(B)(v) of the Social Security Act (42 

U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of 

CHIPRA, is amended by striking ‘‘school or school system’’ and 

inserting ‘‘local educational agency (as defined under section 

9101 of the Elementary and Secondary Education Act of 1965’’. 

(8) Section 211(a)(1)(B) of CHIPRA is amended— 

(A) by striking ‘‘is amended’’ and all that follows 

through ‘‘adding’’ and inserting ‘‘is amended by adding’’; 

and 
Sec. 2201 PPACA (Consolidated) 198 

(B) by redesignating the new subparagraph to be 

added by such section to section 1903(a)(3) of the Social 

Security Act as a new subparagraph (H). 

(b) ARRA.—Effective as if included in the enactment of section 

5006(a) of division B of the American Recovery and Reinvestment 

Act of 2009 (Public Law 111–5), the second sentence of section 

1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o–1(a)(1)) is 

amended by striking ‘‘or (i)’’ and inserting ‘‘, (i), or (j)’’. 

Subtitle C—Medicaid and CHIP 

Enrollment Simplification 

SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 

STATE HEALTH INSURANCE EXCHANGES. 

Title XIX of the Social Security Act (42 U.S.C. 1397aa et seq.) 

is amended by adding at the end the following: 

‘‘SEC. 1943. ø42 U.S.C. 1396w–3¿ ENROLLMENT SIMPLIFICATION AND COORDINATION WITH STATE HEALTH INSURANCE EXCHANGES. 

‘‘(a) CONDITION FOR PARTICIPATION IN MEDICAID.—As a condition of the State plan under this title and receipt of any Federal 

financial assistance under section 1903(a) for calendar quarters beginning after January 1, 2014, a State shall ensure that the requirements of subsection (b) is met. 

‘‘(b) ENROLLMENT SIMPLIFICATION AND COORDINATION WITH

STATE HEALTH INSURANCE EXCHANGES AND CHIP.— ‘‘(1) IN GENERAL.—A State shall establish procedures for— 

‘‘(A) enabling individuals, through an Internet website 

that meets the requirements of paragraph (4), to apply for 

medical assistance under the State plan or under a waiver 

of the plan, to be enrolled in the State plan or waiver, to 

renew their enrollment in the plan or waiver, and to consent to enrollment or reenrollment in the State plan 

through electronic signature; 

‘‘(B) enrolling, without any further determination by 

the State and through such website, individuals who are 

identified by an Exchange established by the State under 

section 1311 of the Patient Protection and Affordable Care 

Act as being eligible for— 

‘‘(i) medical assistance under the State plan or 

under a waiver of the plan; or 

‘‘(ii) child health assistance under the State child 

health plan under title XXI; 

‘‘(C) ensuring that individuals who apply for but are 

determined to be ineligible for medical assistance under 

the State plan or a waiver or ineligible for child health assistance under the State child health plan under title XXI, 

are screened for eligibility for enrollment in qualified 

health plans offered through such an Exchange and, if applicable, premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue 

Code of 1986 (and, if applicable, advance payment of such 

assistance under section 1412 of the Patient Protection 
199 Sec. 2201 PPACA (Consolidated) \1943 SSA 

and Affordable Care Act), and, if eligible, enrolled in such 

a plan without having to submit an additional or separate 

application, and that such individuals receive information 

regarding reduced cost-sharing for eligible individuals 

under section 1402 of the Patient Protection and Affordable Care Act, and any other assistance or subsidies available for coverage obtained through the Exchange; 

‘‘(D) ensuring that the State agency responsible for administering the State plan under this title (in this section 

referred to as the ‘State Medicaid agency’), the State agency responsible for administering the State child health 

plan under title XXI (in this section referred to as the 

‘State CHIP agency’) and an Exchange established by the 

State under section 1311 of the Patient Protection and Affordable Care Act utilize a secure electronic interface sufficient to allow for a determination of an individual’s eligibility for such medical assistance, child health assistance, 

or premium assistance, and enrollment in the State plan 

under this title, title XXI, or a qualified health plan, as appropriate; 

‘‘(E) coordinating, for individuals who are enrolled in 

the State plan or under a waiver of the plan and who are 

also enrolled in a qualified health plan offered through 

such an Exchange, and for individuals who are enrolled in 

the State child health plan under title XXI and who are 

also enrolled in a qualified health plan, the provision of 

medical assistance or child health assistance to such individuals with the coverage provided under the qualified 

health plan in which they are enrolled, including services 

described in section 1905(a)(4)(B) (relating to early and 

periodic screening, diagnostic, and treatment services defined in section 1905(r)) and provided in accordance with 

the requirements of section 1902(a)(43); and 

‘‘(F) conducting outreach to and enrolling vulnerable 

and underserved populations eligible for medical assistance under this title XIX or for child health assistance 

under title XXI, including children, unaccompanied homeless youth, children and youth with special health care 

needs, pregnant women, racial and ethnic minorities, rural 

populations, victims of abuse or trauma, individuals with 

mental health or substance-related disorders, and individuals with HIV/AIDS. 

‘‘(2) AGREEMENTS WITH STATE HEALTH INSURANCE EXCHANGES.—The State Medicaid agency and the State CHIP 

agency may enter into an agreement with an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act under which the State Medicaid 

agency or State CHIP agency may determine whether a State 

resident is eligible for premium assistance for the purchase of 

a qualified health plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such 

assistance under section 1412 of the Patient Protection and Affordable Care Act), so long as the agreement meets such conditions and requirements as the Secretary of the Treasury may 
Sec. 2202 PPACA (Consolidated) 200 

prescribe to reduce administrative costs and the likelihood of 

eligibility errors and disruptions in coverage. 

‘‘(3) STREAMLINED ENROLLMENT SYSTEM.—The State Medicaid agency and State CHIP agency shall participate in and 

comply with the requirements for the system established under 

section 1413 of the Patient Protection and Affordable Care Act 

(relating to streamlined procedures for enrollment through an 

Exchange, Medicaid, and CHIP). 

‘‘(4) ENROLLMENT WEBSITE REQUIREMENTS.—The procedures established by State under paragraph (1) shall include 

establishing and having in operation, not later than January 

1, 2014, an Internet website that is linked to any website of 

an Exchange established by the State under section 1311 of the 

Patient Protection and Affordable Care Act and to the State 

CHIP agency (if different from the State Medicaid agency) and 

allows an individual who is eligible for medical assistance 

under the State plan or under a waiver of the plan and who 

is eligible to receive premium credit assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 to compare the benefits, premiums, 

and cost-sharing applicable to the individual under the State 

plan or waiver with the benefits, premiums, and cost-sharing 

available to the individual under a qualified health plan offered through such an Exchange, including, in the case of a 

child, the coverage that would be provided for the child 

through the State plan or waiver with the coverage that would 

be provided to the child through enrollment in family coverage 

under that plan and as supplemental coverage by the State 

under the State plan or waiver. 

‘‘(5) CONTINUED NEED FOR ASSESSMENT FOR HOME AND

COMMUNITY-BASED SERVICES.—Nothing in paragraph (1) shall 

limit or modify the requirement that the State assess an individual for purposes of providing home and community-based 

services under the State plan or under any waiver of such plan 

for individuals described in subsection (a)(10)(A)(ii)(VI).’’. 

SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE ELIGIBILITY DETERMINATIONS FOR ALL MEDICAID ELIGIBLE 

POPULATIONS. 

(a) IN GENERAL.—Section 1902(a)(47) of the Social Security Act 

(42 U.S.C. 1396a(a)(47)) is amended— 

(1) by striking ‘‘at the option of the State, provide’’ and inserting ‘‘provide— 

‘‘(A) at the option of the State,’’; 

(2) by inserting ‘‘and’’ after the semicolon; and 

(3) by adding at the end the following: 

‘‘(B) that any hospital that is a participating provider 

under the State plan may elect to be a qualified entity for 

purposes of determining, on the basis of preliminary information, whether any individual is eligible for medical assistance under the State plan or under a waiver of the 

plan for purposes of providing the individual with medical 

assistance during a presumptive eligibility period, in the 

same manner, and subject to the same requirements, as 

apply to the State options with respect to populations de-
201 Sec. 2301 PPACA (Consolidated) 

scribed in section 1920, 1920A, or 1920B (but without regard to whether the State has elected to provide for a presumptive eligibility period under any such sections), subject to such guidance as the Secretary shall establish;’’. 

(b) CONFORMING AMENDMENT.—Section 1903(u)(1)(D)(v) of such 

Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended— 

(1) by striking ‘‘or for’’ and inserting ‘‘for’’; and 

(2) by inserting before the period at the end the following: 

‘‘, or for medical assistance provided to an individual during a 

presumptive eligibility period resulting from a determination of 

presumptive eligibility made by a hospital that elects under 

section 1902(a)(47)(B) to be a qualified entity for such purpose’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

take effect on January 1, 2014, and apply to services furnished on 

or after that date. 

Subtitle D—Improvements to Medicaid 

Services 

SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES. 

(a) IN GENERAL.—Section 1905 of the Social Security Act (42 

U.S.C. 1396d), is amended— 

(1) in subsection (a)— 

(A) in paragraph (27), by striking ‘‘and’’ at the end; 

(B) by redesignating paragraph (28) as paragraph (29); 

and 

(C) by inserting after paragraph (27) the following new 

paragraph: 

‘‘(28) freestanding birth center services (as defined in subsection (l)(3)(A)) and other ambulatory services that are offered 

by a freestanding birth center (as defined in subsection 

(l)(3)(B)) and that are otherwise included in the plan; and’’; and 

(2) in subsection (l), by adding at the end the following 

new paragraph: 

‘‘(3)(A) The term ‘freestanding birth center services’ means 

services furnished to an individual at a freestanding birth center 

(as defined in subparagraph (B)) at such center. 

‘‘(B) The term ‘freestanding birth center’ means a health facility— 

‘‘(i) that is not a hospital; 

‘‘(ii) where childbirth is planned to occur away from the 

pregnant woman’s residence; 

‘‘(iii) that is licensed or otherwise approved by the State to 

provide prenatal labor and delivery or postpartum care and 

other ambulatory services that are included in the plan; and 

‘‘(iv) that complies with such other requirements relating 

to the health and safety of individuals furnished services by 

the facility as the State shall establish. 

‘‘(C) A State shall provide separate payments to providers administering prenatal labor and delivery or postpartum care in a 

freestanding birth center (as defined in subparagraph (B)), such as 

nurse midwives and other providers of services such as birth at-
Sec. 2302 PPACA (Consolidated) 202 

tendants recognized under State law, as determined appropriate by 

the Secretary. For purposes of the preceding sentence, the term 

‘birth attendant’ means an individual who is recognized or registered by the State involved to provide health care at childbirth 

and who provides such care within the scope of practice under 

which the individual is legally authorized to perform such care 

under State law (or the State regulatory mechanism provided by 

State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing 

State law requirements applicable to a birth attendant.’’. 

(b) CONFORMING AMENDMENT.—Section 1902(a)(10)(A) of the 

Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended in the 

matter preceding clause (i) by striking ‘‘and (21)’’ and inserting ‘‘, 

(21), and (28)’’. 

(c) EFFECTIVE DATE.— 

(1) IN GENERAL.—Except as provided in paragraph (2), the 

amendments made by this section shall take effect on the date 

of the enactment of this Act and shall apply to services furnished on or after such date. 

(2) EXCEPTION IF STATE LEGISLATION REQUIRED.—In the 

case of a State plan for medical assistance under title XIX of 

the Social Security Act which the Secretary of Health and 

Human Services determines requires State legislation (other 

than legislation appropriating funds) in order for the plan to 

meet the additional requirement imposed by the amendments 

made by this section, the State plan shall not be regarded as 

failing to comply with the requirements of such title solely on 

the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after 

the close of the first regular session of the State legislature 

that begins after the date of the enactment of this Act. For 

purposes of the previous sentence, in the case of a State that 

has a 2-year legislative session, each year of such session shall 

be deemed to be a separate regular session of the State legislature. 

SEC. 2302. CONCURRENT CARE FOR CHILDREN. 

(a) IN GENERAL.—Section 1905(o)(1) of the Social Security Act 

(42 U.S.C. 1396d(o)(1)) is amended— 

(1) in subparagraph (A), by striking ‘‘subparagraph (B)’’ 

and inserting ‘‘subparagraphs (B) and (C)’’; and 

(2) by adding at the end the following new subparagraph: 

‘‘(C) A voluntary election to have payment made for hospice 

care for a child (as defined by the State) shall not constitute a 

waiver of any rights of the child to be provided with, or to have 

payment made under this title for, services that are related to the 

treatment of the child’s condition for which a diagnosis of terminal 

illness has been made.’’. 

(b) APPLICATION TO CHIP.—Section 2110(a)(23) of the Social 

Security Act (42 U.S.C. 1397jj(a)(23)) is amended by inserting 

‘‘(concurrent, in the case of an individual who is a child, with care 

related to the treatment of the child’s condition with respect to 
203 Sec. 2303 PPACA (Consolidated) 

which a diagnosis of terminal illness has been made’’ after ‘‘hospice 

care’’. 

SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERVICES. 

(a) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY GROUP.— (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the Social 

Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by section 2001(e), is amended— 

(A) in subclause (XIX), by striking ‘‘or’’ at the end; 

(B) in subclause (XX), by adding ‘‘or’’ at the end; and 

(C) by adding at the end the following new subclause: 

‘‘(XXI) who are described in subsection (ii) (relating to individuals who meet certain income 

standards);’’. 

(2) GROUP DESCRIBED.—Section 1902 of such Act (42 

U.S.C. 1396a), as amended by section 2001(d), is amended by 

adding at the end the following new subsection: 

‘‘(ii)(1) Individuals described in this subsection are individuals— 

‘‘(A) whose income does not exceed an income eligibility level established by the State that does not exceed 

the highest income eligibility level established under the 

State plan under this title (or under its State child health 

plan under title XXI) for pregnant women; and 

‘‘(B) who are not pregnant. 

‘‘(2) At the option of a State, individuals described in this 

subsection may include individuals who, had individuals applied on or before January 1, 2007, would have been made eligible pursuant to the standards and processes imposed by that 

State for benefits described in clause (XV) of the matter following subparagraph (G) of section subsection (a)(10) pursuant 

to a waiver granted under section 1115. 

‘‘(3) At the option of a State, for purposes of subsection 

(a)(17)(B), in determining eligibility for services under this subsection, the State may consider only the income of the applicant or recipient.’’. 

(3) LIMITATION ON BENEFITS.—Section 1902(a)(10) of 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)— 

(A) by striking ‘‘and (XV)’’ and inserting ‘‘(XV)’’; and 

(B) by inserting ‘‘, and (XVI) the medical assistance 

made available to an individual described in subsection (ii) 

shall be limited to family planning services and supplies 

described in section 1905(a)(4)(C) including medical diagnosis and treatment services that are provided pursuant to 

a family planning service in a family planning setting’’ before the semicolon. 

(4) CONFORMING AMENDMENTS.— 

(A) Section 1905(a) of the Social Security Act (42 

U.S.C. 1396d(a)), as amended by section 2001(e)(2)(A), is 

amended in the matter preceding paragraph (1)— 

(i) in clause (xiv), by striking ‘‘or’’ at the end; 

(ii) in clause (xv), by adding ‘‘or’’ at the end; and 
Sec. 2303\1920C SSA PPACA (Consolidated) 204 

(iii) by inserting after clause (xv) the following: 

‘‘(xvi) individuals described in section 1902(ii),’’. 

(B) Section 1903(f)(4) of such Act (42 U.S.C. 

1396b(f)(4)), as amended by section 2001(e)(2)(B), is 

amended by inserting ‘‘1902(a)(10)(A)(ii)(XXI),’’ after 

‘‘1902(a)(10)(A)(ii)(XX),’’. 

(b) PRESUMPTIVE ELIGIBILITY.— 

(1) IN GENERAL.—Title XIX of the Social Security Act (42 

U.S.C. 1396 et seq.) is amended by inserting after section 

1920B the following: 

‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING SERVICES

‘‘SEC. 1920C. ø42 U.S.C. 1396r–1c¿ (a) STATE OPTION.—State 

plan approved under section 1902 may provide for making medical 

assistance available to an individual described in section 1902(ii) 

(relating to individuals who meet certain income eligibility standard) during a presumptive eligibility period. In the case of an individual described in section 1902(ii), such medical assistance shall 

be limited to family planning services and supplies described in 

1905(a)(4)(C) and, at the State’s option, medical diagnosis and 

treatment services that are provided in conjunction with a family 

planning service in a family planning setting. 

‘‘(b) DEFINITIONS.—For purposes of this section: 

‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The term ‘presumptive eligibility period’ means, with respect to an individual described in subsection (a), the period that— 

‘‘(A) begins with the date on which a qualified entity 

determines, on the basis of preliminary information, that 

the individual is described in section 1902(ii); and 

‘‘(B) ends with (and includes) the earlier of— 

‘‘(i) the day on which a determination is made 

with respect to the eligibility of such individual for 

services under the State plan; or 

‘‘(ii) in the case of such an individual who does not 

file an application by the last day of the month following the month during which the entity makes the 

determination referred to in subparagraph (A), such 

last day. 

‘‘(2) QUALIFIED ENTITY.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

term ‘qualified entity’ means any entity that— 

‘‘(i) is eligible for payments under a State plan approved under this title; and 

‘‘(ii) is determined by the State agency to be capable of making determinations of the type described in 

paragraph (1)(A). 

‘‘(B) RULE OF CONSTRUCTION.—Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities in order to prevent fraud and abuse. 

‘‘(c) ADMINISTRATION.— 

‘‘(1) IN GENERAL.—The State agency shall provide qualified 

entities with— 
205 Sec. 2303 PPACA (Consolidated) 

‘‘(A) such forms as are necessary for an application to 

be made by an individual described in subsection (a) for 

medical assistance under the State plan; and 

‘‘(B) information on how to assist such individuals in 

completing and filing such forms. 

‘‘(2) NOTIFICATION REQUIREMENTS.—A qualified entity that 

determines under subsection (b)(1)(A) that an individual described in subsection (a) is presumptively eligible for medical 

assistance under a State plan shall— 

‘‘(A) notify the State agency of the determination within 5 working days after the date on which determination 

is made; and 

‘‘(B) inform such individual at the time the determination is made that an application for medical assistance is 

required to be made by not later than the last day of the 

month following the month during which the determination is made. 

‘‘(3) APPLICATION FOR MEDICAL ASSISTANCE.—In the case of 

an individual described in subsection (a) who is determined by 

a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply for medical assistance by not later than the last day of the month following the month during which the determination is made. 

‘‘(d) PAYMENT.—Notwithstanding any other provision of law, 

medical assistance that— 

‘‘(1) is furnished to an individual described in subsection 

(a)— 

‘‘(A) during a presumptive eligibility period; and 

‘‘(B) by a entity that is eligible for payments under the 

State plan; and 

‘‘(2) is included in the care and services covered by the 

State plan, 

shall be treated as medical assistance provided by such plan for 

purposes of clause (4) of the first sentence of section 1905(b).’’. 

(2) CONFORMING AMENDMENTS.— 

(A) Section 1902(a)(47) of the Social Security Act (42 

U.S.C. 1396a(a)(47)), as amended by section 2202(a), is 

amended— 

(i) in subparagraph (A), by inserting before the 

semicolon at the end the following: ‘‘and provide for 

making medical assistance available to individuals described in subsection (a) of section 1920C during a presumptive eligibility period in accordance with such 

section’’; and 

(ii) in subparagraph (B), by striking ‘‘or 1920B’’ 

and inserting ‘‘1920B, or 1920C’’. 

(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 

1396b(u)(1)(D)(v)), as amended by section 2202(b), is 

amended by inserting ‘‘or for medical assistance provided 

to an individual described in subsection (a) of section 

1920C during a presumptive eligibility period under such 

section,’’ after ‘‘1920B during a presumptive eligibility period under such section,’’. 
Sec. 2304 PPACA (Consolidated) 206 

(c) CLARIFICATION OF COVERAGE OF FAMILY PLANNING SERVICES AND SUPPLIES.—Section 1937(b) of the Social Security Act (42 

U.S.C. 1396u–7(b)), as amended by section 2001(c), is amended by 

adding at the end the following: 

‘‘(7) COVERAGE OF FAMILY PLANNING SERVICES AND SUPPLIES.—Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through 

enrollment of an individual with benchmark coverage or benchmark-equivalent coverage under this section unless such coverage includes for any individual described in section 

1905(a)(4)(C), medical assistance for family planning services 

and supplies in accordance with such section.’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

take effect on the date of the enactment of this Act and shall apply 

to items and services furnished on or after such date. 

SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE. 

Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 

is amended by inserting ‘‘or the care and services themselves, or 

both’’ before ‘‘(if provided in or after’’. 

Subtitle E—New Options for States to 

Provide Long-Term Services and Supports 

SEC. 2401. COMMUNITY FIRST CHOICE OPTION. 

Section 1915 of the Social Security Act (42 U.S.C. 1396n) is 

amended by adding at the end the following: 

‘‘(k) STATE PLAN OPTION TO PROVIDE HOME AND COMMUNITYBASED ATTENDANT SERVICES AND SUPPORTS.— 

‘‘(1) IN GENERAL.—øAs revised by section 1205 of HCERA¿ 

Subject to the succeeding provisions of this subsection, beginning October 1, 2011, a State may provide through a State 

plan amendment for the provision of medical assistance for 

home and community-based attendant services and supports 

for individuals who are eligible for medical assistance under 

the State plan whose income does not exceed 150 percent of 

the poverty line (as defined in section 2110(c)(5)) or, if greater, 

the income level applicable for an individual who has been determined to require an institutional level of care to be eligible 

for nursing facility services under the State plan and with respect to whom there has been a determination that, but for the 

provision of such services, the individuals would require the 

level of care provided in a hospital, a nursing facility, an intermediate care facility for the mentally retarded, or an institution for mental diseases, the cost of which could be reimbursed 

under the State plan, but only if the individual chooses to receive such home and community-based attendant services and 

supports, and only if the State meets the following requirements: 

‘‘(A) AVAILABILITY.—The State shall make available 

home and community-based attendant services and supports to eligible individuals, as needed, to assist in accomplishing activities of daily living, instrumental activities of 
207 Sec. 2401 PPACA (Consolidated) 

daily living, and health-related tasks through hands-on assistance, supervision, or cueing— 

‘‘(i) under a person-centered plan of services and 

supports that is based on an assessment of functional 

need and that is agreed to in writing by the individual 

or, as appropriate, the individual’s representative; 

‘‘(ii) in a home or community setting, which does 

not include a nursing facility, institution for mental 

diseases, or an intermediate care facility for the mentally retarded; 

‘‘(iii) under an agency-provider model or other 

model (as defined in paragraph (6)(C )); and 

‘‘(iv) the furnishing of which— 

‘‘(I) is selected, managed, and dismissed by 

the individual, or, as appropriate, with assistance 

from the individual’s representative; 

‘‘(II) is controlled, to the maximum extent possible, by the individual or where appropriate, the 

individual’s representative, regardless of who may 

act as the employer of record; and 

‘‘(III) provided by an individual who is qualified to provide such services, including family 

members (as defined by the Secretary). 

‘‘(B) INCLUDED SERVICES AND SUPPORTS.—In addition 

to assistance in accomplishing activities of daily living, instrumental activities of daily living, and health related 

tasks, the home and community-based attendant services 

and supports made available include— 

‘‘(i) the acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living, instrumental activities 

of daily living, and health related tasks; 

‘‘(ii) back-up systems or mechanisms (such as the 

use of beepers or other electronic devices) to ensure 

continuity of services and supports; and 

‘‘(iii) voluntary training on how to select, manage, 

and dismiss attendants. 

‘‘(C) EXCLUDED SERVICES AND SUPPORTS.—Subject to 

subparagraph (D), the home and community-based attendant services and supports made available do not include— 

‘‘(i) room and board costs for the individual; 

‘‘(ii) special education and related services provided under the Individuals with Disabilities Education Act and vocational rehabilitation services provided under the Rehabilitation Act of 1973; 

‘‘(iii) assistive technology devices and assistive 

technology services other than those under (1)(B)(ii); 

‘‘(iv) medical supplies and equipment; or 

‘‘(v) home modifications. 

‘‘(D) PERMISSIBLE SERVICES AND SUPPORTS.—The home 

and community-based attendant services and supports 

may include— 

‘‘(i) expenditures for transition costs such as rent 

and utility deposits, first month’s rent and utilities, 
Sec. 2401 PPACA (Consolidated) 208 

bedding, basic kitchen supplies, and other necessities 

required for an individual to make the transition from 

a nursing facility, institution for mental diseases, or 

intermediate care facility for the mentally retarded to 

a community-based home setting where the individual 

resides; and 

‘‘(ii) expenditures relating to a need identified in 

an individual’s person-centered plan of services that 

increase independence or substitute for human assistance, to the extent that expenditures would otherwise 

be made for the human assistance. 

‘‘(2) INCREASED FEDERAL FINANCIAL PARTICIPATION.—For 

purposes of payments to a State under section 1903(a)(1), with 

respect to amounts expended by the State to provide medical 

assistance under the State plan for home and communitybased attendant services and supports to eligible individuals in 

accordance with this subsection during a fiscal year quarter occurring during the period described in paragraph (1), the Federal medical assistance percentage applicable to the State (as 

determined under section 1905(b)) shall be increased by 6 percentage points. 

‘‘(3) STATE REQUIREMENTS.—In order for a State plan 

amendment to be approved under this subsection, the State 

shall— 

‘‘(A) develop and implement such amendment in collaboration with a Development and Implementation Council established by the State that includes a majority of 

members with disabilities, elderly individuals, and their 

representatives and consults and collaborates with such individuals; 

‘‘(B) provide consumer controlled home and community-based attendant services and supports to individuals 

on a statewide basis, in a manner that provides such services and supports in the most integrated setting appropriate to the individual’s needs, and without regard to the 

individual’s age, type or nature of disability, severity of 

disability, or the form of home and community-based attendant services and supports that the individual requires 

in order to lead an independent life; 

‘‘(C) with respect to expenditures during the first full 

fiscal year in which the State plan amendment is implemented, maintain or exceed the level of State expenditures 

for medical assistance that is provided under section 

1905(a), section 1915, section 1115, or otherwise to individuals with disabilities or elderly individuals attributable to 

the preceding fiscal year; 

‘‘(D) establish and maintain a comprehensive, continuous quality assurance system with respect to communitybased attendant services and supports that— 

‘‘(i) includes standards for agency-based and other 

delivery models with respect to training, appeals for 

denials and reconsideration procedures of an individual plan, and other factors as determined by the 

Secretary; 
209 Sec. 2401 PPACA (Consolidated) 

‘‘(ii) incorporates feedback from consumers and 

their representatives, disability organizations, providers, families of disabled or elderly individuals, 

members of the community, and others and maximizes 

consumer independence and consumer control; 

‘‘(iii) monitors the health and well-being of each 

individual who receives home and community-based 

attendant services and supports, including a process 

for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in 

connection with the provision of such services and supports; and 

‘‘(iv) provides information about the provisions of 

the quality assurance required under clauses (i) 

through (iii) to each individual receiving such services; 

and 

‘‘(E) collect and report information, as determined necessary by the Secretary, for the purposes of approving the 

State plan amendment, providing Federal oversight, and 

conducting an evaluation under paragraph (5)(A), including data regarding how the State provides home and community-based attendant services and supports and other 

home and community-based services, the cost of such services and supports, and how the State provides individuals 

with disabilities who otherwise qualify for institutional 

care under the State plan or under a waiver the choice to 

instead receive home and community-based services in lieu 

of institutional care. 

‘‘(4) COMPLIANCE WITH CERTAIN LAWS.—A State shall ensure that, regardless of whether the State uses an agency-provider model or other models to provide home and communitybased attendant services and supports under a State plan 

amendment under this subsection, such services and supports 

are provided in accordance with the requirements of the Fair 

Labor Standards Act of 1938 and applicable Federal and State 

laws regarding— 

‘‘(A) withholding and payment of Federal and State income and payroll taxes; 

‘‘(B) the provision of unemployment and workers compensation insurance; 

‘‘(C) maintenance of general liability insurance; and 

‘‘(D) occupational health and safety. 

‘‘(5) EVALUATION, DATA COLLECTION, AND REPORT TO CONGRESS.— 

‘‘(A) EVALUATION.—The Secretary shall conduct an 

evaluation of the provision of home and community-based 

attendant services and supports under this subsection in 

order to determine the effectiveness of the provision of 

such services and supports in allowing the individuals receiving such services and supports to lead an independent 

life to the maximum extent possible; the impact on the 

physical and emotional health of the individuals who receive such services; and an comparative analysis of the 

costs of services provided under the State plan amendment 
Sec. 2401 PPACA (Consolidated) 210 

under this subsection and those provided under institutional care in a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded. 

‘‘(B) DATA COLLECTION.—The State shall provide the 

Secretary with the following information regarding the 

provision of home and community-based attendant services 

and supports under this subsection for each fiscal year for 

which such services and supports are provided: 

‘‘(i) The number of individuals who are estimated 

to receive home and community-based attendant services and supports under this subsection during the fiscal year. 

‘‘(ii) The number of individuals that received such 

services and supports during the preceding fiscal year. 

‘‘(iii) The specific number of individuals served by 

type of disability, age, gender, education level, and 

employment status. 

‘‘(iv) Whether the specific individuals have been 

previously served under any other home and community based services program under the State plan or 

under a waiver. 

‘‘(C) REPORTS.—Not later than— 

‘‘(i) December 31, 2013, the Secretary shall submit 

to Congress and make available to the public an interim report on the findings of the evaluation under 

subparagraph (A); and 

‘‘(ii) December 31, 2015, the Secretary shall submit to Congress and make available to the public a 

final report on the findings of the evaluation under 

subparagraph (A). 

‘‘(6) DEFINITIONS.—In this subsection: 

‘‘(A) ACTIVITIES OF DAILY LIVING.—The term ‘activities 

of daily living’ includes tasks such as eating, toileting, 

grooming, dressing, bathing, and transferring. 

‘‘(B) CONSUMER CONTROLLED.—The term ‘consumer 

controlled’ means a method of selecting and providing services and supports that allow the individual, or where appropriate, the individual’s representative, maximum control of the home and community-based attendant services 

and supports, regardless of who acts as the employer of 

record. 

‘‘(C) DELIVERY MODELS.— 

‘‘(i) AGENCY-PROVIDER MODEL.—The term ‘agencyprovider model’ means, with respect to the provision of 

home and community-based attendant services and 

supports for an individual, subject to paragraph (4), a 

method of providing consumer controlled services and 

supports under which entities contract for the provision of such services and supports. 

‘‘(ii) OTHER MODELS.—The term ‘other models’ 

means, subject to paragraph (4), methods, other than 

an agency-provider model, for the provision of consumer controlled services and supports. Such models 
211 Sec. 2402 PPACA (Consolidated) 

may include the provision of vouchers, direct cash payments, or use of a fiscal agent to assist in obtaining 

services. 

‘‘(D) HEALTH-RELATED TASKS.—The term ‘health-related tasks’ means specific tasks related to the needs of an 

individual, which can be delegated or assigned by licensed 

health-care professionals under State law to be performed 

by an attendant. 

‘‘(E) INDIVIDUAL’S REPRESENTATIVE.—The term ‘individual’s representative’ means a parent, family member, 

guardian, advocate, or other authorized representative of 

an individual 

‘‘(F) INSTRUMENTAL ACTIVITIES OF DAILY LIVING.—The 

term ‘instrumental activities of daily living’ includes (but 

is not limited to) meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around 

and participating in the community.’’. 

øNote that section 10202, on p. 845, provides incentives for 

States to offer home and community-based services as long-term 

care alternative to nursing homes¿ 

SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND COMMUNITY-BASED SERVICES. 

(a) OVERSIGHT AND ASSESSMENT OF THE ADMINISTRATION OF

HOME AND COMMUNITY-BASED SERVICES.—The Secretary of Health 

and Human Services shall promulgate regulations to ensure that 

all States develop service systems that are designed to— 

(1) allocate resources for services in a manner that is responsive to the changing needs and choices of beneficiaries receiving non-institutionally-based long-term services and supports (including such services and supports that are provided 

under programs other the State Medicaid program), and that 

provides strategies for beneficiaries receiving such services to 

maximize their independence, including through the use of client-employed providers; 

(2) provide the support and coordination needed for a beneficiary in need of such services (and their family caregivers or 

representative, if applicable) to design an individualized, selfdirected, community-supported life; and 

(3) improve coordination among, and the regulation of, all 

providers of such services under federally and State-funded 

programs in order to— 

(A) achieve a more consistent administration of policies and procedures across programs in relation to the provision of such services; and 

(B) oversee and monitor all service system functions to 

assure— 

(i) coordination of, and effectiveness of, eligibility 

determinations and individual assessments; 

(ii) development and service monitoring of a complaint system, a management system, a system to 

qualify and monitor providers, and systems for rolesetting and individual budget determinations; and 
Sec. 2402 PPACA (Consolidated) 212 

(iii) an adequate number of qualified direct care 

workers to provide self-directed personal assistance 

services. 

(b) ADDITIONAL STATE OPTIONS.—Section 1915(i) of the Social 

Security Act (42 U.S.C. 1396n(i)) is amended by adding at the end 

the following new paragraphs: 

‘‘(6) STATE OPTION TO PROVIDE HOME AND COMMUNITY- BASED SERVICES TO INDIVIDUALS ELIGIBLE FOR SERVICES UNDER

A WAIVER.— 

‘‘(A) IN GENERAL.—A State that provides home and 

community-based services in accordance with this subsection to individuals who satisfy the needs-based criteria 

for the receipt of such services established under paragraph (1)(A) may, in addition to continuing to provide such 

services to such individuals, elect to provide home and 

community-based services in accordance with the requirements of this paragraph to individuals who are eligible for 

home and community-based services under a waiver approved for the State under subsection (c), (d), or (e) or 

under section 1115 to provide such services, but only for 

those individuals whose income does not exceed 300 percent of the supplemental security income benefit rate established by section 1611(b)(1). 

‘‘(B) APPLICATION OF SAME REQUIREMENTS FOR INDIVID- UALS SATISFYING NEEDS-BASED CRITERIA.—Subject to subparagraph (C), a State shall provide home and communitybased services to individuals under this paragraph in the 

same manner and subject to the same requirements as 

apply under the other paragraphs of this subsection to the 

provision of home and community-based services to individuals who satisfy the needs-based criteria established 

under paragraph (1)(A). 

‘‘(C) AUTHORITY TO OFFER DIFFERENT TYPE, AMOUNT, 

DURATION, OR SCOPE OF HOME AND COMMUNITY-BASED

SERVICES.—A State may offer home and community-based 

services to individuals under this paragraph that differ in 

type, amount, duration, or scope from the home and community-based services offered for individuals who satisfy 

the needs-based criteria established under paragraph 

(1)(A), so long as such services are within the scope of 

services described in paragraph (4)(B) of subsection (c) for 

which the Secretary has the authority to approve a waiver 

and do not include room or board. 

‘‘(7) STATE OPTION TO OFFER HOME AND COMMUNITY-BASED

SERVICES TO SPECIFIC, TARGETED POPULATIONS.— 

‘‘(A) IN GENERAL.—A State may elect in a State plan 

amendment under this subsection to target the provision 

of home and community-based services under this subsection to specific populations and to differ the type, 

amount, duration, or scope of such services to such specific 

populations. 

‘‘(B) 5-YEAR TERM.— 

‘‘(i) IN GENERAL.—An election by a State under 

this paragraph shall be for a period of 5 years. 
213 Sec. 2402 PPACA (Consolidated) 

‘‘(ii) PHASE-IN OF SERVICES AND ELIGIBILITY PER- MITTED DURING INITIAL 5-YEAR PERIOD.—A State making an election under this paragraph may, during the 

first 5-year period for which the election is made, 

phase-in the enrollment of eligible individuals, or the 

provision of services to such individuals, or both, so 

long as all eligible individuals in the State for such 

services are enrolled, and all such services are provided, before the end of the initial 5-year period. 

‘‘(C) RENEWAL.—An election by a State under this 

paragraph may be renewed for additional 5-year terms if 

the Secretary determines, prior to beginning of each such 

renewal period, that the State has— 

‘‘(i) adhered to the requirements of this subsection 

and paragraph in providing services under such an 

election; and 

‘‘(ii) met the State’s objectives with respect to 

quality improvement and beneficiary outcomes.’’. 

(c) REMOVAL OF LIMITATION ON SCOPE OF SERVICES.—Paragraph (1) of section 1915(i) of the Social Security Act (42 U.S.C. 

1396n(i)), as amended by subsection (a), is amended by striking ‘‘or 

such other services requested by the State as the Secretary may 

approve’’. 

(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE FULL MED- ICAID BENEFITS TO INDIVIDUALS RECEIVING HOME AND COMMUNITY- BASED SERVICES UNDER A STATE PLAN AMENDMENT.— (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the Social 

Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by section 2304(a)(1), is amended— 

(A) in subclause (XX), by striking ‘‘or’’ at the end; 

(B) in subclause (XXI), by adding ‘‘or’’ at the end; and 

(C) by inserting after subclause (XXI), the following 

new subclause: 

‘‘(XXII) who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of section 

1915(i), or who are eligible for home and community-based services under paragraph (6) of such 

section, and who will receive home and community-based services pursuant to a State plan 

amendment under such subsection;’’. 

(2) CONFORMING AMENDMENTS.— 

(A) Section 1903(f)(4) of the Social Security Act (42 

U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), is 

amended in the matter preceding subparagraph (A), by inserting ‘‘1902(a)(10)(A)(ii)(XXII),’’ after 

‘‘1902(a)(10)(A)(ii)(XXI),’’. 

(B) Section 1905(a) of the Social Security Act (42 

U.S.C. 1396d(a)), as so amended, is amended in the matter 

preceding paragraph (1)— 

(i) in clause (xv), by striking ‘‘or’’ at the end; 

(ii) in clause (xvi), by adding ‘‘or’’ at the end; and 

(iii) by inserting after clause (xvi) the following 

new clause: 
Sec. 2403 PPACA (Consolidated) 214 

‘‘(xvii) individuals who are eligible for home and community-based services under needs-based criteria established 

under paragraph (1)(A) of section 1915(i), or who are eligible 

for home and community-based services under paragraph (6) of 

such section, and who will receive home and community-based 

services pursuant to a State plan amendment under such subsection,’’. 

(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF ELIGIBLE INDIVIDUALS OR LENGTH OF PERIOD FOR GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA IS MODIFIED.—Paragraph (1) of section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended— 

(1) by striking subparagraph (C) and inserting the following: 

‘‘(C) PROJECTION OF NUMBER OF INDIVIDUALS TO BE

PROVIDED HOME AND COMMUNITY-BASED SERVICES.—The 

State submits to the Secretary, in such form and manner, 

and upon such frequency as the Secretary shall specify, 

the projected number of individuals to be provided home 

and community-based services.’’; and 

(2) in subclause (II) of subparagraph (D)(ii), by striking ‘‘to 

be eligible for such services for a period of at least 12 months 

beginning on the date the individual first received medical assistance for such services’’ and inserting ‘‘to continue to be eligible for such services after the effective date of the modification and until such time as the individual no longer meets the 

standard for receipt of such services under such pre-modified 

criteria’’. 

(f) ELIMINATION OF OPTION TO WAIVE STATEWIDENESS; ADDITION OF OPTION TO WAIVE COMPARABILITY.—Paragraph (3) of section 1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by striking 

‘‘1902(a)(1) (relating to statewideness)’’ and inserting 

‘‘1902(a)(10)(B) (relating to comparability)’’. 

(g) EFFECTIVE DATE.—The amendments made by subsections 

(b) through (f) take effect on the first day of the first fiscal year 

quarter that begins after the date of enactment of this Act. 

SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION. 

(a) EXTENSION OF DEMONSTRATION.— 

(1) IN GENERAL.—Section 6071(h) of the Deficit Reduction 

Act of 2005 (42 U.S.C. 1396a note) is amended— 

(A) in paragraph (1)(E), by striking ‘‘fiscal year 2011’’ 

and inserting ‘‘each of fiscal years 2011 through 2016’’; and 

(B) in paragraph (2), by striking ‘‘2011’’ and inserting 

‘‘2016’’. 

(2) EVALUATION.—Paragraphs (2) and (3) of section 6071(g) 

of such Act is amended are each amended by striking ‘‘2011’’ 

and inserting ‘‘2016’’. 

(b) REDUCTION OF INSTITUTIONAL RESIDENCY PERIOD.— 

(1) IN GENERAL.—Section 6071(b)(2) of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended— 

(A) in subparagraph (A)(i), by striking ‘‘, for a period 

of not less than 6 months or for such longer minimum period, not to exceed 2 years, as may be specified by the 
215 Sec. 2406 PPACA (Consolidated) 

State’’ and inserting ‘‘for a period of not less than 90 consecutive days’’; and 

(B) by adding at the end the following: 

‘‘Any days that an individual resides in an institution on the 

basis of having been admitted solely for purposes of receiving 

short-term rehabilitative services for a period for which payment for such services is limited under title XVIII shall not be 

taken into account for purposes of determining the 90-day period required under subparagraph (A)(i).’’. 

(2) EFFECTIVE DATE.—The amendments made by this subsection take effect 30 days after the date of enactment of this 

Act. 

SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITYBASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT. 

During the 5-year period that begins on January 1, 2014, section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r– 

5(h)(1)(A)) shall be applied as though ‘‘is eligible for medical assistance for home and community-based services provided under subsection (c), (d), or (i) of section 1915, under a waiver approved 

under section 1115, or who is eligible for such medical assistance 

by reason of being determined eligible under section 1902(a)(10)(C) 

or by reason of section 1902(f) or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care, or who is eligible for medical assistance for home and 

community-based attendant services and supports under section 

1915(k)’’ were substituted in such section for ‘‘(at the option of the 

State) is described in section 1902(a)(10)(A)(ii)(VI)’’. 

SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY RESOURCE CENTERS. 

Out of any funds in the Treasury not otherwise appropriated, 

there is appropriated to the Secretary of Health and Human Services, acting through the Assistant Secretary for Aging, $10,000,000 

for each of fiscal years 2010 through 2014, to carry out subsections 

(a)(20)(B)(iii) and (b)(8) of section 202 of the Older Americans Act 

of 1965 (42 U.S.C. 3012). 

SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE. 

(a) FINDINGS.—The Senate makes the following findings: 

(1) Nearly 2 decades have passed since Congress seriously 

considered long-term care reform. The United States Bipartisan Commission on Comprehensive Health Care, also know 

as the ‘‘Pepper Commission’’, released its ‘‘Call for Action’’ 

blueprint for health reform in September 1990. In the 20 years 

since those recommendations were made, Congress has never 

acted on the report. 

(2) In 1999, under the United States Supreme Court’s decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals with 

disabilities have the right to choose to receive their long-term 

services and supports in the community, rather than in an institutional setting. 

(3) Despite the Pepper Commission and Olmstead decision, 

the long-term care provided to our Nation’s elderly and disabled has not improved. In fact, for many, it has gotten far 

worse. 
Sec. 2501 PPACA (Consolidated) 216 

(4) In 2007, 69 percent of Medicaid long-term care spending for elderly individuals and adults with physical disabilities 

paid for institutional services. Only 6 states spent 50 percent 

or more of their Medicaid long-term care dollars on home and 

community-based services for elderly individuals and adults 

with physical disabilities while 1⁄2 of the States spent less than 

25 percent. This disparity continues even though, on average, 

it is estimated that Medicaid dollars can support nearly 3 elderly individuals and adults with physical disabilities in home 

and community-based services for every individual in a nursing home. Although every State has chosen to provide certain 

services under home and community-based waivers, these services are unevenly available within and across States, and reach 

a small percentage of eligible individuals. 

(b) SENSE OF THE SENATE.—It is the sense of the Senate that— 

(1) during the 111th session of Congress, Congress should 

address long-term services and supports in a comprehensive 

way that guarantees elderly and disabled individuals the care 

they need; and 

(2) long term services and supports should be made available in the community in addition to in institutions. 

Subtitle F—Medicaid Prescription Drug 

Coverage 

SEC. 2501. PRESCRIPTION DRUG REBATES. 

(a) INCREASE IN MINIMUM REBATE PERCENTAGE FOR SINGLE

SOURCE DRUGS AND INNOVATOR MULTIPLE SOURCE DRUGS.— (1) IN GENERAL.—Section 1927(c)(1)(B) of the Social Security Act (42 U.S.C. 1396r–8(c)(1)(B)) is amended— 

(A) in clause (i)— 

(i) in subclause (IV), by striking ‘‘and’’ at the end; 

(ii) in subclause (V)— 

(I) by inserting ‘‘and before January 1, 2010’’ 

after ‘‘December 31, 1995,’’; and 

(II) by striking the period at the end and inserting ‘‘; and’’; and 

(iii) by adding at the end the following new subclause: 

‘‘(VI) except as provided in clause (iii), after 

December 31, 2009, 23.1 percent.’’; and 

(B) by adding at the end the following new clause: 

‘‘(iii) MINIMUM REBATE PERCENTAGE FOR CERTAIN

DRUGS.— 

‘‘(I) IN GENERAL.—In the case of a single 

source drug or an innovator multiple source drug 

described in subclause (II), the minimum rebate 

percentage for rebate periods specified in clause 

(i)(VI) is 17.1 percent. 

‘‘(II) DRUG DESCRIBED.—For purposes of subclause (I), a single source drug or an innovator 

multiple source drug described in this subclause is 

any of the following drugs: 
217 Sec. 2501 PPACA (Consolidated) 

‘‘(aa) A clotting factor for which a separate furnishing payment is made under section 1842(o)(5) and which is included on a list 

of such factors specified and updated regularly by the Secretary. 

‘‘(bb) A drug approved by the Food and 

Drug Administration exclusively for pediatric 

indications.’’. 

(2) RECAPTURE OF TOTAL SAVINGS DUE TO INCREASE.—Section 1927(b)(1) of such Act (42 U.S.C. 1396r–8(b)(1)) is amended by adding at the end the following new subparagraph: 

‘‘(C) SPECIAL RULE FOR INCREASED MINIMUM REBATE

PERCENTAGE.— ‘‘(i) IN GENERAL.—In addition to the amounts applied as a reduction under subparagraph (B), for rebate periods beginning on or after January 1, 2010, 

during a fiscal year, the Secretary shall reduce payments to a State under section 1903(a) in the manner 

specified in clause (ii), in an amount equal to the product of— 

‘‘(I) 100 percent minus the Federal medical 

assistance percentage applicable to the rebate period for the State; and 

‘‘(II) the amounts received by the State under 

such subparagraph that are attributable (as estimated by the Secretary based on utilization and 

other data) to the increase in the minimum rebate 

percentage effected by the amendments made by 

subsections (a)(1), (b), and (d) of section 2501 of 

the Patient Protection and Affordable Care Act, 

taking into account the additional drugs included 

under the amendments made by subsection (c) of 

section 2501 of such Act. 

The Secretary shall adjust such payment reduction for 

a calendar quarter to the extent the Secretary determines, based upon subsequent utilization and other 

data, that the reduction for such quarter was greater 

or less than the amount of payment reduction that 

should have been made. 

‘‘(ii) MANNER OF PAYMENT REDUCTION.—The 

amount of the payment reduction under clause (i) for 

a State for a quarter shall be deemed an overpayment 

to the State under this title to be disallowed against 

the State’s regular quarterly draw for all Medicaid 

spending under section 1903(d)(2). Such a disallowance is not subject to a reconsideration under section 

1116(d).’’. 

(b) INCREASE IN REBATE FOR OTHER DRUGS.—Section 

1927(c)(3)(B) of such Act (42 U.S.C. 1396r–8(c)(3)(B)) is amended— 

(1) in clause (i), by striking ‘‘and’’ at the end; 

(2) in clause (ii)— 

(A) by inserting ‘‘and before January 1, 2010,’’ after 

‘‘December 31, 1993,’’; and 

(B) by striking the period and inserting ‘‘; and’’; and 
Sec. 2501 PPACA (Consolidated) 218 

(3) by adding at the end the following new clause: 

‘‘(iii) after December 31, 2009, is 13 percent.’’. 

(c) EXTENSION OF PRESCRIPTION DRUG DISCOUNTS TO ENROLL- EES OF MEDICAID MANAGED CARE ORGANIZATIONS.— (1) IN GENERAL.—Section 1903(m)(2)(A) of such Act (42 

U.S.C. 1396b(m)(2)(A)) is amended— 

(A) in clause (xi), by striking ‘‘and’’ at the end; 

(B) in clause (xii), by striking the period at the end 

and inserting ‘‘; and’’; and 

(C) by adding at the end the following: 

‘‘(xiii) such contract provides that (I) covered outpatient drugs dispensed to individuals eligible for 

medical assistance who are enrolled with the entity 

shall be subject to the same rebate required by the 

agreement entered into under section 1927 as the 

State is subject to and that the State shall collect such 

rebates from manufacturers, (II) capitation rates paid 

to the entity shall be based on actual cost experience 

related to rebates and subject to the Federal regulations requiring actuarially sound rates, and (III) the 

entity shall report to the State, on such timely and 

periodic basis as specified by the Secretary in order to 

include in the information submitted by the State to 

a manufacturer and the Secretary under section 

1927(b)(2)(A), information on the total number of units 

of each dosage form and strength and package size by 

National Drug Code of each covered outpatient drug 

dispensed to individuals eligible for medical assistance 

who are enrolled with the entity and for which the entity is responsible for coverage of such drug under this 

subsection (other than covered outpatient drugs that 

under subsection (j)(1) of section 1927 are not subject 

to the requirements of that section) and such other 

data as the Secretary determines necessary to carry 

out this subsection.’’. 

(2) CONFORMING AMENDMENTS.—Section 1927 (42 U.S.C. 

1396r–8) is amended— 

(A) in subsection (b)— 

(i) in paragraph (1)(A), in the first sentence, by inserting ‘‘, including such drugs dispensed to individuals enrolled with a medicaid managed care organization if the organization is responsible for coverage of 

such drugs’’ before the period; and 

(ii) in paragraph (2)(A), by inserting ‘‘including 

such information reported by each medicaid managed 

care organization,’’ after ‘‘for which payment was made 

under the plan during the period,’’; and 

(B) in subsection (j), by striking paragraph (1) and inserting the following: 

‘‘(1) Covered outpatient drugs are not subject to the requirements of this section if such drugs are— 

‘‘(A) dispensed by health maintenance organizations, 

including Medicaid managed care organizations that contract under section 1903(m); and 
219 Sec. 2502 PPACA (Consolidated) 

‘‘(B) subject to discounts under section 340B of the 

Public Health Service Act.’’. 

(d) ADDITIONAL REBATE FOR NEW FORMULATIONS OF EXISTING

DRUGS.— 

(1) IN GENERAL.—Section 1927(c)(2) of the Social Security 

Act (42 U.S.C. 1396r–8(c)(2)) is amended by adding at the end 

the following new subparagraph: 

‘‘(C) TREATMENT OF NEW FORMULATIONS.—øReplaced 

by section 1206(a) of HCERA¿ In the case of a drug that 

is a line extension of a single source drug or an innovator 

multiple source drug that is an oral solid dosage form, the 

rebate obligation with respect to such drug under this section shall be the amount computed under this section for 

such new drug or, if greater, the product of— 

‘‘(i) the average manufacturer price of the line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form; 

‘‘(ii) the highest additional rebate (calculated as a 

percentage of average manufacturer price) under this 

section for any strength of the original single source 

drug or innovator multiple source drug; and 

‘‘(iii) the total number of units of each dosage form 

and strength of the line extension product paid for 

under the State plan in the rebate period (as reported 

by the State). 

In this subparagraph, the term ‘line extension’ means, 

with respect to a drug, a new formulation of the drug, such 

as an extended release formulation.’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall apply to drugs that are paid for by a State after December 31, 2009. 

(e) MAXIMUM REBATE AMOUNT.—Section 1927(c)(2) of such Act 

(42 U.S.C. 1396r–8(c)(2)), as amended by subsection (d), is amended by adding at the end the following new subparagraph: 

‘‘(D) MAXIMUM REBATE AMOUNT.—In no case shall the 

sum of the amounts applied under paragraph (1)(A)(ii) and 

this paragraph with respect to each dosage form and 

strength of a single source drug or an innovator multiple 

source drug for a rebate period beginning after December 

31, 2009, exceed 100 percent of the average manufacturer 

price of the drug.’’. 

(f) CONFORMING AMENDMENTS.— 

(1) IN GENERAL.—Section 340B of the Public Health Service Act (42 U.S.C. 256b) is amended— 

(A) in subsection (a)(2)(B)(i), by striking ‘‘1927(c)(4)’’ 

and inserting ‘‘1927(c)(3)’’; and 

(B) by striking subsection (c); and 

(C) redesignating subsection (d) as subsection (c). 

(2) EFFECTIVE DATE.—The amendments made by this subsection take effect on January 1, 2010. 

SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN 

DRUGS. 

(a) IN GENERAL.—Section 1927(d) of the Social Security Act (42 

U.S.C. 1397r–8(d)) is amended— 
Sec. 2503 PPACA (Consolidated) 220 

(1) in paragraph (2)— 

(A) by striking subparagraphs (E), (I), and (J), respectively; and 

(B) by redesignating subparagraphs (F), (G), (H), and 

(K) as subparagraphs (E), (F), (G), and (H), respectively; 

and 

(2) by adding at the end the following new paragraph: 

‘‘(7) NON-EXCLUDABLE DRUGS.—The following drugs or 

classes of drugs, or their medical uses, shall not be excluded 

from coverage: 

‘‘(A) Agents when used to promote smoking cessation, 

including agents approved by the Food and Drug Administration under the over-the-counter monograph process for 

purposes of promoting, and when used to promote, tobacco 

cessation. 

‘‘(B) Barbiturates. 

‘‘(C) Benzodiazepines.’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to services furnished on or after January 1, 2014. 

SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT. 

(a) PHARMACY REIMBURSEMENT LIMITS.— 

(1) IN GENERAL.—Section 1927(e) of the Social Security Act 

(42 U.S.C. 1396r–8(e)) is amended— 

(A) in paragraph (4), by striking ‘‘(or, effective January 

1, 2007, two or more)’’; and 

(B) by striking paragraph (5) and inserting the following: 

‘‘(5) USE OF AMP IN UPPER PAYMENT LIMITS.—The Secretary 

shall calculate the Federal upper reimbursement limit established under paragraph (4) as no less than 175 percent of the 

weighted average (determined on the basis of utilization) of the 

most recently reported monthly average manufacturer prices 

for pharmaceutically and therapeutically equivalent multiple 

source drug products that are available for purchase by retail 

community pharmacies on a nationwide basis. The Secretary 

shall implement a smoothing process for average manufacturer 

prices. Such process shall be similar to the smoothing process 

used in determining the average sales price of a drug or biological under section 1847A.’’. 

(2) DEFINITION OF AMP.—Section 1927(k)(1) of such Act (42 

U.S.C. 1396r–8(k)(1)) is amended— 

(A) in subparagraph (A), by striking ‘‘by’’ and all that 

follows through the period and inserting ‘‘by— 

‘‘(i) wholesalers for drugs distributed to retail community pharmacies; and 

‘‘(ii) retail community pharmacies that purchase 

drugs directly from the manufacturer.’’; and 

(B) by striking subparagraph (B) and inserting the following: 

‘‘(B) EXCLUSION OF CUSTOMARY PROMPT PAY DISCOUNTS

AND OTHER PAYMENTS.— 

‘‘(i) IN GENERAL.—The average manufacturer price 

for a covered outpatient drug shall exclude— 
221 Sec. 2503 PPACA (Consolidated) 

‘‘(I) customary prompt pay discounts extended 

to wholesalers; 

‘‘(II) bona fide service fees paid by manufacturers to wholesalers or retail community pharmacies, including (but not limited to) distribution 

service fees, inventory management fees, product 

stocking allowances, and fees associated with administrative services agreements and patient care 

programs (such as medication compliance programs and patient education programs); 

‘‘(III) reimbursement by manufacturers for recalled, damaged, expired, or otherwise unsalable 

returned goods, including (but not limited to) reimbursement for the cost of the goods and any reimbursement of costs associated with return goods 

handling and processing, reverse logistics, and 

drug destruction; 

‘‘(IV) payments received from, and rebates or 

discounts provided to, pharmacy benefit managers, managed care organizations, health maintenance organizations, insurers, hospitals, clinics, 

mail order pharmacies, long term care providers, 

manufacturers, or any other entity that does not 

conduct business as a wholesaler or a retail community pharmacy, unless the drug is an inhalation, infusion, instilled, implanted, or injectable 

drug that is not generally dispensed through a retail community pharmacy; and øAs amended by 

section 202 of P.L. 111–226¿ 

‘‘(V) discounts provided by manufacturers 

under section 1860D–14A. øAs added by section 

1101(c)(3) of HCERA¿ 

‘‘(ii) INCLUSION OF OTHER DISCOUNTS AND PAYMENTS.—Notwithstanding clause (i), any other discounts, rebates, payments, or other financial transactions that are received by, paid by, or passed 

through to, retail community pharmacies shall be included in the average manufacturer price for a covered 

outpatient drug.’’; and 

(C) in subparagraph (C), by striking ‘‘the retail pharmacy class of trade’’ and inserting ‘‘retail community pharmacies’’. 

(3) DEFINITION OF MULTIPLE SOURCE DRUG.—Section 

1927(k)(7) of such Act (42 U.S.C. 1396r–8(k)(7)) is amended— 

(A) in subparagraph (A)(i)(III), by striking ‘‘the State’’ 

and inserting ‘‘the United States’’; and 

(B) in subparagraph (C)— 

(i) in clause (i), by inserting ‘‘and’’ after the semicolon; 

(ii) in clause (ii), by striking ‘‘; and’’ and inserting 

a period; and 

(iii) by striking clause (iii). 
Sec. 2503 PPACA (Consolidated) 222 

(4) DEFINITIONS OF RETAIL COMMUNITY PHARMACY; WHOLESALER.—Section 1927(k) of such Act (42 U.S.C. 1396r–8(k)) is 

amended by adding at the end the following new paragraphs: 

‘‘(10) RETAIL COMMUNITY PHARMACY.—The term ‘retail 

community pharmacy’ means an independent pharmacy, a 

chain pharmacy, a supermarket pharmacy, or a mass merchandiser pharmacy that is licensed as a pharmacy by the State 

and that dispenses medications to the general public at retail 

prices. Such term does not include a pharmacy that dispenses 

prescription medications to patients primarily through the 

mail, nursing home pharmacies, long-term care facility pharmacies, hospital pharmacies, clinics, charitable or not-for-profit 

pharmacies, government pharmacies, or pharmacy benefit 

managers. 

‘‘(11) WHOLESALER.—The term ‘wholesaler’ means a drug 

wholesaler that is engaged in wholesale distribution of prescription drugs to retail community pharmacies, including (but 

not limited to) manufacturers, repackers, distributors, ownlabel distributors, private-label distributors, jobbers, brokers, 

warehouses (including manufacturer’s and distributor’s warehouses, chain drug warehouses, and wholesale drug warehouses) independent wholesale drug traders, and retail community pharmacies that conduct wholesale distributions.’’. 

(b) DISCLOSURE OF PRICE INFORMATION TO THE PUBLIC.—Section 1927(b)(3) of such Act (42 U.S.C. 1396r–8(b)(3)) is amended— 

(1) in subparagraph (A)— 

(A) in the first sentence, by inserting after clause (iii) 

the following: 

‘‘(iv) not later than 30 days after the last day of 

each month of a rebate period under the agreement, 

on the manufacturer’s total number of units that are 

used to calculate the monthly average manufacturer 

price for each covered outpatient drug;’’; and 

(B) in the second sentence, by inserting ‘‘(relating to 

the weighted average of the most recently reported monthly average manufacturer prices)’’ after ‘‘(D)(v)’’; and 

(2) in subparagraph (D)(v), by striking ‘‘average manufacturer prices’’ and inserting ‘‘the weighted average of the most 

recently reported monthly average manufacturer prices and 

the average retail survey price determined for each multiple 

source drug in accordance with subsection (f)’’. 

(c) CLARIFICATION OF APPLICATION OF SURVEY OF RETAIL

PRICES.—Section 1927(f)(1) of such Act (42 U.S.C. 1396r–8(b)(1)) is 

amended— 

(1) in subparagraph (A)(i), by inserting ‘‘with respect to a 

retail community pharmacy,’’ before ‘‘the determination’’; and 

(2) in subparagraph (C)(ii), by striking ‘‘retail pharmacies’’ 

and inserting ‘‘retail community pharmacies’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall take effect on the first day of the first calendar year quarter 

that begins at least 180 days after the date of enactment of this 

Act, without regard to whether or not final regulations to carry out 

such amendments have been promulgated by such date. 
223 Sec. 2551 PPACA (Consolidated) 

Subtitle G—Medicaid Disproportionate 

Share Hospital (DSH) Payments 

SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS. 

(a) IN GENERAL.—Section 1923(f) of the Social Security Act (42 

U.S.C. 1396r–4(f)) is amended— 

(1) in paragraph (1), by striking ‘‘and (3)’’ and inserting ‘‘, 

(3), and (7)’’; 

(2) in paragraph (3)(A), by striking ‘‘paragraph (6)’’ and inserting ‘‘paragraphs (6) and (7)’’; 

øNote: clause (v) added to paragraph (6)(A) of section 1923(f) 

by section 1203(b) of HCERA¿ 

øNote: a clause (iii) is added to paragraph (6)(B) of section 

1923(f) by section 10201(e)(1)(A)¿ 

(3) by redesignating paragraph (7) as paragraph (8); and 

(4) by inserting after paragraph (6) the following new 

paragraph: 

‘‘(7) MEDICAID DSH REDUCTIONS.—øReplaced by section 

1203(2) of HCERA; previously revised by section 10201(e)(1)(B)¿ 

‘‘(A) REDUCTIONS.— ‘‘(i) IN GENERAL.—For each of fiscal years 2014 

through 2020 the Secretary shall effect the following 

reductions: 

‘‘(I) REDUCTION IN DSH ALLOTMENTS.—The 

Secretary shall reduce DSH allotments to States 

in the amount specified under the DSH health reform methodology under subparagraph (B) for the 

State for the fiscal year. 

‘‘(II) REDUCTIONS IN PAYMENTS.—The Secretary shall reduce payments to States under section 1903(a) for each calendar quarter in the fiscal 

year, in the manner specified in clause (iii), in an 

amount equal to 1⁄4 of the DSH allotment reduction under subclause (I) for the State for the fiscal 

year. 

‘‘(ii) AGGREGATE REDUCTIONS.—The aggregate reductions in DSH allotments for all States under clause 

(i)(I) shall be equal to— 

‘‘(I) $500,000,000 for fiscal year 2014; 

‘‘(II) $600,000,000 for fiscal year 2015; 

‘‘(III) $600,000,000 for fiscal year 2016; 

‘‘(IV) $1,800,000,000 for fiscal year 2017; 

‘‘(V) $5,000,000,000 for fiscal year 2018; 

‘‘(VI) $5,600,000,000 for fiscal year 2019; and 

‘‘(VII) $4,000,000,000 for fiscal year 2020. 

The Secretary shall distribute such aggregate reductions among States in accordance with subparagraph 

(B). 

‘‘(iii) MANNER OF PAYMENT REDUCTION.—The 

amount of the payment reduction under clause (i)(II) 

for a State for a quarter shall be deemed an overpayment to the State under this title to be disallowed 

against the State’s regular quarterly draw for all 
Sec. 2601 PPACA (Consolidated) 224 

spending under section 1903(d)(2). Such a disallowance is not subject to a reconsideration under subsections (d) and (e) of section 1116. 

‘‘(iv) DEFINITION.—In this paragraph, the term 

‘State’ means the 50 States and the District of Columbia. 

‘‘(B) DSH HEALTH REFORM METHODOLOGY.—The Secretary shall carry out subparagraph (A) through use of a 

DSH Health Reform methodology that meets the following 

requirements: 

‘‘(i) The methodology imposes the largest percentage reductions on the States that— 

‘‘(I) have the lowest percentages of uninsured 

individuals (determined on the basis of data from 

the Bureau of the Census, audited hospital cost 

reports, and other information likely to yield accurate data) during the most recent year for which 

such data are available; or 

‘‘(II) do not target their DSH payments on— 

‘‘(aa) hospitals with high volumes of Medicaid inpatients (as defined in subsection 

(b)(1)(A)); and 

‘‘(bb) hospitals that have high levels of 

uncompensated care (excluding bad debt). 

‘‘(ii) The methodology imposes a smaller percentage reduction on low DSH States described in paragraph (5)(B). 

‘‘(iii) The methodology takes into account the extent to which the DSH allotment for a State was included in the budget neutrality calculation for a coverage expansion approved under section 1115 as of 

July 31, 2009.’’. 

øSubsection (b) stricken by section 10201(f)¿ 

Subtitle H—Improved Coordination for 

Dual Eligible Beneficiaries 

SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS. 

(a) IN GENERAL.—Section 1915(h) of the Social Security Act (42 

U.S.C. 1396n(h)) is amended— 

(1) by inserting ‘‘(1)’’ after ‘‘(h)’’; 

(2) by inserting ‘‘, or a waiver described in paragraph (2)’’ 

after ‘‘(e)’’; and 

(3) by adding at the end the following new paragraph: 

‘‘(2)(A) Notwithstanding subsections (c)(3) and (d) (3), any 

waiver under subsection (b), (c), or (d), or a waiver under section 

1115, that provides medical assistance for dual eligible individuals 

(including any such waivers under which non dual eligible individuals may be enrolled in addition to dual eligible individuals) may 

be conducted for a period of 5 years and, upon the request of the 

State, may be extended for additional 5-year periods unless the 

Secretary determines that for the previous waiver period the conditions for the waiver have not been met or it would no longer be 
225 Sec. 2602 PPACA (Consolidated) 

cost-effective and efficient, or consistent with the purposes of this 

title, to extend the waiver. 

‘‘(B) In this paragraph, the term ‘dual eligible individual’ 

means an individual who is entitled to, or enrolled for, benefits 

under part A of title XVIII, or enrolled for benefits under part B 

of title XVIII, and is eligible for medical assistance under the State 

plan under this title or under a waiver of such plan.’’. 

(b) CONFORMING AMENDMENTS.— 

(1) Section 1915 of such Act (42 U.S.C. 1396n) is amended— 

(A) in subsection (b), by adding at the end the following new sentence: ‘‘Subsection (h)(2) shall apply to a 

waiver under this subsection.’’; 

(B) in subsection (c)(3), in the second sentence, by inserting ‘‘(other than a waiver described in subsection 

(h)(2))’’ after ‘‘A waiver under this subsection’’; 

(C) in subsection (d)(3), in the second sentence, by inserting ‘‘(other than a waiver described in subsection 

(h)(2))’’ after ‘‘A waiver under this subsection’’. 

(2) Section 1115 of such Act (42 U.S.C. 1315) is amended— 

(A) in subsection (e)(2), by inserting ‘‘(5 years, in the 

case of a waiver described in section 1915(h)(2))’’ after ‘‘3 

years’’; and 

(B) in subsection (f)(6), by inserting ‘‘(5 years, in the 

case of a waiver described in section 1915(h)(2))’’ after ‘‘3 

years’’. 

SEC. 2602. ø42 U.S.C. 1315b¿ PROVIDING FEDERAL COVERAGE AND PAYMENT COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES. 

(a) ESTABLISHMENT OF FEDERAL COORDINATED HEALTH CARE

OFFICE.— 

(1) IN GENERAL.—Not later than March 1, 2010, the Secretary of Health and Human Services (in this section referred 

to as the ‘‘Secretary’’) shall establish a Federal Coordinated 

Health Care Office. 

(2) ESTABLISHMENT AND REPORTING TO CMS ADMINISTRATOR.—The Federal Coordinated Health Care Office— 

(A) shall be established within the Centers for Medicare & Medicaid Services; and 

(B) have as the Office a Director who shall be appointed by, and be in direct line of authority to, the Administrator of the Centers for Medicare & Medicaid Services. 

(b) PURPOSE.—The purpose of the Federal Coordinated Health 

Care Office is to bring together officers and employees of the Medicare and Medicaid programs at the Centers for Medicare & Medicaid Services in order to— 

(1) more effectively integrate benefits under the Medicare 

program under title XVIII of the Social Security Act and the 

Medicaid program under title XIX of such Act; and 

(2) improve the coordination between the Federal Government and States for individuals eligible for benefits under both 

such programs in order to ensure that such individuals get full 
Sec. 2602 PPACA (Consolidated) 226 

access to the items and services to which they are entitled 

under titles XVIII and XIX of the Social Security Act. 

(c) GOALS.—The goals of the Federal Coordinated Health Care 

Office are as follows: 

(1) Providing dual eligible individuals full access to the 

benefits to which such individuals are entitled under the Medicare and Medicaid programs. 

(2) Simplifying the processes for dual eligible individuals 

to access the items and services they are entitled to under the 

Medicare and Medicaid programs. 

(3) Improving the quality of health care and long-term 

services for dual eligible individuals. 

(4) Increasing dual eligible individuals’ understanding of 

and satisfaction with coverage under the Medicare and Medicaid programs. 

(5) Eliminating regulatory conflicts between rules under 

the Medicare and Medicaid programs. 

(6) Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals. 

(7) Eliminating cost-shifting between the Medicare and 

Medicaid program and among related health care providers. 

(8) Improving the quality of performance of providers of 

services and suppliers under the Medicare and Medicaid programs. 

(d) SPECIFIC RESPONSIBILITIES.—The specific responsibilities of 

the Federal Coordinated Health Care Office are as follows: 

(1) Providing States, specialized MA plans for special 

needs individuals (as defined in section 1859(b)(6) of the Social 

Security Act (42 U.S.C. 1395w–28(b)(6))), physicians and other 

relevant entities or individuals with the education and tools 

necessary for developing programs that align benefits under 

the Medicare and Medicaid programs for dual eligible individuals. 

(2) Supporting State efforts to coordinate and align acute 

care and long-term care services for dual eligible individuals 

with other items and services furnished under the Medicare 

program. 

(3) Providing support for coordination of contracting and 

oversight by States and the Centers for Medicare & Medicaid 

Services with respect to the integration of the Medicare and 

Medicaid programs in a manner that is supportive of the goals 

described in paragraph (3). 

(4) To consult and coordinate with the Medicare Payment 

Advisory Commission established under section 1805 of the Social Security Act (42 U.S.C. 1395b–6) and the Medicaid and 

CHIP Payment and Access Commission established under section 1900 of such Act (42 U.S.C. 1396) with respect to policies 

relating to the enrollment in, and provision of, benefits to dual 

eligible individuals under the Medicare program under title 

XVIII of the Social Security Act and the Medicaid program 

under title XIX of such Act. 

(5) To study the provision of drug coverage for new fullbenefit dual eligible individuals (as defined in section 

1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), 
227 Sec. 2701 PPACA (Consolidated) \1139B SSA 

as well as to monitor and report annual total expenditures, 

health outcomes, and access to benefits for all dual eligible individuals. 

(e) REPORT.—The Secretary shall, as part of the budget transmitted under section 1105(a) of title 31, United States Code, submit to Congress an annual report containing recommendations for 

legislation that would improve care coordination and benefits for 

dual eligible individuals. 

(f) DUAL ELIGIBLE DEFINED.—In this section, the term ‘‘dual eligible individual’’ means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security 

Act, or enrolled for benefits under part B of title XVIII of such Act, 

and is eligible for medical assistance under a State plan under title 

XIX of such Act or under a waiver of such plan. 

Subtitle I—Improving the Quality of 

Medicaid for Patients and Providers 

SEC. 2701. ADULT HEALTH QUALITY MEASURES. 

Title XI of the Social Security Act (42 U.S.C. 1301 et seq.), as 

amended by section 401 of the Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111–3), is amended 

by inserting after section 1139A the following new section: 

‘‘SEC. 1139B. ø42 U.S.C. 1320b–9b¿ ADULT HEALTH QUALITY MEASURES. 

‘‘(a) DEVELOPMENT OF CORE SET OF HEALTH CARE QUALITY

MEASURES FOR ADULTS ELIGIBLE FOR BENEFITS UNDER MEDICAID.—The Secretary shall identify and publish a recommended 

core set of adult health quality measures for Medicaid eligible 

adults in the same manner as the Secretary identifies and publishes a core set of child health quality measures under section 

1139A, including with respect to identifying and publishing existing adult health quality measures that are in use under public and 

privately sponsored health care coverage arrangements, or that are 

part of reporting systems that measure both the presence and duration of health insurance coverage over time, that may be applicable to Medicaid eligible adults. 

‘‘(b) DEADLINES.— 

‘‘(1) RECOMMENDED MEASURES.—Not later than January 1, 

2011, the Secretary shall identify and publish for comment a 

recommended core set of adult health quality measures for 

Medicaid eligible adults. 

‘‘(2) DISSEMINATION.—Not later than January 1, 2012, the 

Secretary shall publish an initial core set of adult health quality measures that are applicable to Medicaid eligible adults. 

‘‘(3) STANDARDIZED REPORTING.—Not later than January 1, 

2013, the Secretary, in consultation with States, shall develop 

a standardized format for reporting information based on the 

initial core set of adult health quality measures and create procedures to encourage States to use such measures to voluntarily report information regarding the quality of health care 

for Medicaid eligible adults. 
Sec. 2701\1139B SSA PPACA (Consolidated) 228 

‘‘(4) REPORTS TO CONGRESS.—Not later than January 1, 

2014, and every 3 years thereafter, the Secretary shall include 

in the report to Congress required under section 1139A(a)(6) 

information similar to the information required under that section with respect to the measures established under this section. 

‘‘(5) ESTABLISHMENT OF MEDICAID QUALITY MEASUREMENT

PROGRAM.— 

‘‘(A) IN GENERAL.—Not later than 12 months after the 

release of the recommended core set of adult health quality 

measures under paragraph (1)), the Secretary shall establish a Medicaid Quality Measurement Program in the 

same manner as the Secretary establishes the pediatric 

quality measures program under section 1139A(b). The aggregate amount awarded by the Secretary for grants and 

contracts for the development, testing, and validation of 

emerging and innovative evidence-based measures under 

such program shall equal the aggregate amount awarded 

by the Secretary for grants under section 1139A(b)(4)(A) 

‘‘(B) REVISING, STRENGTHENING, AND IMPROVING INI- TIAL CORE MEASURES.—Beginning not later than 24 

months after the establishment of the Medicaid Quality 

Measurement Program, and annually thereafter, the Secretary shall publish recommended changes to the initial 

core set of adult health quality measures that shall reflect 

the results of the testing, validation, and consensus process for the development of adult health quality measures. 

‘‘(c) CONSTRUCTION.—Nothing in this section shall be construed 

as supporting the restriction of coverage, under title XIX or XXI or 

otherwise, to only those services that are evidence-based, or in anyway limiting available services. 

‘‘(d) ANNUAL STATE REPORTS REGARDING STATE-SPECIFIC QUALITY OF CARE MEASURES APPLIED UNDER MEDICAID.— 

‘‘(1) ANNUAL STATE REPORTS.—Each State with a State 

plan or waiver approved under title XIX shall annually report 

(separately or as part of the annual report required under section 1139A(c)), to the Secretary on the— 

‘‘(A) State-specific adult health quality measures applied by the State under the such plan, including measures 

described in subsection (a)(5); and 

‘‘(B) State-specific information on the quality of health 

care furnished to Medicaid eligible adults under such plan, 

including information collected through external quality 

reviews of managed care organizations under section 1932 

and benchmark plans under section 1937. 

‘‘(2) PUBLICATION.—Not later than September 30, 2014, 

and annually thereafter, the Secretary shall collect, analyze, 

and make publicly available the information reported by States 

under paragraph (1). 

‘‘(e) APPROPRIATION.—Out of any funds in the Treasury not 

otherwise appropriated, there is appropriated for each of fiscal 

years 2010 through 2014, $60,000,000 for the purpose of carrying 

out this section. Funds appropriated under this subsection shall remain available until expended.’’. 
229 Sec. 2703 PPACA (Consolidated) \1945 SSA 

SEC. 2702. ø42 U.S.C. 1396b–1¿ PAYMENT ADJUSTMENT FOR HEALTH 

CARE-ACQUIRED CONDITIONS. 

(a) IN GENERAL.—The Secretary of Health and Human Services (in this subsection referred to as the ‘‘Secretary’’) shall identify 

current State practices that prohibit payment for health care-acquired conditions and shall incorporate the practices identified, or 

elements of such practices, which the Secretary determines appropriate for application to the Medicaid program in regulations. Such 

regulations shall be effective as of July 1, 2011, and shall prohibit 

payments to States under section 1903 of the Social Security Act 

for any amounts expended for providing medical assistance for 

health care-acquired conditions specified in the regulations. The 

regulations shall ensure that the prohibition on payment for health 

care-acquired conditions shall not result in a loss of access to care 

or services for Medicaid beneficiaries. 

(b) HEALTH CARE-ACQUIRED CONDITION.—In this section. the 

term ‘‘health care-acquired condition’’ means a medical condition 

for which an individual was diagnosed that could be identified by 

a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of 

the Social Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)). 

(c) MEDICARE PROVISIONS.—In carrying out this section, the 

Secretary shall apply to State plans (or waivers) under title XIX of 

the Social Security Act the regulations promulgated pursuant to 

section 1886(d)(4)(D) of such Act (42 U.S.C. 1395ww(d)(4)(D)) relating to the prohibition of payments based on the presence of a secondary diagnosis code specified by the Secretary in such regulations, as appropriate for the Medicaid program. The Secretary may 

exclude certain conditions identified under title XVIII of the Social 

Security Act for non-payment under title XIX of such Act when the 

Secretary finds the inclusion of such conditions to be inapplicable 

to beneficiaries under title XIX. 

SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES WITH CHRONIC CONDITIONS. 

(a) STATE PLAN AMENDMENT.—Title XIX of the Social Security 

Act (42 U.S.C. 1396a et seq.), as amended by sections 2201 and 

2305, is amended by adding at the end the following new section: 

‘‘SEC. 1945. ø42 U.S.C. 1396w–4¿ State Option To Provide Coordinated Care Through a Health Home for Individuals With 

Chronic Conditions.— 

‘‘(a) IN GENERAL.—Notwithstanding section 1902(a)(1) (relating 

to statewideness), section 1902(a)(10)(B) (relating to comparability), 

and any other provision of this title for which the Secretary determines it is necessary to waive in order to implement this section, 

beginning January 1, 2011, a State, at its option as a State plan 

amendment, may provide for medical assistance under this title to 

eligible individuals with chronic conditions who select a designated 

provider (as described under subsection (h)(5)), a team of health 

care professionals (as described under subsection (h)(6)) operating 

with such a provider, or a health team (as described under subsection (h)(7)) as the individual’s health home for purposes of providing the individual with health home services. 

‘‘(b) HEALTH HOME QUALIFICATION STANDARDS.—The Secretary 

shall establish standards for qualification as a designated provider 
Sec. 2703\1945 SSA PPACA (Consolidated) 230 

for the purpose of being eligible to be a health home for purposes 

of this section. 

‘‘(c) PAYMENTS.— ‘‘(1) IN GENERAL.—A State shall provide a designated provider, a team of health care professionals operating with such 

a provider, or a health team with payments for the provision 

of health home services to each eligible individual with chronic 

conditions that selects such provider, team of health care professionals, or health team as the individual’s health home. Payments made to a designated provider, a team of health care 

professionals operating with such a provider, or a health team 

for such services shall be treated as medical assistance for purposes of section 1903(a), except that, during the first 8 fiscal 

year quarters that the State plan amendment is in effect, the 

Federal medical assistance percentage applicable to such payments shall be equal to 90 percent. 

‘‘(2) METHODOLOGY.— ‘‘(A) IN GENERAL.—The State shall specify in the State 

plan amendment the methodology the State will use for 

determining payment for the provision of health home 

services. Such methodology for determining payment— 

‘‘(i) may be tiered to reflect, with respect to each 

eligible individual with chronic conditions provided 

such services by a designated provider, a team of 

health care professionals operating with such a provider, or a health team, as well as the severity or 

number of each such individual’s chronic conditions or 

the specific capabilities of the provider, team of health 

care professionals, or health team; and 

‘‘(ii) shall be established consistent with section 

1902(a)(30)(A). 

‘‘(B) ALTERNATE MODELS OF PAYMENT.—The methodology for determining payment for provision of health 

home services under this section shall not be limited to a 

per-member per-month basis and may provide (as proposed 

by the State and subject to approval by the Secretary) for 

alternate models of payment. 

‘‘(3) PLANNING GRANTS.— 

‘‘(A) IN GENERAL.—Beginning January 1, 2011, the 

Secretary may award planning grants to States for purposes of developing a State plan amendment under this 

section. A planning grant awarded to a State under this 

paragraph shall remain available until expended. 

‘‘(B) STATE CONTRIBUTION.—A State awarded a planning grant shall contribute an amount equal to the State 

percentage determined under section 1905(b) (without regard to section 5001 of Public Law 111–5) for each fiscal 

year for which the grant is awarded. 

‘‘(C) LIMITATION.—The total amount of payments made 

to States under this paragraph shall not exceed 

$25,000,000. 

‘‘(d) HOSPITAL REFERRALS.—A State shall include in the State 

plan amendment a requirement for hospitals that are participating 

providers under the State plan or a waiver of such plan to establish 
231 Sec. 2703 PPACA (Consolidated) \1945 SSA 

procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers. 

‘‘(e) COORDINATION.—A State shall consult and coordinate, as 

appropriate, with the Substance Abuse and Mental Health Services 

Administration in addressing issues regarding the prevention and 

treatment of mental illness and substance abuse among eligible individuals with chronic conditions. 

‘‘(f) MONITORING.—A State shall include in the State plan 

amendment— 

‘‘(1) a methodology for tracking avoidable hospital readmissions and calculating savings that result from improved chronic care coordination and management under this section; and 

‘‘(2) a proposal for use of health information technology in 

providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider). 

‘‘(g) REPORT ON QUALITY MEASURES.—As a condition for receiving payment for health home services provided to an eligible individual with chronic conditions, a designated provider shall report 

to the State, in accordance with such requirements as the Secretary shall specify, on all applicable measures for determining the 

quality of such services. When appropriate and feasible, a designated provider shall use health information technology in providing the State with such information. 

‘‘(h) DEFINITIONS.—In this section: 

‘‘(1) ELIGIBLE INDIVIDUAL WITH CHRONIC CONDITIONS.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

term ‘eligible individual with chronic conditions’ means an 

individual who— 

‘‘(i) is eligible for medical assistance under the 

State plan or under a waiver of such plan; and 

‘‘(ii) has at least— 

‘‘(I) 2 chronic conditions; 

‘‘(II) 1 chronic condition and is at risk of having a second chronic condition; or 

‘‘(III) 1 serious and persistent mental health 

condition. 

‘‘(B) RULE OF CONSTRUCTION.—Nothing in this paragraph shall prevent the Secretary from establishing higher 

levels as to the number or severity of chronic or mental 

health conditions for purposes of determining eligibility for 

receipt of health home services under this section. 

‘‘(2) CHRONIC CONDITION.—The term ‘chronic condition’ has 

the meaning given that term by the Secretary and shall include, but is not limited to, the following: 

‘‘(A) A mental health condition. 

‘‘(B) Substance use disorder. 

‘‘(C) Asthma. 

‘‘(D) Diabetes. 

‘‘(E) Heart disease. 
Sec. 2703\1945 SSA PPACA (Consolidated) 232 

‘‘(F) Being overweight, as evidenced by having a Body 

Mass Index (BMI) over 25. 

‘‘(3) HEALTH HOME.—The term ‘health home’ means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health 

team selected by an eligible individual with chronic conditions 

to provide health home services. 

‘‘(4) HEALTH HOME SERVICES.— ‘‘(A) IN GENERAL.—The term ‘health home services’ 

means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team. 

‘‘(B) SERVICES DESCRIBED.—The services described in 

this subparagraph are— 

‘‘(i) comprehensive care management; 

‘‘(ii) care coordination and health promotion; 

‘‘(iii) comprehensive transitional care, including 

appropriate follow-up, from inpatient to other settings; 

‘‘(iv) patient and family support (including authorized representatives); 

‘‘(v) referral to community and social support services, if relevant; and 

‘‘(vi) use of health information technology to link 

services, as feasible and appropriate. 

‘‘(5) DESIGNATED PROVIDER.—The term ‘designated provider’ means a physician, clinical practice or clinical group 

practice, rural clinic, community health center, community 

mental health center, home health agency, or any other entity 

or provider (including pediatricians, gynecologists, and obstetricians) that is determined by the State and approved by the 

Secretary to be qualified to be a health home for eligible individuals with chronic conditions on the basis of documentation 

evidencing that the physician, practice, or clinic— 

‘‘(A) has the systems and infrastructure in place to 

provide health home services; and 

‘‘(B) satisfies the qualification standards established 

by the Secretary under subsection (b). 

‘‘(6) TEAM OF HEALTH CARE PROFESSIONALS.—The term 

‘team of health care professionals’ means a team of health professionals (as described in the State plan amendment) that 

may— 

‘‘(A) include physicians and other professionals, such 

as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed 

appropriate by the State; and 

‘‘(B) be free standing, virtual, or based at a hospital, 

community health center, community mental health center, rural clinic, clinical practice or clinical group practice, 

academic health center, or any entity deemed appropriate 

by the State and approved by the Secretary. 

‘‘(7) HEALTH TEAM.—The term ‘health team’ has the meaning given such term for purposes of section 3502 of the Patient 

Protection and Affordable Care Act.’’. 
233 Sec. 2704 PPACA (Consolidated) 

(b) EVALUATION.— 

(1) INDEPENDENT EVALUATION.— 

(A) IN GENERAL.—The Secretary shall enter into a contract with an independent entity or organization to conduct an evaluation and assessment of the States that have 

elected the option to provide coordinated care through a 

health home for Medicaid beneficiaries with chronic conditions under section 1945 of the Social Security Act (as 

added by subsection (a)) for the purpose of determining the 

effect of such option on reducing hospital admissions, 

emergency room visits, and admissions to skilled nursing 

facilities. 

(B) EVALUATION REPORT.—Not later than January 1, 

2017, the Secretary shall report to Congress on the evaluation and assessment conducted under subparagraph (A). 

(2) SURVEY AND INTERIM REPORT.— 

(A) IN GENERAL.—Not later than January 1, 2014, the 

Secretary of Health and Human Services shall survey 

States that have elected the option under section 1945 of 

the Social Security Act (as added by subsection (a)) and report to Congress on the nature, extent, and use of such option, particularly as it pertains to— 

(i) hospital admission rates; 

(ii) chronic disease management; 

(iii) coordination of care for individuals with 

chronic conditions; 

(iv) assessment of program implementation; 

(v) processes and lessons learned (as described in 

subparagraph (B)); 

(vi) assessment of quality improvements and clinical outcomes under such option; and 

(vii) estimates of cost savings. 

(B) IMPLEMENTATION REPORTING.—A State that has 

elected the option under section 1945 of the Social Security 

Act (as added by subsection (a)) shall report to the Secretary, as necessary, on processes that have been developed and lessons learned regarding provision of coordinated care through a health home for Medicaid beneficiaries with chronic conditions under such option. 

SEC. 2704. ø42 U.S.C. 1396a note¿ DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE AROUND A HOSPITALIZATION. 

(a) AUTHORITY TO CONDUCT PROJECT.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as the ‘‘Secretary’’) shall establish a demonstration project under title XIX of the Social 

Security Act to evaluate the use of bundled payments for the 

provision of integrated care for a Medicaid beneficiary— 

(A) with respect to an episode of care that includes a 

hospitalization; and 

(B) for concurrent physicians services provided during 

a hospitalization. 

(2) DURATION.—The demonstration project shall begin on 

January 1, 2012, and shall end on December 31, 2016. 
Sec. 2704 PPACA (Consolidated) 234 

(b) REQUIREMENTS.—The demonstration project shall be conducted in accordance with the following: 

(1) The demonstration project shall be conducted in up to 

8 States, determined by the Secretary based on consideration 

of the potential to lower costs under the Medicaid program 

while improving care for Medicaid beneficiaries. A State selected to participate in the demonstration project may target 

the demonstration project to particular categories of beneficiaries, beneficiaries with particular diagnoses, or particular 

geographic regions of the State, but the Secretary shall insure 

that, as a whole, the demonstration project is, to the greatest 

extent possible, representative of the demographic and geographic composition of Medicaid beneficiaries nationally. 

(2) The demonstration project shall focus on conditions 

where there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished to 

Medicaid beneficiaries while reducing total expenditures under 

the State Medicaid programs selected to participate, as determined by the Secretary. 

(3) A State selected to participate in the demonstration 

project shall specify the 1 or more episodes of care the State 

proposes to address in the project, the services to be included 

in the bundled payments, and the rationale for the selection of 

such episodes of care and services. The Secretary may modify 

the episodes of care as well as the services to be included in 

the bundled payments prior to or after approving the project. 

The Secretary may also vary such factors among the different 

States participating in the demonstration project. 

(4) The Secretary shall ensure that payments made under 

the demonstration project are adjusted for severity of illness 

and other characteristics of Medicaid beneficiaries within a category or having a diagnosis targeted as part of the demonstration project. States shall ensure that Medicaid beneficiaries are 

not liable for any additional cost sharing than if their care had 

not been subject to payment under the demonstration project. 

(5) Hospitals participating in the demonstration project 

shall have or establish robust discharge planning programs to 

ensure that Medicaid beneficiaries requiring post-acute care 

are appropriately placed in, or have ready access to, post-acute 

care settings. 

(6) The Secretary and each State selected to participate in 

the demonstration project shall ensure that the demonstration 

project does not result in the Medicaid beneficiaries whose care 

is subject to payment under the demonstration project being 

provided with less items and services for which medical assistance is provided under the State Medicaid program than the 

items and services for which medical assistance would have 

been provided to such beneficiaries under the State Medicaid 

program in the absence of the demonstration project. 

(c) WAIVER OF PROVISIONS.—Notwithstanding section 1115(a) 

of the Social Security Act (42 U.S.C. 1315(a)), the Secretary may 

waive such provisions of titles XIX, XVIII, and XI of that Act as 

may be necessary to accomplish the goals of the demonstration, en-
235 Sec. 2705 PPACA (Consolidated) 

sure beneficiary access to acute and post-acute care, and maintain 

quality of care. 

(d) EVALUATION AND REPORT.— 

(1) DATA.—Each State selected to participate in the demonstration project under this section shall provide to the Secretary, in such form and manner as the Secretary shall specify, 

relevant data necessary to monitor outcomes, costs, and quality, and evaluate the rationales for selection of the episodes of 

care and services specified by States under subsection (b)(3). 

(2) REPORT.—Not later than 1 year after the conclusion of 

the demonstration project, the Secretary shall submit a report 

to Congress on the results of the demonstration project. 

SEC. 2705. ø42 U.S.C. 1315a note¿ MEDICAID GLOBAL PAYMENT SYSTEM 

DEMONSTRATION PROJECT. 

(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’) shall, in coordination with the Center for Medicare and Medicaid Innovation (as 

established under section 1115A of the Social Security Act, as 

added by section 3021 of this Act), establish the Medicaid Global 

Payment System Demonstration Project under which a participating State shall adjust the payments made to an eligible safety 

net hospital system or network from a fee-for-service payment 

structure to a global capitated payment model. 

(b) DURATION AND SCOPE.—The demonstration project conducted under this section shall operate during a period of fiscal 

years 2010 through 2012. The Secretary shall select not more than 

5 States to participate in the demonstration project. 

(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR NETWORK.—For 

purposes of this section, the term ‘‘eligible safety net hospital system or network’’ means a large, safety net hospital system or network (as defined by the Secretary) that operates within a State selected by the Secretary under subsection (b). 

(d) EVALUATION.— 

(1) TESTING.—The Innovation Center shall test and evaluate the demonstration project conducted under this section to 

examine any changes in health care quality outcomes and 

spending by the eligible safety net hospital systems or networks. 

(2) BUDGET NEUTRALITY.—During the testing period under 

paragraph (1), any budget neutrality requirements under section 1115A(b)(3) of the Social Security Act (as so added) shall 

not be applicable. 

(3) MODIFICATION.—During the testing period under paragraph (1), the Secretary may, in the Secretary’s discretion, 

modify or terminate the demonstration project conducted under 

this section. 

(e) REPORT.—Not later than 12 months after the date of completion of the demonstration project under this section, the Secretary shall submit to Congress a report containing the results of 

the evaluation and testing conducted under subsection (d), together 

with recommendations for such legislation and administrative action as the Secretary determines appropriate. 
Sec. 2706 PPACA (Consolidated) 236 

(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated such sums as are necessary to carry out this 

section. 

SEC. 2706. ø42 U.S.C. 1396a note¿ PEDIATRIC ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT. 

(a) AUTHORITY TO CONDUCT DEMONSTRATION.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services (referred to in this section as the ‘‘Secretary’’) shall establish the Pediatric Accountable Care Organization Demonstration Project to authorize a participating State to allow 

pediatric medical providers that meet specified requirements to 

be recognized as an accountable care organization for purposes 

of receiving incentive payments (as described under subsection 

(d)), in the same manner as an accountable care organization 

is recognized and provided with incentive payments under section 1899 of the Social Security Act (as added by section 3022). 

(2) DURATION.—The demonstration project shall begin on 

January 1, 2012, and shall end on December 31, 2016. 

(b) APPLICATION.—A State that desires to participate in the 

demonstration project under this section shall submit to the Secretary an application at such time, in such manner, and containing 

such information as the Secretary may require. 

(c) REQUIREMENTS.— 

(1) PERFORMANCE GUIDELINES.—The Secretary, in consultation with the States and pediatric providers, shall establish guidelines to ensure that the quality of care delivered to 

individuals by a provider recognized as an accountable care organization under this section is not less than the quality of 

care that would have otherwise been provided to such individuals. 

(2) SAVINGS REQUIREMENT.—A participating State, in consultation with the Secretary, shall establish an annual minimal level of savings in expenditures for items and services covered under the Medicaid program under title XIX of the Social 

Security Act and the CHIP program under title XXI of such 

Act that must be reached by an accountable care organization 

in order for such organization to receive an incentive payment 

under subsection (d). 

(3) MINIMUM PARTICIPATION PERIOD.—A provider desiring 

to be recognized as an accountable care organization under the 

demonstration project shall enter into an agreement with the 

State to participate in the project for not less than a 3-year period. 

(d) INCENTIVE PAYMENT.—An accountable care organization 

that meets the performance guidelines established by the Secretary 

under subsection (c)(1) and achieves savings greater than the annual minimal savings level established by the State under subsection (c)(2) shall receive an incentive payment for such year equal 

to a portion (as determined appropriate by the Secretary) of the 

amount of such excess savings. The Secretary may establish an annual cap on incentive payments for an accountable care organization. 
237 Sec. 2707 PPACA (Consolidated) 

(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated such sums as are necessary to carry out this 

section. 

SEC. 2707. ø42 U.S.C. 1396a note¿ MEDICAID EMERGENCY PSYCHIATRIC 

DEMONSTRATION PROJECT. 

(a) AUTHORITY TO CONDUCT DEMONSTRATION PROJECT.—The 

Secretary of Health and Human Services (in this section referred 

to as the ‘‘Secretary’’) shall establish a demonstration project under 

which an eligible State (as described in subsection (c)) shall provide 

payment under the State Medicaid plan under title XIX of the Social Security Act to an institution for mental diseases that is not 

publicly owned or operated and that is subject to the requirements 

of section 1867 of the Social Security Act (42 U.S.C. 1395dd) for the 

provision of medical assistance available under such plan to individuals who— 

(1) have attained age 21, but have not attained age 65; 

(2) are eligible for medical assistance under such plan; and 

(3) require such medical assistance to stabilize an emergency medical condition. 

(b) STABILIZATION REVIEW.—A State shall specify in its application described in subsection (c)(1) establish a mechanism for how 

it will ensure that institutions participating in the demonstration 

will determine whether or not such individuals have been stabilized (as defined in subsection (h)(5)). This mechanism shall commence before the third day of the inpatient stay. States participating in the demonstration project may manage the provision of 

services for the stabilization of medical emergency conditions 

through utilization review, authorization, or management practices, 

or the application of medical necessity and appropriateness criteria 

applicable to behavioral health. 

(c) ELIGIBLE STATE DEFINED.— (1) IN GENERAL.—An eligible State is a State that has 

made an application and has been selected pursuant to paragraphs (2) and (3). 

(2) APPLICATION.—A State seeking to participate in the 

demonstration project under this section shall submit to the 

Secretary, at such time and in such format as the Secretary requires, an application that includes such information, provisions, and assurances, as the Secretary may require. 

(3) SELECTION.—A State shall be determined eligible for 

the demonstration by the Secretary on a competitive basis 

among States with applications meeting the requirements of 

paragraph (1). In selecting State applications for the demonstration project, the Secretary shall seek to achieve an appropriate national balance in the geographic distribution of 

such projects. 

(d) LENGTH OF DEMONSTRATION PROJECT.—The demonstration 

project established under this section shall be conducted for a period of 3 consecutive years. 

(e) LIMITATIONS ON FEDERAL FUNDING.— 

(1) APPROPRIATION.— 

(A) IN GENERAL.—Out of any funds in the Treasury 

not otherwise appropriated, there is appropriated to carry 

out this section, $75,000,000 for fiscal year 2011. 
Sec. 2707 PPACA (Consolidated) 238 

(B) BUDGET AUTHORITY.—Subparagraph (A) constitutes budget authority in advance of appropriations Act 

and represents the obligation of the Federal Government 

to provide for the payment of the amounts appropriated 

under that subparagraph. 

(2) 5-YEAR AVAILABILITY.—Funds appropriated under paragraph (1) shall remain available for obligation through December 31, 2015. 

(3) LIMITATION ON PAYMENTS.—In no case may— 

(A) the aggregate amount of payments made by the 

Secretary to eligible States under this section exceed 

$75,000,000; or 

(B) payments be provided by the Secretary under this 

section after December 31, 2015. 

(4) FUNDS ALLOCATED TO STATES.—Funds shall be allocated to eligible States on the basis of criteria, including a 

State’s application and the availability of funds, as determined 

by the Secretary. 

(5) PAYMENTS TO STATES.—The Secretary shall pay to each 

eligible State, from its allocation under paragraph (4), an 

amount each quarter equal to the Federal medical assistance 

percentage of expenditures in the quarter for medical assistance described in subsection (a). As a condition of receiving 

payment, a State shall collect and report information, as determined necessary by the Secretary, for the purposes of providing Federal oversight and conducting an evaluation under 

subsection (f)(1). 

(f) EVALUATION AND REPORT TO CONGRESS.— (1) EVALUATION.—The Secretary shall conduct an evaluation of the demonstration project in order to determine the impact on the functioning of the health and mental health service 

system and on individuals enrolled in the Medicaid program 

and shall include the following: 

(A) An assessment of access to inpatient mental health 

services under the Medicaid program; average lengths of 

inpatient stays; and emergency room visits. 

(B) An assessment of discharge planning by participating hospitals. 

(C) An assessment of the impact of the demonstration 

project on the costs of the full range of mental health services (including inpatient, emergency and ambulatory care). 

(D) An analysis of the percentage of consumers with 

Medicaid coverage who are admitted to inpatient facilities 

as a result of the demonstration project as compared to 

those admitted to these same facilities through other 

means. 

(E) A recommendation regarding whether the demonstration project should be continued after December 31, 

2013, and expanded on a national basis. 

(2) REPORT.—Not later than December 31, 2013, the Secretary shall submit to Congress and make available to the public a report on the findings of the evaluation under paragraph 

(1). 

(g) WAIVER AUTHORITY.— 
239 Sec. 2801 PPACA (Consolidated) 

(1) IN GENERAL.—The Secretary shall waive the limitation 

of subdivision (B) following paragraph (28) of section 1905(a) of 

the Social Security Act (42 U.S.C. 1396d(a)) (relating to limitations on payments for care or services for individuals under 65 

years of age who are patients in an institution for mental diseases) for purposes of carrying out the demonstration project 

under this section. 

(2) LIMITED OTHER WAIVER AUTHORITY.—The Secretary 

may waive other requirements of titles XI and XIX of the Social Security Act (including the requirements of sections 

1902(a)(1) (relating to statewideness) and 1902(1)(10)(B) (relating to comparability)) only to extent necessary to carry out the 

demonstration project under this section. 

(h) DEFINITIONS.—In this section: 

(1) EMERGENCY MEDICAL CONDITION.—The term ‘‘emergency medical condition’’ means, with respect to an individual, 

an individual who expresses suicidal or homicidal thoughts or 

gestures, if determined dangerous to self or others. 

(2) FEDERAL MEDICAL ASSISTANCE PERCENTAGE.—The term 

‘‘Federal medical assistance percentage’’ has the meaning given 

that term with respect to a State under section 1905(b) of the 

Social Security Act (42 U.S.C. 1396d(b)). 

(3) INSTITUTION FOR MENTAL DISEASES.—The term ‘‘institution for mental diseases’’ has the meaning given to that term 

in section 1905(i) of the Social Security Act (42 U.S.C. 

1396d(i)). 

(4) MEDICAL ASSISTANCE.—The term ‘‘medical assistance’’ 

has the meaning given that term in section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)). 

(5) STABILIZED.—The term ‘‘stabilized’’ means, with respect 

to an individual, that the emergency medical condition no 

longer exists with respect to the individual and the individual 

is no longer dangerous to self or others. 

(6) STATE.—The term ‘‘State’’ has the meaning given that 

term for purposes of title XIX of the Social Security Act (42 

U.S.C. 1396 et seq.). 

Subtitle J—Improvements to the Medicaid 

and CHIP Payment and Access Commission (MACPAC) 

SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL MEDICAID BENEFICIARIES. 

(a) IN GENERAL.—Section 1900 of the Social Security Act (42 

U.S.C. 1396) is amended— 

(1) in subsection (b)— 

(A) in paragraph (1)— 

(i) in the paragraph heading, by inserting ‘‘FOR

ALL STATES’’ before ‘‘AND ANNUAL’’; and 

(ii) in subparagraph (A), by striking ‘‘children’s’’; 

(iii) in subparagraph (B), by inserting ‘‘, the Secretary, and States’’ after ‘‘Congress’’; 
Sec. 2801 PPACA (Consolidated) 240 

(iv) in subparagraph (C), by striking ‘‘March 1’’ 

and inserting ‘‘March 15’’; and 

(v) in subparagraph (D), by striking ‘‘June 1’’ and 

inserting ‘‘June 15’’; 

(B) in paragraph (2)— 

(i) in subparagraph (A)— 

(I) in clause (i)— 

(aa) by inserting ‘‘the efficient provision 

of’’ after ‘‘expenditures for’’; and 

(bb) by striking ‘‘hospital, skilled nursing 

facility, physician, Federally-qualified health 

center, rural health center, and other fees’’ 

and inserting ‘‘payments to medical, dental, 

and health professionals, hospitals, residential and long-term care providers, providers of 

home and community based services, Federally-qualified health centers and rural health 

clinics, managed care entities, and providers 

of other covered items and services’’; and 

(II) in clause (iii), by inserting ‘‘(including how 

such factors and methodologies enable such beneficiaries to obtain the services for which they are 

eligible, affect provider supply, and affect providers that serve a disproportionate share of lowincome and other vulnerable populations)’’ after 

‘‘beneficiaries’’; 

(ii) by redesignating subparagraphs (B) and (C) as 

subparagraphs (F) and (H), respectively; 

(iii) by inserting after subparagraph (A), the following: 

‘‘(B) ELIGIBILITY POLICIES.—Medicaid and CHIP eligibility policies, including a determination of the degree to 

which Federal and State policies provide health care coverage to needy populations. 

‘‘(C) ENROLLMENT AND RETENTION PROCESSES.—Medicaid and CHIP enrollment and retention processes, including a determination of the degree to which Federal and 

State policies encourage the enrollment of individuals who 

are eligible for such programs and screen out individuals 

who are ineligible, while minimizing the share of program 

expenses devoted to such processes. 

‘‘(D) COVERAGE POLICIES.—Medicaid and CHIP benefit 

and coverage policies, including a determination of the degree to which Federal and State policies provide access to 

the services enrollees require to improve and maintain 

their health and functional status. 

‘‘(E) QUALITY OF CARE.—Medicaid and CHIP policies 

as they relate to the quality of care provided under those 

programs, including a determination of the degree to 

which Federal and State policies achieve their stated goals 

and interact with similar goals established by other purchasers of health care services.’’; 
241 Sec. 2801 PPACA (Consolidated) 

(iv) by inserting after subparagraph (F) (as redesignated by clause (ii) of this subparagraph), the following: 

‘‘(G) INTERACTIONS WITH MEDICARE AND MEDICAID.— Consistent with paragraph (11), the interaction of policies 

under Medicaid and the Medicare program under title 

XVIII, including with respect to how such interactions affect access to services, payments, and dual eligible individuals.’’ and 

(v) in subparagraph (H) (as so redesignated), by 

inserting ‘‘and preventive, acute, and long-term services and supports’’ after ‘‘barriers’’; 

(C) by redesignating paragraphs (3) through (9) as 

paragraphs (4) through (10), respectively; 

(D) by inserting after paragraph (2), the following new 

paragraph: 

‘‘(3) RECOMMENDATIONS AND REPORTS OF STATE-SPECIFIC

DATA.—MACPAC shall— 

‘‘(A) review national and State-specific Medicaid and 

CHIP data; and 

‘‘(B) submit reports and recommendations to Congress, 

the Secretary, and States based on such reviews.’’; 

(E) in paragraph (4), as redesignated by subparagraph 

(C), by striking ‘‘or any other problems’’ and all that follows through the period and inserting ‘‘, as well as other 

factors that adversely affect, or have the potential to adversely affect, access to care by, or the health care status 

of, Medicaid and CHIP beneficiaries. MACPAC shall include in the annual report required under paragraph 

(1)(D) a description of all such areas or problems identified 

with respect to the period addressed in the report.’’; 

(F) in paragraph (5), as so redesignated,— 

(i) in the paragraph heading, by inserting ‘‘AND

REGULATIONS’’ after ‘‘REPORTS’’; and 

(ii) by striking ‘‘If’’ and inserting the following: 

‘‘(A) CERTAIN SECRETARIAL REPORTS.—If’’; and 

(iii) in the second sentence, by inserting ‘‘and the 

Secretary’’ after ‘‘appropriate committees of Congress’’; 

and 

(iv) by adding at the end the following: 

‘‘(B) REGULATIONS.—MACPAC shall review Medicaid 

and CHIP regulations and may comment through submission of a report to the appropriate committees of Congress 

and the Secretary, on any such regulations that affect access, quality, or efficiency of health care.’’; 

(G) in paragraph (10), as so redesignated, by inserting 

‘‘, and shall submit with any recommendations, a report on 

the Federal and State-specific budget consequences of the 

recommendations’’ before the period; and 

(H) by adding at the end the following: 

‘‘(11) CONSULTATION AND COORDINATION WITH MEDPAC.— 

‘‘(A) IN GENERAL.—MACPAC shall consult with the 

Medicare Payment Advisory Commission (in this paragraph referred to as ‘MedPAC’) established under section 
Sec. 2801 PPACA (Consolidated) 242 

1805 in carrying out its duties under this section, as appropriate and particularly with respect to the issues specified in paragraph (2) as they relate to those Medicaid 

beneficiaries who are dually eligible for Medicaid and the 

Medicare program under title XVIII, adult Medicaid beneficiaries (who are not dually eligible for Medicare), and 

beneficiaries under Medicare. Responsibility for analysis of 

and recommendations to change Medicare policy regarding 

Medicare beneficiaries, including Medicare beneficiaries 

who are dually eligible for Medicare and Medicaid, shall 

rest with MedPAC. 

‘‘(B) INFORMATION SHARING.—MACPAC and MedPAC 

shall have access to deliberations and records of the other 

such entity, respectively, upon the request of the other 

such entity. 

‘‘(12) CONSULTATION WITH STATES.—MACPAC shall regularly consult with States in carrying out its duties under this 

section, including with respect to developing processes for carrying out such duties, and shall ensure that input from States 

is taken into account and represented in MACPAC’s recommendations and reports. 

‘‘(13) COORDINATE AND CONSULT WITH THE FEDERAL CO- ORDINATED HEALTH CARE OFFICE.—MACPAC shall coordinate 

and consult with the Federal Coordinated Health Care Office 

established under section 2081 of the Patient Protection and 

Affordable Care Act before making any recommendations regarding dual eligible individuals. 

‘‘(14) PROGRAMMATIC OVERSIGHT VESTED IN THE SEC- RETARY.—MACPAC’s authority to make recommendations in 

accordance with this section shall not affect, or be considered 

to duplicate, the Secretary’s authority to carry out Federal responsibilities with respect to Medicaid and CHIP.’’; 

(2) in subsection (c)(2)— 

(A) by striking subparagraphs (A) and (B) and inserting the following: 

‘‘(A) IN GENERAL.—The membership of MACPAC shall 

include individuals who have had direct experience as enrollees or parents or caregivers of enrollees in Medicaid or 

CHIP and individuals with national recognition for their 

expertise in Federal safety net health programs, health finance and economics, actuarial science, health plans and 

integrated delivery systems, reimbursement for health 

care, health information technology, and other providers of 

health services, public health, and other related fields, who 

provide a mix of different professions, broad geographic 

representation, and a balance between urban and rural 

representation. 

‘‘(B) INCLUSION.—The membership of MACPAC shall 

include (but not be limited to) physicians, dentists, and 

other health professionals, employers, third-party payers, 

and individuals with expertise in the delivery of health 

services. Such membership shall also include representatives of children, pregnant women, the elderly, individuals 

with disabilities, caregivers, and dual eligible individuals, 
243 Sec. 2801 PPACA (Consolidated) 

current or former representatives of State agencies responsible for administering Medicaid, and current or former 

representatives of State agencies responsible for administering CHIP.’’. 

(3) in subsection (d)(2), by inserting ‘‘and State’’ after ‘‘Federal’’; 

(4) in subsection (e)(1), in the first sentence, by inserting 

‘‘and, as a condition for receiving payments under sections 

1903(a) and 2105(a), from any State agency responsible for administering Medicaid or CHIP,’’ after ‘‘United States’’; and 

(5) in subsection (f)— 

(A) in the subsection heading, by striking ‘‘AUTHORIZA- TION OF APPROPRIATIONS’’ and inserting ‘‘FUNDING’’; 

(B) in paragraph (1), by inserting ‘‘(other than for fiscal year 2010)’’ before ‘‘in the same manner’’; and 

(C) by adding at the end the following: 

‘‘(3) FUNDING FOR FISCAL YEAR 2010.— ‘‘(A) IN GENERAL.—Out of any funds in the Treasury 

not otherwise appropriated, there is appropriated to 

MACPAC to carry out the provisions of this section for fiscal year 2010, $9,000,000. 

‘‘(B) TRANSFER OF FUNDS.—Notwithstanding section 

2104(a)(13), from the amounts appropriated in such section 

for fiscal year 2010, $2,000,000 is hereby transferred and 

made available in such fiscal year to MACPAC to carry out 

the provisions of this section. 

‘‘(4) AVAILABILITY.—Amounts made available under paragraphs (2) and (3) to MACPAC to carry out the provisions of 

this section shall remain available until expended.’’. 

(b) CONFORMING MEDPAC AMENDMENTS.—Section 1805(b) of 

the Social Security Act (42 U.S.C. 1395b–6(b)), is amended— 

(1) in paragraph (1)(C), by striking ‘‘March 1 of each year 

(beginning with 1998)’’ and inserting ‘‘March 15’’; 

(2) in paragraph (1)(D), by inserting ‘‘, and (beginning with 

2012) containing an examination of the topics described in 

paragraph (9), to the extent feasible’’ before the period; and 

(3) by adding at the end the following: 

‘‘(9) REVIEW AND ANNUAL REPORT ON MEDICAID AND COMMERCIAL TRENDS.—The Commission shall review and report on 

aggregate trends in spending, utilization, and financial performance under the Medicaid program under title XIX and the 

private market for health care services with respect to providers for which, on an aggregate national basis, a significant 

portion of revenue or services is associated with the Medicaid 

program. Where appropriate, the Commission shall conduct 

such review in consultation with the Medicaid and CHIP Payment and Access Commission established under section 1900 

(in this section referred to as ‘MACPAC’). 

‘‘(10) COORDINATE AND CONSULT WITH THE FEDERAL COORDINATED HEALTH CARE OFFICE.—The Commission shall coordinate and consult with the Federal Coordinated Health 

Care Office established under section 2081 of the Patient Protection and Affordable Care Act before making any recommendations regarding dual eligible individuals. 
Sec. 2901 PPACA (Consolidated) 244 

‘‘(11) INTERACTION OF MEDICAID AND MEDICARE.—The Commission shall consult with MACPAC in carrying out its duties 

under this section, as appropriate. Responsibility for analysis 

of and recommendations to change Medicare policy regarding 

Medicare beneficiaries, including Medicare beneficiaries who 

are dually eligible for Medicare and Medicaid, shall rest with 

the Commission. Responsibility for analysis of and recommendations to change Medicaid policy regarding Medicaid 

beneficiaries, including Medicaid beneficiaries who are dually 

eligible for Medicare and Medicaid, shall rest with MACPAC.’’. 

Subtitle K—Protections for American 

Indians and Alaska Natives 

SEC. 2901. ø25 U.S.C. 1623¿ SPECIAL RULES RELATING TO INDIANS. 

(a) NO COST-SHARING FOR INDIANS WITH INCOME AT OR BELOW

300 PERCENT OF POVERTY ENROLLED IN COVERAGE THROUGH A

STATE EXCHANGE.—For provisions prohibiting cost sharing for Indians enrolled in any qualified health plan in the individual market 

through an Exchange, see section 1402(d) of the Patient Protection 

and Affordable Care Act. 

(b) PAYER OF LAST RESORT.—Health programs operated by the 

Indian Health Service, Indian tribes, tribal organizations, and 

Urban Indian organizations (as those terms are defined in section 

4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)) 

shall be the payer of last resort for services provided by such Service, tribes, or organizations to individuals eligible for services 

through such programs, notwithstanding any Federal, State, or 

local law to the contrary. 

(c) FACILITATING ENROLLMENT OF INDIANS UNDER THE EXPRESS

LANE OPTION.—Section 1902(e)(13)(F)(ii) of the Social Security Act 

(42 U.S.C. 1396a(e)(13)(F)(ii)) is amended— 

(1) in the clause heading, by inserting ‘‘AND INDIAN TRIBES

AND TRIBAL ORGANIZATIONS’’ after ‘‘AGENCIES’’; and 

(2) by adding at the end the following: 

‘‘(IV) The Indian Health Service, an Indian 

Tribe, Tribal Organization, or Urban Indian Organization (as defined in section 1139(c)).’’. 

(d) TECHNICAL CORRECTIONS.—Section 1139(c) of the Social Security Act (42 U.S.C. 1320b–9(c)) is amended by striking ‘‘In this 

section’’ and inserting ‘‘For purposes of this section, title XIX, and 

title XXI’’. 

SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL 

MEDICARE PART B SERVICES FURNISHED BY CERTAIN INDIAN HOSPITALS AND CLINICS. 

(a) REIMBURSEMENT FOR ALL MEDICARE PART B SERVICES FUR- NISHED BY CERTAIN INDIAN HOSPITALS AND CLINICS.—Section 

1880(e)(1)(A) of the Social Security Act (42 U.S.C. 1395qq(e)(1)(A)) 

is amended by striking ‘‘during the 5-year period beginning on’’ and 

inserting ‘‘on or after’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to items or services furnished on or after January 1, 

2010. 
245 Sec. 2951 PPACA (Consolidated) \511 SSA 

Subtitle L—Maternal and Child Health 

Services 

SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAMS. 

Title V of the Social Security Act (42 U.S.C. 701 et seq.) is 

amended by adding at the end the following new section: 

‘‘SEC. 511. ø42 U.S.C. 711¿ MATERNAL, INFANT, AND EARLY CHILDHOOD 

HOME VISITING PROGRAMS. 

‘‘(a) PURPOSES.—The purposes of this section are— 

‘‘(1) to strengthen and improve the programs and activities 

carried out under this title; 

‘‘(2) to improve coordination of services for at risk communities; and 

‘‘(3) to identify and provide comprehensive services to improve outcomes for families who reside in at risk communities. 

‘‘(b) REQUIREMENT FOR ALL STATES TO ASSESS STATEWIDE

NEEDS AND IDENTIFY AT RISK COMMUNITIES.— ‘‘(1) IN GENERAL.—Not later than 6 months after the date 

of enactment of this section, each State shall, as a condition of 

receiving payments from an allotment for the State under section 502 for fiscal year 2011, conduct a statewide needs assessment (which shall be separate from the statewide needs assessment required under section 505(a)) that identifies— 

‘‘(A) communities with concentrations of— 

‘‘(i) premature birth, low-birth weight infants, and 

infant mortality, including infant death due to neglect, 

or other indicators of at-risk prenatal, maternal, newborn, or child health; 

‘‘(ii) poverty; 

‘‘(iii) crime; 

‘‘(iv) domestic violence; 

‘‘(v) high rates of high-school drop-outs; 

‘‘(vi) substance abuse; 

‘‘(vii) unemployment; or 

‘‘(viii) child maltreatment; 

‘‘(B) the quality and capacity of existing programs or 

initiatives for early childhood home visitation in the State 

including— 

‘‘(i) the number and types of individuals and families who are receiving services under such programs or 

initiatives; 

‘‘(ii) the gaps in early childhood home visitation in 

the State; and 

‘‘(iii) the extent to which such programs or initiatives are meeting the needs of eligible families described in subsection (k)(2); and 

‘‘(C) the State’s capacity for providing substance abuse 

treatment and counseling services to individuals and families in need of such treatment or services. 

‘‘(2) COORDINATION WITH OTHER ASSESSMENTS.—In conducting the statewide needs assessment required under paragraph (1), the State shall coordinate with, and take into ac-
Sec. 2951\511 SSA PPACA (Consolidated) 246 

count, other appropriate needs assessments conducted by the 

State, as determined by the Secretary, including the needs assessment required under section 505(a) (both the most recently 

completed assessment and any such assessment in progress), 

the communitywide strategic planning and needs assessments 

conducted in accordance with section 640(g)(1)(C) of the Head 

Start Act, and the inventory of current unmet needs and current community-based and prevention-focused programs and 

activities to prevent child abuse and neglect, and other family 

resource services operating in the State required under section 

205(3) of the Child Abuse Prevention and Treatment Act. 

‘‘(3) SUBMISSION TO THE SECRETARY.—Each State shall submit to the Secretary, in such form and manner as the Secretary shall require— 

‘‘(A) the results of the statewide needs assessment required under paragraph (1); and 

‘‘(B) a description of how the State intends to address 

needs identified by the assessment, particularly with respect to communities identified under paragraph (1)(A), 

which may include applying for a grant to conduct an early 

childhood home visitation program in accordance with the 

requirements of this section. 

‘‘(c) GRANTS FOR EARLY CHILDHOOD HOME VISITATION PRO- GRAMS.— 

‘‘(1) AUTHORITY TO MAKE GRANTS.—In addition to any other 

payments made under this title to a State, the Secretary shall 

make grants to eligible entities to enable the entities to deliver 

services under early childhood home visitation programs that 

satisfy the requirements of subsection (d) to eligible families in 

order to promote improvements in maternal and prenatal 

health, infant health, child health and development, parenting 

related to child development outcomes, school readiness, and 

the socioeconomic status of such families, and reductions in 

child abuse, neglect, and injuries. 

‘‘(2) AUTHORITY TO USE INITIAL GRANT FUNDS FOR PLANNING OR IMPLEMENTATION.—An eligible entity that receives a 

grant under paragraph (1) may use a portion of the funds 

made available to the entity during the first 6 months of the 

period for which the grant is made for planning or implementation activities to assist with the establishment of early childhood home visitation programs that satisfy the requirements of 

subsection (d). 

‘‘(3) GRANT DURATION.—The Secretary shall determine the 

period of years for which a grant is made to an eligible entity 

under paragraph (1). 

‘‘(4) TECHNICAL ASSISTANCE.—The Secretary shall provide 

an eligible entity that receives a grant under paragraph (1) 

with technical assistance in administering programs or activities conducted in whole or in part with grant funds. 

‘‘(d) REQUIREMENTS.—The requirements of this subsection for 

an early childhood home visitation program conducted with a grant 

made under this section are as follows: 

‘‘(1) QUANTIFIABLE, MEASURABLE IMPROVEMENT IN BENCHMARK AREAS.— 
247 Sec. 2951 PPACA (Consolidated) \511 SSA 

‘‘(A) IN GENERAL.—The eligible entity establishes, subject to the approval of the Secretary, quantifiable, measurable 3- and 5-year benchmarks for demonstrating that the 

program results in improvements for the eligible families 

participating in the program in each of the following areas: 

‘‘(i) Improved maternal and newborn health. 

‘‘(ii) Prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits. 

‘‘(iii) Improvement in school readiness and 

achievement. 

‘‘(iv) Reduction in crime or domestic violence. 

‘‘(v) Improvements in family economic self-sufficiency. 

‘‘(vi) Improvements in the coordination and referrals for other community resources and supports. 

‘‘(B) DEMONSTRATION OF IMPROVEMENTS AFTER 3

YEARS.— ‘‘(i) REPORT TO THE SECRETARY.—Not later than 30 

days after the end of the 3rd year in which the eligible 

entity conducts the program, the entity submits to the 

Secretary a report demonstrating improvement in at 

least 4 of the areas specified in subparagraph (A). 

‘‘(ii) CORRECTIVE ACTION PLAN.—If the report submitted by the eligible entity under clause (i) fails to 

demonstrate improvement in at least 4 of the areas 

specified in subparagraph (A), the entity shall develop 

and implement a plan to improve outcomes in each of 

the areas specified in subparagraph (A), subject to approval by the Secretary. The plan shall include provisions for the Secretary to monitor implementation of 

the plan and conduct continued oversight of the program, including through submission by the entity of 

regular reports to the Secretary. 

‘‘(iii) TECHNICAL ASSISTANCE.— 

‘‘(I) IN GENERAL.—The Secretary shall provide 

an eligible entity required to develop and implement an improvement plan under clause (ii) with 

technical assistance to develop and implement the 

plan. The Secretary may provide the technical assistance directly or through grants, contracts, or 

cooperative agreements. 

‘‘(II) ADVISORY PANEL.—The Secretary shall 

establish an advisory panel for purposes of obtaining recommendations regarding the technical assistance provided to entities in accordance with 

subclause (I). 

‘‘(iv) NO IMPROVEMENT OR FAILURE TO SUBMIT REPORT.—If the Secretary determines after a period of 

time specified by the Secretary that an eligible entity 

implementing an improvement plan under clause (ii) 

has failed to demonstrate any improvement in the 

areas specified in subparagraph (A), or if the Secretary 

determines that an eligible entity has failed to submit 
Sec. 2951\511 SSA PPACA (Consolidated) 248 

the report required under clause (i), the Secretary 

shall terminate the entity’s grant and may include any 

unexpended grant funds in grants made to nonprofit 

organizations under subsection (h)(2)(B). 

‘‘(C) FINAL REPORT.—Not later than December 31, 

2015, the eligible entity shall submit a report to the Secretary demonstrating improvements (if any) in each of the 

areas specified in subparagraph (A). 

‘‘(2) IMPROVEMENTS IN OUTCOMES FOR INDIVIDUAL FAMI- LIES.— ‘‘(A) IN GENERAL.—The program is designed, with respect to an eligible family participating in the program, to 

result in the participant outcomes described in subparagraph (B) that the eligible entity identifies on the basis of 

an individualized assessment of the family, are relevant 

for that family. 

‘‘(B) PARTICIPANT OUTCOMES.—The participant outcomes described in this subparagraph are the following: 

‘‘(i) Improvements in prenatal, maternal, and newborn health, including improved pregnancy outcomes 

‘‘(ii) Improvements in child health and development, including the prevention of child injuries and 

maltreatment and improvements in cognitive, language, social-emotional, and physical developmental 

indicators. 

‘‘(iii) Improvements in parenting skills. 

‘‘(iv) Improvements in school readiness and child 

academic achievement. 

‘‘(v) Reductions in crime or domestic violence. 

‘‘(vi) Improvements in family economic self-sufficiency. 

‘‘(vii) Improvements in the coordination of referrals for, and the provision of, other community resources and supports for eligible families, consistent 

with State child welfare agency training. 

‘‘(3) CORE COMPONENTS.—The program includes the following core components: 

‘‘(A) SERVICE DELIVERY MODEL OR MODELS.— 

‘‘(i) IN GENERAL.—Subject to clause (ii), the program is conducted using 1 or more of the service delivery models described in item (aa) or (bb) of subclause 

(I) or in subclause (II) selected by the eligible entity: 

‘‘(I) The model conforms to a clear consistent 

home visitation model that has been in existence 

for at least 3 years and is research-based, grounded in relevant empirically-based knowledge, linked 

to program determined outcomes, associated with 

a national organization or institution of higher 

education that has comprehensive home visitation 

program standards that ensure high quality service delivery and continuous program quality improvement, and has demonstrated significant, 

(and in the case of the service delivery model described in item (aa), sustained) positive outcomes, 
249 Sec. 2951 PPACA (Consolidated) \511 SSA 

as described in the benchmark areas specified in 

paragraph (1)(A) and the participant outcomes described in paragraph (2)(B), when evaluated using 

well-designed and rigorous— 

‘‘(aa) randomized controlled research designs, and the evaluation results have been 

published in a peer-reviewed journal; or 

‘‘(bb) quasi-experimental research designs. 

‘‘(II) The model conforms to a promising and 

new approach to achieving the benchmark areas 

specified in paragraph (1)(A) and the participant 

outcomes described in paragraph (2)(B), has been 

developed or identified by a national organization 

or institution of higher education, and will be 

evaluated through well-designed and rigorous 

process. 

‘‘(ii) MAJORITY OF GRANT FUNDS USED FOR EVIDENCE-BASED MODELS.—An eligible entity shall use 

not more than 25 percent of the amount of the grant 

paid to the entity for a fiscal year for purposes of conducting a program using the service delivery model described in clause (i)(II). 

‘‘(iii) CRITERIA FOR EVIDENCE OF EFFECTIVENESS

OF MODELS.—The Secretary shall establish criteria for 

evidence of effectiveness of the service delivery models 

and shall ensure that the process for establishing the 

criteria is transparent and provides the opportunity 

for public comment. 

‘‘(B) ADDITIONAL REQUIREMENTS.— 

‘‘(i) The program adheres to a clear, consistent 

model that satisfies the requirements of being grounded in empirically-based knowledge related to home visiting and linked to the benchmark areas specified in 

paragraph (1)(A) and the participant outcomes described in paragraph (2)(B) related to the purposes of 

the program. 

‘‘(ii) The program employs well-trained and competent staff, as demonstrated by education or training, 

such as nurses, social workers, educators, child development specialists, or other well-trained and competent staff, and provides ongoing and specific training 

on the model being delivered. 

‘‘(iii) The program maintains high quality supervision to establish home visitor competencies. 

‘‘(iv) The program demonstrates strong organizational capacity to implement the activities involved. 

‘‘(v) The program establishes appropriate linkages 

and referral networks to other community resources 

and supports for eligible families. 

‘‘(vi) The program monitors the fidelity of program 

implementation to ensure that services are delivered 

pursuant to the specified model. 
Sec. 2951\511 SSA PPACA (Consolidated) 250 

‘‘(4) PRIORITY FOR SERVING HIGH-RISK POPULATIONS.—The 

eligible entity gives priority to providing services under the 

program to the following: 

‘‘(A) Eligible families who reside in communities in 

need of such services, as identified in the statewide needs 

assessment required under subsection (b)(1)(A). 

‘‘(B) Low-income eligible families. 

‘‘(C) Eligible families who are pregnant women who 

have not attained age 21. 

‘‘(D) Eligible families that have a history of child 

abuse or neglect or have had interactions with child welfare services. 

‘‘(E) Eligible families that have a history of substance 

abuse or need substance abuse treatment. 

‘‘(F) Eligible families that have users of tobacco products in the home. 

‘‘(G) Eligible families that are or have children with 

low student achievement. 

‘‘(H) Eligible families with children with developmental delays or disabilities. 

‘‘(I) Eligible families who, or that include individuals 

who, are serving or formerly served in the Armed Forces, 

including such families that have members of the Armed 

Forces who have had multiple deployments outside of the 

United States. 

‘‘(e) APPLICATION REQUIREMENTS.—An eligible entity desiring a 

grant under this section shall submit an application to the Secretary for approval, in such manner as the Secretary may require, 

that includes the following: 

‘‘(1) A description of the populations to be served by the 

entity, including specific information regarding how the entity 

will serve high risk populations described in subsection (d)(4). 

‘‘(2) An assurance that the entity will give priority to serving low-income eligible families and eligible families who reside 

in at risk communities identified in the statewide needs assessment required under subsection (b)(1)(A). 

‘‘(3) The service delivery model or models described in subsection (d)(3)(A) that the entity will use under the program and 

the basis for the selection of the model or models. 

‘‘(4) A statement identifying how the selection of the populations to be served and the service delivery model or models 

that the entity will use under the program for such populations 

is consistent with the results of the statewide needs assessment conducted under subsection (b). 

‘‘(5) The quantifiable, measurable benchmarks established 

by the State to demonstrate that the program contributes to 

improvements in the areas specified in subsection (d)(1)(A). 

‘‘(6) An assurance that the entity will obtain and submit 

documentation or other appropriate evidence from the organization or entity that developed the service delivery model or 

models used under the program to verify that the program is 

implemented and services are delivered according to the model 

specifications. 
251 Sec. 2951 PPACA (Consolidated) \511 SSA 

‘‘(7) Assurances that the entity will establish procedures to 

ensure that— 

‘‘(A) the participation of each eligible family in the program is voluntary; and 

‘‘(B) services are provided to an eligible family in accordance with the individual assessment for that family. 

‘‘(8) Assurances that the entity will— 

‘‘(A) submit annual reports to the Secretary regarding 

the program and activities carried out under the program 

that include such information and data as the Secretary 

shall require; and 

‘‘(B) participate in, and cooperate with, data and information collection necessary for the evaluation required 

under subsection (g)(2) and other research and evaluation 

activities carried out under subsection (h)(3). 

‘‘(9) A description of other State programs that include 

home visitation services, including, if applicable to the State, 

other programs carried out under this title with funds made 

available from allotments under section 502(c), programs funded under title IV, title II of the Child Abuse Prevention and 

Treatment Act (relating to community-based grants for the 

prevention of child abuse and neglect), and section 645A of the 

Head Start Act (relating to Early Head Start programs). 

‘‘(10) Other information as required by the Secretary. 

‘‘(f) MAINTENANCE OF EFFORT.—Funds provided to an eligible 

entity receiving a grant under this section shall supplement, and 

not supplant, funds from other sources for early childhood home 

visitation programs or initiatives. 

‘‘(g) EVALUATION.— 

‘‘(1) INDEPENDENT, EXPERT ADVISORY PANEL.—The Secretary, in accordance with subsection (h)(1)(A), shall appoint 

an independent advisory panel consisting of experts in program evaluation and research, education, and early childhood 

development— 

‘‘(A) to review, and make recommendations on, the design and plan for the evaluation required under paragraph 

(2) within 1 year after the date of enactment of this section; 

‘‘(B) to maintain and advise the Secretary regarding 

the progress of the evaluation; and 

‘‘(C) to comment, if the panel so desires, on the report 

submitted under paragraph (3). 

‘‘(2) AUTHORITY TO CONDUCT EVALUATION.—On the basis of 

the recommendations of the advisory panel under paragraph 

(1), the Secretary shall, by grant, contract, or interagency 

agreement, conduct an evaluation of the statewide needs assessments submitted under subsection (b) and the grants made 

under subsections (c) and (h)(3)(B). The evaluation shall include— 

‘‘(A) an analysis, on a State-by-State basis, of the results of such assessments, including indicators of maternal 

and prenatal health and infant health and mortality, and 

State actions in response to the assessments; and 

‘‘(B) an assessment of— 
Sec. 2951\511 SSA PPACA (Consolidated) 252 

‘‘(i) the effect of early childhood home visitation 

programs on child and parent outcomes, including 

with respect to each of the benchmark areas specified 

in subsection (d)(1)(A) and the participant outcomes 

described in subsection (d)(2)(B); 

‘‘(ii) the effectiveness of such programs on different populations, including the extent to which the 

ability of programs to improve participant outcomes 

varies across programs and populations; and 

‘‘(iii) the potential for the activities conducted 

under such programs, if scaled broadly, to improve 

health care practices, eliminate health disparities, and 

improve health care system quality, efficiencies, and 

reduce costs. 

‘‘(3) REPORT.—Not later than March 31, 2015, the Secretary shall submit a report to Congress on the results of the 

evaluation conducted under paragraph (2) and shall make the 

report publicly available. 

‘‘(h) OTHER PROVISIONS.— 

‘‘(1) INTRA-AGENCY COLLABORATION.—The Secretary shall 

ensure that the Maternal and Child Health Bureau and the 

Administration for Children and Families collaborate with respect to carrying out this section, including with respect to— 

‘‘(A) reviewing and analyzing the statewide needs assessments required under subsection (b), the awarding and 

oversight of grants awarded under this section, the establishment of the advisory panels required under subsections 

(d)(1)(B)(iii)(II) and (g)(1), and the evaluation and report 

required under subsection (g); and 

‘‘(B) consulting with other Federal agencies with responsibility for administering or evaluating programs that 

serve eligible families to coordinate and collaborate with 

respect to research related to such programs and families, 

including the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and 

Human Services, the Centers for Disease Control and Prevention, the National Institute of Child Health and 

Human Development of the National Institutes of Health, 

the Office of Juvenile Justice and Delinquency Prevention 

of the Department of Justice, and the Institute of Education Sciences of the Department of Education. 

‘‘(2) GRANTS TO ELIGIBLE ENTITIES THAT ARE NOT STATES.— 

‘‘(A) INDIAN TRIBES, TRIBAL ORGANIZATIONS, OR URBAN

INDIAN ORGANIZATIONS.—The Secretary shall specify requirements for eligible entities that are Indian Tribes (or 

a consortium of Indian Tribes), Tribal Organizations, or 

Urban Indian Organizations to apply for and conduct an 

early childhood home visitation program with a grant 

under this section. Such requirements shall, to the greatest extent practicable, be consistent with the requirements 

applicable to eligible entities that are States and shall require an Indian Tribe (or consortium), Tribal Organization, 

or Urban Indian Organization to— 
253 Sec. 2951 PPACA (Consolidated) \511 SSA 

‘‘(i) conduct a needs assessment similar to the assessment required for all States under subsection (b); 

and 

‘‘(ii) establish quantifiable, measurable 3- and 5- 

year benchmarks consistent with subsection (d)(1)(A). 

‘‘(B) NONPROFIT ORGANIZATIONS.—If, as of the beginning of fiscal year 2012, a State has not applied or been 

approved for a grant under this section, the Secretary may 

use amounts appropriated under paragraph (1) of subsection (j) that are available for expenditure under paragraph (3) of that subsection to make a grant to an eligible 

entity that is a nonprofit organization described in subsection (k)(1)(B) to conduct an early childhood home visitation program in the State. The Secretary shall specify the 

requirements for such an organization to apply for and 

conduct the program which shall, to the greatest extent 

practicable, be consistent with the requirements applicable 

to eligible entities that are States and shall require the organization to— 

‘‘(i) carry out the program based on the needs assessment conducted by the State under subsection (b); 

and 

‘‘(ii) establish quantifiable, measurable 3- and 5- 

year benchmarks consistent with subsection (d)(1)(A). 

‘‘(3) RESEARCH AND OTHER EVALUATION ACTIVITIES.— ‘‘(A) IN GENERAL.—The Secretary shall carry out a continuous program of research and evaluation activities in 

order to increase knowledge about the implementation and 

effectiveness of home visiting programs, using random assignment designs to the maximum extent feasible. The 

Secretary may carry out such activities directly, or through 

grants, cooperative agreements, or contracts. 

‘‘(B) REQUIREMENTS.—The Secretary shall ensure 

that— 

‘‘(i) evaluation of a specific program or project is 

conducted by persons or individuals not directly involved in the operation of such program or project; and 

‘‘(ii) the conduct of research and evaluation activities includes consultation with independent researchers, State officials, and developers and providers of 

home visiting programs on topics including research 

design and administrative data matching. 

‘‘(4) REPORT AND RECOMMENDATION.—Not later than December 31, 2015, the Secretary shall submit a report to Congress regarding the programs conducted with grants under this 

section. The report required under this paragraph shall include— 

‘‘(A) information regarding the extent to which eligible 

entities receiving grants under this section demonstrated 

improvements in each of the areas specified in subsection 

(d)(1)(A); 

‘‘(B) information regarding any technical assistance 

provided under subsection (d)(1)(B)(iii)(I), including the 

type of any such assistance provided; and 
Sec. 2951\511 SSA PPACA (Consolidated) 254 

‘‘(C) recommendations for such legislative or administrative action as the Secretary determines appropriate. 

‘‘(i) APPLICATION OF OTHER PROVISIONS OF TITLE.— 

‘‘(1) IN GENERAL.—Except as provided in paragraph (2), the 

other provisions of this title shall not apply to a grant made 

under this section. 

‘‘(2) EXCEPTIONS.—The following provisions of this title 

shall apply to a grant made under this section to the same extent and in the same manner as such provisions apply to allotments made under section 502(c): 

‘‘(A) Section 504(b)(6) (relating to prohibition on payments to excluded individuals and entities). 

‘‘(B) Section 504(c) (relating to the use of funds for the 

purchase of technical assistance). 

‘‘(C) Section 504(d) (relating to a limitation on administrative expenditures). 

‘‘(D) Section 506 (relating to reports and audits), but 

only to the extent determined by the Secretary to be appropriate for grants made under this section. 

‘‘(E) Section 507 (relating to penalties for false statements). 

‘‘(F) Section 508 (relating to nondiscrimination). 

‘‘(G) Section 509(a) (relating to the administration of 

the grant program). 

‘‘(j) APPROPRIATIONS.— 

‘‘(1) IN GENERAL.—Out of any funds in the Treasury not 

otherwise appropriated, there are appropriated to the Secretary to carry out this section— 

‘‘(A) $100,000,000 for fiscal year 2010; 

‘‘(B) $250,000,000 for fiscal year 2011; 

‘‘(C) $350,000,000 for fiscal year 2012; 

‘‘(D) $400,000,000 for fiscal year 2013; and 

‘‘(E) $400,000,000 for fiscal year 2014. 

‘‘(2) RESERVATIONS.—Of the amount appropriated under 

this subsection for a fiscal year, the Secretary shall reserve— 

‘‘(A) 3 percent of such amount for purposes of making 

grants to eligible entities that are Indian Tribes (or a consortium of Indian Tribes), Tribal Organizations, or Urban 

Indian Organizations; and 

‘‘(B) 3 percent of such amount for purposes of carrying 

out subsections (d)(1)(B)(iii), (g), and (h)(3). 

‘‘(3) AVAILABILITY.—Funds made available to an eligible 

entity under this section for a fiscal year shall remain available for expenditure by the eligible entity through the end of 

the second succeeding fiscal year after award. Any funds that 

are not expended by the eligible entity during the period in 

which the funds are available under the preceding sentence 

may be used for grants to nonprofit organizations under subsection (h)(2)(B). 

‘‘(k) DEFINITIONS.—In this section: 

‘‘(1) ELIGIBLE ENTITY.— 

‘‘(A) IN GENERAL.—The term ‘eligible entity’ means a 

State, an Indian Tribe, Tribal Organization, or Urban In-
255 Sec. 2952 PPACA (Consolidated) 

dian Organization, Puerto Rico, Guam, the Virgin Islands, 

the Northern Mariana Islands, and American Samoa. 

‘‘(B) NONPROFIT ORGANIZATIONS.—Only for purposes of 

awarding grants under subsection (h)(2)(B), such term 

shall include a nonprofit organization with an established 

record of providing early childhood home visitation programs or initiatives in a State or several States. 

‘‘(2) ELIGIBLE FAMILY.—The term ‘eligible family’ means— 

‘‘(A) a woman who is pregnant, and the father of the 

child if the father is available; or 

‘‘(B) a parent or primary caregiver of a child, including 

grandparents or other relatives of the child, and foster parents, who are serving as the child’s primary caregiver from 

birth to kindergarten entry, and including a noncustodial 

parent who has an ongoing relationship with, and at times 

provides physical care for, the child. 

‘‘(3) INDIAN TRIBE; TRIBAL ORGANIZATION.—The terms ‘Indian Tribe’ and ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given such terms in section 4 of 

the Indian Health Care Improvement Act.’’. 

SEC. 2952. ø42 U.S.C. 712 note¿ SUPPORT, EDUCATION, AND RESEARCH 

FOR POSTPARTUM DEPRESSION. 

(a) RESEARCH ON POSTPARTUM CONDITIONS.— (1) EXPANSION AND INTENSIFICATION OF ACTIVITIES.—The 

Secretary of Health and Human Services (in this subsection 

and subsection (c) referred to as the ‘‘Secretary’’) is encouraged 

to continue activities on postpartum depression or postpartum 

psychosis (in this subsection and subsection (c) referred to as 

‘‘postpartum conditions’’), including research to expand the understanding of the causes of, and treatments for, postpartum 

conditions. Activities under this paragraph shall include conducting and supporting the following: 

(A) Basic research concerning the etiology and causes 

of the conditions. 

(B) Epidemiological studies to address the frequency 

and natural history of the conditions and the differences 

among racial and ethnic groups with respect to the conditions. 

(C) The development of improved screening and diagnostic techniques. 

(D) Clinical research for the development and evaluation of new treatments. 

(E) Information and education programs for health 

care professionals and the public, which may include a coordinated national campaign to increase the awareness 

and knowledge of postpartum conditions. Activities under 

such a national campaign may— 

(i) include public service announcements through 

television, radio, and other means; and 

(ii) focus on— 

(I) raising awareness about screening; 

(II) educating new mothers and their families 

about postpartum conditions to promote earlier diagnosis and treatment; and 
Sec. 2952\512 SSA PPACA (Consolidated) 256 

(III) ensuring that such education includes 

complete information concerning postpartum conditions, including its symptoms, methods of coping 

with the illness, and treatment resources. 

(2) SENSE OF CONGRESS REGARDING LONGITUDINAL STUDY

OF RELATIVE MENTAL HEALTH CONSEQUENCES FOR WOMEN OF

RESOLVING A PREGNANCY.— 

(A) SENSE OF CONGRESS.—It is the sense of Congress 

that the Director of the National Institute of Mental 

Health may conduct a nationally representative longitudinal study (during the period of fiscal years 2010 through 

2019) of the relative mental health consequences for 

women of resolving a pregnancy (intended and unintended) 

in various ways, including carrying the pregnancy to term 

and parenting the child, carrying the pregnancy to term 

and placing the child for adoption, miscarriage, and having 

an abortion. This study may assess the incidence, timing, 

magnitude, and duration of the immediate and long-term 

mental health consequences (positive or negative) of these 

pregnancy outcomes. 

(B) REPORT.—Subject to the completion of the study 

under subsection (a), beginning not later than 5 years 

after the date of the enactment of this Act, and periodically thereafter for the duration of the study, such Director 

may prepare and submit to the Congress reports on the 

findings of the study. 

(b) GRANTS TO PROVIDE SERVICES TO INDIVIDUALS WITH A

POSTPARTUM CONDITION AND THEIR FAMILIES.—Title V of the Social Security Act (42 U.S.C. 701 et seq.), as amended by section 

2951, is amended by adding at the end the following new section: 

‘‘SEC. 512. ø42 U.S.C. 712¿ SERVICES TO INDIVIDUALS WITH A 

POSTPARTUM CONDITION AND THEIR FAMILIES. 

‘‘(a) IN GENERAL.—In addition to any other payments made 

under this title to a State, the Secretary may make grants to eligible entities for projects for the establishment, operation, and coordination of effective and cost-efficient systems for the delivery of 

essential services to individuals with or at risk for postpartum conditions and their families. 

‘‘(b) CERTAIN ACTIVITIES.—To the extent practicable and appropriate, the Secretary shall ensure that projects funded under subsection (a) provide education and services with respect to the diagnosis and management of postpartum conditions for individuals 

with or at risk for postpartum conditions and their families. The 

Secretary may allow such projects to include the following: 

‘‘(1) Delivering or enhancing outpatient and home-based 

health and support services, including case management and 

comprehensive treatment services. 

‘‘(2) Delivering or enhancing inpatient care management 

services that ensure the well-being of the mother and family 

and the future development of the infant. 

‘‘(3) Improving the quality, availability, and organization of 

health care and support services (including transportation 

services, attendant care, homemaker services, day or respite 
257 Sec. 2952 PPACA (Consolidated) \512 SSA 

care, and providing counseling on financial assistance and insurance). 

‘‘(4) Providing education about postpartum conditions to 

promote earlier diagnosis and treatment. Such education may 

include— 

‘‘(A) providing complete information on postpartum 

conditions, symptoms, methods of coping with the illness, 

and treatment resources; and 

‘‘(B) in the case of a grantee that is a State, hospital, 

or birthing facility— 

‘‘(i) providing education to new mothers and fathers, and other family members as appropriate, concerning postpartum conditions before new mothers 

leave the health facility; and 

‘‘(ii) ensuring that training programs regarding 

such education are carried out at the health facility. 

‘‘(c) INTEGRATION WITH OTHER PROGRAMS.—To the extent practicable and appropriate, the Secretary may integrate the grant program under this section with other grant programs carried out by 

the Secretary, including the program under section 330 of the Public Health Service Act. 

‘‘(d) REQUIREMENTS.—The Secretary shall establish requirements for grants made under this section that include a limit on 

the amount of grants funds that may be used for administration, 

accounting, reporting, or program oversight functions and a requirement for each eligible entity that receives a grant to submit, 

for each grant period, a report to the Secretary that describes how 

grant funds were used during such period. 

‘‘(e) TECHNICAL ASSISTANCE.—The Secretary may provide technical assistance to entities seeking a grant under this section in 

order to assist such entities in complying with the requirements of 

this section. 

‘‘(f) APPLICATION OF OTHER PROVISIONS OF TITLE.— 

‘‘(1) IN GENERAL.—Except as provided in paragraph (2), the 

other provisions of this title shall not apply to a grant made 

under this section. 

‘‘(2) EXCEPTIONS.—The following provisions of this title 

shall apply to a grant made under this section to the same extent and in the same manner as such provisions apply to allotments made under section 502(c): 

‘‘(A) Section 504(b)(6) (relating to prohibition on payments to excluded individuals and entities). 

‘‘(B) Section 504(c) (relating to the use of funds for the 

purchase of technical assistance). 

‘‘(C) Section 504(d) (relating to a limitation on administrative expenditures). 

‘‘(D) Section 506 (relating to reports and audits), but 

only to the extent determined by the Secretary to be appropriate for grants made under this section. 

‘‘(E) Section 507 (relating to penalties for false statements). 

‘‘(F) Section 508 (relating to nondiscrimination). 

‘‘(G) Section 509(a) (relating to the administration of 

the grant program). 
Sec. 2952 PPACA (Consolidated) 258 

‘‘(g) DEFINITIONS.—In this section: 

‘‘(1) The term ‘eligible entity’— 

‘‘(A) means a public or nonprofit private entity; and 

‘‘(B) includes a State or local government, public-private partnership, recipient of a grant under section 330H 

of the Public Health Service Act (relating to the Healthy 

Start Initiative), public or nonprofit private hospital, community-based organization, hospice, ambulatory care facility, community health center, migrant health center, public housing primary care center, or homeless health center. 

‘‘(2) The term ‘postpartum condition’ means postpartum 

depression or postpartum psychosis.’’. 

(c) GENERAL PROVISIONS.— 

(1) AUTHORIZATION OF APPROPRIATIONS.—To carry out this 

section and the amendment made by subsection (b), there are 

authorized to be appropriated, in addition to such other sums 

as may be available for such purpose— 

(A) $3,000,000 for fiscal year 2010; and 

(B) such sums as may be necessary for fiscal years 

2011 and 2012. 

(2) REPORT BY THE SECRETARY.— 

(A) STUDY.—The Secretary shall conduct a study on 

the benefits of screening for postpartum conditions. 

(B) REPORT.—Not later than 2 years after the date of 

the enactment of this Act, the Secretary shall complete the 

study required by subparagraph (A) and submit a report 

to the Congress on the results of such study. 

SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION. 

Title V of the Social Security Act (42 U.S.C. 701 et seq.), as 

amended by sections 2951 and 2952(c), is amended by adding at 

the end the following: 

‘‘SEC. 513. ø42 U.S.C. 713¿ PERSONAL RESPONSIBILITY EDUCATION. 

‘‘(a) ALLOTMENTS TO STATES.— 

‘‘(1) AMOUNT.— 

‘‘(A) IN GENERAL.—For the purpose described in subsection (b), subject to the succeeding provisions of this section, for each of fiscal years 2010 through 2014, the Secretary shall allot to each State an amount equal to the 

product of— 

‘‘(i) the amount appropriated under subsection (f) 

for the fiscal year and available for allotments to 

States after the application of subsection (c); and 

‘‘(ii) the State youth population percentage determined under paragraph (2). 

‘‘(B) MINIMUM ALLOTMENT.— 

‘‘(i) IN GENERAL.—Each State allotment under this 

paragraph for a fiscal year shall be at least $250,000. 

‘‘(ii) PRO RATA ADJUSTMENTS.—The Secretary shall 

adjust on a pro rata basis the amount of the State allotments determined under this paragraph for a fiscal 

year to the extent necessary to comply with clause (i). 

‘‘(C) APPLICATION REQUIRED TO ACCESS ALLOTMENTS.— 
259 Sec. 2953 PPACA (Consolidated) \513 SSA 

‘‘(i) IN GENERAL.—A State shall not be paid from 

its allotment for a fiscal year unless the State submits 

an application to the Secretary for the fiscal year and 

the Secretary approves the application (or requires 

changes to the application that the State satisfies) and 

meets such additional requirements as the Secretary 

may specify. 

‘‘(ii) REQUIREMENTS.—The State application shall 

contain an assurance that the State has complied with 

the requirements of this section in preparing and submitting the application and shall include the following 

as well as such additional information as the Secretary may require: 

‘‘(I) Based on data from the Centers for Disease Control and Prevention National Center for 

Health Statistics, the most recent pregnancy rates 

for the State for youth ages 10 to 14 and youth 

ages 15 to 19 for which data are available, the 

most recent birth rates for such youth populations 

in the State for which data are available, and 

trends in those rates for the most recently preceding 5-year period for which such data are available. 

‘‘(II) State-established goals for reducing the 

pregnancy rates and birth rates for such youth 

populations. 

‘‘(III) A description of the State’s plan for 

using the State allotments provided under this 

section to achieve such goals, especially among 

youth populations that are the most high-risk or 

vulnerable for pregnancies or otherwise have special circumstances, including youth in foster care, 

homeless youth, youth with HIV/AIDS, pregnant 

youth who are under 21 years of age, mothers who 

are under 21 years of age, and youth residing in 

areas with high birth rates for youth. 

‘‘(2) STATE YOUTH POPULATION PERCENTAGE.— 

‘‘(A) IN GENERAL.—For purposes of paragraph 

(1)(A)(ii), the State youth population percentage is, with 

respect to a State, the proportion (expressed as a percentage) of— 

‘‘(i) the number of individuals who have attained 

age 10 but not attained age 20 in the State; to 

‘‘(ii) the number of such individuals in all States. 

‘‘(B) DETERMINATION OF NUMBER OF YOUTH.—The 

number of individuals described in clauses (i) and (ii) of 

subparagraph (A) in a State shall be determined on the 

basis of the most recent Bureau of the Census data. 

‘‘(3) AVAILABILITY OF STATE ALLOTMENTS.—Subject to paragraph (4)(A), amounts allotted to a State pursuant to this subsection for a fiscal year shall remain available for expenditure 

by the State through the end of the second succeeding fiscal 

year. 
Sec. 2953\513 SSA PPACA (Consolidated) 260 

‘‘(4) AUTHORITY TO AWARD GRANTS FROM STATE ALLOTMENTS TO LOCAL ORGANIZATIONS AND ENTITIES IN NONPARTICIPATING STATES.— 

‘‘(A) GRANTS FROM UNEXPENDED ALLOTMENTS.—If a 

State does not submit an application under this section for 

fiscal year 2010 or 2011, the State shall no longer be eligible to submit an application to receive funds from the 

amounts allotted for the State for each of fiscal years 2010 

through 2014 and such amounts shall be used by the Secretary to award grants under this paragraph for each of 

fiscal years 2012 through 2014. The Secretary also shall 

use any amounts from the allotments of States that submit 

applications under this section for a fiscal year that remain unexpended as of the end of the period in which the 

allotments are available for expenditure under paragraph 

(3) for awarding grants under this paragraph. 

‘‘(B) 3-YEAR GRANTS.— 

‘‘(i) IN GENERAL.—The Secretary shall solicit applications to award 3-year grants in each of fiscal years 

2012, 2013, and 2014 to local organizations and entities to conduct, consistent with subsection (b), programs and activities in States that do not submit an 

application for an allotment under this section for fiscal year 2010 or 2011. 

‘‘(ii) FAITH-BASED ORGANIZATIONS OR CONSORTIA.— 

The Secretary may solicit and award grants under this 

paragraph to faith-based organizations or consortia. 

‘‘(C) EVALUATION.—An organization or entity awarded 

a grant under this paragraph shall agree to participate in 

a rigorous Federal evaluation. 

‘‘(5) MAINTENANCE OF EFFORT.—No payment shall be made 

to a State from the allotment determined for the State under 

this subsection or to a local organization or entity awarded a 

grant under paragraph (4), if the expenditure of non-federal 

funds by the State, organization, or entity for activities, programs, or initiatives for which amounts from allotments and 

grants under this subsection may be expended is less than the 

amount expended by the State, organization, or entity for such 

programs or initiatives for fiscal year 2009. 

‘‘(6) DATA COLLECTION AND REPORTING.—A State or local 

organization or entity receiving funds under this section shall 

cooperate with such requirements relating to the collection of 

data and information and reporting on outcomes regarding the 

programs and activities carried out with such funds, as the 

Secretary shall specify. 

‘‘(b) PURPOSE.— 

‘‘(1) IN GENERAL.—The purpose of an allotment under subsection (a)(1) to a State is to enable the State (or, in the case 

of grants made under subsection (a)(4)(B), to enable a local organization or entity) to carry out personal responsibility education programs consistent with this subsection. 

‘‘(2) PERSONAL RESPONSIBILITY EDUCATION PROGRAMS.— 
261 Sec. 2953 PPACA (Consolidated) \513 SSA 

‘‘(A) IN GENERAL.—In this section, the term ‘personal 

responsibility education program’ means a program that is 

designed to educate adolescents on— 

‘‘(i) both abstinence and contraception for the prevention of pregnancy and sexually transmitted infections, including HIV/AIDS, consistent with the requirements of subparagraph (B); and 

‘‘(ii) at least 3 of the adulthood preparation subjects described in subparagraph (C). 

‘‘(B) REQUIREMENTS.—The requirements of this subparagraph are the following: 

‘‘(i) The program replicates evidence-based effective programs or substantially incorporates elements 

of effective programs that have been proven on the 

basis of rigorous scientific research to change behavior, which means delaying sexual activity, increasing 

condom or contraceptive use for sexually active youth, 

or reducing pregnancy among youth. 

‘‘(ii) The program is medically-accurate and complete. 

‘‘(iii) The program includes activities to educate 

youth who are sexually active regarding responsible 

sexual behavior with respect to both abstinence and 

the use of contraception. 

‘‘(iv) The program places substantial emphasis on 

both abstinence and contraception for the prevention 

of pregnancy among youth and sexually transmitted 

infections. 

‘‘(v) The program provides age-appropriate information and activities. 

‘‘(vi) The information and activities carried out 

under the program are provided in the cultural context that is most appropriate for individuals in the 

particular population group to which they are directed. 

‘‘(C) ADULTHOOD PREPARATION SUBJECTS.—The adulthood preparation subjects described in this subparagraph 

are the following: 

‘‘(i) Healthy relationships, including marriage and 

family interactions. øReplaced by section 10201(h)¿ 

‘‘(ii) Adolescent development, such as the development of healthy attitudes and values about adolescent 

growth and development, body image, racial and ethnic diversity, and other related subjects. 

‘‘(iii) Financial literacy. 

‘‘(iv) Parent-child communication. 

‘‘(v) Educational and career success, such as developing skills for employment preparation, job seeking, 

independent living, financial self-sufficiency, and 

workplace productivity. 

‘‘(vi) Healthy life skills, such as goal-setting, decision making, negotiation, communication and interpersonal skills, and stress management. 

‘‘(c) RESERVATIONS OF FUNDS.— 
Sec. 2953\513 SSA PPACA (Consolidated) 262 

‘‘(1) GRANTS TO IMPLEMENT INNOVATIVE STRATEGIES.— From the amount appropriated under subsection (f) for the fiscal year, the Secretary shall reserve $10,000,000 of such 

amount for purposes of awarding grants to entities to implement innovative youth pregnancy prevention strategies and 

target services to high-risk, vulnerable, and culturally underrepresented youth populations, including youth in foster care, 

homeless youth, youth with HIV/AIDS, pregnant women who 

are under 21 years of age and their partners, mothers who are 

under 21 years of age and their partners, and youth residing 

in areas with high birth rates for youth. An entity awarded a 

grant under this paragraph shall agree to participate in a rigorous Federal evaluation of the activities carried out with 

grant funds. 

‘‘(2) OTHER RESERVATIONS.—From the amount appropriated under subsection (f) for the fiscal year that remains 

after the application of paragraph (1), the Secretary shall reserve the following amounts: 

‘‘(A) GRANTS FOR INDIAN TRIBES OR TRIBAL ORGANIZA- TIONS.—The Secretary shall reserve 5 percent of such remainder for purposes of awarding grants to Indian tribes 

and tribal organizations in such manner, and subject to 

such requirements, as the Secretary, in consultation with 

Indian tribes and tribal organizations, determines appropriate. 

‘‘(B) SECRETARIAL RESPONSIBILITIES.— ‘‘(i) RESERVATION OF FUNDS.—The Secretary shall 

reserve 10 percent of such remainder for expenditures 

by the Secretary for the activities described in clauses 

(ii) and (iii). 

‘‘(ii) PROGRAM SUPPORT.—The Secretary shall provide, directly or through a competitive grant process, 

research, training and technical assistance, including 

dissemination of research and information regarding 

effective and promising practices, providing consultation and resources on a broad array of teen pregnancy 

prevention strategies, including abstinence and contraception, and developing resources and materials to 

support the activities of recipients of grants and other 

State, tribal, and community organizations working to 

reduce teen pregnancy. In carrying out such functions, 

the Secretary shall collaborate with a variety of entities that have expertise in the prevention of teen pregnancy, HIV and sexually transmitted infections, 

healthy relationships, financial literacy, and other topics addressed through the personal responsibility education programs. 

‘‘(iii) EVALUATION.—The Secretary shall evaluate 

the programs and activities carried out with funds 

made available through allotments or grants under 

this section. 

‘‘(d) ADMINISTRATION.— 

‘‘(1) IN GENERAL.—The Secretary shall administer this section through the Assistant Secretary for the Administration for 
263 Sec. 2954 PPACA (Consolidated) 

Children and Families within the Department of Health and 

Human Services. 

‘‘(2) APPLICATION OF OTHER PROVISIONS OF TITLE.— 

‘‘(A) IN GENERAL.—Except as provided in subparagraph (B), the other provisions of this title shall not apply 

to allotments or grants made under this section. 

‘‘(B) EXCEPTIONS.—The following provisions of this 

title shall apply to allotments and grants made under this 

section to the same extent and in the same manner as 

such provisions apply to allotments made under section 

502(c): 

‘‘(i) Section 504(b)(6) (relating to prohibition on 

payments to excluded individuals and entities). 

‘‘(ii) Section 504(c) (relating to the use of funds for 

the purchase of technical assistance). 

‘‘(iii) Section 504(d) (relating to a limitation on administrative expenditures). 

‘‘(iv) Section 506 (relating to reports and audits), 

but only to the extent determined by the Secretary to 

be appropriate for grants made under this section. 

‘‘(v) Section 507 (relating to penalties for false 

statements). 

‘‘(vi) Section 508 (relating to nondiscrimination). 

‘‘(e) DEFINITIONS.—In this section: 

‘‘(1) AGE-APPROPRIATE.—The term ‘age-appropriate’, with 

respect to the information in pregnancy prevention, means topics, messages, and teaching methods suitable to particular ages 

or age groups of children and adolescents, based on developing 

cognitive, emotional, and behavioral capacity typical for the 

age or age group. 

‘‘(2) MEDICALLY ACCURATE AND COMPLETE.—The term 

‘medically accurate and complete’ means verified or supported 

by the weight of research conducted in compliance with accepted scientific methods and— 

‘‘(A) published in peer-reviewed journals, where applicable; or 

‘‘(B) comprising information that leading professional 

organizations and agencies with relevant expertise in the 

field recognize as accurate, objective, and complete. 

‘‘(3) INDIAN TRIBES; TRIBAL ORGANIZATIONS.—The terms ‘Indian tribe’ and ‘Tribal organization’ have the meanings given 

such terms in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)). 

‘‘(4) YOUTH.—The term ‘youth’ means an individual who 

has attained age 10 but has not attained age 20. 

‘‘(f) APPROPRIATION.—For the purpose of carrying out this section, there is appropriated, out of any money in the Treasury not 

otherwise appropriated, $75,000,000 for each of fiscal years 2010 

through 2014. Amounts appropriated under this subsection shall 

remain available until expended.’’. 

SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION. 

Section 510 of the Social Security Act (42 U.S.C. 710) is 

amended— 
Sec. 2955 PPACA (Consolidated) 264 

(1) in subsection (a), by striking ‘‘fiscal year 1998 and each 

subsequent fiscal year’’ and inserting ‘‘each of fiscal years 2010 

through 2014’’; and 

(2) in subsection (d)— 

(A) in the first sentence, by striking ‘‘1998 through 

2003’’ and inserting ‘‘2010 through 2014’’; and 

(B) in the second sentence, by inserting ‘‘(except that 

such appropriation shall be made on the date of enactment 

of the Patient Protection and Affordable Care Act in the 

case of fiscal year 2010)’’ before the period. 

SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE OF 

HAVING A HEALTH CARE POWER OF ATTORNEY IN TRANSITION PLANNING FOR CHILDREN AGING OUT OF FOSTER 

CARE AND INDEPENDENT LIVING PROGRAMS. 

(a) TRANSITION PLANNING.—Section 475(5)(H) of the Social Security Act (42 U.S.C. 675(5)(H)) is amended by inserting ‘‘includes 

information about the importance of designating another individual 

to make health care treatment decisions on behalf of the child if 

the child becomes unable to participate in such decisions and the 

child does not have, or does not want, a relative who would otherwise be authorized under State law to make such decisions, and 

provides the child with the option to execute a health care power 

of attorney, health care proxy, or other similar document recognized under State law,’’ after ‘‘employment services,’’. 

(b) INDEPENDENT LIVING EDUCATION.—Section 477(b)(3) of 

such Act (42 U.S.C. 677(b)(3)) is amended by adding at the end the 

following: 

‘‘(K) A certification by the chief executive officer of the 

State that the State will ensure that an adolescent participating in the program under this section are provided with 

education about the importance of designating another individual to make health care treatment decisions on behalf 

of the adolescent if the adolescent becomes unable to participate in such decisions and the adolescent does not have, 

or does not want, a relative who would otherwise be authorized under State law to make such decisions, whether 

a health care power of attorney, health care proxy, or other 

similar document is recognized under State law, and how 

to execute such a document if the adolescent wants to do 

so.’’. 

(c) HEALTH OVERSIGHT AND COORDINATION PLAN.—Section 

422(b)(15)(A) of such Act (42 U.S.C. 622(b)(15)(A)) is amended— 

(1) in clause (v), by striking ‘‘and’’ at the end; and 

(2) by adding at the end the following: 

‘‘(vii) steps to ensure that the components of the 

transition plan development process required under 

section 475(5)(H) that relate to the health care needs 

of children aging out of foster care, including the requirements to include options for health insurance, information about a health care power of attorney, 

health care proxy, or other similar document recognized under State law, and to provide the child with 

the option to execute such a document, are met; and’’. 
265 Sec. 2955 PPACA (Consolidated) 

(d) EFFECTIVE DATE.—The amendments made by this section 

take effect on October 1, 2010. 
Sec. 3001 PPACA (Consolidated) 266 

TITLE III—IMPROVING THE QUALITY 

AND EFFICIENCY OF HEALTH CARE 

Subtitle A—Transforming the Health Care 

Delivery System 

PART 1—LINKING PAYMENT TO QUALITY 

OUTCOMES UNDER THE MEDICARE PROGRAM 

SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM. 

(a) PROGRAM.— (1) IN GENERAL.—Section 1886 of the Social Security Act 

(42 U.S.C. 1395ww), as amended by section 4102(a) of the 

HITECH Act (Public Law 111–5), is amended by adding at the 

end the following new subsection: 

‘‘(o) HOSPITAL VALUE-BASED PURCHASING PROGRAM.— ‘‘(1) ESTABLISHMENT.— ‘‘(A) IN GENERAL.—Subject to the succeeding provisions 

of this subsection, the Secretary shall establish a hospital 

value-based purchasing program (in this subsection referred to as the ‘Program’) under which value-based incentive payments are made in a fiscal year to hospitals that 

meet the performance standards under paragraph (3) for 

the performance period for such fiscal year (as established 

under paragraph (4)). 

‘‘(B) PROGRAM TO BEGIN IN FISCAL YEAR 2013.—The 

Program shall apply to payments for discharges occurring 

on or after October 1, 2012. 

‘‘(C) APPLICABILITY OF PROGRAM TO HOSPITALS.— ‘‘(i) IN GENERAL.—For purposes of this subsection, 

subject to clause (ii), the term ‘hospital’ means a subsection (d) hospital (as defined in subsection (d)(1)(B)). 

‘‘(ii) EXCLUSIONS.—The term ‘hospital’ shall not include, with respect to a fiscal year, a hospital— 

‘‘(I) that is subject to the payment reduction 

under subsection (b)(3)(B)(viii)(I) for such fiscal 

year; 

‘‘(II) for which, during the performance period 

for such fiscal year, the Secretary has cited deficiencies that pose immediate jeopardy to the 

health or safety of patients; 

‘‘(III) for which there are not a minimum 

number (as determined by the Secretary) of measures that apply to the hospital for the performance period for such fiscal year; or 

‘‘(IV) for which there are not a minimum 

number (as determined by the Secretary) of cases 

for the measures that apply to the hospital for the 

performance period for such fiscal year. 

‘‘(iii) INDEPENDENT ANALYSIS.—For purposes of determining the minimum numbers under subclauses 

(III) and (IV) of clause (ii), the Secretary shall have 
267 Sec. 3001 PPACA (Consolidated) 

conducted an independent analysis of what numbers 

are appropriate. 

‘‘(iv) EXEMPTION.—In the case of a hospital that is 

paid under section 1814(b)(3), the Secretary may exempt such hospital from the application of this subsection if the State which is paid under such section 

submits an annual report to the Secretary describing 

how a similar program in the State for a participating 

hospital or hospitals achieves or surpasses the measured results in terms of patient health outcomes and 

cost savings established under this subsection. 

‘‘(2) MEASURES.— ‘‘(A) IN GENERAL.—The Secretary shall select measures, other than measures of readmissions, for purposes of 

the Program. Such measures shall be selected from the 

measures specified under subsection (b)(3)(B)(viii). øAs revised by section 10335¿ 

‘‘(B) REQUIREMENTS.— ‘‘(i) FOR FISCAL YEAR 2013.—For value-based incentive payments made with respect to discharges occurring during fiscal year 2013, the Secretary shall ensure the following: 

‘‘(I) CONDITIONS OR PROCEDURES.—Measures 

are selected under subparagraph (A) that cover at 

least the following 5 specific conditions or procedures: 

‘‘(aa) Acute myocardial infarction (AMI). 

‘‘(bb) Heart failure. 

‘‘(cc) Pneumonia. 

‘‘(dd) Surgeries, as measured by the Surgical Care Improvement Project (formerly referred to as ‘Surgical Infection Prevention’ for 

discharges occurring before July 2006). 

‘‘(ee) Healthcare-associated infections, as 

measured by the prevention metrics and targets established in the HHS Action Plan to 

Prevent Healthcare-Associated Infections (or 

any successor plan) of the Department of 

Health and Human Services. 

‘‘(II) HCAHPS.—Measures selected under subparagraph (A) shall be related to the Hospital 

Consumer Assessment of Healthcare Providers 

and Systems survey (HCAHPS). 

‘‘(ii) INCLUSION OF EFFICIENCY MEASURES.—For 

value-based incentive payments made with respect to 

discharges occurring during fiscal year 2014 or a subsequent fiscal year, the Secretary shall ensure that 

measures selected under subparagraph (A) include efficiency measures, including measures of ‘Medicare 

spending per beneficiary’. Such measures shall be adjusted for factors such as age, sex, race, severity of illness, and other factors that the Secretary determines 

appropriate. 

‘‘(C) LIMITATIONS.— 
Sec. 3001 PPACA (Consolidated) 268 

‘‘(i) TIME REQUIREMENT FOR PRIOR REPORTING AND

NOTICE.—The Secretary may not select a measure 

under subparagraph (A) for use under the Program 

with respect to a performance period for a fiscal year 

(as established under paragraph (4)) unless such 

measure has been specified under subsection 

(b)(3)(B)(viii) and included on the Hospital Compare 

Internet website for at least 1 year prior to the beginning of such performance period. 

‘‘(ii) MEASURE NOT APPLICABLE UNLESS HOSPITAL

FURNISHES SERVICES APPROPRIATE TO THE MEASURE.— 

A measure selected under subparagraph (A) shall not 

apply to a hospital if such hospital does not furnish 

services appropriate to such measure. 

‘‘(D) REPLACING MEASURES.—Subclause (VI) of subsection (b)(3)(B)(viii) shall apply to measures selected 

under subparagraph (A) in the same manner as such subclause applies to measures selected under such subsection. 

‘‘(3) PERFORMANCE STANDARDS.— 

‘‘(A) ESTABLISHMENT.—The Secretary shall establish 

performance standards with respect to measures selected 

under paragraph (2) for a performance period for a fiscal 

year (as established under paragraph (4)). 

‘‘(B) ACHIEVEMENT AND IMPROVEMENT.—The performance standards established under subparagraph (A) shall 

include levels of achievement and improvement. 

‘‘(C) TIMING.—The Secretary shall establish and announce the performance standards under subparagraph (A) 

not later than 60 days prior to the beginning of the performance period for the fiscal year involved. 

‘‘(D) CONSIDERATIONS IN ESTABLISHING STANDARDS.— 

In establishing performance standards with respect to 

measures under this paragraph, the Secretary shall take 

into account appropriate factors, such as— 

‘‘(i) practical experience with the measures involved, including whether a significant proportion of 

hospitals failed to meet the performance standard during previous performance periods; 

‘‘(ii) historical performance standards; 

‘‘(iii) improvement rates; and 

‘‘(iv) the opportunity for continued improvement. 

‘‘(4) PERFORMANCE PERIOD.—For purposes of the Program, 

the Secretary shall establish the performance period for a fiscal 

year. Such performance period shall begin and end prior to the 

beginning of such fiscal year. 

‘‘(5) HOSPITAL PERFORMANCE SCORE.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

Secretary shall develop a methodology for assessing the 

total performance of each hospital based on performance 

standards with respect to the measures selected under 

paragraph (2) for a performance period (as established 

under paragraph (4)). Using such methodology, the Secretary shall provide for an assessment (in this subsection 
269 Sec. 3001 PPACA (Consolidated) 

referred to as the ‘hospital performance score’) for each 

hospital for each performance period. 

‘‘(B) APPLICATION.— 

‘‘(i) APPROPRIATE DISTRIBUTION.—The Secretary 

shall ensure that the application of the methodology 

developed under subparagraph (A) results in an appropriate distribution of value-based incentive payments 

under paragraph (6) among hospitals achieving different levels of hospital performance scores, with hospitals achieving the highest hospital performance 

scores receiving the largest value-based incentive payments. 

‘‘(ii) HIGHER OF ACHIEVEMENT OR IMPROVEMENT.— 

The methodology developed under subparagraph (A) 

shall provide that the hospital performance score is 

determined using the higher of its achievement or improvement score for each measure. 

‘‘(iii) WEIGHTS.—The methodology developed under 

subparagraph (A) shall provide for the assignment of 

weights for categories of measures as the Secretary determines appropriate. 

‘‘(iv) NO MINIMUM PERFORMANCE STANDARD.—The 

Secretary shall not set a minimum performance standard in determining the hospital performance score for 

any hospital. 

‘‘(v) REFLECTION OF MEASURES APPLICABLE TO THE

HOSPITAL.—The hospital performance score for a hospital shall reflect the measures that apply to the hospital. 

‘‘(6) CALCULATION OF VALUE-BASED INCENTIVE PAYMENTS.— 

‘‘(A) IN GENERAL.—In the case of a hospital that the 

Secretary determines meets (or exceeds) the performance 

standards under paragraph (3) for the performance period 

for a fiscal year (as established under paragraph (4)), the 

Secretary shall increase the base operating DRG payment 

amount (as defined in paragraph (7)(D)), as determined 

after application of paragraph (7)(B)(i), for a hospital for 

each discharge occurring in such fiscal year by the valuebased incentive payment amount. 

‘‘(B) VALUE-BASED INCENTIVE PAYMENT AMOUNT.—The 

value-based incentive payment amount for each discharge 

of a hospital in a fiscal year shall be equal to the product 

of— 

‘‘(i) the base operating DRG payment amount (as 

defined in paragraph (7)(D)) for the discharge for the 

hospital for such fiscal year; and 

‘‘(ii) the value-based incentive payment percentage 

specified under subparagraph (C) for the hospital for 

such fiscal year. 

‘‘(C) VALUE-BASED INCENTIVE PAYMENT PERCENTAGE.— 

‘‘(i) IN GENERAL.—The Secretary shall specify a 

value-based incentive payment percentage for a hospital for a fiscal year. 
Sec. 3001 PPACA (Consolidated) 270 

‘‘(ii) REQUIREMENTS.—In specifying the valuebased incentive payment percentage for each hospital 

for a fiscal year under clause (i), the Secretary shall 

ensure that— 

‘‘(I) such percentage is based on the hospital 

performance score of the hospital under paragraph 

(5); and 

‘‘(II) the total amount of value-based incentive 

payments under this paragraph to all hospitals in 

such fiscal year is equal to the total amount available for value-based incentive payments for such 

fiscal year under paragraph (7)(A), as estimated 

by the Secretary. 

‘‘(7) FUNDING FOR VALUE-BASED INCENTIVE PAYMENTS.— 

‘‘(A) AMOUNT.—The total amount available for valuebased incentive payments under paragraph (6) for all hospitals for a fiscal year shall be equal to the total amount 

of reduced payments for all hospitals under subparagraph 

(B) for such fiscal year, as estimated by the Secretary. 

‘‘(B) ADJUSTMENT TO PAYMENTS.— 

‘‘(i) IN GENERAL.—The Secretary shall reduce the 

base operating DRG payment amount (as defined in 

subparagraph (D)) for a hospital for each discharge in 

a fiscal year (beginning with fiscal year 2013) by an 

amount equal to the applicable percent (as defined in 

subparagraph (C)) of the base operating DRG payment 

amount for the discharge for the hospital for such fiscal year. The Secretary shall make such reductions for 

all hospitals in the fiscal year involved, regardless of 

whether or not the hospital has been determined by 

the Secretary to have earned a value-based incentive 

payment under paragraph (6) for such fiscal year. 

‘‘(ii) NO EFFECT ON OTHER PAYMENTS.—Payments 

described in items (aa) and (bb) of subparagraph 

(D)(i)(II) for a hospital shall be determined as if this 

subsection had not been enacted. 

‘‘(C) APPLICABLE PERCENT DEFINED.—For purposes of 

subparagraph (B), the term ‘applicable percent’ means— 

‘‘(i) with respect to fiscal year 2013, 1.0 percent; 

‘‘(ii) with respect to fiscal year 2014, 1.25 percent; 

‘‘(iii) with respect to fiscal year 2015, 1.5 percent; 

‘‘(iv) with respect to fiscal year 2016, 1.75 percent; 

and 

‘‘(v) with respect to fiscal year 2017 and succeeding fiscal years, 2 percent. 

‘‘(D) BASE OPERATING DRG PAYMENT AMOUNT DEFINED.— 

‘‘(i) IN GENERAL.—Except as provided in clause (ii), 

in this subsection, the term ‘base operating DRG payment amount’ means, with respect to a hospital for a 

fiscal year— 

‘‘(I) the payment amount that would otherwise 

be made under subsection (d) (determined without 
271 Sec. 3001 PPACA (Consolidated) 

regard to subsection (q)) for a discharge if this 

subsection did not apply; reduced by 

‘‘(II) any portion of such payment amount that 

is attributable to— 

‘‘(aa) payments under paragraphs (5)(A), 

(5)(B), (5)(F), and (12) of subsection (d); and 

‘‘(bb) such other payments under subsection (d) determined appropriate by the Secretary. 

‘‘(ii) SPECIAL RULES FOR CERTAIN HOSPITALS.— ‘‘(I) SOLE COMMUNITY HOSPITALS AND MEDI- CARE-DEPENDENT, SMALL RURAL HOSPITALS.—In 

the case of a medicare-dependent, small rural hospital (with respect to discharges occurring during 

fiscal year 2012 and 2013) or a sole community 

hospital, in applying subparagraph (A)(i), the payment amount that would otherwise be made under 

subsection (d) shall be determined without regard 

to subparagraphs (I) and (L) of subsection (b)(3) 

and subparagraphs (D) and (G) of subsection 

(d)(5). 

‘‘(II) HOSPITALS PAID UNDER SECTION 1814.—In 

the case of a hospital that is paid under section 

1814(b)(3), the term ‘base operating DRG payment 

amount’ means the payment amount under such 

section. 

‘‘(8) ANNOUNCEMENT OF NET RESULT OF ADJUSTMENTS.— Under the Program, the Secretary shall, not later than 60 days 

prior to the fiscal year involved, inform each hospital of the adjustments to payments to the hospital for discharges occurring 

in such fiscal year under paragraphs (6) and (7)(B)(i). 

‘‘(9) NO EFFECT IN SUBSEQUENT FISCAL YEARS.—The valuebased incentive payment under paragraph (6) and the payment 

reduction under paragraph (7)(B)(i) shall each apply only with 

respect to the fiscal year involved, and the Secretary shall not 

take into account such value-based incentive payment or payment reduction in making payments to a hospital under this 

section in a subsequent fiscal year. 

‘‘(10) PUBLIC REPORTING.— 

‘‘(A) HOSPITAL SPECIFIC INFORMATION.— 

‘‘(i) IN GENERAL.—The Secretary shall make information available to the public regarding the performance of individual hospitals under the Program, including— 

‘‘(I) the performance of the hospital with respect to each measure that applies to the hospital; 

‘‘(II) the performance of the hospital with respect to each condition or procedure; and 

‘‘(III) the hospital performance score assessing 

the total performance of the hospital. 

‘‘(ii) OPPORTUNITY TO REVIEW AND SUBMIT CORRECTIONS.—The Secretary shall ensure that a hospital has 

the opportunity to review, and submit corrections for, 

the information to be made public with respect to the 
Sec. 3001 PPACA (Consolidated) 272 

hospital under clause (i) prior to such information 

being made public. 

‘‘(iii) WEBSITE.—Such information shall be posted 

on the Hospital Compare Internet website in an easily 

understandable format. 

‘‘(B) AGGREGATE INFORMATION.—The Secretary shall 

periodically post on the Hospital Compare Internet website 

aggregate information on the Program, including— 

‘‘(i) the number of hospitals receiving value-based 

incentive payments under paragraph (6) and the range 

and total amount of such value-based incentive payments; and 

‘‘(ii) the number of hospitals receiving less than 

the maximum value-based incentive payment available to the hospital for the fiscal year involved and the 

range and amount of such payments. 

‘‘(11) IMPLEMENTATION.— ‘‘(A) APPEALS.—The Secretary shall establish a process 

by which hospitals may appeal the calculation of a hospital’s performance assessment with respect to the performance standards established under paragraph (3)(A) 

and the hospital performance score under paragraph (5). 

The Secretary shall ensure that such process provides for 

resolution of such appeals in a timely manner. 

‘‘(B) LIMITATION ON REVIEW.—Except as provided in 

subparagraph (A), there shall be no administrative or judicial review under section 1869, section 1878, or otherwise 

of the following: 

‘‘(i) The methodology used to determine the 

amount of the value-based incentive payment under 

paragraph (6) and the determination of such amount. 

‘‘(ii) The determination of the amount of funding 

available for such value-based incentive payments 

under paragraph (7)(A) and the payment reduction 

under paragraph (7)(B)(i). 

‘‘(iii) The establishment of the performance standards under paragraph (3) and the performance period 

under paragraph (4). 

‘‘(iv) The measures specified under subsection 

(b)(3)(B)(viii) and the measures selected under paragraph (2). 

‘‘(v) The methodology developed under paragraph 

(5) that is used to calculate hospital performance 

scores and the calculation of such scores. 

‘‘(vi) The validation methodology specified in subsection (b)(3)(B)(viii)(XI). 

‘‘(C) CONSULTATION WITH SMALL HOSPITALS.—The Secretary shall consult with small rural and urban hospitals 

on the application of the Program to such hospitals. 

‘‘(12) PROMULGATION OF REGULATIONS.—The Secretary 

shall promulgate regulations to carry out the Program, including the selection of measures under paragraph (2), the methodology developed under paragraph (5) that is used to calculate 

hospital performance scores, and the methodology used to de-
273 Sec. 3001 PPACA (Consolidated) 

termine the amount of value-based incentive payments under 

paragraph (6).’’. 

(2) AMENDMENTS FOR REPORTING OF HOSPITAL QUALITY IN- FORMATION.—Section 1886(b)(3)(B)(viii) of the Social Security 

Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended— 

(A) in subclause (II), by adding at the end the following sentence: ‘‘The Secretary may require hospitals to 

submit data on measures that are not used for the determination of value-based incentive payments under subsection (o).’’; 

(B) in subclause (V), by striking ‘‘beginning with fiscal 

year 2008’’ and inserting ‘‘for fiscal years 2008 through 

2012’’; 

(C) in subclause (VII), in the first sentence, by striking 

‘‘data submitted’’ and inserting ‘‘information regarding 

measures submitted’’; and 

(D) by adding at the end the following new subclauses: 

‘‘(VIII) Effective for payments beginning with fiscal year 2013, 

with respect to quality measures for outcomes of care, the Secretary shall provide for such risk adjustment as the Secretary determines to be appropriate to maintain incentives for hospitals to 

treat patients with severe illnesses or conditions. 

‘‘(IX)(aa) Subject to item (bb), effective for payments beginning 

with fiscal year 2013, each measure specified by the Secretary 

under this clause shall be endorsed by the entity with a contract 

under section 1890(a). 

‘‘(bb) 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. 

‘‘(X) To the extent practicable, the Secretary shall, with input 

from consensus organizations and other stakeholders, take steps to 

ensure that the measures specified by the Secretary under this 

clause are coordinated and aligned with quality measures applicable to— 

‘‘(aa) physicians under section 1848(k); and 

‘‘(bb) other providers of services and suppliers under this 

title. 

‘‘(XI) The Secretary shall establish a process to validate measures specified under this clause as appropriate. Such process shall 

include the auditing of a number of randomly selected hospitals 

sufficient to ensure validity of the reporting program under this 

clause as a whole and shall provide a hospital with an opportunity 

to appeal the validation of measures reported by such hospital.’’. 

(3) WEBSITE IMPROVEMENTS.—Section 1886(b)(3)(B) of the 

Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended 

by section 4102(b) of the HITECH Act (Public Law 111–5), is 

amended by adding at the end the following new clause: 

‘‘(x)(I) The Secretary shall develop standard Internet website 

reports tailored to meet the needs of various stakeholders such as 

hospitals, patients, researchers, and policymakers. The Secretary 
Sec. 3001 PPACA (Consolidated) 274 

shall seek input from such stakeholders in determining the type of 

information that is useful and the formats that best facilitate the 

use of the information. 

‘‘(II) The Secretary shall modify the Hospital Compare Internet 

website to make the use and navigation of that website readily 

available to individuals accessing it.’’. 

(4) GAO STUDY AND REPORT.— 

(A) STUDY.—The Comptroller General of the United 

States shall conduct a study on the performance of the 

hospital value-based purchasing program established 

under section 1886(o) of the Social Security Act, as added 

by paragraph (1). Such study shall include an analysis of 

the impact of such program on— 

(i) the quality of care furnished to Medicare beneficiaries, including diverse Medicare beneficiary populations (such as diverse in terms of race, ethnicity, and 

socioeconomic status); 

(ii) expenditures under the Medicare program, including any reduced expenditures under Part A of title 

XVIII of such Act that are attributable to the improvement in the delivery of inpatient hospital services by 

reason of such hospital value-based purchasing program; 

(iii) the quality performance among safety net hospitals and any barriers such hospitals face in meeting 

the performance standards applicable under such hospital value-based purchasing program; and 

(iv) the quality performance among small rural 

and small urban hospitals and any barriers such hospitals face in meeting the performance standards applicable under such hospital value-based purchasing 

program. 

(B) REPORTS.— 

(i) INTERIM REPORT.—Not later than October 1, 

2015, the Comptroller General of the United States 

shall submit to Congress an interim report containing 

the results of the study conducted under subparagraph 

(A), together with recommendations for such legislation and administrative action as the Comptroller 

General determines appropriate. 

(ii) FINAL REPORT.—Not later than July 1, 2017, 

the Comptroller General of the United States shall 

submit to Congress a report containing the results of 

the study conducted under subparagraph (A), together 

with recommendations for such legislation and administrative action as the Comptroller General determines 

appropriate. 

(5) HHS STUDY AND REPORT.— 

(A) STUDY.—The Secretary of Health and Human 

Services shall conduct a study on the performance of the 

hospital value-based purchasing program established 

under section 1886(o) of the Social Security Act, as added 

by paragraph (1). Such study shall include an analysis— 
275 Sec. 3001 PPACA (Consolidated) 

(i) of ways to improve the hospital value-based 

purchasing program and ways to address any unintended consequences that may occur as a result of 

such program; 

(ii) of whether the hospital value-based purchasing program resulted in lower spending under the 

Medicare program under title XVIII of such Act or 

other financial savings to hospitals; 

(iii) the appropriateness of the Medicare program 

sharing in any savings generated through the hospital 

value-based purchasing program; and 

(iv) any other area determined appropriate by the 

Secretary. 

(B) REPORT.—Not later than January 1, 2016, the Secretary of Health and Human Services shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. 

(b) VALUE-BASED PURCHASING DEMONSTRATION PROGRAMS.— (1) VALUE-BASED PURCHASING DEMONSTRATION PROGRAM

FOR INPATIENT CRITICAL ACCESS HOSPITALS.— (A) ESTABLISHMENT.— (i) IN GENERAL.—Not later than 2 years after the 

date of enactment of this Act, the Secretary of Health 

and Human Services (in this subsection referred to as 

the ‘‘Secretary’’) shall establish a demonstration program under which the Secretary establishes a valuebased purchasing program under the Medicare program under title XVIII of the Social Security Act for 

critical access hospitals (as defined in paragraph (1) of 

section 1861(mm) of such Act (42 U.S.C. 1395x(mm))) 

with respect to inpatient critical access hospital services (as defined in paragraph (2) of such section) in 

order to test innovative methods of measuring and rewarding quality and efficient health care furnished by 

such hospitals. 

(ii) DURATION.—The demonstration program 

under this paragraph shall be conducted for a 3-year 

period. 

(iii) SITES.—The Secretary shall conduct the demonstration program under this paragraph at an appropriate number (as determined by the Secretary) of critical access hospitals. The Secretary shall ensure that 

such hospitals are representative of the spectrum of 

such hospitals that participate in the Medicare program. 

(B) WAIVER AUTHORITY.—The Secretary may waive 

such requirements of titles XI and XVIII of the Social Security Act as may be necessary to carry out the demonstration program under this paragraph. 

(C) BUDGET NEUTRALITY REQUIREMENT.—In conducting 

the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by 
Sec. 3001 PPACA (Consolidated) 276 

the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program 

under this section was not implemented. 

(D) REPORT.—Not later than 18 months after the completion of the demonstration program under this paragraph, the Secretary shall submit to Congress a report on 

the demonstration program together with— 

(i) recommendations on the establishment of a 

permanent value-based purchasing program under the 

Medicare program for critical access hospitals with respect to inpatient critical access hospital services; and 

(ii) recommendations for such other legislation 

and administrative action as the Secretary determines 

appropriate. 

(2) VALUE-BASED PURCHASING DEMONSTRATION PROGRAM

FOR HOSPITALS EXCLUDED FROM HOSPITAL VALUE-BASED PURCHASING PROGRAM AS A RESULT OF INSUFFICIENT NUMBERS OF

MEASURES AND CASES.— 

(A) ESTABLISHMENT.— 

(i) IN GENERAL.—Not later than 2 years after the 

date of enactment of this Act, the Secretary shall establish a demonstration program under which the Secretary establishes a value-based purchasing program 

under the Medicare program under title XVIII of the 

Social Security Act for applicable hospitals (as defined 

in clause (ii)) with respect to inpatient hospital services (as defined in section 1861(b) of the Social Security Act (42 U.S.C. 1395x(b))) in order to test innovative methods of measuring and rewarding quality and 

efficient health care furnished by such hospitals. 

(ii) APPLICABLE HOSPITAL DEFINED.—For purposes 

of this paragraph, the term ‘‘applicable hospital’’ 

means a hospital described in subclause (III) or (IV) of 

section 1886(o)(1)(C)(ii) of the Social Security Act, as 

added by subsection (a)(1). 

(iii) DURATION.—The demonstration program 

under this paragraph shall be conducted for a 3-year 

period. 

(iv) SITES.—The Secretary shall conduct the demonstration program under this paragraph at an appropriate number (as determined by the Secretary) of applicable hospitals. The Secretary shall ensure that 

such hospitals are representative of the spectrum of 

such hospitals that participate in the Medicare program. 

(B) WAIVER AUTHORITY.—The Secretary may waive 

such requirements of titles XI and XVIII of the Social Security Act as may be necessary to carry out the demonstration program under this paragraph. 

(C) BUDGET NEUTRALITY REQUIREMENT.—In conducting 

the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by 

the Secretary do not exceed the amount which the Sec-
277 Sec. 3002 PPACA (Consolidated) 

retary would have paid if the demonstration program 

under this section was not implemented. 

(D) REPORT.—Not later than 18 months after the completion of the demonstration program under this paragraph, the Secretary shall submit to Congress a report on 

the demonstration program together with— 

(i) recommendations on the establishment of a 

permanent value-based purchasing program under the 

Medicare program for applicable hospitals with respect 

to inpatient hospital services; and 

(ii) recommendations for such other legislation 

and administrative action as the Secretary determines 

appropriate. 

SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING 

SYSTEM. 

(a) EXTENSION.—Section 1848(m) of the Social Security Act (42 

U.S.C. 1395w–4(m)) is amended— 

(1) in paragraph (1)— 

(A) in subparagraph (A), in the matter preceding 

clause (i), by striking ‘‘2010’’ and inserting ‘‘2014’’; and 

(B) in subparagraph (B)— 

(i) in clause (i), by striking ‘‘and’’ at the end; 

(ii) in clause (ii), by striking the period at the end 

and inserting a semicolon; and 

(iii) by adding at the end the following new 

clauses: 

‘‘(iii) for 2011, 1.0 percent; and 

‘‘(iv) for 2012, 2013, and 2014, 0.5 percent.’’; 

(2) in paragraph (3)— 

(A) in subparagraph (A), in the matter preceding 

clause (i), by inserting ‘‘(or, for purposes of subsection 

(a)(8), for the quality reporting period for the year)’’ after 

‘‘reporting period’’; and 

(B) in subparagraph (C)(i), by inserting ‘‘, or, for purposes of subsection (a)(8), for a quality reporting period for 

the year’’ after ‘‘(a)(5), for a reporting period for a year’’; 

(3) in paragraph (5)(E)(iv), by striking ‘‘subsection 

(a)(5)(A)’’ and inserting ‘‘paragraphs (5)(A) and (8)(A) of subsection (a)’’; and 

(4) in paragraph (6)(C)— 

(A) in clause (i)(II), by striking ‘‘, 2009, 2010, and 

2011’’ and inserting ‘‘and subsequent years’’; and 

(B) in clause (iii)— 

(i) by inserting ‘‘(a)(8)’’ after ‘‘(a)(5)’’; and 

(ii) by striking ‘‘under subparagraph (D)(iii) of 

such subsection’’ and inserting ‘‘under subsection 

(a)(5)(D)(iii) or the quality reporting period under subsection (a)(8)(D)(iii), respectively’’. 

(b) INCENTIVE PAYMENT ADJUSTMENT FOR QUALITY REPORTING.—Section 1848(a) of the Social Security Act (42 U.S.C. 1395w– 

4(a)) is amended by adding at the end the following new paragraph: 

‘‘(8) INCENTIVES FOR QUALITY REPORTING.— 

‘‘(A) ADJUSTMENT.— 
Sec. 3002 PPACA (Consolidated) 278 

‘‘(i) IN GENERAL.—With respect to covered professional services furnished by an eligible professional 

during 2015 or any subsequent year, if the eligible 

professional does not satisfactorily submit data on 

quality measures for covered professional services for 

the quality reporting period for the year (as determined under subsection (m)(3)(A)), the fee schedule 

amount for such services furnished by such professional during the year (including the fee schedule 

amount for purposes of determining a payment based 

on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise 

apply to such services under this subsection (determined after application of paragraphs (3), (5), and (7), 

but without regard to this paragraph). 

‘‘(ii) APPLICABLE PERCENT.—For purposes of clause 

(i), the term ‘applicable percent’ means— 

‘‘(I) for 2015, 98.5 percent; and 

‘‘(II) for 2016 and each subsequent year, 98 

percent. 

‘‘(B) APPLICATION.— ‘‘(i) PHYSICIAN REPORTING SYSTEM RULES.—Paragraphs (5), (6), and (8) of subsection (k) shall apply for 

purposes of this paragraph in the same manner as 

they apply for purposes of such subsection. 

‘‘(ii) INCENTIVE PAYMENT VALIDATION RULES.— Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply 

for purposes of this paragraph in a similar manner as 

they apply for purposes of such subsection. 

‘‘(C) DEFINITIONS.—For purposes of this paragraph: 

‘‘(i) ELIGIBLE PROFESSIONAL; COVERED PROFESSIONAL SERVICES.—The terms ‘eligible professional’ 

and ‘covered professional services’ have the meanings 

given such terms in subsection (k)(3). 

‘‘(ii) PHYSICIAN REPORTING SYSTEM.—The term 

‘physician reporting system’ means the system established under subsection (k). 

‘‘(iii) QUALITY REPORTING PERIOD.—The term ‘quality reporting period’ means, with respect to a year, a 

period specified by the Secretary.’’. 

(c) MAINTENANCE OF CERTIFICATION PROGRAMS.— 

(1) IN GENERAL.—Section 1848(k)(4) of the Social Security 

Act (42 U.S.C. 1395w–4(k)(4)) is amended by inserting ‘‘or 

through a Maintenance of Certification program operated by a 

specialty body of the American Board of Medical Specialties 

that meets the criteria for such a registry’’ after ‘‘Database)’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall apply for years after 2010. 

(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 pur-
279 Sec. 3003 PPACA (Consolidated) 

suant 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)). øAs added by section 10327(b)¿ 

(d) INTEGRATION OF PHYSICIAN QUALITY REPORTING AND EHR 

REPORTING.—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) INTEGRATION OF PHYSICIAN QUALITY REPORTING AND

EHR REPORTING.—Not later than January 1, 2012, the Secretary shall develop a plan to integrate reporting on quality 

measures under this subsection with reporting requirements 

under subsection (o) relating to the meaningful use of electronic health records. Such integration shall consist of the following: 

‘‘(A) The selection of measures, the reporting of which 

would both demonstrate— 

‘‘(i) meaningful use of an electronic health record 

for purposes of subsection (o); and 

‘‘(ii) quality of care furnished to an individual. 

‘‘(B) Such other activities as specified by the Secretary.’’. 

øSection 10327(a), p. 871, also added a paragraph (7) to section 

1848(m) adding an additional incentive payment relating to physician quality reporting¿ 

(e) FEEDBACK.—Section 1848(m)(5) of the Social Security Act 

(42 U.S.C. 1395w–4(m)(5)) is amended by adding at the end the following new subparagraph: 

‘‘(H) FEEDBACK.—The Secretary shall provide timely 

feedback to eligible professionals on the performance of the 

eligible professional with respect to satisfactorily submitting data on quality measures under this subsection.’’. 

(f) APPEALS.—Such section is further amended— 

(1) in subparagraph (E), by striking ‘‘There shall’’ and inserting ‘‘Except as provided in subparagraph (I), there shall’’; 

and 

(2) by adding at the end the following new subparagraph: 

‘‘(I) INFORMAL APPEALS PROCESS.—The Secretary shall, 

by not later than January 1, 2011, establish and have in 

place an informal process for eligible professionals to seek 

a review of the determination that an eligible professional 

did not satisfactorily submit data on quality measures 

under this subsection.’’. 

øSection 10331, p. 875, also provides for public reporting of performance information for eligible professionals who participate in 

the Physician Quality Reporting Initiative¿ 

SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM. 

(a) IN GENERAL.—Section 1848(n) of the Social Security Act (42 

U.S.C. 1395w–4(n)) is amended— 

(1) in paragraph (1)— 

(A) in subparagraph (A)— 

(i) by striking ‘‘GENERAL.—The Secretary’’ and inserting ‘‘GENERAL.— 

‘‘(i) ESTABLISHMENT.—The Secretary’’; 
Sec. 3003 PPACA (Consolidated) 280 

(ii) in clause (i), as added by clause (i), by striking 

‘‘the ‘Program’)’’ and all that follows through the period at the end of the second sentence and inserting 

‘‘the ‘Program’).’’; and 

(iii) by adding at the end the following new 

clauses: 

‘‘(ii) REPORTS ON RESOURCES.—The Secretary shall 

use claims data under this title (and may use other 

data) to provide confidential reports to physicians 

(and, as determined appropriate by the Secretary, to 

groups of physicians) that measure the resources involved in furnishing care to individuals under this 

title. 

‘‘(iii) INCLUSION OF CERTAIN INFORMATION.—If determined appropriate by the Secretary, the Secretary 

may include information on the quality of care furnished to individuals under this title by the physician 

(or group of physicians) in such reports.’’; and 

(B) in subparagraph (B), by striking ‘‘subparagraph 

(A)’’ and inserting ‘‘subparagraph (A)(ii)’’; 

(2) in paragraph (4)— 

(A) in the heading, by inserting ‘‘INITIAL’’ after ‘‘FOCUS’’; and 

(B) in the matter preceding subparagraph (A), by inserting ‘‘initial’’ after ‘‘focus the’’; 

(3) in paragraph (6), by adding at the end the following 

new sentence: ‘‘For adjustments for reports on utilization 

under paragraph (9), see subparagraph (D) of such paragraph.’’; and 

(4) by adding at the end the following new paragraphs: 

‘‘(9) REPORTS ON UTILIZATION.— 

‘‘(A) DEVELOPMENT OF EPISODE GROUPER.— 

‘‘(i) IN GENERAL.—The Secretary shall develop an 

episode grouper that combines separate but clinically 

related items and services into an episode of care for 

an individual, as appropriate. 

‘‘(ii) TIMELINE FOR DEVELOPMENT.—The episode 

grouper described in subparagraph (A) shall be developed by not later than January 1, 2012. 

‘‘(iii) PUBLIC AVAILABILITY.—The Secretary shall 

make the details of the episode grouper described in 

subparagraph (A) available to the public. 

‘‘(iv) ENDORSEMENT.—The Secretary shall seek endorsement of the episode grouper described in subparagraph (A) by the entity with a contract under section 1890(a). 

‘‘(B) REPORTS ON UTILIZATION.—Effective beginning 

with 2012, the Secretary shall provide reports to physicians that compare, as determined appropriate by the Secretary, patterns of resource use of the individual physician 

to such patterns of other physicians. 

‘‘(C) ANALYSIS OF DATA.—The Secretary shall, for purposes of preparing reports under this paragraph, establish 

methodologies as appropriate, such as to— 
281 Sec. 3003 PPACA (Consolidated) 

‘‘(i) attribute episodes of care, in whole or in part, 

to physicians; 

‘‘(ii) identify appropriate physicians for purposes 

of comparison under subparagraph (B); and 

‘‘(iii) aggregate episodes of care attributed to a 

physician under clause (i) into a composite measure 

per individual. 

‘‘(D) DATA ADJUSTMENT.—In preparing reports under 

this paragraph, the Secretary shall make appropriate adjustments, including adjustments— 

‘‘(i) to account for differences in socioeconomic and 

demographic characteristics, ethnicity, and health status of individuals (such as to recognize that less 

healthy individuals may require more intensive interventions); and 

‘‘(ii) to eliminate the effect of geographic adjustments in payment rates (as described in subsection 

(e)). 

‘‘(E) PUBLIC AVAILABILITY OF METHODOLOGY.—The Secretary shall make available to the public— 

‘‘(i) the methodologies established under subparagraph (C); 

‘‘(ii) information regarding any adjustments made 

to data under subparagraph (D); and 

‘‘(iii) aggregate reports with respect to physicians. 

‘‘(F) DEFINITION OF PHYSICIAN.—In this paragraph: 

‘‘(i) IN GENERAL.—The term ‘physician’ has the 

meaning given that term in section 1861(r)(1). 

‘‘(ii) TREATMENT OF GROUPS.—Such term includes, 

as the Secretary determines appropriate, a group of 

physicians. 

‘‘(G) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 

1878, or otherwise of the establishment of the methodology 

under subparagraph (C), including the determination of an 

episode of care under such methodology. 

‘‘(10) COORDINATION WITH OTHER VALUE-BASED PURCHASING

REFORMS.—The Secretary shall coordinate the Program with 

the value-based payment modifier established under subsection 

(p) and, as the Secretary determines appropriate, other similar 

provisions of this title.’’. 

(b) CONFORMING AMENDMENT.—Section 1890(b) of the Social 

Security Act (42 U.S.C. 1395aaa(b)) is amended by adding at the 

end the following new paragraph: 

‘‘(6) REVIEW AND ENDORSEMENT OF EPISODE GROUPER

UNDER THE PHYSICIAN FEEDBACK PROGRAM.—The entity shall 

provide for the review and, as appropriate, the endorsement of 

the episode grouper developed by the Secretary under section 

1848(n)(9)(A). Such review shall be conducted on an expedited 

basis.’’. 
Sec. 3004 PPACA (Consolidated) 282 

SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE HOSPITALS, 

INPATIENT REHABILITATION HOSPITALS, AND HOSPICE 

PROGRAMS. 

(a) LONG-TERM CARE HOSPITALS.—Section 1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)), as amended by section 

3401(c), is amended by adding at the end the following new paragraph: 

‘‘(5) 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 long-term care hospital 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 (3), 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 long-term care 

hospital 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 se-
283 Sec. 3004 PPACA (Consolidated) 

lected 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 long-term care hospital has the opportunity to review the data that is to be 

made public with respect to the hospital prior to such data 

being made public. The Secretary shall report quality 

measures that relate to services furnished in inpatient settings in long-term care hospitals on the Internet website 

of the Centers for Medicare & Medicaid Services.’’. 

(b) INPATIENT REHABILITATION HOSPITALS.—Section 1886(j) of 

the Social Security Act (42 U.S.C. 1395ww(j)) is amended— 

(1) by redesignating paragraph (7) as paragraph (8); and 

(2) by inserting after paragraph (6) the following new 

paragraph: 

‘‘(7) QUALITY REPORTING.— ‘‘(A) REDUCTION IN UPDATE FOR FAILURE TO REPORT.— ‘‘(i) IN GENERAL.—For purposes of fiscal year 2014 

and each subsequent fiscal year, in the case of a rehabilitation facility that does not submit data to the Secretary in accordance with subparagraph (C) with respect to such a fiscal year, after determining the increase factor described in paragraph (3)(C), and after 

application of paragraph (3)(D), the Secretary shall reduce such increase factor for payments for discharges 

occurring during such fiscal year by 2 percentage 

points. 

‘‘(ii) SPECIAL RULE.—The application of this subparagraph may result in the increase factor described 

in paragraph (3)(C) being less than 0.0 for a fiscal 

year, and may result in payment rates under this subsection for a fiscal year being less than such payment 

rates for the preceding fiscal year. 

‘‘(B) NONCUMULATIVE APPLICATION.—Any reduction 

under subparagraph (A) shall apply only with respect to 

the fiscal year involved and the Secretary shall not take 

into account such reduction in computing the payment 

amount under this subsection for a subsequent fiscal year. 

‘‘(C) SUBMISSION OF QUALITY DATA.—For fiscal year 

2014 and each subsequent rate year, each rehabilitation 

facility 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 
Sec. 3004 PPACA (Consolidated) 284 

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 fiscal 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 rehabilitation facility 

has the opportunity to review the data that is to be made 

public with respect to the facility prior to such data being 

made public. The Secretary shall report quality measures 

that relate to services furnished in inpatient settings in rehabilitation facilities on the Internet website of the Centers for Medicare & Medicaid Services.’’. 

(c) HOSPICE PROGRAMS.—Section 1814(i) of the Social Security 

Act (42 U.S.C. 1395f(i)) is amended— 

(1) by redesignating paragraph (5) as paragraph (6); and 

(2) by inserting after paragraph (4) the following new 

paragraph: 

‘‘(5) QUALITY REPORTING.— ‘‘(A) REDUCTION IN UPDATE FOR FAILURE TO REPORT.— ‘‘(i) IN GENERAL.—For purposes of fiscal year 2014 

and each subsequent fiscal year, in the case of a hospice program that does not submit data to the Secretary in accordance with subparagraph (C) with respect to such a fiscal year, after determining the market basket percentage increase under paragraph 

(1)(C)(ii)(VII) or paragraph (1)(C)(iii), as applicable, 

and after application of paragraph (1)(C)(iv), with respect to the fiscal year, the Secretary shall reduce 

such market basket percentage increase by 2 percentage points. 

‘‘(ii) SPECIAL RULE.—The application of this subparagraph may result in the market basket percentage 

increase under paragraph (1)(C)(ii)(VII) or paragraph 

(1)(C)(iii), as applicable, being less than 0.0 for a fiscal 

year, and may result in payment rates under this subsection for a fiscal year being less than such payment 

rates for the preceding fiscal year. 

‘‘(B) NONCUMULATIVE APPLICATION.—Any reduction 

under subparagraph (A) shall apply only with respect to 

the fiscal year involved and the Secretary shall not take 

into account such reduction in computing the payment 

amount under this subsection for a subsequent fiscal year. 

‘‘(C) SUBMISSION OF QUALITY DATA.—For fiscal year 

2014 and each subsequent fiscal year, each hospice program shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be 
285 Sec. 3005 PPACA (Consolidated) 

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 fiscal 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 hospice program has 

the opportunity to review the data that is to be made public with respect to the hospice program prior to such data 

being made public. The Secretary shall report quality 

measures that relate to hospice care provided by hospice 

programs on the Internet website of the Centers for Medicare & Medicaid Services.’’. 

SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER HOSPITALS. 

Section 1866 of the Social Security Act (42 U.S.C. 1395cc) is 

amended— 

(1) in subsection (a)(1)— 

(A) in subparagraph (U), by striking ‘‘and’’ at the end; 

(B) in subparagraph (V), by striking the period at the 

end and inserting ‘‘, and’’; and 

(C) by adding at the end the following new subparagraph: 

‘‘(W) in the case of a hospital described in section 

1886(d)(1)(B)(v), to report quality data to the Secretary in 

accordance with subsection (k).’’; and 

(2) by adding at the end the following new subsection: 

‘‘(k) QUALITY REPORTING BY CANCER HOSPITALS.— 

‘‘(1) IN GENERAL.—For purposes of fiscal year 2014 and 

each subsequent fiscal year, a hospital described in section 

1886(d)(1)(B)(v) shall submit data to the Secretary in accordance with paragraph (2) with respect to such a fiscal year. 

‘‘(2) SUBMISSION OF QUALITY DATA.—For fiscal year 2014 

and each subsequent fiscal year, each hospital described in 

such section shall submit to the Secretary data on quality 

measures specified under paragraph (3). Such data shall be 
Sec. 3006 PPACA (Consolidated) 286 

submitted in a form and manner, and at a time, specified by 

the Secretary for purposes of this subparagraph. 

‘‘(3) QUALITY MEASURES.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B), any 

measure specified by the Secretary under this paragraph 

must have been endorsed by the entity with a contract 

under section 1890(a). 

‘‘(B) 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. 

‘‘(C) TIME FRAME.—Not later than October 1, 2012, the 

Secretary shall publish the measures selected under this 

paragraph that will be applicable with respect to fiscal 

year 2014. 

‘‘(4) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The Secretary shall establish procedures for making data submitted 

under paragraph (4) available to the public. Such procedures 

shall ensure that a hospital described in section 

1886(d)(1)(B)(v) has the opportunity to review the data that is 

to be made public with respect to the hospital prior to such 

data being made public. The Secretary shall report quality 

measures of process, structure, outcome, patients’ perspective 

on care, efficiency, and costs of care that relate to services furnished in such hospitals on the Internet website of the Centers 

for Medicare & Medicaid Services.’’. 

SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR 

SKILLED NURSING FACILITIES AND HOME HEALTH AGENCIES. 

(a) SKILLED NURSING FACILITIES.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as 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 skilled nursing facilities (as defined 

in section 1819(a) of such Act (42 U.S.C. 1395i–3(a))). 

(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 such Act, as added by section 3014), to the extent 

feasible and practicable, of all dimensions of quality and 

efficiency in skilled nursing facilities. øAs revised by section 10301(b)¿ 

(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 
287 Sec. 3006 PPACA (Consolidated) 

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 skilled nursing facilities. 

(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 October 1, 2011, 

the Secretary shall submit to Congress a report containing the 

plan developed under paragraph (1). 

(b) HOME HEALTH AGENCIES.— (1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as 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 home health agencies (as defined in 

section 1861(o) of such Act (42 U.S.C. 1395x(o))). 

(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 such Act, as added by section 3014), to the extent 

feasible and practicable, of all dimensions of quality and 

efficiency in home health agencies. 

(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 home health agencies. 

(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 October 1, 2011, 

the Secretary shall submit to Congress a report containing the 

plan developed under paragraph (1). 

øSection 10301 added a new subsection (f) at the end. There are 

no subsections (c)-(e)¿ 

(f) AMBULATORY SURGICAL CENTERS.—øAs added by section 

10301(a)¿ 
Sec. 3007 PPACA (Consolidated) 288 

(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). 

SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN 

FEE SCHEDULE. 

Section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is 

amended— 

(1) in subsection (b)(1), by inserting ‘‘subject to subsection 

(p),’’ after ‘‘1998,’’; and 

(2) by adding at the end the following new subsection: 

‘‘(p) ESTABLISHMENT OF VALUE-BASED PAYMENT MODIFIER.— 

‘‘(1) IN GENERAL.—The Secretary shall establish a payment 

modifier that provides for differential payment to a physician 

or a group of physicians under the fee schedule established 

under subsection (b) based upon the quality of care furnished 

compared to cost (as determined under paragraphs (2) and (3), 

respectively) during a performance period. Such payment modifier shall be separate from the geographic adjustment factors 

established under subsection (e). 

‘‘(2) QUALITY.— 

‘‘(A) IN GENERAL.—For purposes of paragraph (1), 

quality of care shall be evaluated, to the extent practicable, based on a composite of measures of the quality of 
289 Sec. 3007 PPACA (Consolidated) 

care furnished (as established by the Secretary under subparagraph (B)). 

‘‘(B) MEASURES.— 

‘‘(i) The Secretary shall establish appropriate 

measures of the quality of care furnished by a physician or group of physicians to individuals enrolled 

under this part, such as measures that reflect health 

outcomes. Such measures shall be risk adjusted as determined appropriate by the Secretary. 

‘‘(ii) The Secretary shall seek endorsement of the 

measures established under this subparagraph by the 

entity with a contract under section 1890(a). 

‘‘(3) COSTS.—For purposes of paragraph (1), costs shall be 

evaluated, to the extent practicable, based on a composite of 

appropriate measures of costs established by the Secretary 

(such as the composite measure under the methodology established under subsection (n)(9)(C)(iii)) that eliminate the effect 

of geographic adjustments in payment rates (as described in 

subsection (e)), and take into account risk factors (such as socioeconomic and demographic characteristics, ethnicity, and 

health status of individuals (such as to recognize that less 

healthy individuals may require more intensive interventions) 

and other factors determined appropriate by the Secretary. 

‘‘(4) IMPLEMENTATION.— 

‘‘(A) PUBLICATION OF MEASURES, DATES OF IMPLEMENTATION, PERFORMANCE PERIOD.—Not later than January 1, 

2012, the Secretary shall publish the following: 

‘‘(i) The measures of quality of care and costs established under paragraphs (2) and (3), respectively. 

‘‘(ii) The dates for implementation of the payment 

modifier (as determined under subparagraph (B)). 

‘‘(iii) The initial performance period (as specified 

under subparagraph (B)(ii)). 

‘‘(B) DEADLINES FOR IMPLEMENTATION.— 

‘‘(i) INITIAL IMPLEMENTATION.—Subject to the preceding provisions of this subparagraph, the Secretary 

shall begin implementing the payment modifier established under this subsection through the rulemaking 

process during 2013 for the physician fee schedule established under subsection (b). 

‘‘(ii) INITIAL PERFORMANCE PERIOD.— 

‘‘(I) IN GENERAL.—The Secretary shall specify 

an initial performance period for application of the 

payment modifier established under this subsection with respect to 2015. 

‘‘(II) PROVISION OF INFORMATION DURING INITIAL PERFORMANCE PERIOD.—During the initial 

performance period, the Secretary shall, to the extent practicable, provide information to physicians 

and groups of physicians about the quality of care 

furnished by the physician or group of physicians 

to individuals enrolled under this part compared 

to cost (as determined under paragraphs (2) and 
Sec. 3007 PPACA (Consolidated) 290 

(3), respectively) with respect to the performance 

period. 

‘‘(iii) APPLICATION.—The Secretary shall apply the 

payment modifier established under this subsection for 

items and services furnished— 

‘‘(I) beginning on January 1, 2015, with respect to specific physicians and groups of physicians the Secretary determines appropriate; and 

‘‘(II) beginning not later than January 1, 

2017, with respect to all physicians and groups of 

physicians. 

‘‘(C) BUDGET NEUTRALITY.—The payment modifier established under this subsection shall be implemented in a 

budget neutral manner. 

‘‘(5) SYSTEMS-BASED CARE.—The Secretary shall, as appropriate, apply the payment modifier established under this subsection in a manner that promotes systems-based care. 

‘‘(6) CONSIDERATION OF SPECIAL CIRCUMSTANCES OF CERTAIN PROVIDERS.—In applying the payment modifier under this 

subsection, the Secretary shall, as appropriate, take into account the special circumstances of physicians or groups of physicians in rural areas and other underserved communities. 

‘‘(7) APPLICATION.—For purposes of the initial application 

of the payment modifier established under this subsection during the period beginning on January 1, 2015, and ending on 

December 31, 2016, the term ‘physician’ has the meaning given 

such term in section 1861(r). On or after January 1, 2017, the 

Secretary may apply this subsection to eligible professionals 

(as defined in subsection (k)(3)(B)) as the Secretary determines 

appropriate. 

‘‘(8) DEFINITIONS.—For purposes of this subsection: 

‘‘(A) COSTS.—The term ‘costs’ means expenditures per 

individual as determined appropriate by the Secretary. In 

making the determination under the preceding sentence, 

the Secretary may take into account the amount of growth 

in expenditures per individual for a physician compared to 

the amount of such growth for other physicians. 

‘‘(B) PERFORMANCE PERIOD.—The term ‘performance 

period’ means a period specified by the Secretary. 

‘‘(9) COORDINATION WITH OTHER VALUE-BASED PURCHASING

REFORMS.—The Secretary shall coordinate the value-based payment modifier established under this subsection with the Physician Feedback Program under subsection (n) and, as the Secretary determines appropriate, other similar provisions of this 

title. 

‘‘(10) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or 

otherwise of— 

‘‘(A) the establishment of the value-based payment 

modifier under this subsection; 

‘‘(B) the evaluation of quality of care under paragraph 

(2), including the establishment of appropriate measures of 

the quality of care under paragraph (2)(B); 
291 Sec. 3008 PPACA (Consolidated) 

‘‘(C) the evaluation of costs under paragraph (3), including the establishment of appropriate measures of costs 

under such paragraph; 

‘‘(D) the dates for implementation of the value-based 

payment modifier; 

‘‘(E) the specification of the initial performance period 

and any other performance period under paragraphs 

(4)(B)(ii) and (8)(B), respectively; 

‘‘(F) the application of the value-based payment modifier under paragraph (7); and 

‘‘(G) the determination of costs under paragraph 

(8)(A).’’. 

SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS ACQUIRED IN 

HOSPITALS. 

(a) IN GENERAL.—Section 1886 of the Social Security Act (42 

U.S.C. 1395ww), as amended by section 3001, is amended by adding at the end the following new subsection: 

‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR HOSPITAL AC- QUIRED CONDITIONS.— ‘‘(1) IN GENERAL.—In order to provide an incentive for applicable hospitals to reduce hospital acquired conditions under 

this title, with respect to discharges from an applicable hospital occurring during fiscal year 2015 or a subsequent fiscal 

year, the amount of payment under this section or section 

1814(b)(3), as applicable, for such discharges during the fiscal 

year shall be equal to 99 percent of the amount of payment 

that would otherwise apply to such discharges under this section or section 1814(b)(3) (determined after the application of 

subsections (o) and (q) and section 1814(l)(4) but without regard to this subsection). 

‘‘(2) APPLICABLE HOSPITALS.— ‘‘(A) IN GENERAL.—For purposes of this subsection, the 

term ‘applicable hospital’ means a subsection (d) hospital 

that meets the criteria described in subparagraph (B). 

‘‘(B) CRITERIA DESCRIBED.— ‘‘(i) IN GENERAL.—The criteria described in this 

subparagraph, with respect to a subsection (d) hospital, is that the subsection (d) hospital is in the top 

quartile of all subsection (d) hospitals, relative to the 

national average, of hospital acquired conditions during the applicable period, as determined by the Secretary. 

‘‘(ii) RISK ADJUSTMENT.—In carrying out clause (i), 

the Secretary shall establish and apply an appropriate 

risk adjustment methodology. 

‘‘(C) EXEMPTION.—In the case of a hospital that is paid 

under section 1814(b)(3), the Secretary may exempt such 

hospital from the application of this subsection if the State 

which is paid under such section submits an annual report 

to the Secretary describing how a similar program in the 

State for a participating hospital or hospitals achieves or 

surpasses the measured results in terms of patient health 

outcomes and cost savings established under this subsection. 
Sec. 3008 PPACA (Consolidated) 292 

‘‘(3) HOSPITAL ACQUIRED CONDITIONS.—For purposes of this 

subsection, the term ‘hospital acquired condition’ means a condition identified for purposes of subsection (d)(4)(D)(iv) and any 

other condition determined appropriate by the Secretary that 

an individual acquires during a stay in an applicable hospital, 

as determined by the Secretary. 

‘‘(4) APPLICABLE PERIOD.—In this subsection, the term ‘applicable period’ means, with respect to a fiscal year, a period 

specified by the Secretary. 

‘‘(5) REPORTING TO HOSPITALS.—Prior to fiscal year 2015 

and each subsequent fiscal year, the Secretary shall provide 

confidential reports to applicable hospitals with respect to hospital acquired conditions of the applicable hospital during the 

applicable period. 

‘‘(6) REPORTING HOSPITAL SPECIFIC INFORMATION.— ‘‘(A) IN GENERAL.—The Secretary shall make information available to the public regarding hospital acquired 

conditions of each applicable hospital. 

‘‘(B) OPPORTUNITY TO REVIEW AND SUBMIT CORREC- TIONS.—The Secretary shall ensure that an applicable hospital has the opportunity to review, and submit corrections 

for, the information to be made public with respect to the 

hospital under subparagraph (A) prior to such information 

being made public. 

‘‘(C) WEBSITE.—Such information shall be posted on 

the Hospital Compare Internet website in an easily understandable format. 

‘‘(7) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or 

otherwise of the following: 

‘‘(A) The criteria described in paragraph (2)(A). 

‘‘(B) The specification of hospital acquired conditions 

under paragraph (3). 

‘‘(C) The specification of the applicable period under 

paragraph (4). 

‘‘(D) The provision of reports to applicable hospitals 

under paragraph (5) and the information made available to 

the public under paragraph (6).’’. 

(b) STUDY AND REPORT ON EXPANSION OF HEALTHCARE ACQUIRED CONDITIONS POLICY TO OTHER PROVIDERS.— 

(1) STUDY.—The Secretary of Health and Human Services 

shall conduct a study on expanding the healthcare acquired 

conditions policy under subsection (d)(4)(D) of section 1886 of 

the Social Security Act (42 U.S.C. 1395ww) to payments made 

to other facilities under the Medicare program under title 

XVIII of the Social Security Act, including such payments 

made to inpatient rehabilitation facilities, long-term care hospitals (as described in subsection(d)(1)(B)(iv) of such section), 

hospital outpatient departments, and other hospitals excluded 

from the inpatient prospective payment system under such section, skilled nursing facilities, ambulatory surgical centers, and 

health clinics. Such study shall include an analysis of how such 

policies could impact quality of patient care, patient safety, 

and spending under the Medicare program. 
293 Sec. 3011 PPACA (Consolidated) \399HH PHSA 

(2) REPORT.—Not later than January 1, 2012, the Secretary shall submit to Congress a report containing the results 

of the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as 

the Secretary determines appropriate. 

PART 2—NATIONAL STRATEGY TO IMPROVE 

HEALTH CARE QUALITY 

SEC. 3011. NATIONAL STRATEGY. 

Title III of the Public Health Service Act (42 U.S.C. 241 et 

seq.) is amended by adding at the end the following: 

‘‘PART S—HEALTH CARE QUALITY PROGRAMS 

‘‘Subpart I—National Strategy for Quality 

Improvement in Health Care 

‘‘SEC. 399HH. ø42 U.S.C. 280j¿ NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE. 

‘‘(a) ESTABLISHMENT OF NATIONAL STRATEGY AND PRIORITIES.— 

‘‘(1) NATIONAL STRATEGY.—The Secretary, through a transparent collaborative process, shall establish a national strategy 

to improve the delivery of health care services, patient health 

outcomes, and population health. 

‘‘(2) IDENTIFICATION OF PRIORITIES.— 

‘‘(A) IN GENERAL.—The Secretary shall identify national priorities for improvement in developing the strategy under paragraph (1). 

‘‘(B) REQUIREMENTS.—The Secretary shall ensure that 

priorities identified under subparagraph (A) will— 

‘‘(i) have the greatest potential for improving the 

health outcomes, efficiency, and patient-centeredness 

of health care for all populations, including children 

and vulnerable populations; 

‘‘(ii) identify areas in the delivery of health care 

services that have the potential for rapid improvement 

in the quality and efficiency of patient care; 

‘‘(iii) address gaps in quality, efficiency, comparative effectiveness information (taking into consideration the limitations set forth in subsections (c) and 

(d) of section 1182 of the Social Security Act), and 

health outcomes measures and data aggregation techniques; øAs revised by section 10302¿ 

‘‘(iv) improve Federal payment policy to emphasize 

quality and efficiency; 

‘‘(v) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes; 

‘‘(vi) address the health care provided to patients 

with high-cost chronic diseases; 

‘‘(vii) improve research and dissemination of strategies and best practices to improve patient safety and 
Sec. 3011\399HH PHSA PPACA (Consolidated) 294 

reduce medical errors, preventable admissions and readmissions, and health care-associated infections; 

‘‘(viii) reduce health disparities across health disparity populations (as defined in section 485E) and geographic areas; and 

‘‘(ix) address other areas as determined appropriate by the Secretary. 

‘‘(C) CONSIDERATIONS.—In identifying priorities under 

subparagraph (A), the Secretary shall take into consideration the recommendations submitted by the entity with a 

contract under section 1890(a) of the Social Security Act 

and other stakeholders. 

‘‘(D) COORDINATION WITH STATE AGENCIES.—The Secretary shall collaborate, coordinate, and consult with State 

agencies responsible for administering the Medicaid program under title XIX of the Social Security Act and the 

Children’s Health Insurance Program under title XXI of 

such Act with respect to developing and disseminating 

strategies, goals, models, and timetables that are consistent with the national priorities identified under subparagraph (A). 

‘‘(b) STRATEGIC PLAN.— 

‘‘(1) IN GENERAL.—The national strategy shall include a 

comprehensive strategic plan to achieve the priorities described 

in subsection (a). 

‘‘(2) REQUIREMENTS.—The strategic plan shall include provisions for addressing, at a minimum, the following: 

‘‘(A) Coordination among agencies within the Department, which shall include steps to minimize duplication of 

efforts and utilization of common quality measures, where 

available. Such common quality measures shall be measures identified by the Secretary under section 1139A or 

1139B of the Social Security Act or endorsed under section 

1890 of such Act. 

‘‘(B) Agency-specific strategic plans to achieve national 

priorities. 

‘‘(C) Establishment of annual benchmarks for each relevant agency to achieve national priorities. 

‘‘(D) A process for regular reporting by the agencies to 

the Secretary on the implementation of the strategic plan. 

‘‘(E) Strategies to align public and private payers with 

regard to quality and patient safety efforts. 

‘‘(F) Incorporating quality improvement and measurement in the strategic plan for health information technology required by the American Recovery and Reinvestment Act of 2009 (Public Law 111–5). 

‘‘(c) PERIODIC UPDATE OF NATIONAL STRATEGY.—The Secretary 

shall update the national strategy not less than annually. Any such 

update shall include a review of short- and long-term goals. 

‘‘(d) SUBMISSION AND AVAILABILITY OF NATIONAL STRATEGY AND

UPDATES.— 

‘‘(1) DEADLINE FOR INITIAL SUBMISSION OF NATIONAL STRATEGY.—Not later than January 1, 2011, the Secretary shall sub-
295 Sec. 3012 PPACA (Consolidated) 

mit to the relevant committees of Congress the national strategy described in subsection (a). 

‘‘(2) UPDATES.— ‘‘(A) IN GENERAL.—The Secretary shall submit to the 

relevant committees of Congress an annual update to the 

strategy described in paragraph (1). 

‘‘(B) INFORMATION SUBMITTED.—Each update submitted under subparagraph (A) shall include— 

‘‘(i) a review of the short- and long-term goals of 

the national strategy and any gaps in such strategy; 

‘‘(ii) an analysis of the progress, or lack of 

progress, in meeting such goals and any barriers to 

such progress; 

‘‘(iii) the information reported under section 1139A 

of the Social Security Act, consistent with the reporting requirements of such section; and 

‘‘(iv) in the case of an update required to be submitted on or after January 1, 2014, the information reported under section 1139B(b)(4) of the Social Security 

Act, consistent with the reporting requirements of 

such section. 

‘‘(C) SATISFACTION OF OTHER REPORTING REQUIRE- MENTS.—Compliance with the requirements of clauses (iii) 

and (iv) of subparagraph (B) shall satisfy the reporting requirements under sections 1139A(a)(6) and 1139B(b)(4), respectively, of the Social Security Act. 

‘‘(e) HEALTH CARE QUALITY INTERNET WEBSITE.—Not later 

than January 1, 2011, the Secretary shall create an Internet 

website to make public information regarding— 

‘‘(1) the national priorities for health care quality improvement established under subsection (a)(2); 

‘‘(2) the agency-specific strategic plans for health care 

quality described in subsection (b)(2)(B); and 

‘‘(3) other information, as the Secretary determines to be 

appropriate.’’. 

SEC. 3012. ø42 U.S.C. 280j note¿ INTERAGENCY WORKING GROUP ON 

HEALTH CARE QUALITY. 

(a) IN GENERAL.—The President shall convene a working group 

to be known as the Interagency Working Group on Health Care 

Quality (referred to in this section as the ‘‘Working Group’’). 

(b) GOALS.—The goals of the Working Group shall be to 

achieve the following: 

(1) Collaboration, cooperation, and consultation between 

Federal departments and agencies with respect to developing 

and disseminating strategies, goals, models, and timetables 

that are consistent with the national priorities identified under 

section 399HH(a)(2) of the Public Health Service Act (as added 

by section 3011). 

(2) Avoidance of inefficient duplication of quality improvement efforts and resources, where practicable, and a streamlined process for quality reporting and compliance requirements. 

(3) Assess alignment of quality efforts in the public sector 

with private sector initiatives. 
Sec. 3013 PPACA (Consolidated) 296 

(c) COMPOSITION.— 

(1) IN GENERAL.—The Working Group shall be composed of 

senior level representatives of— 

(A) the Department of Health and Human Services; 

(B) the Centers for Medicare & Medicaid Services; 

(C) the National Institutes of Health; 

(D) the Centers for Disease Control and Prevention; 

(E) the Food and Drug Administration; 

(F) the Health Resources and Services Administration; 

(G) the Agency for Healthcare Research and Quality; 

(H) the Office of the National Coordinator for Health 

Information Technology; 

(I) the Substance Abuse and Mental Health Services 

Administration; 

(J) the Administration for Children and Families; 

(K) the Department of Commerce; 

(L) the Office of Management and Budget; 

(M) the United States Coast Guard; 

(N) the Federal Bureau of Prisons; 

(O) the National Highway Traffic Safety Administration; 

(P) the Federal Trade Commission; 

(Q) the Social Security Administration; 

(R) the Department of Labor; 

(S) the United States Office of Personnel Management; 

(T) the Department of Defense; 

(U) the Department of Education; 

(V) the Department of Veterans Affairs; 

(W) the Veterans Health Administration; and 

(X) any other Federal agencies and departments with 

activities relating to improving health care quality and 

safety, as determined by the President. 

(2) CHAIR AND VICE-CHAIR.— 

(A) CHAIR.—The Working Group shall be chaired by 

the Secretary of Health and Human Services. 

(B) VICE CHAIR.—Members of the Working Group, 

other than the Secretary of Health and Human Services, 

shall serve as Vice Chair of the Group on a rotating basis, 

as determined by the Group. 

(d) REPORT TO CONGRESS.—Not later than December 31, 2010, 

and annually thereafter, the Working Group shall submit to the 

relevant Committees of Congress, and make public on an Internet 

website, a report describing the progress and recommendations of 

the Working Group in meeting the goals described in subsection 

(b). 

SEC. 3013. QUALITY MEASURE DEVELOPMENT. 

(a) PUBLIC HEALTH SERVICE ACT.—Title IX of the Public 

Health Service Act (42 U.S.C. 299 et seq.) is amended— 

(1) by redesignating part D as part E; 

(2) by redesignating sections 931 through 938 as sections 

941 through 948, respectively; 

(3) in section 948(1), as so redesignated, by striking ‘‘931’’ 

and inserting ‘‘941’’; and 
297 Sec. 3013 PPACA (Consolidated) \931 PHSA 

(4) by inserting after section 926 the following: 

‘‘PART D—HEALTH CARE QUALITY 

IMPROVEMENT 

‘‘Subpart I—Quality Measure Development 

‘‘SEC. 931. ø42 U.S.C. 299b–31¿ QUALITY MEASURE DEVELOPMENT. 

‘‘(a) QUALITY MEASURE.—In this subpart, the term ‘quality 

measure’ means a standard for measuring the performance and improvement of population health or of health plans, providers of 

services, and other clinicians in the delivery of health care services. 

‘‘(b) IDENTIFICATION OF QUALITY MEASURES.— 

‘‘(1) IDENTIFICATION.—The Secretary, in consultation with 

the Director of the Agency for Healthcare Research and Quality and the Administrator of the Centers for Medicare & Medicaid Services, shall identify, not less often than triennially, 

gaps where no quality measures exist and existing quality 

measures that need improvement, updating, or expansion, consistent with the national strategy under section 399HH, to the 

extent available, for use in Federal health programs. In identifying such gaps and existing quality measures that need improvement, the Secretary shall take into consideration— 

‘‘(A) the gaps identified by the entity with a contract 

under section 1890(a) of the Social Security Act and other 

stakeholders; 

‘‘(B) quality measures identified by the pediatric quality measures program under section 1139A of the Social 

Security Act; and 

‘‘(C) quality measures identified through the Medicaid 

Quality Measurement Program under section 1139B of the 

Social Security Act. 

‘‘(2) PUBLICATION.—The Secretary shall make available to 

the public on an Internet website a report on any gaps identified under paragraph (1) and the process used to make such 

identification. 

‘‘(c) GRANTS OR CONTRACTS FOR QUALITY MEASURE DEVELOPMENT.— 

‘‘(1) IN GENERAL.—The Secretary shall award grants, contracts, or intergovernmental agreements to eligible entities for 

purposes of developing, improving, updating, or expanding 

quality measures identified under subsection (b). 

‘‘(2) PRIORITIZATION IN THE DEVELOPMENT OF QUALITY

MEASURES.—In awarding grants, contracts, or agreements 

under this subsection, the Secretary shall give priority to the 

development of quality measures that allow the assessment 

of— 

‘‘(A) health outcomes and functional status of patients; 

‘‘(B) the management and coordination of health care 

across episodes of care and care transitions for patients 

across the continuum of providers, health care settings, 

and health plans; 
Sec. 3013\931 PHSA PPACA (Consolidated) 298 

‘‘(C) the experience, quality, and use of information 

provided to and used by patients, caregivers, and authorized representatives to inform decisionmaking about treatment options, including the use of shared decisionmaking 

tools and preference sensitive care (as defined in section 

936); 

‘‘(D) the meaningful use of health information technology; 

‘‘(E) the safety, effectiveness, patient-centeredness, appropriateness, and timeliness of care; 

‘‘(F) the efficiency of care; 

‘‘(G) the equity of health services and health disparities across health disparity populations (as defined in section 485E) and geographic areas; 

‘‘(H) patient experience and satisfaction; 

‘‘(I) the use of innovative strategies and methodologies 

identified under section 933; and 

‘‘(J) other areas determined appropriate by the Secretary. 

‘‘(3) ELIGIBLE ENTITIES.—To be eligible for a grant or contract under this subsection, an entity shall— 

‘‘(A) have demonstrated expertise and capacity in the 

development and evaluation of quality measures; 

‘‘(B) have adopted procedures to include in the quality 

measure development process— 

‘‘(i) the views of those providers or payers whose 

performance will be assessed by the measure; and 

‘‘(ii) the views of other parties who also will use 

the quality measures (such as patients, consumers, 

and health care purchasers); 

‘‘(C) collaborate with the entity with a contract under 

section 1890(a) of the Social Security Act and other stakeholders, as practicable, and the Secretary so that quality 

measures developed by the eligible entity will meet the requirements to be considered for endorsement by the entity 

with a contract under such section 1890(a); 

‘‘(D) have transparent policies regarding governance 

and conflicts of interest; and 

‘‘(E) submit an application to the Secretary at such 

time and in such manner, as the Secretary may require. 

‘‘(4) USE OF FUNDS.—An entity that receives a grant, contract, or agreement under this subsection shall use such award 

to develop quality measures that meet the following requirements: 

‘‘(A) Such measures support measures required to be 

reported under the Social Security Act, where applicable, 

and in support of gaps and existing quality measures that 

need improvement, as described in subsection (b)(1)(A). 

‘‘(B) Such measures support measures developed under 

section 1139A of the Social Security Act and the Medicaid 

Quality Measurement Program under section 1139B of 

such Act, where applicable. 
299 Sec. 3013 PPACA (Consolidated) 

‘‘(C) To the extent practicable, data on such quality 

measures is able to be collected using health information 

technologies. 

‘‘(D) Each quality measure is free of charge to users of 

such measure. 

‘‘(E) Each quality measure is publicly available on an 

Internet website. 

‘‘(d) OTHER ACTIVITIES BY THE SECRETARY.—The Secretary may 

use amounts available under this section to update and test, where 

applicable, quality measures endorsed by the entity with a contract 

under section 1890(a) of the Social Security Act or adopted by the 

Secretary. 

‘‘(e) COORDINATION OF GRANTS.—The Secretary shall ensure 

that grants or contracts awarded under this section are coordinated 

with grants and contracts awarded under sections 1139A(5) and 

1139B(4)(A) of the Social Security Act. 

‘‘(f) DEVELOPMENT OF OUTCOME MEASURES.—øAs added by section 10303(a)¿ 

‘‘(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) SOCIAL SECURITY ACT.—Section 1890A of the Social Security Act, as added by section 3014(b), is amended by adding at the 

end the following new subsection: øNote: amendment made by section 10304 strikes ‘‘quality’’ and inserts ‘‘quality and efficiency’’ in 
Sec. 3014 PPACA (Consolidated) 300 

section 1890A of the Social Security Act but did not specifically 

amend headings below (which have different typeface)¿ 

‘‘(e) DEVELOPMENT OF QUALITY [AND EFFICIENCY] MEASURES.— 

The Administrator of the Center for Medicare & Medicaid Services 

shall through contracts develop quality and efficiency measures (as 

determined appropriate by the Administrator) for use under this 

Act. In developing such measures, the Administrator shall consult 

with the Director of the Agency for Healthcare Research and Quality. 

øA subsection (f) was also added by section 10303 as shown 

below:¿ 

‘‘(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) FUNDING.—There are authorized to be appropriated to the 

Secretary of Health and Human Services to carry out this section, 

$75,000,000 for each of fiscal years 2010 through 2014. Of the 

amounts appropriated under the preceding sentence in a fiscal 

year, not less than 50 percent of such amounts shall be used pursuant to subsection (e) of section 1890A of the Social Security Act, as 

added by subsection (b), with respect to programs under such Act. 

Amounts appropriated under this subsection for a fiscal year shall 

remain available until expended. 

SEC. 3014. QUALITY MEASUREMENT. 

(a) NEW DUTIES FOR CONSENSUS-BASED ENTITY.— 

(1) MULTI-STAKEHOLDER GROUP INPUT.—Section 1890(b) of 

the Social Security Act (42 U.S.C. 1395aaa(b)), as amended by 

section 3003, is amended by adding at the end the following 

new paragraphs: øamendment by section 10304 strikes ‘‘quality’’ and inserts ‘‘quality and efficiency’’ in new paragraph (7) 

but did not specifically amend heading of paragraph (7)(B) 

below (which has different typeface).¿ 

‘‘(7) CONVENING MULTI-STAKEHOLDER GROUPS.— 

‘‘(A) IN GENERAL.—The entity shall convene multistakeholder groups to provide input on— 

‘‘(i) the selection of quality and efficiency measures described in subparagraph (B), from among— 

‘‘(I) such measures that have been endorsed 

by the entity; and 

‘‘(II) such measures that have not been considered for endorsement by such entity but are 

used or proposed to be used by the Secretary for 

the collection or reporting of quality and efficiency 

measures; and 

‘‘(ii) national priorities (as identified under section 

399HH of the Public Health Service Act) for improvement in population health and in the delivery of 

health care services for consideration under the national strategy established under section 399HH of the 

Public Health Service Act. 
301 Sec. 3014 PPACA (Consolidated) 

‘‘(B) QUALITY [AND EFFICIENCY] MEASURES.— ‘‘(i) IN GENERAL.—Subject to clause (ii), the quality 

and efficiency measures described in this subparagraph are quality and efficiency measures— 

‘‘(I) for use pursuant to sections 1814(i)(5)(D), 

1833(i)(7), 1833(t)(17), 1848(k)(2)(C), 1866(k)(3), 

1881(h)(2)(A)(iii), 1886(b)(3)(B)(viii), 1886(j)(7)(D), 

1886(m)(5)(D), 1886(o)(2), 1886(s)(4)(D), and 

1895(b)(3)(B)(v); øAs revised by section 10322(b)¿ 

‘‘(II) for use in reporting performance information to the public; and 

‘‘(III) for use in health care programs other 

than for use under this Act. 

‘‘(ii) EXCLUSION.—Data sets (such as the outcome 

and assessment information set for home health services and the minimum data set for skilled nursing facility services) that are used for purposes of classification systems used in establishing payment rates under 

this title shall not be quality and efficiency measures 

described in this subparagraph. 

‘‘(C) REQUIREMENT FOR TRANSPARENCY IN PROCESS.— ‘‘(i) IN GENERAL.—In convening multi-stakeholder 

groups under subparagraph (A) with respect to the selection of quality and efficiency measures, the entity 

shall provide for an open and transparent process for 

the activities conducted pursuant to such convening. 

‘‘(ii) SELECTION OF ORGANIZATIONS PARTICIPATING

IN MULTI-STAKEHOLDER GROUPS.—The process described in clause (i) shall ensure that the selection of 

representatives comprising such groups provides for 

public nominations for, and the opportunity for public 

comment on, such selection. 

‘‘(D) MULTI-STAKEHOLDER GROUP DEFINED.—In this 

paragraph, the term ‘multi-stakeholder group’ means, with 

respect to a quality and efficiency measure, a voluntary 

collaborative of organizations representing a broad group 

of stakeholders interested in or affected by the use of such 

quality and efficiency measure. 

‘‘(8) TRANSMISSION OF MULTI-STAKEHOLDER INPUT.—Not 

later than February 1 of each year (beginning with 2012), the 

entity shall transmit to the Secretary the input of multi-stakeholder groups provided under paragraph (7).’’. 

(2) ANNUAL REPORT.—Section 1890(b)(5)(A) of the Social 

Security Act (42 U.S.C. 1395aaa(b)(5)(A)) is amended— 

(A) in clause (ii), by striking ‘‘and’’ at the end; 

(B) in clause (iii), by striking the period at the end and 

inserting a semicolon; and 

(C) by adding at the end the following new clauses: 

‘‘(iv) gaps in endorsed quality measures, which 

shall include measures that are within priority areas 

identified by the Secretary under the national strategy 

established under section 399HH of the Public Health 

Service Act, and where quality measures are unavailable or inadequate to identify or address such gaps; 
Sec. 3014\1890A SSA PPACA (Consolidated) 302 

‘‘(v) areas in which evidence is insufficient to support endorsement of quality measures in priority areas 

identified by the Secretary under the national strategy 

established under section 399HH of the Public Health 

Service Act and where targeted research may address 

such gaps; and 

‘‘(vi) the matters described in clauses (i) and (ii) of 

paragraph (7)(A).’’. 

(b) MULTI-STAKEHOLDER GROUP INPUT INTO SELECTION OF

QUALITY MEASURES.—Title XVIII of the Social Security Act (42 

U.S.C. 1395 et seq.) is amended by inserting after section 1890 the 

following: øamendment by section 10304 strikes ‘‘quality’’ and inserts ‘‘quality and efficiency’’ in new section but did not specifically 

amend headings below (which have different typefaces).¿ 

‘‘QUALITY [AND EFFICIENCY] MEASUREMENT

‘‘SEC. 1890A. ø42 U.S.C. 1395aaa–1¿ (a) MULTI-STAKEHOLDER

GROUP INPUT INTO SELECTION OF QUALITY [AND EFFICIENCY] 

MEASURES.—The Secretary shall establish a pre-rulemaking process under which the following steps occur with respect to the selection of quality and efficiency measures described in section 

1890(b)(7)(B): 

‘‘(1) INPUT.—Pursuant to section 1890(b)(7), the entity with 

a contract under section 1890 shall convene multi-stakeholder 

groups to provide input to the Secretary on the selection of 

quality and efficiency measures described in subparagraph (B) 

of such paragraph. 

‘‘(2) PUBLIC AVAILABILITY OF MEASURES CONSIDERED FOR

SELECTION.—Not later than December 1 of each year (beginning with 2011), the Secretary shall make available to the public a list of quality and efficiency measures described in section 

1890(b)(7)(B) that the Secretary is considering under this title. 

‘‘(3) TRANSMISSION OF MULTI-STAKEHOLDER INPUT.—Pursuant to section 1890(b)(8), not later than February 1 of each 

year (beginning with 2012), the entity shall transmit to the 

Secretary the input of multi-stakeholder groups described in 

paragraph (1). 

‘‘(4) CONSIDERATION OF MULTI-STAKEHOLDER INPUT.—The 

Secretary shall take into consideration the input from multistakeholder groups described in paragraph (1) in selecting 

quality and efficiency measures described in section 

1890(b)(7)(B) that have been endorsed by the entity with a contract under section 1890 and measures that have not been endorsed by such entity. 

‘‘(5) RATIONALE FOR USE OF QUALITY [AND EFFICIENCY]

MEASURES.—The Secretary shall publish in the Federal Register the rationale for the use of any quality and efficiency 

measure described in section 1890(b)(7)(B) that has not been 

endorsed by the entity with a contract under section 1890. 

‘‘(6) ASSESSMENT OF IMPACT.—Not later than March 1, 

2012, and at least once every three years thereafter, the Secretary shall— 
303 Sec. 3014 PPACA (Consolidated) \1890A SSA 

‘‘(A) conduct an assessment of the quality and efficiency impact of the use of endorsed measures described in 

section 1890(b)(7)(B); and 

‘‘(B) make such assessment available to the public. 

‘‘(b) PROCESS FOR DISSEMINATION OF MEASURES USED BY THE

SECRETARY.— 

‘‘(1) IN GENERAL.—The Secretary shall establish a process 

for disseminating quality and efficiency measures used by the 

Secretary. Such process shall include the following: 

‘‘(A) The incorporation of such measures, where applicable, in workforce programs, training curricula, and any 

other means of dissemination determined appropriate by 

the Secretary. 

‘‘(B) The dissemination of such quality and efficiency 

measures through the national strategy developed under 

section 399HH of the Public Health Service Act. 

‘‘(2) EXISTING METHODS.—To the extent practicable, the 

Secretary shall utilize and expand existing dissemination 

methods in disseminating quality and efficiency measures 

under the process established under paragraph (1). 

‘‘(c) REVIEW OF QUALITY [AND EFFICIENCY] MEASURES USED BY

THE SECRETARY.— 

‘‘(1) IN GENERAL.—The Secretary shall— 

‘‘(A) periodically (but in no case less often than once 

every 3 years) review quality and efficiency measures described in section 1890(b)(7)(B); and 

‘‘(B) with respect to each such measure, determine 

whether to— 

‘‘(i) maintain the use of such measure; or 

‘‘(ii) phase out such measure. 

‘‘(2) CONSIDERATIONS.—In conducting the review under 

paragraph (1), the Secretary shall take steps to— 

‘‘(A) seek to avoid duplication of measures used; and 

‘‘(B) take into consideration current innovative methodologies and strategies for quality and efficiency improvement practices in the delivery of health care services that 

represent best practices for such quality and efficiency improvement and measures endorsed by the entity with a 

contract under section 1890 since the previous review by 

the Secretary. 

‘‘(d) RULE OF CONSTRUCTION.—Nothing in this section shall 

preclude a State from using the quality and efficiency measures 

identified under sections 1139A and 1139B. 

øNote: A subsection (e) was also added by section 3013(b) and 

a subsection (f) was also added by section 10303(b) of HCERA¿ 

(c) FUNDING.—For purposes of carrying out the amendments 

made by this section, 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 under section 1841 

of such Act (42 U.S.C. 1395t), in such proportion as the Secretary 

determines appropriate, of $20,000,000, to the Centers for Medicare 

& Medicaid Services Program Management Account for each of fis-
Sec. 3015 PPACA (Consolidated) 304 

cal years 2010 through 2014. Amounts transferred under the preceding sentence shall remain available until expended. 

SEC. 3015. DATA COLLECTION; PUBLIC REPORTING. 

Title III of the Public Health Service Act (42 U.S.C. 241 et 

seq.), as amended by section 3011, is further amended by adding 

at the end the following: 

‘‘SEC. 399II. ø42 U.S.C. 280–1¿ COLLECTION AND ANALYSIS OF DATA FOR 

QUALITY AND RESOURCE USE MEASURES. 

‘‘(a) IN GENERAL.—øReplaced by section 10305¿ 

‘‘(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. 

‘‘(b) GRANTS OR CONTRACTS FOR DATA COLLECTION.— 

‘‘(1) IN GENERAL.—The Secretary may award grants or contracts to eligible entities to support new, or improve existing, 

efforts to collect and aggregate quality and resource use measures described under subsection (c). 

‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a grant or contract under this subsection, an entity shall— 

‘‘(A) be— 

‘‘(i) a multi-stakeholder entity that coordinates the 

development of methods and implementation plans for 

the consistent reporting of summary quality and cost 

information; 

‘‘(ii) an entity capable of submitting such summary data for a particular population and providers, 

such as a disease registry, regional collaboration, 

health plan collaboration, or other population-wide 

source; or 

‘‘(iii) a Federal Indian Health Service program or 

a health program operated by an Indian tribe (as defined in section 4 of the Indian Health Care Improvement Act); 

‘‘(B) promote the use of the systems that provide data 

to improve and coordinate patient care; 
305 Sec. 3015 PPACA (Consolidated) \399JJ PHSA 

‘‘(C) support the provision of timely, consistent quality 

and resource use information to health care providers, and 

other groups and organizations as appropriate, with an opportunity for providers to correct inaccurate measures; and 

‘‘(D) agree to report, as determined by the Secretary, 

measures on quality and resource use to the public in accordance with the public reporting process established 

under section 399JJ. 

‘‘(c) CONSISTENT DATA AGGREGATION.—The Secretary may 

award grants or contracts under this section only to entities that 

enable summary data that can be integrated and compared across 

multiple sources. The Secretary shall provide standards for the protection of the security and privacy of patient data. 

‘‘(d) 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. 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To carry out this 

section, there are authorized to be appropriated such sums as may 

be necessary for fiscal years 2010 through 2014. 

‘‘SEC. 399JJ. ø42 U.S.C. 280j–2¿ PUBLIC REPORTING OF PERFORMANCE 

INFORMATION. 

‘‘(a) DEVELOPMENT OF PERFORMANCE WEBSITES.—The Secretary shall make available to the public, through standardized 

Internet websites, performance information summarizing data on 

quality measures. Such information shall be tailored to respond to 

the differing needs of hospitals and other institutional health care 

providers, physicians and other clinicians, patients, consumers, researchers, policymakers, States, and other stakeholders, as the Secretary may specify. 

‘‘(b) INFORMATION ON CONDITIONS.—The performance information made publicly available on an Internet website, as described 

in subsection (a), shall include information regarding clinical conditions to the extent such information is available, and the information shall, where appropriate, be provider-specific and sufficiently 

disaggregated and specific to meet the needs of patients with different clinical conditions. 

‘‘(c) CONSULTATION.— 

‘‘(1) IN GENERAL.—In carrying out this section, the Secretary shall consult with the entity with a contract under section 1890(a) of the Social Security Act, and other entities, as 

appropriate, to determine the type of information that is useful 

to stakeholders and the format that best facilitates use of the 

reports and of performance reporting Internet websites. 

‘‘(2) CONSULTATION WITH STAKEHOLDERS.—The entity with 

a contract under section 1890(a) of the Social Security Act 

shall convene multi-stakeholder groups, as described in such 

section, to review the design and format of each Internet 
Sec. 3021 PPACA (Consolidated) 306 

website made available under subsection (a) and shall transmit 

to the Secretary the views of such multi-stakeholder groups 

with respect to each such design and format. 

‘‘(d) COORDINATION.—Where appropriate, the Secretary shall 

coordinate the manner in which data are presented through Internet websites described in subsection (a) and for public reporting of 

other quality measures by the Secretary, including such quality 

measures under title XVIII of the Social Security Act. 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To carry out this 

section, there are authorized to be appropriated such sums as may 

be necessary for fiscal years 2010 through 2014.’’. 

PART 3—ENCOURAGING DEVELOPMENT OF 

NEW PATIENT CARE MODELS 

SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID INNOVATION WITHIN CMS. 

(a) IN GENERAL.—Title XI of the Social Security Act is amended by inserting after section 1115 the following new section: 

‘‘CENTER FOR MEDICARE AND MEDICAID INNOVATION

‘‘SEC. 1115A. ø42 U.S.C. 1315a¿ (a) CENTER FOR MEDICARE

AND MEDICAID INNOVATION ESTABLISHED.— 

‘‘(1) IN GENERAL.—There is created within the Centers for 

Medicare & Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the ‘CMI’) to 

carry out the duties described in this section. The purpose of 

the CMI is to test innovative payment and service delivery 

models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care 

services furnished to applicable individuals defined in paragraph (4)(A). 

‘‘(2) DEADLINE.—The Secretary shall ensure that the CMI 

is carrying out the duties described in this section by not later 

than January 1, 2011. 

‘‘(3) CONSULTATION.—In carrying out the duties under this 

section, the CMI shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise 

in medicine and health care management. The CMI shall use 

open door forums or other mechanisms to seek input from interested parties. 

‘‘(4) DEFINITIONS.—In this section: 

‘‘(A) APPLICABLE INDIVIDUAL.—The term ‘applicable individual’ means— 

‘‘(i) an individual who is entitled to, or enrolled 

for, benefits under part A of title XVIII or enrolled for 

benefits under part B of such title; 

‘‘(ii) an individual who is eligible for medical assistance under title XIX, under a State plan or waiver; 

or 
307 Sec. 3021 PPACA (Consolidated) \1115A SSA 

‘‘(iii) an individual who meets the criteria of both 

clauses (i) and (ii). 

‘‘(B) APPLICABLE TITLE.—The term ‘applicable title’ 

means title XVIII, title XIX, or both. 

‘‘(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. øAs added by section 10306(1)¿ 

‘‘(b) TESTING OF MODELS (PHASE I).— 

‘‘(1) IN GENERAL.—The CMI shall test payment and service 

delivery models in accordance with selection criteria under 

paragraph (2) to determine the effect of applying such models 

under the applicable title (as defined in subsection (a)(4)(B)) on 

program expenditures under such titles and the quality of care 

received by individuals receiving benefits under such title. 

‘‘(2) SELECTION OF MODELS TO BE TESTED.— 

‘‘(A) IN GENERAL.—øAs revised by section 

10306(a)(2)(A)¿ The Secretary shall select models to be 

tested from models where the Secretary determines that 

there is evidence that the model addresses a defined population for which there are deficits in care leading to poor 

clinical outcomes or potentially avoidable expenditures. 

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. The models selected 

under this subparagraph may include, but are not limited 

to, the models described in subparagraph (B). 

‘‘(B) OPPORTUNITIES.—The models described in this 

subparagraph are the following models: 

‘‘(i) Promoting broad payment and practice reform 

in primary care, including patient-centered medical 

home models for high-need applicable individuals, 

medical homes that address women’s unique health 

care needs, and models that transition primary care 

practices away from fee-for-service based reimbursement and toward comprehensive payment or salarybased payment. 

‘‘(ii) Contracting directly with groups of providers 

of services and suppliers to promote innovative care 

delivery models, such as through risk-based comprehensive payment or salary-based payment. 

‘‘(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including 

through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one 

of the following: 

‘‘(I) An inability to perform 2 or more activities of daily living. 

‘‘(II) Cognitive impairment, including dementia. 

‘‘(iv) Promote care coordination between providers 

of services and suppliers that transition health care 
Sec. 3021\1115A SSA PPACA (Consolidated) 308 

providers away from fee-for-service based reimbursement and toward salary-based payment. 

‘‘(v) Supporting care coordination for chronically-ill 

applicable individuals at high risk of hospitalization 

through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology. 

‘‘(vi) Varying payment to physicians who order advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) according to the physician’s adherence to appropriateness criteria for the ordering of 

such services, as determined in consultation with physician specialty groups and other relevant stakeholders. 

‘‘(vii) Utilizing medication therapy management 

services, such as those described in section 935 of the 

Public Health Service Act. 

‘‘(viii) Establishing community-based health teams 

to support small-practice medical homes by assisting 

the primary care practitioner in chronic care management, including patient self-management, activities. 

‘‘(ix) Assisting applicable individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support 

tools, including tools that meet the standards developed and identified under section 936(c)(2)(A) of the 

Public Health Service Act, that improve applicable individual and caregiver understanding of medical treatment options. 

‘‘(x) Allowing States to test and evaluate fully integrating care for dual eligible individuals in the 

State, including the management and oversight of all 

funds under the applicable titles with respect to such 

individuals. 

‘‘(xi) Allowing States to test and evaluate systems 

of all-payer payment reform for the medical care of 

residents of the State, including dual eligible individuals. 

‘‘(xii) Aligning nationally recognized, evidencebased guidelines of cancer care with payment incentives under title XVIII in the areas of treatment planning and follow-up care planning for applicable individuals described in clause (i) or (iii) of subsection 

(a)(4)(A) with cancer, including the identification of 

gaps in applicable quality measures. 

‘‘(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or 

skilled nursing care during an inpatient stay and the 

30 days immediately following discharge. 

‘‘(xiv) Funding home health providers who offer 

chronic care management services to applicable individuals in cooperation with interdisciplinary teams. 
309 Sec. 3021 PPACA (Consolidated) \1115A SSA 

‘‘(xv) Promoting improved quality and reduced cost 

by developing a collaborative of high-quality, low-cost 

health care institutions that is responsible for— 

‘‘(I) developing, documenting, and disseminating best practices and proven care methods; 

‘‘(II) implementing such best practices and 

proven care methods within such institutions to 

demonstrate further improvements in quality and 

efficiency; and 

‘‘(III) providing assistance to other health care 

institutions on how best to employ such best practices and proven care methods to improve health 

care quality and lower costs. 

‘‘(xvi) Facilitate inpatient care, including intensive 

care, of hospitalized applicable individuals at their 

local hospital through the use of electronic monitoring 

by specialists, including intensivists and critical care 

specialists, based at integrated health systems. 

‘‘(xvii) Promoting greater efficiencies and timely 

access to outpatient services (such as outpatient physical therapy services) through models that do not require a physician or other health professional to refer 

the service or be involved in establishing the plan of 

care for the service, when such service is furnished by 

a health professional who has the authority to furnish 

the service under existing State law. 

‘‘(xviii) Establishing comprehensive payments to 

Healthcare Innovation Zones, consisting of groups of 

providers that include a teaching hospital, physicians, 

and other clinical entities, that, through their structure, operations, and joint-activity deliver a full spectrum of integrated and comprehensive health care 

services to applicable individuals while also incorporating innovative methods for the clinical training of 

future health care professionals. 

øClauses (xix) and (xx) added by section 10306(2)(B)¿ 

‘‘(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 
Sec. 3021\1115A SSA PPACA (Consolidated) 310 

Demonstration Project under section 4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b–1 note). 

‘‘(C) ADDITIONAL FACTORS FOR CONSIDERATION.—In selecting models for testing under subparagraph (A), the 

CMI may consider the following additional factors: 

‘‘(i) Whether the model includes a regular process 

for monitoring and updating patient care plans in a 

manner that is consistent with the needs and preferences of applicable individuals. 

‘‘(ii) Whether the model places the applicable individual, including family members and other informal 

caregivers of the applicable individual, at the center of 

the care team of the applicable individual. 

‘‘(iii) Whether the model provides for in-person 

contact with applicable individuals. 

‘‘(iv) Whether the model utilizes technology, such 

as electronic health records and patient-based remote 

monitoring systems, to coordinate care over time and 

across settings. 

‘‘(v) Whether the model provides for the maintenance of a close relationship between care coordinators, primary care practitioners, specialist physicians, 

community-based organizations, and other providers of 

services and suppliers. 

‘‘(vi) Whether the model relies on a team-based 

approach to interventions, such as comprehensive care 

assessments, care planning, and self-management 

coaching. 

‘‘(vii) Whether, under the model, providers of services and suppliers are able to share information with 

patients, caregivers, and other providers of services 

and suppliers on a real time basis. 

‘‘(viii) øAs added by section 10306(2)(C)¿ Whether 

the model demonstrates effective linkage with other 

public sector or private sector payers. 

‘‘(3) BUDGET NEUTRALITY.— 

‘‘(A) INITIAL PERIOD.—The Secretary shall not require, 

as a condition for testing a model under paragraph (1), 

that the design of such model ensure that such model is 

budget neutral initially with respect to expenditures under 

the applicable title. 

‘‘(B) TERMINATION OR MODIFICATION.—The Secretary 

shall terminate or modify the design and implementation 

of a model unless the Secretary determines (and the Chief 

Actuary of the Centers for Medicare & Medicaid Services, 

with respect to program spending under the applicable 

title, certifies), after testing has begun, that the model is 

expected to— 

‘‘(i) improve the quality of care (as determined by 

the Administrator of the Centers for Medicare & Medicaid Services) without increasing spending under the 

applicable title; 

‘‘(ii) reduce spending under the applicable title 

without reducing the quality of care; or 
311 Sec. 3021 PPACA (Consolidated) \1115A SSA 

‘‘(iii) improve the quality of care and reduce 

spending. 

Such termination may occur at any time after such testing 

has begun and before completion of the testing. 

‘‘(4) EVALUATION.— 

‘‘(A) IN GENERAL.—The Secretary shall conduct an 

evaluation of each model tested under this subsection. 

Such evaluation shall include an analysis of— 

‘‘(i) the quality of care furnished under the model, 

including the measurement of patient-level outcomes 

and patient-centeredness criteria determined appropriate by the Secretary; and 

‘‘(ii) the changes in spending under the applicable 

titles by reason of the model. 

‘‘(B) INFORMATION.—The Secretary shall make the results of each evaluation under this paragraph available to 

the public in a timely fashion and may establish requirements for States and other entities participating in the 

testing of models under this section to collect and report 

information that the Secretary determines is necessary to 

monitor and evaluate such models. 

‘‘(C) MEASURE SELECTION.—øAs added by section 

10306(3)¿ 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). 

‘‘(c) EXPANSION OF MODELS (PHASE II).—Taking into account 

the evaluation under subsection (b)(4), the Secretary may, through 

rulemaking, expand (including implementation on a nationwide 

basis) the duration and the scope of a model that is being tested 

under subsection (b) or a demonstration project under section 

1866C, to the extent determined appropriate by the Secretary, if— 

øAs revised by section 10306(4)¿ 

‘‘(1) the Secretary determines that such expansion is expected to— 

‘‘(A) reduce spending under applicable title without reducing the quality of care; or 

‘‘(B) improve the quality of patient care without increasing spending; 

‘‘(2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce (or 

would not result in any increase in) net program spending 

under applicable titles; and 

øParagraph (3) and succeeding sentence added by section 

10306(4)¿ 

‘‘(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. 

‘‘(d) IMPLEMENTATION.— 
Sec. 3021\1115A SSA PPACA (Consolidated) 312 

‘‘(1) WAIVER AUTHORITY.—The Secretary may waive such 

requirements of titles XI and XVIII and of sections 1902(a)(1), 

1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary solely 

for purposes of carrying out this section with respect to testing 

models described in subsection (b). 

‘‘(2) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or 

otherwise of— 

‘‘(A) the selection of models for testing or expansion 

under this section; 

‘‘(B) the selection of organizations, sites, or participants to test those models selected; 

‘‘(C) the elements, parameters, scope, and duration of 

such models for testing or dissemination; 

‘‘(D) determinations regarding budget neutrality under 

subsection (b)(3); 

‘‘(E) the termination or modification of the design and 

implementation of a model under subsection (b)(3)(B); and 

‘‘(F) determinations about expansion of the duration 

and scope of a model under subsection (c), including the 

determination that a model is not expected to meet criteria 

described in paragraph (1) or (2) of such subsection. 

‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, United 

States Code, shall not apply to the testing and evaluation of 

models or expansion of such models under this section. 

‘‘(e) APPLICATION TO CHIP.—The Center may carry out activities under this section with respect to title XXI in the same manner as provided under this section with respect to the program 

under the applicable titles. 

‘‘(f) FUNDING.— 

‘‘(1) IN GENERAL.—There are appropriated, from amounts 

in the Treasury not otherwise appropriated— 

‘‘(A) $5,000,000 for the design, implementation, and 

evaluation of models under subsection (b) for fiscal year 

2010; 

‘‘(B) $10,000,000,000 for the activities initiated under 

this section for the period of fiscal years 2011 through 

2019; and 

‘‘(C) the amount described in subparagraph (B) for the 

activities initiated under this section for each subsequent 

10-year fiscal period (beginning with the 10-year fiscal period beginning with fiscal year 2020). 

Amounts appropriated under the preceding sentence shall remain available until expended. 

‘‘(2) USE OF CERTAIN FUNDS.—Out of amounts appropriated 

under subparagraphs (B) and (C) of paragraph (1), not less 

than $25,000,000 shall be made available each such fiscal year 

to design, implement, and evaluate models under subsection 

(b). 

‘‘(g) REPORT TO CONGRESS.—Beginning in 2012, and not less 

than once every other year thereafter, the Secretary shall submit 

to Congress a report on activities under this section. Each such report shall describe the models tested under subsection (b), including the number of individuals described in subsection (a)(4)(A)(i) 
313 Sec. 3022 PPACA (Consolidated) \1899 SSA 

and of individuals described in subsection (a)(4)(A)(ii) participating 

in such models and payments made under applicable titles for services on behalf of such individuals, any models chosen for expansion 

under subsection (c), and the results from evaluations under subsection (b)(4). In addition, each such report shall provide such recommendations as the Secretary determines are appropriate for legislative action to facilitate the development and expansion of successful payment models.’’. 

(b) MEDICAID CONFORMING AMENDMENT.—Section 1902(a) of 

the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 

8002(b), is amended— 

(1) in paragraph (81), by striking ‘‘and’’ at the end; 

(2) in paragraph (82), by striking the period at the end and 

inserting ‘‘; and’’; and 

(3) by inserting after paragraph (82) the following new 

paragraph: 

‘‘(83) provide for implementation of the payment models 

specified by the Secretary under section 1115A(c) for implementation on a nationwide basis unless the State demonstrates 

to the satisfaction of the Secretary that implementation would 

not be administratively feasible or appropriate to the health 

care delivery system of the State.’’. 

(c) REVISIONS TO HEALTH CARE QUALITY DEMONSTRATION PROGRAM.—Subsections (b) and (f) of section 1866C of the Social Security Act (42 U.S.C. 1395cc–3) are amended by striking ‘‘5-year’’ 

each place it appears. 

SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM. 

Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) 

is amended by adding at the end the following new section: 

‘‘SHARED SAVINGS PROGRAM

‘‘SEC. 1899. ø42 U.S.C. 1395jjj¿ (a) ESTABLISHMENT.— 

‘‘(1) IN GENERAL.—Not later than January 1, 2012, the Secretary shall establish a shared savings program (in this section 

referred to as the ‘program’) that promotes accountability for a 

patient population and coordinates items and services under 

parts A and B, and encourages investment in infrastructure 

and redesigned care processes for high quality and efficient 

service delivery. Under such program— 

‘‘(A) groups of providers of services and suppliers 

meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-forservice beneficiaries through an accountable care organization (referred to in this section as an ‘ACO’); and 

‘‘(B) ACOs that meet quality performance standards 

established by the Secretary are eligible to receive payments for shared savings under subsection (d)(2). 

‘‘(b) ELIGIBLE ACOS.— 

‘‘(1) IN GENERAL.—Subject to the succeeding provisions of 

this subsection, as determined appropriate by the Secretary, 

the following groups of providers of services and suppliers 

which have established a mechanism for shared governance 
Sec. 3022\1899 SSA PPACA (Consolidated) 314 

are eligible to participate as ACOs under the program under 

this section: 

‘‘(A) ACO professionals in group practice arrangements. 

‘‘(B) Networks of individual practices of ACO professionals. 

‘‘(C) Partnerships or joint venture arrangements between hospitals and ACO professionals. 

‘‘(D) Hospitals employing ACO professionals. 

‘‘(E) Such other groups of providers of services and 

suppliers as the Secretary determines appropriate. 

‘‘(2) REQUIREMENTS.—An ACO shall meet the following requirements: 

‘‘(A) The ACO shall be willing to become accountable 

for the quality, cost, and overall care of the Medicare feefor-service beneficiaries assigned to it. 

‘‘(B) The ACO shall enter into an agreement with the 

Secretary to participate in the program for not less than 

a 3-year period (referred to in this section as the ‘agreement period’). 

‘‘(C) The ACO shall have a formal legal structure that 

would allow the organization to receive and distribute payments for shared savings under subsection (d)(2) to participating providers of services and suppliers. 

‘‘(D) The ACO shall include primary care ACO professionals that are sufficient for the number of Medicare feefor-service beneficiaries assigned to the ACO under subsection (c). At a minimum, the ACO shall have at least 

5,000 such beneficiaries assigned to it under subsection (c) 

in order to be eligible to participate in the ACO program. 

‘‘(E) The ACO shall provide the Secretary with such 

information regarding ACO professionals participating in 

the ACO as the Secretary determines necessary to support 

the assignment of Medicare fee-for-service beneficiaries to 

an ACO, the implementation of quality and other reporting 

requirements under paragraph (3), and the determination 

of payments for shared savings under subsection (d)(2). 

‘‘(F) The ACO shall have in place a leadership and 

management structure that includes clinical and administrative systems. 

‘‘(G) The ACO shall define processes to promote evidence-based medicine and patient engagement, report on 

quality and cost measures, and coordinate care, such as 

through the use of telehealth, remote patient monitoring, 

and other such enabling technologies. 

‘‘(H) The ACO shall demonstrate to the Secretary that 

it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans. 

‘‘(3) QUALITY AND OTHER REPORTING REQUIREMENTS.— 

‘‘(A) IN GENERAL.—The Secretary shall determine appropriate measures to assess the quality of care furnished 

by the ACO, such as measures of— 

‘‘(i) clinical processes and outcomes; 
315 Sec. 3022 PPACA (Consolidated) \1899 SSA 

‘‘(ii) patient and, where practicable, caregiver experience of care; and 

‘‘(iii) utilization (such as rates of hospital admissions for ambulatory care sensitive conditions). 

‘‘(B) REPORTING REQUIREMENTS.—An ACO shall submit data in a form and manner specified by the Secretary 

on measures the Secretary determines necessary for the 

ACO to report in order to evaluate the quality of care furnished by the ACO. Such data may include care transitions across health care settings, including hospital discharge planning and post-hospital discharge follow-up by 

ACO professionals, as the Secretary determines appropriate. 

‘‘(C) QUALITY PERFORMANCE STANDARDS.—The Secretary shall establish quality performance standards to assess the quality of care furnished by ACOs. The Secretary 

shall seek to improve the quality of care furnished by 

ACOs over time by specifying higher standards, new measures, or both for purposes of assessing such quality of care. 

‘‘(D) OTHER REPORTING REQUIREMENTS.—The Secretary 

may, as the Secretary determines appropriate, incorporate 

reporting requirements and incentive payments related to 

the physician quality reporting initiative (PQRI) under section 1848, including such requirements and such payments 

related to electronic prescribing, electronic health records, 

and other similar initiatives under section 1848, and may 

use alternative criteria than would otherwise apply under 

such section for determining whether to make such payments. The incentive payments described in the preceding 

sentence shall not be taken into consideration when calculating any payments otherwise made under subsection (d). 

‘‘(4) NO DUPLICATION IN PARTICIPATION IN SHARED SAVINGS

PROGRAMS.—A provider of services or supplier that participates 

in any of the following shall not be eligible to participate in an 

ACO under this section: 

‘‘(A) A model tested or expanded under section 1115A 

that involves shared savings under this title, or any other 

program or demonstration project that involves such 

shared savings. 

‘‘(B) The independence at home medical practice pilot 

program under section 1866E. 

‘‘(c) ASSIGNMENT OF MEDICARE FEE-FOR-SERVICE BENEFICIARIES

TO ACOS.—The Secretary shall determine an appropriate method 

to assign Medicare fee-for-service beneficiaries to an ACO based on 

their utilization of primary care services provided under this title 

by an ACO professional described in subsection (h)(1)(A). 

‘‘(d) PAYMENTS AND TREATMENT OF SAVINGS.— 

‘‘(1) PAYMENTS.— 

‘‘(A) IN GENERAL.—Under the program, subject to 

paragraph (3), payments shall continue to be made to providers of services and suppliers participating in an ACO 

under the original Medicare fee-for-service program under 

parts A and B in the same manner as they would otherwise be made except that a participating ACO is eligible 
Sec. 3022\1899 SSA PPACA (Consolidated) 316 

to receive payment for shared savings under paragraph (2) 

if— 

‘‘(i) the ACO meets quality performance standards 

established by the Secretary under subsection (b)(3); 

and 

‘‘(ii) the ACO meets the requirement under subparagraph (B)(i). 

‘‘(B) SAVINGS REQUIREMENT AND BENCHMARK.— ‘‘(i) DETERMINING SAVINGS.—In each year of the 

agreement period, an ACO shall be eligible to receive 

payment for shared savings under paragraph (2) only 

if the estimated average per capita Medicare expenditures under the ACO for Medicare fee-for-service beneficiaries for parts A and B services, adjusted for beneficiary characteristics, is at least the percent specified 

by the Secretary below the applicable benchmark 

under clause (ii). The Secretary shall determine the 

appropriate percent described in the preceding sentence to account for normal variation in expenditures 

under this title, based upon the number of Medicare 

fee-for-service beneficiaries assigned to an ACO. 

‘‘(ii) ESTABLISH AND UPDATE BENCHMARK.—The 

Secretary shall estimate a benchmark for each agreement period for each ACO using the most recent available 3 years of per-beneficiary expenditures for parts 

A and B services for Medicare fee-for-service beneficiaries assigned to the ACO. Such benchmark shall 

be adjusted for beneficiary characteristics and such 

other factors as the Secretary determines appropriate 

and updated by the projected absolute amount of 

growth in national per capita expenditures for parts A 

and B services under the original Medicare fee-forservice program, as estimated by the Secretary. Such 

benchmark shall be reset at the start of each agreement period. 

‘‘(2) PAYMENTS FOR SHARED SAVINGS.—Subject to performance with respect to the quality performance standards established by the Secretary under subsection (b)(3), if an ACO 

meets the requirements under paragraph (1), a percent (as determined appropriate by the Secretary) of the difference between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, under 

the ACO and such benchmark for the ACO may be paid to the 

ACO as shared savings and the remainder of such difference 

shall be retained by the program under this title. The Secretary shall establish limits on the total amount of shared savings that may be paid to an ACO under this paragraph. 

‘‘(3) MONITORING AVOIDANCE OF AT-RISK PATIENTS.—If the 

Secretary determines that an ACO has taken steps to avoid patients at risk in order to reduce the likelihood of increasing 

costs to the ACO the Secretary may impose an appropriate 

sanction on the ACO, including termination from the program. 

‘‘(4) TERMINATION.—The Secretary may terminate an 

agreement with an ACO if it does not meet the quality per-
317 Sec. 3022 PPACA (Consolidated) \1899 SSA 

formance standards established by the Secretary under subsection (b)(3). 

‘‘(e) ADMINISTRATION.—Chapter 35 of title 44, United States 

Code, shall not apply to the program. 

‘‘(f) WAIVER AUTHORITY.—The Secretary may waive such requirements of sections 1128A and 1128B and title XVIII of this Act 

as may be necessary to carry out the provisions of this section. 

‘‘(g) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of— 

‘‘(1) the specification of criteria under subsection (a)(1)(B); 

‘‘(2) the assessment of the quality of care furnished by an 

ACO and the establishment of performance standards under 

subsection (b)(3); 

‘‘(3) the assignment of Medicare fee-for-service beneficiaries to an ACO under subsection (c); 

‘‘(4) the determination of whether an ACO is eligible for 

shared savings under subsection (d)(2) and the amount of such 

shared savings, including the determination of the estimated 

average per capita Medicare expenditures under the ACO for 

Medicare fee-for-service beneficiaries assigned to the ACO and 

the average benchmark for the ACO under subsection (d)(1)(B); 

‘‘(5) the percent of shared savings specified by the Secretary under subsection (d)(2) and any limit on the total 

amount of shared savings established by the Secretary under 

such subsection; and 

‘‘(6) the termination of an ACO under subsection (d)(4). 

‘‘(h) DEFINITIONS.—In this section: 

‘‘(1) ACO PROFESSIONAL.—The term ‘ACO professional’ 

means— 

‘‘(A) a physician (as defined in section 1861(r)(1)); and 

‘‘(B) a practitioner described in section 

1842(b)(18)(C)(i). 

‘‘(2) HOSPITAL.—The term ‘hospital’ means a subsection (d) 

hospital (as defined in section 1886(d)(1)(B)). 

‘‘(3) MEDICARE FEE-FOR-SERVICE BENEFICIARY.—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 and is not enrolled in an MA plan under 

part C, an eligible organization under section 1876, or a PACE 

program under section 1894. 

øSubsections (i)-(k) added by section 10307¿ 

‘‘(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 
Sec. 3023 PPACA (Consolidated) 318 

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. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING. 

Title XVIII of the Social Security Act, as amended by section 

3021, is amended by inserting after section 1866C the following 

new section: øAs revised by section 10308(b)(1)¿ 

‘‘NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING

‘‘SEC. 1866D. ø42 U.S.C. 1395cc–4¿ (a) IMPLEMENTATION.— 

‘‘(1) IN GENERAL.—The Secretary shall establish a pilot 

program for integrated care during an episode of care provided 

to an applicable beneficiary around a hospitalization in order 

to improve the coordination, quality, and efficiency of health 

care services under this title. 

‘‘(2) DEFINITIONS.—In this section: 

‘‘(A) APPLICABLE BENEFICIARY.—The term ‘applicable 

beneficiary’ means an individual who— 

‘‘(i) is entitled to, or enrolled for, benefits under 

part A and enrolled for benefits under part B of such 

title, but not enrolled under part C or a PACE program under section 1894; and 

‘‘(ii) is admitted to a hospital for an applicable 

condition. 

‘‘(B) APPLICABLE CONDITION.—The term ‘applicable 

condition’ means 1 or more of 10 conditions selected by the 
319 Sec. 3023 PPACA (Consolidated) \1866D SSA 

Secretary. In selecting conditions under the preceding sentence, the Secretary shall take into consideration the following factors: øAs revised by section 10308(a)(1)¿ 

‘‘(i) Whether the conditions selected include a mix 

of chronic and acute conditions. 

‘‘(ii) Whether the conditions selected include a mix 

of surgical and medical conditions. 

‘‘(iii) Whether a condition is one for which there is 

evidence of an opportunity for providers of services 

and suppliers to improve the quality of care furnished 

while reducing total expenditures under this title. 

‘‘(iv) Whether a condition has significant variation 

in— 

‘‘(I) the number of readmissions; and 

‘‘(II) the amount of expenditures for postacute care spending under this title. 

‘‘(v) Whether a condition is high-volume and has 

high post-acute care expenditures under this title. 

‘‘(vi) Which conditions the Secretary determines 

are most amenable to bundling across the spectrum of 

care given practice patterns under this title. 

‘‘(C) APPLICABLE SERVICES.—The term ‘applicable services’ means the following: 

‘‘(i) Acute care inpatient services. 

‘‘(ii) Physicians’ services delivered in and outside 

of an acute care hospital setting. 

‘‘(iii) Outpatient hospital services, including emergency department services. 

‘‘(iv) Post-acute care services, including home 

health services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services 

furnished by a long-term care hospital. 

‘‘(v) Other services the Secretary determines appropriate. 

‘‘(D) EPISODE OF CARE.— 

‘‘(i) IN GENERAL.—Subject to clause (ii), the term 

‘episode of care’ means, with respect to an applicable 

condition and an applicable beneficiary, the period 

that includes— 

‘‘(I) the 3 days prior to the admission of the 

applicable beneficiary to a hospital for the applicable condition; 

‘‘(II) the length of stay of the applicable beneficiary in such hospital; and 

‘‘(III) the 30 days following the discharge of 

the applicable beneficiary from such hospital. 

‘‘(ii) ESTABLISHMENT OF PERIOD BY THE SECRETARY.—The Secretary, as appropriate, may establish 

a period (other than the period described in clause (i)) 

for an episode of care under the pilot program. 

‘‘(E) PHYSICIANS’ SERVICES.—The term ‘physicians’ 

services’ has the meaning given such term in section 

1861(q). 
Sec. 3023\1866D SSA PPACA (Consolidated) 320 

‘‘(F) PILOT PROGRAM.—The term ‘pilot program’ means 

the pilot program under this section. 

‘‘(G) PROVIDER OF SERVICES.—The term ‘provider of 

services’ has the meaning given such term in section 

1861(u). 

‘‘(H) READMISSION.—The term ‘readmission’ has the 

meaning given such term in section 1886(q)(5)(E). 

‘‘(I) SUPPLIER.—The term ‘supplier’ has the meaning 

given such term in section 1861(d). 

‘‘(3) DEADLINE FOR IMPLEMENTATION.—The Secretary shall 

establish the pilot program not later than January 1, 2013. 

‘‘(b) DEVELOPMENTAL PHASE.— ‘‘(1) DETERMINATION OF PATIENT ASSESSMENT INSTRU- MENT.—The Secretary shall determine which patient assessment instrument (such as the Continuity Assessment Record 

and Evaluation (CARE) tool) shall be used under the pilot program to evaluate the applicable condition of an applicable beneficiary for purposes of determining the most clinically appropriate site for the provision of post-acute care to the applicable 

beneficiary. 

‘‘(2) DEVELOPMENT OF QUALITY MEASURES FOR AN EPISODE

OF CARE AND FOR POST-ACUTE CARE.— ‘‘(A) IN GENERAL.—The Secretary, in consultation with 

the Agency for Healthcare Research and Quality and the 

entity with a contract under section 1890(a) of the Social 

Security Act, shall develop quality measures for use in the 

pilot program— 

‘‘(i) for episodes of care; and 

‘‘(ii) for post-acute care. 

‘‘(B) SITE-NEUTRAL POST-ACUTE CARE QUALITY MEASURES.—Any quality measures developed under subparagraph (A)(ii) shall be site-neutral. 

‘‘(C) COORDINATION WITH QUALITY MEASURE DEVELOPMENT AND ENDORSEMENT PROCEDURES.—The Secretary 

shall ensure that the development of quality measures 

under subparagraph (A) is done in a manner that is consistent with the measures developed and endorsed under 

section 1890 and 1890A that are applicable to all postacute care settings. 

‘‘(c) DETAILS.— 

‘‘(1) DURATION.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

pilot program shall be conducted for a period of 5 years. 

‘‘(B) EXPANSION.—øReplaced by section 10308(a)(2)¿ 

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; 
321 Sec. 3023 PPACA (Consolidated) \1866D SSA 

‘‘(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. 

‘‘(2) PARTICIPATING PROVIDERS OF SERVICES AND SUPPLIERS.— 

‘‘(A) IN GENERAL.—An entity comprised of providers of 

services and suppliers, including a hospital, a physician 

group, a skilled nursing facility, and a home health agency, who are otherwise participating under this title, may 

submit an application to the Secretary to provide applicable services to applicable individuals under this section. 

‘‘(B) REQUIREMENTS.—The Secretary shall develop requirements for entities to participate in the pilot program 

under this section. Such requirements shall ensure that 

applicable beneficiaries have an adequate choice of providers of services and suppliers under the pilot program. 

‘‘(3) PAYMENT METHODOLOGY.— 

‘‘(A) IN GENERAL.— 

‘‘(i) ESTABLISHMENT OF PAYMENT METHODS.—The 

Secretary shall develop payment methods for the pilot 

program for entities participating in the pilot program. 

Such payment methods may include bundled payments and bids from entities for episodes of care. The 

Secretary shall make payments to the entity for services covered under this section. 

‘‘(ii) NO ADDITIONAL PROGRAM EXPENDITURES.— 

Payments under this section for applicable items and 

services under this title (including payment for services described in subparagraph (B)) for applicable 

beneficiaries for a year shall be established in a manner that does not result in spending more for such entity for such beneficiaries than would otherwise be expended for such entity for such beneficiaries for such 

year if the pilot program were not implemented, as estimated by the Secretary. 

‘‘(B) INCLUSION OF CERTAIN SERVICES.—A payment 

methodology tested under the pilot program shall include 

payment for the furnishing of applicable services and other 

appropriate services, such as care coordination, medication 

reconciliation, discharge planning, transitional care services, and other patient-centered activities as determined 

appropriate by the Secretary. 

‘‘(C) BUNDLED PAYMENTS.— 

‘‘(i) IN GENERAL.—A bundled payment under the 

pilot program shall— 

‘‘(I) be comprehensive, covering the costs of 

applicable services and other appropriate services 

furnished to an individual during an episode of 

care (as determined by the Secretary); and 
Sec. 3023\1866D SSA PPACA (Consolidated) 322 

‘‘(II) be made to the entity which is participating in the pilot program. 

‘‘(ii) REQUIREMENT FOR PROVISION OF APPLICABLE

SERVICES AND OTHER APPROPRIATE SERVICES.—Applicable services and other appropriate services for which 

payment is made under this subparagraph shall be 

furnished or directed by the entity which is participating in the pilot program. 

‘‘(D) PAYMENT FOR POST-ACUTE CARE SERVICES AFTER

THE EPISODE OF CARE.—The Secretary shall establish procedures, in the case where an applicable beneficiary requires continued post-acute care services after the last day 

of the episode of care, under which payment for such services shall be made. 

‘‘(4) QUALITY MEASURES.— 

‘‘(A) IN GENERAL.—The Secretary shall establish quality measures (including quality measures of process, outcome, and structure) related to care provided by entities 

participating in the pilot program. Quality measures established under the preceding sentence shall include measures of the following: 

‘‘(i) Functional status improvement. 

‘‘(ii) Reducing rates of avoidable hospital readmissions. 

‘‘(iii) Rates of discharge to the community. 

‘‘(iv) Rates of admission to an emergency room 

after a hospitalization. 

‘‘(v) Incidence of health care acquired infections. 

‘‘(vi) Efficiency measures. 

‘‘(vii) Measures of patient-centeredness of care. 

‘‘(viii) Measures of patient perception of care. 

‘‘(ix) Other measures, including measures of patient outcomes, determined appropriate by the Secretary. 

‘‘(B) REPORTING ON QUALITY MEASURES.— 

‘‘(i) IN GENERAL.—A entity shall submit data to 

the Secretary on quality measures established under 

subparagraph (A) during each year of the pilot program (in a form and manner, subject to clause (iii), 

specified by the Secretary). 

‘‘(ii) SUBMISSION OF DATA THROUGH ELECTRONIC

HEALTH RECORD.—To the extent practicable, the Secretary shall specify that data on measures be submitted under clause (i) through the use of an qualified 

electronic health record (as defined in section 3000(13) 

of the Public Health Service Act (42 U.S.C. 300jj– 

11(13)) in a manner specified by the Secretary. 

‘‘(d) WAIVER.—The Secretary may waive such provisions of this 

title and title XI as may be necessary to carry out the pilot program. 

‘‘(e) INDEPENDENT EVALUATION AND REPORTS ON PILOT PROGRAM.— 
323 Sec. 3023 PPACA (Consolidated) \1866D SSA 

‘‘(1) INDEPENDENT EVALUATION.—The Secretary shall conduct an independent evaluation of the pilot program, including 

the extent to which the pilot program has— 

‘‘(A) improved quality measures established under subsection (c)(4)(A); 

‘‘(B) improved health outcomes; 

‘‘(C) improved applicable beneficiary access to care; 

and 

‘‘(D) reduced spending under this title. 

‘‘(2) REPORTS.— ‘‘(A) INTERIM REPORT.—Not later than 2 years after 

the implementation of the pilot program, the Secretary 

shall submit to Congress a report on the initial results of 

the independent evaluation conducted under paragraph 

(1). 

‘‘(B) FINAL REPORT.—Not later than 3 years after the 

implementation of the pilot program, the Secretary shall 

submit to Congress a report on the final results of the 

independent evaluation conducted under paragraph (1). 

‘‘(f) CONSULTATION.—The Secretary shall consult with representatives of small rural hospitals, including critical access hospitals (as defined in section 1861(mm)(1)), regarding their participation in the pilot program. Such consultation shall include consideration of innovative methods of implementing bundled payments 

in hospitals described in the preceding sentence, taking into consideration any difficulties in doing so as a result of the low volume 

of services provided by such hospitals. 

‘‘(g) APPLICATION OF PILOT PROGRAM TO CONTINUING CARE

HOSPITALS.—øReplaced by section 10308(a)(3)¿ 

‘‘(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 section 1886(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). 

‘‘(h) ADMINISTRATION.—Chapter 35 of title 44, United States 

Code, shall not apply to the selection, testing, and evaluation of 

models or the expansion of such models under this section.’’. 
Sec. 3024 PPACA (Consolidated) 324 

SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM. 

Title XVIII of the Social Security Act is amended by inserting 

after section 1866D, as inserted by section 3023, the following new 

section: øAs revised by section 10308(b)(2)¿ 

‘‘INDEPENDENCE AT HOME MEDICAL PRACTICE DEMONSTRATION

PROGRAM

‘‘SEC. 1866E. ø42 U.S.C. 1395cc–5¿ (a) ESTABLISHMENT.— ‘‘(1) IN GENERAL.—The Secretary shall conduct a demonstration program (in this section referred to as the ‘demonstration program’) to test a payment incentive and service 

delivery model that utilizes physician and nurse practitioner 

directed home-based primary care teams designed to reduce expenditures and improve health outcomes in the provision of 

items and services under this title to applicable beneficiaries 

(as defined in subsection (d)). 

‘‘(2) REQUIREMENT.—The demonstration program shall test 

whether a model described in paragraph (1), which is accountable for providing comprehensive, coordinated, continuous, and 

accessible care to high-need populations at home and coordinating health care across all treatment settings, results in— 

‘‘(A) reducing preventable hospitalizations; 

‘‘(B) preventing hospital readmissions; 

‘‘(C) reducing emergency room visits; 

‘‘(D) improving health outcomes commensurate with 

the beneficiaries’ stage of chronic illness; 

‘‘(E) improving the efficiency of care, such as by reducing duplicative diagnostic and laboratory tests; 

‘‘(F) reducing the cost of health care services covered 

under this title; and 

‘‘(G) achieving beneficiary and family caregiver satisfaction. 

‘‘(b) INDEPENDENCE AT HOME MEDICAL PRACTICE.— 

‘‘(1) INDEPENDENCE AT HOME MEDICAL PRACTICE DEFINED.—In this section: 

‘‘(A) IN GENERAL.—The term ‘independence at home 

medical practice’ means a legal entity that— 

‘‘(i) is comprised of an individual physician or 

nurse practitioner or group of physicians and nurse 

practitioners that provides care as part of a team that 

includes physicians, nurses, physician assistants, 

pharmacists, and other health and social services staff 

as appropriate who have experience providing homebased primary care to applicable beneficiaries, make 

in-home visits, and are available 24 hours per day, 7 

days per week to carry out plans of care that are tailored to the individual beneficiary’s chronic conditions 

and designed to achieve the results in subsection (a); 

‘‘(ii) is organized at least in part for the purpose 

of providing physicians’ services; 

‘‘(iii) has documented experience in providing 

home-based primary care services to high-cost chronically ill beneficiaries, as determined appropriate by 

the Secretary; 
325 Sec. 3024 PPACA (Consolidated) \1866E SSA 

‘‘(iv) furnishes services to at least 200 applicable 

beneficiaries (as defined in subsection (d)) during each 

year of the demonstration program; 

‘‘(v) has entered into an agreement with the Secretary; 

‘‘(vi) uses electronic health information systems, 

remote monitoring, and mobile diagnostic technology; 

and 

‘‘(vii) meets such other criteria as the Secretary 

determines to be appropriate to participate in the 

demonstration program. 

The entity shall report on quality measures (in such form, 

manner, and frequency as specified by the Secretary, 

which may be for the group, for providers of services and 

suppliers, or both) and report to the Secretary (in a form, 

manner, and frequency as specified by the Secretary) such 

data as the Secretary determines appropriate to monitor 

and evaluate the demonstration program. 

‘‘(B) PHYSICIAN.—The term ‘physician’ includes, except 

as the Secretary may otherwise provide, any individual 

who furnishes services for which payment may be made as 

physicians’ services and has the medical training or experience to fulfill the physician’s role described in subparagraph (A)(i). 

‘‘(2) PARTICIPATION OF NURSE PRACTITIONERS AND PHYSI- CIAN ASSISTANTS.—Nothing in this section shall be construed to 

prevent a nurse practitioner or physician assistant from participating in, or leading, a home-based primary care team as 

part of an independence at home medical practice if— 

‘‘(A) all the requirements of this section are met; 

‘‘(B) the nurse practitioner or physician assistant, as 

the case may be, is acting consistent with State law; and 

‘‘(C) the nurse practitioner or physician assistant has 

the medical training or experience to fulfill the nurse practitioner or physician assistant role described in paragraph 

(1)(A)(i). 

‘‘(3) INCLUSION OF PROVIDERS AND PRACTITIONERS.—Nothing in this subsection shall be construed as preventing an independence at home medical practice from including a provider 

of services or a participating practitioner described in section 

1842(b)(18)(C) that is affiliated with the practice under an arrangement structured so that such provider of services or practitioner participates in the demonstration program and shares 

in any savings under the demonstration program. 

‘‘(4) QUALITY AND PERFORMANCE STANDARDS.—The Secretary shall develop quality performance standards for independence at home medical practices participating in the demonstration program. 

‘‘(c) PAYMENT METHODOLOGY.— 

‘‘(1) ESTABLISHMENT OF TARGET SPENDING LEVEL.—The 

Secretary shall establish an estimated annual spending target, 

for the amount the Secretary estimates would have been spent 

in the absence of the demonstration, for items and services covered under parts A and B furnished to applicable beneficiaries 
Sec. 3024\1866E SSA PPACA (Consolidated) 326 

for each qualifying independence at home medical practice 

under this section. Such spending targets shall be determined 

on a per capita basis. Such spending targets shall include a 

risk corridor that takes into account normal variation in expenditures for items and services covered under parts A and B 

furnished to such beneficiaries with the size of the corridor 

being related to the number of applicable beneficiaries furnished services by each independence at home medical practice. The spending targets may also be adjusted for other factors as the Secretary determines appropriate. 

‘‘(2) INCENTIVE PAYMENTS.—Subject to performance on 

quality measures, a qualifying independence at home medical 

practice is eligible to receive an incentive payment under this 

section if actual expenditures for a year for the applicable 

beneficiaries it enrolls are less than the estimated spending 

target established under paragraph (1) for such year. An incentive payment for such year shall be equal to a portion (as determined by the Secretary) of the amount by which actual expenditures (including incentive payments under this paragraph) for applicable beneficiaries under parts A and B for 

such year are estimated to be less than 5 percent less than the 

estimated spending target for such year, as determined under 

paragraph (1). 

‘‘(d) APPLICABLE BENEFICIARIES.— 

‘‘(1) DEFINITION.—In this section, the term ‘applicable beneficiary’ means, with respect to a qualifying independence at 

home medical practice, an individual who the practice has determined— 

‘‘(A) is entitled to benefits under part A and enrolled 

for benefits under part B; 

‘‘(B) is not enrolled in a Medicare Advantage plan 

under part C or a PACE program under section 1894; 

‘‘(C) has 2 or more chronic illnesses, such as congestive 

heart failure, diabetes, other dementias designated by the 

Secretary, chronic obstructive pulmonary disease, ischemic 

heart disease, stroke, Alzheimer’s Disease and 

neurodegenerative diseases, and other diseases and conditions designated by the Secretary which result in high 

costs under this title; 

‘‘(D) within the past 12 months has had a nonelective 

hospital admission; 

‘‘(E) within the past 12 months has received acute or 

subacute rehabilitation services; 

‘‘(F) has 2 or more functional dependencies requiring 

the assistance of another person (such as bathing, dressing, toileting, walking, or feeding); and 

‘‘(G) meets such other criteria as the Secretary determines appropriate. 

‘‘(2) PATIENT ELECTION TO PARTICIPATE.—The Secretary 

shall determine an appropriate method of ensuring that applicable beneficiaries have agreed to enroll in an independence at 

home medical practice under the demonstration program. Enrollment in the demonstration program shall be voluntary. 
327 Sec. 3024 PPACA (Consolidated) \1866E SSA 

‘‘(3) BENEFICIARY ACCESS TO SERVICES.—Nothing in this 

section shall be construed as encouraging physicians or nurse 

practitioners to limit applicable beneficiary access to services 

covered under this title and applicable beneficiaries shall not 

be required to relinquish access to any benefit under this title 

as a condition of receiving services from an independence at 

home medical practice. 

‘‘(e) IMPLEMENTATION.— ‘‘(1) STARTING DATE.—The demonstration program shall 

begin no later than January 1, 2012. An agreement with an 

independence at home medical practice under the demonstration program may cover not more than a 3-year period. 

‘‘(2) NO PHYSICIAN DUPLICATION IN DEMONSTRATION PAR- TICIPATION.—The Secretary shall not pay an independence at 

home medical practice under this section that participates in 

section 1899. 

‘‘(3) NO BENEFICIARY DUPLICATION IN DEMONSTRATION PAR- TICIPATION.—The Secretary shall ensure that no applicable 

beneficiary enrolled in an independence at home medical practice under this section is participating in the programs under 

section 1899. 

‘‘(4) PREFERENCE.—In approving an independence at home 

medical practice, the Secretary shall give preference to practices that are— 

‘‘(A) located in high-cost areas of the country; 

‘‘(B) have experience in furnishing health care services 

to applicable beneficiaries in the home; and 

‘‘(C) use electronic medical records, health information 

technology, and individualized plans of care. 

‘‘(5) LIMITATION ON NUMBER OF PRACTICES.—In selecting 

qualified independence at home medical practices to participate under the demonstration program, the Secretary shall 

limit the number of such practices so that the number of applicable beneficiaries that may participate in the demonstration 

program does not exceed 10,000. 

‘‘(6) WAIVER.—The Secretary may waive such provisions of 

this title and title XI as the Secretary determines necessary in 

order to implement the demonstration program. 

‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, United 

States Code, shall not apply to this section. 

‘‘(f) EVALUATION AND MONITORING.— 

‘‘(1) IN GENERAL.—The Secretary shall evaluate each independence at home medical practice under the demonstration 

program to assess whether the practice achieved the results 

described in subsection (a). 

‘‘(2) MONITORING APPLICABLE BENEFICIARIES.—The Secretary may monitor data on expenditures and quality of services under this title after an applicable beneficiary discontinues 

receiving services under this title through a qualifying independence at home medical practice. 

‘‘(g) REPORTS TO CONGRESS.—The Secretary shall conduct an 

independent evaluation of the demonstration program and submit 

to Congress a final report, including best practices under the demonstration program. Such report shall include an analysis of the 
Sec. 3025 PPACA (Consolidated) 328 

demonstration program on coordination of care, expenditures under 

this title, applicable beneficiary access to services, and the quality 

of health care services provided to applicable beneficiaries. 

‘‘(h) FUNDING.—For purposes of administering and carrying out 

the demonstration program, other than for payments for items and 

services furnished under this title and incentive payments under 

subsection (c), in addition to funds otherwise appropriated, there 

shall be transferred to the Secretary for the Center for Medicare 

& Medicaid Services Program Management Account from the Federal Hospital Insurance Trust Fund under section 1817 and the 

Federal Supplementary Medical Insurance Trust Fund under section 1841 (in proportions determined appropriate by the Secretary) 

$5,000,000 for each of fiscal years 2010 through 2015. Amounts 

transferred under this subsection for a fiscal year shall be available 

until expended. 

‘‘(i) TERMINATION.— 

‘‘(1) MANDATORY TERMINATION.—The Secretary shall terminate an agreement with an independence at home medical 

practice if— 

‘‘(A) the Secretary estimates or determines that such 

practice will not receive an incentive payment for the second of 2 consecutive years under the demonstration program; or 

‘‘(B) such practice fails to meet quality standards during any year of the demonstration program. 

‘‘(2) PERMISSIVE TERMINATION.—The Secretary may terminate an agreement with an independence at home medical 

practice for such other reasons determined appropriate by the 

Secretary.’’. 

SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM. 

(a) IN GENERAL.—Section 1886 of the Social Security Act (42 

U.S.C. 1395ww), as amended by sections 3001 and 3008, is amended by adding at the end the following new subsection: 

‘‘(q) HOSPITAL READMISSIONS REDUCTION PROGRAM.— 

‘‘(1) IN GENERAL.—With respect to payment for discharges 

from an applicable hospital (as defined in paragraph (5)(C)) occurring during a fiscal year beginning on or after October 1, 

2012, in order to account for excess readmissions in the hospital, 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—øAs revised by section 10309¿ 

‘‘(A) the base operating DRG payment amount (as defined in paragraph (2)) for the discharge; and 

‘‘(B) the adjustment factor (described in paragraph 

(3)(A)) for the hospital for the fiscal year. 

‘‘(2) BASE OPERATING DRG PAYMENT AMOUNT DEFINED.— 

‘‘(A) IN GENERAL.—Except as provided in subparagraph (B), in this subsection, the term ‘base operating 

DRG payment amount’ means, with respect to a hospital 

for a fiscal year— 
329 Sec. 3025 PPACA (Consolidated) 

‘‘(i) the payment amount that would otherwise be 

made under subsection (d) (determined without regard 

to subsection (o)) for a discharge if this subsection did 

not apply; reduced by 

‘‘(ii) any portion of such payment amount that is 

attributable to payments under paragraphs (5)(A), 

(5)(B), (5)(F), and (12) of subsection (d). 

‘‘(B) SPECIAL RULES FOR CERTAIN HOSPITALS.— ‘‘(i) SOLE COMMUNITY HOSPITALS AND MEDICARE- DEPENDENT, SMALL RURAL HOSPITALS.—In the case of 

a medicare-dependent, small rural hospital (with respect to discharges occurring during fiscal years 2012 

and 2013) or a sole community hospital, in applying 

subparagraph (A)(i), the payment amount that would 

otherwise be made under subsection (d) shall be determined without regard to subparagraphs (I) and (L) of 

subsection (b)(3) and subparagraphs (D) and (G) of 

subsection (d)(5). 

‘‘(ii) HOSPITALS PAID UNDER SECTION 1814.—In the 

case of a hospital that is paid under section 1814(b)(3), 

the Secretary may exempt such hospitals provided 

that States paid under such section submit an annual 

report to the Secretary describing how a similar program in the State for a participating hospital or hospitals achieves or surpasses the measured results in 

terms of patient health outcomes and cost savings established herein with respect to this section. 

‘‘(3) ADJUSTMENT FACTOR.— ‘‘(A) IN GENERAL.—For purposes of paragraph (1), the 

adjustment factor under this paragraph for an applicable 

hospital for a fiscal year is equal to the greater of— 

‘‘(i) the ratio described in subparagraph (B) for the 

hospital for the applicable period (as defined in paragraph (5)(D)) for such fiscal year; or 

‘‘(ii) the floor adjustment factor specified in subparagraph (C). 

‘‘(B) RATIO.—The ratio described in this subparagraph 

for a hospital for an applicable period is equal to 1 minus 

the ratio of— 

‘‘(i) the aggregate payments for excess readmissions (as defined in paragraph (4)(A)) with respect to 

an applicable hospital for the applicable period; and 

‘‘(ii) the aggregate payments for all discharges (as 

defined in paragraph (4)(B)) with respect to such applicable hospital for such applicable period. 

‘‘(C) FLOOR ADJUSTMENT FACTOR.—For purposes of 

subparagraph (A), the floor adjustment factor specified in 

this subparagraph for— 

‘‘(i) fiscal year 2013 is 0.99; 

‘‘(ii) fiscal year 2014 is 0.98; or 

‘‘(iii) fiscal year 2015 and subsequent fiscal years 

is 0.97. 

‘‘(4) AGGREGATE PAYMENTS, EXCESS READMISSION RATIO DEFINED.—For purposes of this subsection: 
Sec. 3025 PPACA (Consolidated) 330 

‘‘(A) AGGREGATE PAYMENTS FOR EXCESS READMIS- SIONS.—The term ‘aggregate payments for excess readmissions’ means, for a hospital for an applicable period, the 

sum, for applicable conditions (as defined in paragraph 

(5)(A)), of the product, for each applicable condition, of— 

‘‘(i) the base operating DRG payment amount for 

such hospital for such applicable period for such condition; 

‘‘(ii) the number of admissions for such condition 

for such hospital for such applicable period; and 

‘‘(iii) the excess readmissions ratio (as defined in 

subparagraph (C)) for such hospital for such applicable 

period minus 1. 

‘‘(B) AGGREGATE PAYMENTS FOR ALL DISCHARGES.—The 

term ‘aggregate payments for all discharges’ means, for a 

hospital for an applicable period, the sum of the base operating DRG payment amounts for all discharges for all conditions from such hospital for such applicable period. 

‘‘(C) EXCESS READMISSION RATIO.— ‘‘(i) IN GENERAL.—Subject to clause (ii), the term 

‘excess readmissions ratio’ means, with respect to an 

applicable condition for a hospital for an applicable period, the ratio (but not less than 1.0) of— 

‘‘(I) the risk adjusted readmissions based on 

actual readmissions, as determined consistent 

with a readmission measure methodology that has 

been endorsed under paragraph (5)(A)(ii)(I), for an 

applicable hospital for such condition with respect 

to such applicable period; to 

‘‘(II) the risk adjusted expected readmissions 

(as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period. 

‘‘(ii) EXCLUSION OF CERTAIN READMISSIONS.—For 

purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for 

an applicable condition for which there are fewer than 

a minimum number (as determined by the Secretary) 

of discharges for such applicable condition for the applicable period and such hospital. 

‘‘(5) DEFINITIONS.—For purposes of this subsection: 

‘‘(A) APPLICABLE CONDITION.—The term ‘applicable 

condition’ means, subject to subparagraph (B), a condition 

or procedure selected by the Secretary among conditions 

and procedures for which— 

‘‘(i) readmissions (as defined in subparagraph (E)) 

that represent conditions or procedures that are high 

volume or high expenditures under this title (or other 

criteria specified by the Secretary); and 

‘‘(ii) measures of such readmissions— 

‘‘(I) have been endorsed by the entity with a 

contract under section 1890(a); and 

‘‘(II) such endorsed measures have exclusions 

for readmissions that are unrelated to the prior 
331 Sec. 3025 PPACA (Consolidated) 

discharge (such as a planned readmission or 

transfer to another applicable hospital). 

‘‘(B) EXPANSION OF APPLICABLE CONDITIONS.—Beginning with fiscal year 2015, the Secretary shall, to the extent practicable, expand the applicable conditions beyond 

the 3 conditions for which measures have been endorsed as 

described in subparagraph (A)(ii)(I) as of the date of the 

enactment of this subsection to the additional 4 conditions 

that have been identified by the Medicare Payment Advisory Commission in its report to Congress in June 2007 

and to other conditions and procedures as determined appropriate by the Secretary. In expanding such applicable 

conditions, the Secretary shall seek the endorsement described in subparagraph (A)(ii)(I) but may apply such 

measures without such an endorsement 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) as long as due consideration is given to 

measures that have been endorsed or adopted by a consensus organization identified by the Secretary. 

‘‘(C) APPLICABLE HOSPITAL.—The term ‘applicable hospital’ means a subsection (d) hospital or a hospital that is 

paid under section 1814(b)(3), as the case may be. 

‘‘(D) APPLICABLE PERIOD.—The term ‘applicable period’ 

means, with respect to a fiscal year, such period as the 

Secretary shall specify. 

‘‘(E) READMISSION.—The term ‘readmission’ means, in 

the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same 

or another applicable hospital within a time period specified by the Secretary from the date of such discharge. Insofar as the discharge relates to an applicable condition for 

which there is an endorsed measure described in subparagraph (A)(ii)(I), such time period (such as 30 days) shall be 

consistent with the time period specified for such measure. 

‘‘(6) REPORTING HOSPITAL SPECIFIC INFORMATION.— 

‘‘(A) IN GENERAL.—The Secretary shall make information available to the public regarding readmission rates of 

each subsection (d) hospital under the program. 

‘‘(B) OPPORTUNITY TO REVIEW AND SUBMIT CORRECTIONS.—The Secretary shall ensure that a subsection (d) 

hospital has the opportunity to review, and submit corrections for, the information to be made public with respect 

to the hospital under subparagraph (A) prior to such information being made public. 

‘‘(C) WEBSITE.—Such information shall be posted on 

the Hospital Compare Internet website in an easily understandable format. 

‘‘(7) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or 

otherwise of the following: 

‘‘(A) The determination of base operating DRG payment amounts. 
Sec. 3025 PPACA (Consolidated) 332 

‘‘(B) The methodology for determining the adjustment 

factor under paragraph (3), including excess readmissions 

ratio under paragraph (4)(C), aggregate payments for excess readmissions under paragraph (4)(A), and aggregate 

payments for all discharges under paragraph (4)(B), and 

applicable periods and applicable conditions under paragraph (5). 

‘‘(C) The measures of readmissions as described in 

paragraph (5)(A)(ii). 

‘‘(8) READMISSION RATES FOR ALL PATIENTS.— ‘‘(A) CALCULATION OF READMISSION.—The Secretary 

shall calculate readmission rates for all patients (as defined in subparagraph (D)) for a specified hospital (as defined in subparagraph (D)(ii)) for an applicable condition 

(as defined in paragraph (5)(B)) and other conditions 

deemed appropriate by the Secretary for an applicable period (as defined in paragraph (5)(D)) in the same manner 

as used to calculate such readmission rates for hospitals 

with respect to this title and posted on the CMS Hospital 

Compare website. 

‘‘(B) POSTING OF HOSPITAL SPECIFIC ALL PATIENT READ- MISSION RATES.—The Secretary shall make information on 

all patient readmission rates calculated under subparagraph (A) available on the CMS Hospital Compare website 

in a form and manner determined appropriate by the Secretary. The Secretary may also make other information determined appropriate by the Secretary available on such 

website. 

‘‘(C) HOSPITAL SUBMISSION OF ALL PATIENT DATA.— 

‘‘(i) Except as provided for in clause (ii), each specified hospital (as defined in subparagraph (D)(ii)) shall 

submit to the Secretary, in a form, manner and time 

specified by the Secretary, data and information determined necessary by the Secretary for the Secretary to 

calculate the all patient readmission rates described in 

subparagraph (A). 

‘‘(ii) Instead of a specified hospital submitting to 

the Secretary the data and information described in 

clause (i), such data and information may be submitted to the Secretary, on behalf of such a specified 

hospital, by a state or an entity determined appropriate by the Secretary. 

‘‘(D) DEFINITIONS.—For purposes of this paragraph: 

‘‘(i) The term ‘all patients’ means patients who are 

treated on an inpatient basis and discharged from a 

specified hospital (as defined in clause (ii)). 

‘‘(ii) The term ‘specified hospital’ means a subsection (d) hospital, hospitals described in clauses (i) 

through (v) of subsection (d)(1)(B) and, as determined 

feasible and appropriate by the Secretary, other hospitals not otherwise described in this subparagraph.’’. 

(b) QUALITY IMPROVEMENT.—Part S of title III of the Public 

Health Service Act, as amended by section 3015, is further amended by adding at the end the following: 
333 Sec. 3026 PPACA (Consolidated) 

‘‘SEC. 399KK. ø42 U.S.C. 280j–3¿ QUALITY IMPROVEMENT PROGRAM FOR 

HOSPITALS WITH A HIGH SEVERITY ADJUSTED READMISSION RATE. 

‘‘(a) ESTABLISHMENT.— 

‘‘(1) IN GENERAL.—Not later than 2 years after the date of 

enactment of this section, the Secretary shall make available 

a program for eligible hospitals to improve their readmission 

rates through the use of patient safety organizations (as defined in section 921(4)). 

‘‘(2) ELIGIBLE HOSPITAL DEFINED.—In this subsection, the 

term ‘eligible hospital’ means a hospital that the Secretary determines has a high rate of risk adjusted readmissions for the 

conditions described in section 1886(q)(8)(A) of the Social Security Act and has not taken appropriate steps to reduce such readmissions and improve patient safety as evidenced through 

historically high rates of readmissions, as determined by the 

Secretary. 

‘‘(3) RISK ADJUSTMENT.—The Secretary shall utilize appropriate risk adjustment measures to determine eligible hospitals. 

‘‘(b) REPORT TO THE SECRETARY.—As determined appropriate 

by the Secretary, eligible hospitals and patient safety organizations 

working with those hospitals shall report to the Secretary on the 

processes employed by the hospital to improve readmission rates 

and the impact of such processes on readmission rates.’’. 

SEC. 3026. ø42 U.S.C. 1395b–1 note¿ COMMUNITY-BASED CARE TRANSITIONS PROGRAM. 

(a) IN GENERAL.—The Secretary shall establish a CommunityBased Care Transitions Program under which the Secretary provides funding to eligible entities that furnish improved care transition services to high-risk Medicare beneficiaries. 

(b) DEFINITIONS.—In this section: 

(1) ELIGIBLE ENTITY.—The term ‘‘eligible entity’’ means the 

following: 

(A) A subsection (d) hospital (as defined in section 

1886(d)(1)(B) of the Social Security Act (42 U.S.C. 

1395ww(d)(1)(B))) identified by the Secretary as having a 

high readmission rate, such as under section 1886(q) of the 

Social Security Act, as added by section 3025. 

(B) An appropriate community-based organization that 

provides care transition services under this section across 

a continuum of care through arrangements with subsection 

(d) hospitals (as so defined) to furnish the services described in subsection (c)(2)(B)(i) and whose governing body 

includes sufficient representation of multiple health care 

stakeholders (including consumers). 

(2) HIGH-RISK MEDICARE BENEFICIARY.—The term ‘‘highrisk Medicare beneficiary’’ means a Medicare beneficiary who 

has attained a minimum hierarchical condition category score, 

as determined by the Secretary, based on a diagnosis of multiple chronic conditions or other risk factors associated with a 

hospital readmission or substandard transition into post-hospitalization care, which may include 1 or more of the following: 

(A) Cognitive impairment. 
Sec. 3026 PPACA (Consolidated) 334 

(B) Depression. 

(C) A history of multiple readmissions. 

(D) Any other chronic disease or risk factor as determined by the Secretary. 

(3) MEDICARE BENEFICIARY.—The term ‘‘Medicare beneficiary’’ means an individual who is entitled to benefits under 

part A of title XVIII of the Social Security Act (42 U.S.C. 1395 

et seq.) and enrolled under part B of such title, but not enrolled under part C of such title. 

(4) PROGRAM.—The term ‘‘program’’ means the program 

conducted under this section. 

(5) READMISSION.—The term ‘‘readmission’’ has the meaning given such term in section 1886(q)(5)(E) of the Social Security Act, as added by section 3025. 

(6) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health and Human Services. 

(c) REQUIREMENTS.— (1) DURATION.— (A) IN GENERAL.—The program shall be conducted for 

a 5-year period, beginning January 1, 2011. 

(B) EXPANSION.—The Secretary may expand the duration and the scope of the program, to the extent determined appropriate by the Secretary, if the Secretary determines (and the Chief Actuary of the Centers for Medicare 

& Medicaid Services, with respect to spending under this 

title, certifies) that such expansion would reduce spending 

under this title without reducing quality. 

(2) APPLICATION; PARTICIPATION.— (A) IN GENERAL.— 

(i) APPLICATION.—An eligible entity seeking to 

participate in the program shall submit an application 

to the Secretary at such time, in such manner, and 

containing such information as the Secretary may require. 

(ii) PARTNERSHIP.—If an eligible entity is a hospital, such hospital shall enter into a partnership with 

a community-based organization to participate in the 

program. 

(B) INTERVENTION PROPOSAL.—Subject to subparagraph (C), an application submitted under subparagraph 

(A)(i) shall include a detailed proposal for at least 1 care 

transition intervention, which may include the following: 

(i) Initiating care transition services for a highrisk Medicare beneficiary not later than 24 hours prior 

to the discharge of the beneficiary from the eligible entity. 

(ii) Arranging timely post-discharge follow-up 

services to the high-risk Medicare beneficiary to provide the beneficiary (and, as appropriate, the primary 

caregiver of the beneficiary) with information regarding responding to symptoms that may indicate additional health problems or a deteriorating condition. 

(iii) Providing the high-risk Medicare beneficiary 

(and, as appropriate, the primary caregiver of the ben-
335 Sec. 3027 PPACA (Consolidated) 

eficiary) with assistance to ensure productive and 

timely interactions between patients and post-acute 

and outpatient providers. 

(iv) Assessing and actively engaging with a highrisk Medicare beneficiary (and, as appropriate, the primary caregiver of the beneficiary) through the provision of self-management support and relevant information that is specific to the beneficiary’s condition. 

(v) Conducting comprehensive medication review 

and management (including, if appropriate, counseling 

and self-management support). 

(C) LIMITATION.—A care transition intervention proposed under subparagraph (B) may not include payment 

for services required under the discharge planning process 

described in section 1861(ee) of the Social Security Act (42 

U.S.C. 1395x(ee)). 

(3) SELECTION.—In selecting eligible entities to participate 

in the program, the Secretary shall give priority to eligible entities that— 

(A) participate in a program administered by the Administration on Aging to provide concurrent care transitions interventions with multiple hospitals and practitioners; or 

(B) provide services to medically underserved populations, small communities, and rural areas. 

(d) IMPLEMENTATION.—Notwithstanding any other provision of 

law, the Secretary may implement the provisions of this section by 

program instruction or otherwise. 

(e) WAIVER AUTHORITY.—The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act as may 

be necessary to carry out the program. 

(f) FUNDING.—For purposes of carrying out this section, the 

Secretary of Health and Human Services 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 under section 1841 of such Act (42 U.S.C. 1395t), in such proportion as the 

Secretary determines appropriate, of $500,000,000, to the Centers 

for Medicare & Medicaid Services Program Management Account 

for the period of fiscal years 2011 through 2015. Amounts transferred under the preceding sentence shall remain available until 

expended. 

SEC. 3027. 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,’’. 
Sec. 3101 PPACA (Consolidated) 336 

(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’’. 

Subtitle B—Improving Medicare for 

Patients and Providers 

PART I—ENSURING BENEFICIARY ACCESS TO 

PHYSICIAN CARE AND OTHER SERVICES 

SEC. 3101. øINCREASE IN THE PHYSICIAN PAYMENT UPDATE¿øREPEALED¿. 

øThis section (and amendment made by this section) repealed 

by section 10310. The repeal did not redesignate subsequent sections.¿ 

SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND 

REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE 

SCHEDULE. 

(a) EXTENSION OF WORK GPCI FLOOR.—Section 1848(e)(1)(E) of 

the Social Security Act (42 U.S.C. 1395w–4(e)(1)(E)) is amended by 

striking ‘‘before January 1, 2010’’ and inserting ‘‘before January 1, 

2011’’. 

(b) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 2010 AND

SUBSEQUENT YEARS.—Section 1848(e)(1) of the Social Security Act 

(42 U.S.C. 1395w4(e)(1)) is amended— 

(1) in subparagraph (A), by striking ‘‘and (G)’’ and inserting ‘‘(G), and (H)’’; and 

(2) by adding at the end the following new subparagraph: 

‘‘(H) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR

2010 AND SUBSEQUENT YEARS.— 

‘‘(i) FOR 2010.—Subject to clause (iii), for services 

furnished during 2010, the employee wage and rent 

portions of the practice expense geographic index described in subparagraph (A)(i) shall reflect 1⁄2 of the 

difference between the relative costs of employee 

wages and rents in each of the different fee schedule 

areas and the national average of such employee 

wages and rents. øAs revised by section 1108 of 

HCERA¿ 

‘‘(ii) FOR 2011.—Subject to clause (iii), for services 

furnished during 2011, the employee wage and rent 

portions of the practice expense geographic index described in subparagraph (A)(i) shall reflect 1⁄2 of the 

difference between the relative costs of employee 

wages and rents in each of the different fee schedule 
337 Sec. 3102 PPACA (Consolidated) 

areas and the national average of such employee 

wages and rents. 

‘‘(iii) HOLD HARMLESS.—The practice expense portion of the geographic adjustment factor applied in a 

fee schedule area for services furnished in 2010 or 

2011 shall not, as a result of the application of clause 

(i) or (ii), be reduced below the practice expense portion of the geographic adjustment factor under subparagraph (A)(i) (as calculated prior to the application 

of such clause (i) or (ii), respectively) for such area for 

such year. 

‘‘(iv) ANALYSIS.—The Secretary shall analyze current methods of establishing practice expense geographic adjustments under subparagraph (A)(i) and 

evaluate data that fairly and reliably establishes distinctions in the costs of operating a medical practice in 

the different fee schedule areas. Such analysis shall 

include an evaluation of the following: 

‘‘(I) The feasibility of using actual data or reliable survey data developed by medical organizations on the costs of operating a medical practice, 

including office rents and non-physician staff 

wages, in different fee schedule areas. 

‘‘(II) The office expense portion of the practice 

expense geographic adjustment described in subparagraph (A)(i), including the extent to which 

types of office expenses are determined in local 

markets instead of national markets. 

‘‘(III) The weights assigned to each of the categories within the practice expense geographic adjustment described in subparagraph (A)(i). 

‘‘(v) REVISION FOR 2012 AND SUBSEQUENT YEARS.— 

As a result of the analysis described in clause (iv), the 

Secretary shall, not later than January 1, 2012, make 

appropriate adjustments to the practice expense geographic adjustment described in subparagraph (A)(i) to 

ensure accurate geographic adjustments across fee 

schedule areas, including— 

‘‘(I) basing the office rents component and its 

weight on office expenses that vary among fee 

schedule areas; and 

‘‘(II) considering a representative range of professional and non-professional personnel employed 

in a medical office based on the use of the American Community Survey data or other reliable 

data for wage adjustments. 

Such adjustments shall be made without regard to adjustments made pursuant to clauses (i) and (ii) and 

shall be made in a budget neutral manner.’’. 

øSection 10324(c) of PPACA, p. 869, provided for amendments 

to section 1848(e)(1) of Social Security Act providing a floor on practice expense index for services in frontier States.¿ 
Sec. 3103 PPACA (Consolidated) 338 

SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE 

THERAPY CAPS. 

Section 1833(g)(5) of the Social Security Act (42 U.S.C. 

1395l(g)(5)) is amended by striking ‘‘December 31, 2009’’ and inserting ‘‘December 31, 2010’’. 

SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF 

CERTAIN PHYSICIAN PATHOLOGY SERVICES. 

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 

Improvement and Protection Act of 2000 (as enacted into law by 

section 1(a)(6) of Public Law 106–554), as amended by section 732 

of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w–4 note), section 104 of division 

B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w– 

4 note), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110–173), and section 136 of the 

Medicare Improvements for Patients and Providers Act of 2008 

(Public Law 110–275), is amended by striking ‘‘and 2009’’ and inserting ‘‘2009, and 2010’’. 

SEC. 3105. 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)) is amended—øAs would be 

revised by section 10311(a)¿ 

(1) in the matter preceding clause (i), by striking ‘‘2010’’ 

and inserting ‘‘2011’’; and 

(2) in each of clauses (i) and (ii), 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) is amended øAs would be revised by section 10311(b)¿ by 

striking ‘‘December 31, 2009’’ 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)) is amended øAs 

would be revised by section 10311(c)¿ by striking ‘‘2010’’ and inserting ‘‘2011’’. 

SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM 

CARE HOSPITAL SERVICES AND OF MORATORIUM ON THE 

ESTABLISHMENT OF CERTAIN HOSPITALS AND FACILITIES. 

(a) EXTENSION OF 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), is further 

amended by striking ‘‘3-year period’’ each place it appears and inserting ‘‘5-year period’’. øAs revised by section 10312(a)¿ 

(b) EXTENSION OF MORATORIUM.—Section 114(d)(1) of such Act 

(42 U.S.C. 1395ww note), in the matter preceding subparagraph 

(A), is amended by striking ‘‘3-year period’’ and inserting ‘‘5-year 

period’’. øAs revised by section 10312(b)¿ 

SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL 

HEALTH ADD-ON. 

Section 138(a)(1) of the Medicare Improvements for Patients 

and Providers Act of 2008 (Public Law 110–275) is amended by 

striking ‘‘December 31, 2009’’ and inserting ‘‘December 31, 2010’’. 
339 Sec. 3109 PPACA (Consolidated) 

SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL EXTENDED CARE SERVICES. 

(a) ORDERING POST-HOSPITAL EXTENDED CARE SERVICES.— (1) IN GENERAL.—Section 1814(a)(2) of the Social Security 

Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subparagraph (A), is amended by striking ‘‘or clinical nurse specialist’’ 

and inserting ‘‘, a clinical nurse specialist, or a physician assistant (as those terms are defined in section 1861(aa)(5))’’ 

after ‘‘nurse practitioner’’. 

(2) CONFORMING AMENDMENT.—Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended, in the second 

sentence, by striking ‘‘or clinical nurse specialist’’ and inserting 

‘‘clinical nurse specialist, or physician assistant’’ after ‘‘nurse 

practitioner,’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to items and services furnished on or after January 1, 

2011. 

SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION REQUIREMENTS. 

(a) IN GENERAL.—Section 1834(a)(20) of the Social Security Act 

(42 U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of the 

Medicare Improvements for Patients and Providers Act of 2008 

(Public Law 100–275), is amended— 

(1) in subparagraph (F)(i)— 

(A) by inserting ‘‘and subparagraph (G)’’ after ‘‘clause 

(ii)’’; and 

(B) by inserting ‘‘, except that the Secretary shall not 

require a pharmacy to have submitted to the Secretary 

such evidence of accreditation prior to January 1, 2011’’ 

before the semicolon at the end; and 

(2) by adding at the end the following new subparagraph: 

‘‘(G) APPLICATION OF ACCREDITATION REQUIREMENT TO

CERTAIN PHARMACIES.— 

‘‘(i) IN GENERAL.—With respect to items and services furnished on or after January 1, 2011, in implementing quality standards under this paragraph— 

‘‘(I) subject to subclause (II), in applying such 

standards and the accreditation requirement of 

subparagraph (F)(i) with respect to pharmacies 

described in clause (ii) furnishing such items and 

services, such standards and accreditation requirement shall not apply to such pharmacies; 

and 

‘‘(II) the Secretary may apply to such pharmacies an alternative accreditation requirement 

established by the Secretary if the Secretary determines such alternative accreditation requirement is more appropriate for such pharmacies. 

‘‘(ii) PHARMACIES DESCRIBED.—A pharmacy described in this clause is a pharmacy that meets each 

of the following criteria: 

‘‘(I) The total billings by the pharmacy for 

such items and services under this title are less 

than 5 percent of total pharmacy sales, as deter-
Sec. 3110 PPACA (Consolidated) 340 

mined based on the average total pharmacy sales 

for the previous 3 calendar years, 3 fiscal years, or 

other yearly period specified by the Secretary. 

‘‘(II) The pharmacy has been enrolled under 

section 1866(j) as a supplier of durable medical 

equipment, prosthetics, orthotics, and supplies, 

has been issued (which may include the renewal 

of) a provider number for at least 5 years, and for 

which a final adverse action (as defined in section 

424.57(a) of title 42, Code of Federal Regulations) 

has not been imposed in the past 5 years. 

‘‘(III) The pharmacy submits to the Secretary 

an attestation, in a form and manner, and at a 

time, specified by the Secretary, that the pharmacy meets the criteria described in subclauses (I) 

and (II). Such attestation shall be subject to section 1001 of title 18, United States Code. 

‘‘(IV) The pharmacy agrees to submit materials as requested by the Secretary, or during the 

course of an audit conducted on a random sample 

of pharmacies selected annually, to verify that the 

pharmacy meets the criteria described in subclauses (I) and (II). Materials submitted under the 

preceding sentence shall include a certification by 

an accountant on behalf of the pharmacy or the 

submission of tax returns filed by the pharmacy 

during the relevant periods, as requested by the 

Secretary.’’. 

(b) ADMINISTRATION.—Notwithstanding any other provision of 

law, the Secretary may implement the amendments made by subsection (a) by program instruction or otherwise. 

(c) RULE OF CONSTRUCTION.—Nothing in the provisions of or 

amendments made by this section shall be construed as affecting 

the application of an accreditation requirement for pharmacies to 

qualify for bidding in a competitive acquisition area under section 

1847 of the Social Security Act (42 U.S.C. 1395w–3). 

SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED 

TRICARE BENEFICIARIES. 

(a) IN GENERAL.— (1) IN GENERAL.—Section 1837 of the Social Security Act 

(42 U.S.C. 1395p) is amended by adding at the end the following new subsection: 

‘‘(l)(1) In the case of any individual who is a covered beneficiary (as defined in section 1072(5) of title 10, United States 

Code) at the time the individual is entitled to part A under section 

226(b) or section 226A and who is eligible to enroll but who has 

elected not to enroll (or to be deemed enrolled) during the individual’s initial enrollment period, there shall be a special enrollment 

period described in paragraph (2). 

‘‘(2) The special enrollment period described in this paragraph, 

with respect to an individual, is the 12-month period beginning on 

the day after the last day of the initial enrollment period of the individual or, if later, the 12-month period beginning with the month 

the individual is notified of enrollment under this section. 
341 Sec. 3111 PPACA (Consolidated) 

‘‘(3) In the case of an individual who enrolls during the special 

enrollment period provided under paragraph (1), the coverage period under this part shall begin on the first day of the month in 

which the individual enrolls, or, at the option of the individual, the 

first month after the end of the individual’s initial enrollment period. 

‘‘(4) An individual may only enroll during the special enrollment period provided under paragraph (1) one time during the individual’s lifetime. 

‘‘(5) The Secretary shall ensure that the materials relating to 

coverage under this part that are provided to an individual described in paragraph (1) prior to the individual’s initial enrollment 

period contain information concerning the impact of not enrolling 

under this part, including the impact on health care benefits under 

the TRICARE program under chapter 55 of title 10, United States 

Code. 

‘‘(6) The Secretary of Defense shall collaborate with the Secretary of Health and Human Services and the Commissioner of Social Security to provide for the accurate identification of individuals 

described in paragraph (1). The Secretary of Defense shall provide 

such individuals with notification with respect to this subsection. 

The Secretary of Defense shall collaborate with the Secretary of 

Health and Human Services and the Commissioner of Social Security to ensure appropriate follow up pursuant to any notification 

provided under the preceding sentence.’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall apply to elections made with respect to initial enrollment periods that end after the date of the enactment of this 

Act. 

(b) WAIVER OF INCREASE OF PREMIUM.—Section 1839(b) of the 

Social Security Act (42 U.S.C. 1395r(b)) is amended by striking 

‘‘section 1837(i)(4)’’ and inserting ‘‘subsection (i)(4) or (l) of section 

1837’’. 

SEC. 3111. PAYMENT FOR BONE DENSITY TESTS. 

(a) PAYMENT.— 

(1) IN GENERAL.—Section 1848 of the Social Security Act 

(42 U.S.C. 1395w–4) is amended— 

(A) in subsection (b)— 

(i) in paragraph (4)(B), by inserting ‘‘, and for 

2010 and 2011, dual-energy x-ray absorptiometry services (as described in paragraph (6))’’ before the period 

at the end; and 

(ii) by adding at the end the following new paragraph: 

‘‘(6) TREATMENT OF BONE MASS SCANS.—For dual-energy xray absorptiometry services (identified in 2006 by HCPCS 

codes 76075 and 76077 (and any succeeding codes)) furnished 

during 2010 and 2011, instead of the payment amount that 

would otherwise be determined under this section for such 

years, the payment amount shall be equal to 70 percent of the 

product of— 

‘‘(A) the relative value for the service (as determined 

in subsection (c)(2)) for 2006; 
Sec. 3112 PPACA (Consolidated) 342 

‘‘(B) the conversion factor (established under subsection (d)) for 2006; and 

‘‘(C) the geographic adjustment factor (established 

under subsection (e)(2)) for the service for the fee schedule 

area for 2010 and 2011, respectively.’’; and 

(B) in subsection (c)(2)(B)(iv)— 

(i) in subclause (II), by striking ‘‘and’’ at the end; 

(ii) in subclause (III), by striking the period at the 

end and inserting ‘‘; and’’; and 

(iii) by adding at the end the following new subclause: 

‘‘(IV) subsection (b)(6) shall not be taken into 

account in applying clause (ii)(II) for 2010 or 

2011.’’. 

(2) IMPLEMENTATION.—Notwithstanding any other provision of law, the Secretary may implement the amendments 

made by paragraph (1) by program instruction or otherwise. 

(b) STUDY AND REPORT BY THE INSTITUTE OF MEDICINE.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services is authorized to enter into an agreement with the Institute of Medicine of the National Academies to conduct a 

study on the ramifications of Medicare payment reductions for 

dual-energy x-ray absorptiometry (as described in section 

1848(b)(6) of the Social Security Act, as added by subsection 

(a)(1)) during 2007, 2008, and 2009 on beneficiary access to 

bone mass density tests. 

(2) REPORT.—An agreement entered into under paragraph 

(1) shall provide for the Institute of Medicine to submit to the 

Secretary and to Congress a report containing the results of 

the study conducted under such paragraph. 

SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND. 

Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 

1395iii) is amended by striking ‘‘$22,290,000,000’’ and inserting 

‘‘$0’’. 

SEC. 3113. ø42 U.S.C. 1395l note¿ TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORATORY TESTS. 

(a) DEMONSTRATION PROJECT.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as the ‘‘Secretary’’) shall 

conduct a demonstration project under part B title XVIII of the 

Social Security Act under which separate payments are made 

under such part for complex diagnostic laboratory tests provided to individuals under such part. Under the demonstration 

project, the Secretary shall establish appropriate payment 

rates for such tests. 

(2) COVERED COMPLEX DIAGNOSTIC LABORATORY TEST DEFINED.—In this section, the term ‘‘complex diagnostic laboratory test’’ means a diagnostic laboratory test— 

(A) that is an analysis of gene protein expression, 

topographic genotyping, or a cancer chemotherapy sensitivity assay; 
343 Sec. 3114 PPACA (Consolidated) 

(B) that is determined by the Secretary to be a laboratory test for which there is not an alternative test having 

equivalent performance characteristics; 

(C) which is billed using a Health Care Procedure Coding System (HCPCS) code other than a not otherwise classified code under such Coding System; 

(D) which is approved or cleared by the Food and Drug 

Administration or is covered under title XVIII of the Social 

Security Act; and 

(E) is described in section 1861(s)(3) of the Social Security Act (42 U.S.C. 1395x(s)(3)). 

(3) SEPARATE PAYMENT DEFINED.—In this section, the term 

‘‘separate payment’’ means direct payment to a laboratory (including a hospital-based or independent laboratory) that performs a complex diagnostic laboratory test with respect to a 

specimen collected from an individual during a period in which 

the individual is a patient of a hospital if the test is performed 

after such period of hospitalization and if separate payment 

would not otherwise be made under title XVIII of the Social 

Security Act by reason of sections 1862(a)(14) and 

1866(a)(1)(H)(i) of the such Act (42 U.S.C. 1395y(a)(14); 42 

U.S.C. 1395cc(a)(1)(H)(i)). 

(b) DURATION.—Subject to subsection (c)(2), the Secretary shall 

conduct the demonstration project under this section for the 2-year 

period beginning on July 1, 2011. 

(c) PAYMENTS AND LIMITATION.—Payments under the demonstration project under this section shall— 

(1) be made from the Federal Supplemental Medical Insurance Trust Fund under section 1841 of the Social Security Act 

(42 U.S.C. 1395t); and 

(2) may not exceed $100,000,000. 

(d) REPORT.—Not later than 2 years after the completion of the 

demonstration project under this section, the Secretary shall submit to Congress a report on the project. Such report shall include— 

(1) an assessment of the impact of the demonstration 

project on access to care, quality of care, health outcomes, and 

expenditures under title XVIII of the Social Security Act (including any savings under such title); and 

(2) such recommendations as the Secretary determines appropriate. 

(e) IMPLEMENTATION FUNDING.—For purposes of administering 

this section (including preparing and submitting the report under 

subsection (d)), the Secretary shall provide for the transfer, from 

the Federal Supplemental Medical Insurance Trust Fund under 

section 1841 of the Social Security Act (42 U.S.C. 1395t), to the 

Centers for Medicare & Medicaid Services Program Management 

Account, of $5,000,000. Amounts transferred under the preceding 

sentence shall remain available until expended. 

SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERVICES. 

Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C. 

1395l(a)(1)(K)) is amended by inserting ‘‘(or 100 percent for services 

furnished on or after January 1, 2011)’’ after ‘‘1992, 65 percent’’. 
Sec. 3121 PPACA (Consolidated) 344 

PART II—RURAL PROTECTIONS 

SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION. 

(a) IN GENERAL.—Section 1833(t)(7)(D)(i) of the Social Security 

Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

(1) in subclause (II)— 

(A) in the first sentence, by striking ‘‘2010’’and inserting ‘‘2011’’; and 

(B) in the second sentence, by striking ‘‘or 2009’’ and 

inserting ‘‘, 2009, or 2010’’; and 

(2) in subclause (III), by striking ‘‘January 1, 2010’’ and inserting ‘‘January 1, 2011’’. 

(b) PERMITTING ALL SOLE COMMUNITY HOSPITALS TO BE ELIGI- BLE FOR HOLD HARMLESS.—Section 1833(t)(7)(D)(i)(III) of the Social 

Security Act (42 U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by adding 

at the end the following new sentence: ‘‘In the case of covered OPD 

services furnished on or after January 1, 2010, and before January 

1, 2011, the preceding sentence shall be applied without regard to 

the 100-bed limitation.’’. 

SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS 

FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY 

TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN 

RURAL AREAS. 

Section 416(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395l–4), as 

amended by section 105 of division B of the Tax Relief and Health 

Care Act of 2006 (42 U.S.C. 1395l note) and section 107 of the 

Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 

1395l note), is amended by inserting ‘‘or during the 1-year period 

beginning on July 1, 2010’’ before the period at the end. 

SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL DEMONSTRATION PROGRAM. 

(a) ONE-YEAR EXTENSION.—Section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2272) is amended by adding at the end 

the following new subsection: 

‘‘(g) FIVE-YEAR EXTENSION OF DEMONSTRATION PROGRAM.— øReplaced by section 10313(a)¿ 

‘‘(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 
345 Sec. 3124 PPACA (Consolidated) 

subsection (a)(4), during the 5-year extension period, not more 

than 30 rural community hospitals may participate in the demonstration program under this section. 

‘‘(4) HOSPITALS IN DEMONSTRATION PROGRAM ON DATE OF

ENACTMENT.—In the case of a rural community hospital that is 

participating in the demonstration program under this section 

as of the last day of the initial 5-year period, the Secretary— 

‘‘(A) shall provide for the continued 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) is 

amended by inserting ‘‘(in this section referred to as the ‘initial 5- 

year period’) and, as provided in subsection (g), for the 5-year extension period’’ after ‘‘5-year period’’.øAs revised by section 

10313(b)¿ 

(c) TECHNICAL AMENDMENTS.— (1) Subsection (b) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2272) is amended— 

(A) in paragraph (1)(B)(ii), by striking ‘‘2)’’ and inserting ‘‘2))’’; and 

(B) in paragraph (2), by inserting ‘‘cost’’ before ‘‘reporting period’’ the first place such term appears in each of 

subparagraphs (A) and (B). 

(2) Subsection (f)(1) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 

(Public Law 108–173; 117 Stat. 2272) is amended— 

(A) in subparagraph (A)(ii), by striking ‘‘paragraph (2)’’ 

and inserting ‘‘subparagraph (B)’’; and 

(B) in subparagraph (B), by striking ‘‘paragraph 

(1)(B)’’ and inserting ‘‘subparagraph (A)(ii)’’. 

SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL 

(MDH) PROGRAM. 

(a) EXTENSION OF PAYMENT METHODOLOGY.—Section 

1886(d)(5)(G) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) 

is amended— 
Sec. 3125 PPACA (Consolidated) 346 

(1) in clause (i), by striking ‘‘October 1, 2011’’ and inserting 

‘‘October 1, 2012’’; and 

(2) in clause (ii)(II), by striking ‘‘October 1, 2011’’ and inserting ‘‘October 1, 2012’’. 

(b) CONFORMING AMENDMENTS.— (1) EXTENSION OF TARGET AMOUNT.—Section 1886(b)(3)(D) 

of the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is 

amended— 

(A) in the matter preceding clause (i), by striking ‘‘October 1, 2011’’ and inserting ‘‘October 1, 2012’’; and 

(B) in clause (iv), by striking ‘‘through fiscal year 

2011’’ and inserting ‘‘through fiscal year 2012’’. 

(2) PERMITTING HOSPITALS TO DECLINE RECLASSIFICA- TION.—Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of 1993 (42 U.S.C. 1395ww note) is amended by striking ‘‘through fiscal year 2011’’ and inserting ‘‘through fiscal 

year 2012’’. 

SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT HOSPITAL PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS. 

Section 1886(d)(12) of the Social Security Act (42 U.S.C. 

1395ww(d)(12)) is amended— 

(1) in subparagraph (A), by inserting ‘‘or (D)’’ after ‘‘subparagraph (B)’’; 

(2) in subparagraph (B), in the matter preceding clause (i), 

by striking ‘‘The Secretary’’ and inserting ‘‘For discharges occurring in fiscal years 2005 through 2010 and for discharges 

occurring in fiscal year 2013 and subsequent fiscal years, the 

Secretary’’; 

(3) in subparagraph (C)(i)— 

(A) by inserting ‘‘(or, with respect to fiscal years 2011 

and 2012, 15 road miles)’’ after ‘‘25 road miles’’; and 

(B) by inserting ‘‘(or, with respect to fiscal years 2011 

and 2012, 1,600 discharges of individuals entitled to, or enrolled for, benefits under part A)’’ after ‘‘800 discharges’’; 

and øAs revised by section 10314(1)¿ 

(4) by adding at the end the following new subparagraph: 

‘‘(D) TEMPORARY APPLICABLE PERCENTAGE INCREASE.— 

For discharges occurring in fiscal years 2011 and 2012, the 

Secretary shall determine an applicable percentage increase for purposes of subparagraph (A) using a continuous 

linear sliding scale ranging from 25 percent for low-volume 

hospitals with 200 or fewer discharges of individuals entitled to, or enrolled for, benefits under part A in the fiscal 

year to 0 percent for low-volume hospitals with greater 

than 1,600 discharges of such individuals in the fiscal 

year.øAs revised by section 10314(2)¿’’. 

SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON 

COMMUNITY HEALTH INTEGRATION MODELS IN CERTAIN 

RURAL COUNTIES. 

(a) REMOVAL OF LIMITATION ON NUMBER OF ELIGIBLE COUNTIES SELECTED.—Subsection (d)(3) of section 123 of the Medicare 

Improvements for Patients and Providers Act of 2008 (42 U.S.C. 

1395i–4 note) is amended by striking ‘‘not more than 6’’. 
347 Sec. 3129 PPACA (Consolidated) 

(b) REMOVAL OF REFERENCES TO RURAL HEALTH CLINIC SERVICES AND INCLUSION OF PHYSICIANS’ SERVICES IN SCOPE OF DEMONSTRATION PROJECT.—Such section 123 is amended— 

(1) in subsection (d)(4)(B)(i)(3), by striking subclause (III); 

and 

(2) in subsection (j)— 

(A) in paragraph (8), by striking subparagraph (B) and 

inserting the following: 

‘‘(B) Physicians’ services (as defined in section 1861(q) 

of the Social Security Act (42 U.S.C. 1395x(q)).’’; 

(B) by striking paragraph (9); and 

(C) by redesignating paragraph (10) as paragraph (9). 

SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS 

FOR HEALTH CARE PROVIDERS SERVING IN RURAL 

AREAS. 

(a) STUDY.—The Medicare Payment Advisory Commission shall 

conduct a study on the adequacy of payments for items and services furnished by providers of services and suppliers in rural areas 

under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such study shall include an analysis of— 

(1) any adjustments in payments to providers of services 

and suppliers that furnish items and services in rural areas; 

(2) access by Medicare beneficiaries to items and services 

in rural areas; 

(3) the adequacy of payments to providers of services and 

suppliers that furnish items and services in rural areas; and 

(4) the quality of care furnished in rural areas. 

(b) REPORT.—Not later than January 1, 2011, the Medicare 

Payment Advisory Commission shall submit to Congress a report 

containing the results of the study conducted under subsection (a). 

Such report shall include recommendations on appropriate modifications to any adjustments in payments to providers of services 

and suppliers that furnish items and services in rural areas, together with recommendations for such legislation and administrative action as the Medicare Payment Advisory Commission determines appropriate. 

SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS 

HOSPITAL SERVICES. 

(a) IN GENERAL.—Subsections (g)(2)(A) and (l)(8) of section 

1834 of the Social Security Act (42 U.S.C. 1395m) are each amended by inserting ‘‘101 percent of’’ before ‘‘the reasonable costs’’. 

(b) EFFECTIVE DATE.—The amendments made by subsection (a) 

shall take effect as if included in the enactment of section 405(a) 

of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2266). 

SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM. 

(a) AUTHORIZATION.—Section 1820(j) of the Social Security Act 

(42 U.S.C. 1395i–4(j)) is amended— 

(1) by striking ‘‘2010, and for’’ and inserting ‘‘2010, for’’; 

and 
Sec. 3131 PPACA (Consolidated) 348 

(2) by inserting ‘‘and for making grants to all States under 

subsection (g), such sums as may be necessary in each of fiscal 

years 2011 and 2012, to remain available until expended’’ before the period at the end. 

(b) USE OF FUNDS.—Section 1820(g)(3) of the Social Security 

Act (42 U.S.C. 1395i–4(g)(3)) is amended— 

(1) in subparagraph (A), by inserting ‘‘and to assist such 

hospitals in participating in delivery system reforms under the 

provisions of and amendments made by the Patient Protection 

and Affordable Care Act, such as value-based purchasing programs, accountable care organizations under section 1899, the 

National pilot program on payment bundling under section 

1866D, and other delivery system reform programs determined 

appropriate by the Secretary’’ before the period at the end; and 

(2) in subparagraph (E)— 

(A) by striking ‘‘, and to offset’’ and inserting ‘‘, to offset’’; and 

(B) by inserting ‘‘and to participate in delivery system 

reforms under the provisions of and amendments made by 

the Patient Protection and Affordable Care Act, such as 

value-based purchasing programs, accountable care organizations under section 1899, the National pilot program on 

payment bundling under section 1866D, and other delivery 

system reform programs determined appropriate by the 

Secretary’’ before the period at the end. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to grants made on or after January 1, 2010. 

øSection 10324(a) of PPACA, p. 868, amended section 

1886(d)(3)(E) of the Social Security Act to add a floor on the area 

wage index for hospitals in frontier States¿ 

PART III—IMPROVING PAYMENT ACCURACY 

SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE. 

(a) REBASING HOME HEALTH PROSPECTIVE PAYMENT

AMOUNT.— 

(1) IN GENERAL.—Section 1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended— 

(A) in clause (i)(III), by striking ‘‘For periods’’ and inserting ‘‘Subject to clause (iii), for periods’’; and 

(B) by adding at the end the following new clause: øAs 

revised by section 10315(a)¿ 

‘‘(iii) ADJUSTMENT FOR 2014 AND SUBSEQUENT

YEARS.— ‘‘(I) IN GENERAL.—Subject to subclause (II), for 

2014 and subsequent years, the amount (or 

amounts) that would otherwise be applicable 

under clause (i)(III) shall be adjusted by a percentage determined appropriate by the Secretary 

to reflect such factors as changes in the number of 

visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other factors that the Secretary con-
349 Sec. 3131 PPACA (Consolidated) 

siders to be relevant. In conducting the analysis 

under the preceding sentence, the Secretary may 

consider differences between hospital-based and 

freestanding agencies, between for-profit and nonprofit agencies, and between the resource costs of 

urban and rural agencies. Such adjustment shall 

be made before the update under subparagraph 

(B) is applied for the year. 

‘‘(II) TRANSITION.—The Secretary shall provide for a 4-year phase-in (in equal increments) of 

the adjustment under subclause (I), with such adjustment being fully implemented for 2017. During each year of such phase-in, the amount of any 

adjustment under subclause (I) for the year may 

not exceed 3.5 percent of the amount (or amounts) 

applicable under clause (i)(III) as of the date of 

enactment of the Patient Protection and Affordable Care Act.’’. 

(2) MEDPAC STUDY AND REPORT.— (A) STUDY.—The Medicare Payment Advisory Commission shall conduct a study on the implementation of the 

amendments made by paragraph (1). Such study shall include an analysis of the impact of such amendments on— 

(i) access to care; 

(ii) quality outcomes; 

(iii) the number of home health agencies; and 

(iv) rural agencies, urban agencies, for-profit agencies, and nonprofit agencies. 

(B) REPORT.—Not later than January 1, 2015, the 

Medicare Payment Advisory Commission shall submit to 

Congress a report on the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Commission determines appropriate. 

(b) PROGRAM-SPECIFIC OUTLIER CAP.—Section 1895(b) of the 

Social Security Act (42 U.S.C. 1395fff(b)) is amended— 

(1) in paragraph (3)(C), by striking ‘‘the aggregate’’ and all 

that follows through the period at the end and inserting ‘‘5 percent of the total payments estimated to be made based on the 

prospective payment system under this subsection for the period.’’; and 

(2) in paragraph (5)— 

(A) by striking ‘‘OUTLIERS.—The Secretary’’ and inserting the following: ‘‘OUTLIERS.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

Secretary’’; 

(B) in subparagraph (A), as added by subparagraph 

(A), by striking ‘‘5 percent’’ and inserting ‘‘2.5 percent’’; 

and 

(C) by adding at the end the following new subparagraph: 

‘‘(B) PROGRAM SPECIFIC OUTLIER CAP.—The estimated 

total amount of additional payments or payment adjustments made under subparagraph (A) with respect to a 
Sec. 3131 PPACA (Consolidated) 350 

home health agency for a year (beginning with 2011) may 

not exceed an amount equal to 10 percent of the estimated 

total amount of payments made under this section (without regard to this paragraph) with respect to the home 

health agency for the year.’’. 

(c) APPLICATION OF THE MEDICARE RURAL HOME HEALTH ADD- ON POLICY.—Section 421 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 

117 Stat. 2283), as amended by section 5201(b) of the Deficit Reduction Act of 2005 (Public Law 109–171; 120 Stat. 46), is amended— 

(1) in the section heading, by striking ‘‘ONE-YEAR’’ and 

inserting ‘‘TEMPORARY’’; and 

(2) in subsection (a)— 

(A) by striking ‘‘, and episodes’’ and inserting ‘‘, episodes’’; 

(B) by inserting ‘‘and episodes and visits ending on or 

after April 1, 2010, and before January 1, 2016,’’ after 

‘‘January 1, 2007,’’; and 

(C) by inserting ‘‘(or, in the case of episodes and visits 

ending on or after April 1, 2010, and before January 1, 

2016, 3 percent)’’ before the period at the end. 

(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.—øReplaced by section 10315(b)¿ 

(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 
351 Sec. 3131 PPACA (Consolidated) 

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 
Sec. 3132 PPACA (Consolidated) 352 

(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. 3132. HOSPICE REFORM. 

(a) HOSPICE CARE PAYMENT REFORMS.— 

(1) IN GENERAL.—Section 1814(i) of the Social Security Act 

(42 U.S.C. 1395f(i)), as amended by section 3004(c), is amended— 

(A) by redesignating paragraph (6) as paragraph (7); 

and 

(B) by inserting after paragraph (5) the following new 

paragraph: 

‘‘(6)(A) The Secretary shall collect additional data and information as the Secretary determines appropriate to revise 

payments for hospice care under this subsection pursuant to 

subparagraph (D) and for other purposes as determined appropriate by the Secretary. The Secretary shall begin to collect 

such data by not later than January 1, 2011. 

‘‘(B) The additional data and information to be collected 

under subparagraph (A) may include data and information 

on— 

‘‘(i) charges and payments; 

‘‘(ii) the number of days of hospice care which are attributable to individuals who are entitled to, or enrolled 

for, benefits under part A; and 

‘‘(iii) with respect to each type of service included in 

hospice care— 
353 Sec. 3132 PPACA (Consolidated) 

‘‘(I) the number of days of hospice care attributable to the type of service; 

‘‘(II) the cost of the type of service; and 

‘‘(III) the amount of payment for the type of service; 

‘‘(iv) charitable contributions and other revenue of the 

hospice program; 

‘‘(v) the number of hospice visits; 

‘‘(vi) the type of practitioner providing the visit; and 

‘‘(vii) the length of the visit and other basic information with respect to the visit. 

‘‘(C) The Secretary may collect the additional data and information under subparagraph (A) on cost reports, claims, or 

other mechanisms as the Secretary determines to be appropriate. 

‘‘(D)(i) Notwithstanding the preceding paragraphs of this 

subsection, not earlier than October 1, 2013, the Secretary 

shall, by regulation, implement revisions to the methodology 

for determining the payment rates for routine home care and 

other services included in hospice care under this part, as the 

Secretary determines to be appropriate. Such revisions may be 

based on an analysis of data and information collected under 

subparagraph (A). Such revisions may include adjustments to 

per diem payments that reflect changes in resource intensity 

in providing such care and services during the course of the entire episode of hospice care. 

‘‘(ii) Revisions in payment implemented pursuant to clause 

(i) shall result in the same estimated amount of aggregate expenditures under this title for hospice care furnished in the fiscal year in which such revisions in payment are implemented 

as would have been made under this title for such care in such 

fiscal year if such revisions had not been implemented. 

‘‘(E) The Secretary shall consult with hospice programs 

and the Medicare Payment Advisory Commission regarding the 

additional data and information to be collected under subparagraph (A) and the payment revisions under subparagraph 

(D).’’. 

(2) CONFORMING AMENDMENTS.—Section 1814(i)(1)(C) of 

the Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended— 

(A) in clause (ii)— 

(i) in the matter preceding subclause (I), by inserting ‘‘(before the first fiscal year in which the payment 

revisions described in paragraph (6)(D) are implemented)’’ after ‘‘subsequent fiscal year’’; and 

(ii) in subclause (VII), by inserting ‘‘(before the 

first fiscal year in which the payment revisions described in paragraph (6)(D) are implemented), subject 

to clause (iv),’’ after ‘‘subsequent fiscal year’’; and 

(B) by adding at the end the following new clause: 

‘‘(iii) With respect to routine home care and other 

services included in hospice care furnished during fiscal years subsequent to the first fiscal year in which 

payment revisions described in paragraph (6)(D) are 

implemented, the payment rates for such care and 
Sec. 3133 PPACA (Consolidated) 354 

services shall be the payment rates in effect under 

this clause during the preceding fiscal year increased 

by, subject to clause (iv), the market basket percentage increase (as defined in section 1886(b)(3)(B)(iii)) 

for the fiscal year.’’. 

(b) ADOPTION OF MEDPAC HOSPICE PROGRAM ELIGIBILITY RECERTIFICATION RECOMMENDATIONS.—Section 1814(a)(7) of the Social Security Act (42 U.S.C. 1395f(a)(7)) is amended— 

(1) in subparagraph (B), by striking ‘‘and’’ at the end; and 

(2) by adding at the end the following new subparagraph: 

‘‘(D) on and after January 1, 2011— 

‘‘(i) a hospice physician or nurse practitioner has 

a face-to-face encounter with the individual to determine continued eligibility of the individual for hospice 

care prior to the 180th-day recertification and each 

subsequent recertification under subparagraph (A)(ii) 

and attests that such visit took place (in accordance 

with procedures established by the Secretary); and 

‘‘(ii) in the case of hospice care provided an individual for more than 180 days by a hospice program 

for which the number of such cases for such program 

comprises more than a percent (specified by the Secretary) of the total number of such cases for all programs under this title, the hospice care provided to 

such individual is medically reviewed (in accordance 

with procedures established by the Secretary); and’’. 

SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE 

HOSPITAL (DSH) PAYMENTS. 

Section 1886 of the Social Security Act (42 U.S.C. 1395ww), as 

amended by sections 3001, 3008, and 3025, is amended— 

(1) in subsection (d)(5)(F)(i), by striking ‘‘For’’ and inserting ‘‘Subject to subsection (r), for’’; and 

(2) by adding at the end the following new subsection: 

‘‘(r) ADJUSTMENTS TO MEDICARE DSH PAYMENTS.—øAs revised 

by section 1104 of HCERA¿ 

‘‘(1) EMPIRICALLY JUSTIFIED DSH PAYMENTS.—For fiscal 

year 2014 and each subsequent fiscal year, instead of the 

amount of disproportionate share hospital payment that would 

otherwise be made under subsection (d)(5)(F) to a subsection 

(d) hospital for the fiscal year, the Secretary shall pay to the 

subsection (d) hospital 25 percent of such amount (which represents the empirically justified amount for such payment, as 

determined by the Medicare Payment Advisory Commission in 

its March 2007 Report to the Congress). 

‘‘(2) ADDITIONAL PAYMENT.—In addition to the payment 

made to a subsection (d) hospital under paragraph (1), for fiscal year 2014 and each subsequent fiscal year, the Secretary 

shall pay to such subsection (d) hospitals an additional amount 

equal to the product of the following factors: 

‘‘(A) FACTOR ONE.—A factor equal to the difference between— 

‘‘(i) the aggregate amount of payments that would 

be made to subsection (d) hospitals under subsection 
355 Sec. 3133 PPACA (Consolidated) 

(d)(5)(F) if this subsection did not apply for such fiscal 

year (as estimated by the Secretary); and 

‘‘(ii) the aggregate amount of payments that are 

made to subsection (d) hospitals under paragraph (1) 

for such fiscal year (as so estimated). 

‘‘(B) FACTOR TWO.—øAs revised by section 10316¿ 

‘‘(i) FISCAL YEARS 2014, 2015, 2016, AND 2017.—For 

each of fiscal years 2014, 2015, 2016, and 2017, a factor equal to 1 minus the percent change in the percent 

of individuals under the age of 65 who are uninsured, 

as determined by comparing the percent of such individuals— 

‘‘(I) who are uninsured in 2013, the last year 

before coverage expansion under the Patient Protection and Affordable Care Act (as calculated by 

the Secretary based on the most recent estimates 

available from the Director of the Congressional 

Budget Office before a vote in either House on the 

Health Care and Education Reconciliation Act of 

2010 that, if determined in the affirmative, would 

clear such Act for enrollment); and 

‘‘(II) who are uninsured in the most recent period for which data is available (as so calculated), 

minus 0.1 percentage points for fiscal year 2014 and 

minus 0.2 percentage points for each of fiscal years 

2015, 2016, and 2017. 

‘‘(ii) 2018 AND SUBSEQUENT YEARS.—For fiscal year 

2018 and each subsequent fiscal year, a factor equal to 

1 minus the percent change in the percent of individuals who are uninsured, as determined by comparing 

the percent of individuals— 

‘‘(I) who are uninsured in 2013 (as estimated 

by the Secretary, based on data from the Census 

Bureau or other sources the Secretary determines 

appropriate, and certified by the Chief Actuary of 

the Centers for Medicare & Medicaid Services); 

and 

‘‘(II) who are uninsured in the most recent period for which data is available (as so estimated 

and certified), 

minus 0.2 percentage points for each of fiscal years 

2018 and 2019. 

‘‘(C) FACTOR THREE.—A factor equal to the percent, for 

each subsection (d) hospital, that represents the quotient 

of— 

‘‘(i) the amount of uncompensated care for such 

hospital for a period selected by the Secretary (as estimated by the Secretary, based on appropriate data (including, in the case where the Secretary determines 

that alternative data is available which is a better 

proxy for the costs of subsection (d) hospitals for treating the uninsured, the use of such alternative data)); 

and 
Sec. 3134 PPACA (Consolidated) 356 

‘‘(ii) the aggregate amount of uncompensated care 

for all subsection (d) hospitals that receive a payment 

under this subsection for such period (as so estimated, 

based on such data). 

‘‘(3) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or 

otherwise of the following: 

‘‘(A) Any estimate of the Secretary for purposes of determining the factors described in paragraph (2). 

‘‘(B) Any period selected by the Secretary for such purposes.’’. 

SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE. 

(a) IN GENERAL.—Section 1848(c)(2) of the Social Security Act 

(42 U.S.C. 1395w–4(c)(2)) is amended by adding at the end the following new subparagraphs: 

‘‘(K) POTENTIALLY MISVALUED CODES.— ‘‘(i) IN GENERAL.—The Secretary shall— 

‘‘(I) periodically identify services as being potentially misvalued using criteria specified in 

clause (ii); and 

‘‘(II) review and make appropriate adjustments to the relative values established under 

this paragraph for services identified as being potentially misvalued under subclause (I). 

‘‘(ii) IDENTIFICATION OF POTENTIALLY MISVALUED

CODES.—For purposes of identifying potentially 

misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to 

be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; 

codes (and families of codes as appropriate) that have 

experienced substantial changes in practice expenses; 

codes for new technologies or services within an appropriate period (such as 3 years) after the relative values 

are initially established for such codes; multiple codes 

that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple 

times for a single treatment; codes which have not 

been subject to review since the implementation of the 

RBRVS (the so-called ‘Harvard-valued codes’); and 

such other codes determined to be appropriate by the 

Secretary. 

‘‘(iii) REVIEW AND ADJUSTMENTS.— 

‘‘(I) The Secretary may use existing processes 

to receive recommendations on the review and appropriate adjustment of potentially misvalued 

services described in clause (i)(II). 

‘‘(II) The Secretary may conduct surveys, 

other data collection activities, studies, or other 

analyses as the Secretary determines to be appropriate to facilitate the review and appropriate adjustment described in clause (i)(II). 
357 Sec. 3134 PPACA (Consolidated) 

‘‘(III) The Secretary may use analytic contractors to identify and analyze services identified 

under clause (i)(I), conduct surveys or collect data, 

and make recommendations on the review and appropriate adjustment of services described in 

clause (i)(II). 

‘‘(IV) The Secretary may coordinate the review 

and appropriate adjustment described in clause 

(i)(II) with the periodic review described in subparagraph (B). 

‘‘(V) As part of the review and adjustment described in clause (i)(II), including with respect to 

codes with low relative values described in clause 

(ii), the Secretary may make appropriate coding 

revisions (including using existing processes for 

consideration of coding changes) which may include consolidation of individual services into bundled codes for payment under the fee schedule 

under subsection (b). 

‘‘(VI) The provisions of subparagraph 

(B)(ii)(II) shall apply to adjustments to relative 

value units made pursuant to this subparagraph 

in the same manner as such provisions apply to 

adjustments under subparagraph (B)(ii)(II). 

‘‘(L) VALIDATING RELATIVE VALUE UNITS.— 

‘‘(i) IN GENERAL.—The Secretary shall establish a 

process to validate relative value units under the fee 

schedule under subsection (b). 

‘‘(ii) COMPONENTS AND ELEMENTS OF WORK.—The 

process described in clause (i) may include validation 

of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, 

and stress due to risk) involved with furnishing a 

service and may include validation of the pre-, post-, 

and intra-service components of work. 

‘‘(iii) SCOPE OF CODES.—The validation of work relative value units shall include a sampling of codes for 

services that is the same as the codes listed under 

subparagraph (K)(ii). 

‘‘(iv) METHODS.—The Secretary may conduct the 

validation under this subparagraph using methods described in subclauses (I) through (V) of subparagraph 

(K)(iii) as the Secretary determines to be appropriate. 

‘‘(v) ADJUSTMENTS.—The Secretary shall make appropriate adjustments to the work relative value units 

under the fee schedule under subsection (b). The provisions of subparagraph (B)(ii)(II) shall apply to adjustments to relative value units made pursuant to 

this subparagraph in the same manner as such provisions apply to adjustments under subparagraph 

(B)(ii)(II).’’. 

(b) IMPLEMENTATION.— 

(1) ADMINISTRATION.— 
Sec. 3135 PPACA (Consolidated) 358 

(A) Chapter 35 of title 44, United States Code and the 

provisions of the Federal Advisory Committee Act (5 

U.S.C. App.) shall not apply to this section or the amendment made by this section. 

(B) Notwithstanding any other provision of law, the 

Secretary may implement subparagraphs (K) and (L) of 

1848(c)(2) of the Social Security Act, as added by subsection (a), by program instruction or otherwise. 

(C) Section 4505(d) of the Balanced Budget Act of 1997 

is repealed. 

(D) Except for provisions related to confidentiality of 

information, the provisions of the Federal Acquisition Regulation shall not apply to this section or the amendment 

made by this section. 

(2) FOCUSING CMS RESOURCES ON POTENTIALLY OVERVALUED CODES.—Section 1868(a) of the Social Security Act (42 

U.S.C. 1395ee(a)) is repealed. 

SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR 

ADVANCED IMAGING SERVICES. 

(a) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER

PRESUMED UTILIZATION.—Section 1848 of the Social Security Act 

(42 U.S.C. 1395w–4) is amended— 

(1) in subsection (b)(4)— 

ø(A) in subparagraph (B), by striking ‘‘subparagraph 

(A)’’ and inserting ‘‘this paragraph’’; and øAmendment 

made by section 1107(1)(A) of HCERA in effect reverses this 

amendment¿¿ 

(B) by adding at the end the following new subparagraph: 

‘‘(C) ADJUSTMENT IN IMAGING UTILIZATION RATE.—øReplaced by section 1107(1)(B) of HCERA¿ With respect to 

fee schedules established for 2011 and subsequent years, 

in the methodology for determining practice expense relative value units for expensive diagnostic imaging equipment under the final rule published by the Secretary in 

the Federal Register on November 25, 2009 (42 CFR 410 

et al.), the Secretary shall use a 75 percent assumption instead of the utilization rates otherwise established in such 

final rule.’’; and 

(2) in subsection (c)(2)(B)(v), by adding at the end the following new subclauses: øReflects amendment made by section 

1107(2) of HCERA that struck subclauses (III), (IV), and (V) inserted by this paragraph and inserting a single new subclause¿ 

‘‘(III) CHANGE IN UTILIZATION RATE FOR CERTAIN IMAGING SERVICES.—Effective for fee schedules established beginning with 2011, reduced expenditures attributable to the change in the utilization rate applicable to 2011, as described in subsection (b)(4)(C).’’. 

(b) ADJUSTMENT IN TECHNICAL COMPONENT ‘‘DISCOUNT’’ ON

SINGLE-SESSION IMAGING TO CONSECUTIVE BODY PARTS.—Section 

1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended 

by subsection (a), is amended— 
359 Sec. 3136 PPACA (Consolidated) 

(1) in subsection (b)(4), by adding at the end the following 

new subparagraph: 

‘‘(D) ADJUSTMENT IN TECHNICAL COMPONENT DISCOUNT

ON SINGLE-SESSION IMAGING INVOLVING CONSECUTIVE BODY

PARTS.—For services furnished on or after July 1, 2010, 

the Secretary shall increase the reduction in payments attributable to the multiple procedure payment reduction applicable to the technical component for imaging under the 

final rule published by the Secretary in the Federal Register on November 21, 2005 (part 405 of title 42, Code of 

Federal Regulations) from 25 percent to 50 percent.’’; and 

(2) in subsection (c)(2)(B)(v), by adding at the end the following new subclause: 

‘‘(VI) ADDITIONAL REDUCED PAYMENT FOR MUL- TIPLE IMAGING PROCEDURES.—Effective for fee 

schedules established beginning with 2010 (but 

not applied for services furnished prior to July 1, 

2010), reduced expenditures attributable to the increase in the multiple procedure payment reduction from 25 to 50 percent (as described in subsection (b)(4)(D)).’’. 

(c) ANALYSIS BY THE CHIEF ACTUARY OF THE CENTERS FOR

MEDICARE & MEDICAID SERVICES.—Not later than January 1, 2013, 

the Chief Actuary of the Centers for Medicare & Medicaid Services 

shall make publicly available an analysis of whether, for the period 

of 2010 through 2019, the cumulative expenditure reductions under 

title XVIII of the Social Security Act that are attributable to the 

adjustments under the amendments made by this section are projected to exceed $3,000,000,000. 

SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS. 

(a) IN GENERAL.—Section 1834(a)(7)(A) of the Social Security 

Act (42 U.S.C. 1395m(a)(7)(A)) is amended— 

(1) in clause (i)— 

(A) in subclause (II), by inserting ‘‘subclause (III) and’’ 

after ‘‘Subject to’’; and 

(B) by adding at the end the following new subclause: 

‘‘(III) SPECIAL RULE FOR POWER-DRIVEN

WHEELCHAIRS.—For purposes of payment for 

power-driven wheelchairs, subclause (II) shall be 

applied by substituting ‘15 percent’ and ‘6 percent’ 

for ‘10 percent’ and ‘7.5 percent’, respectively.’’; 

and 

(2) in clause (iii)— 

(A) in the heading, by inserting ‘‘COMPLEX, REHABILITATIVE’’ before ‘‘POWER-DRIVEN’’; and 

(B) by inserting ‘‘complex, rehabilitative’’ before 

‘‘power-driven’’. 

(b) TECHNICAL AMENDMENT.—Section 1834(a)(7)(C)(ii)(II) of the 

Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended by 

striking ‘‘(A)(ii) or’’. 

(c) EFFECTIVE DATE.— 

(1) IN GENERAL.—Subject to paragraph (2), the amendments made by subsection (a) shall take effect on January 1, 
Sec. 3137 PPACA (Consolidated) 360 

2011, and shall apply to power-driven wheelchairs furnished 

on or after such date. 

(2) APPLICATION TO COMPETITIVE BIDDING.—The amendments made by subsection (a) shall not apply to payment made 

for items and services furnished pursuant to contracts entered 

into under section 1847 of the Social Security Act (42 U.S.C. 

1395w–3) prior to January 1, 2011, pursuant to the implementation of subsection (a)(1)(B)(i)(I) of such section 1847. 

SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT. 

(a) EXTENSION.—øReplaced by section 10317¿ 

(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. 

(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 be-
361 Sec. 3137 PPACA (Consolidated) 

ginning 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. 

(b) PLAN FOR REFORMING THE MEDICARE HOSPITAL WAGE

INDEX SYSTEM.— (1) IN GENERAL.—Not later than December 31, 2011, the 

Secretary of Health and Human Services (in this section referred to as the ‘‘Secretary’’) shall submit to Congress a report 

that includes a plan to reform the hospital wage index system 

under section 1886 of the Social Security Act. 

(2) DETAILS.—In developing the plan under paragraph (1), 

the Secretary shall take into account the goals for reforming 

such system set forth in the Medicare Payment Advisory Commission June 2007 report entitled ‘‘Report to Congress: Promoting Greater Efficiency in Medicare’’, including establishing 

a new hospital compensation index system that— 

(A) uses Bureau of Labor Statistics data, or other data 

or methodologies, to calculate relative wages for each geographic area involved; 

(B) minimizes wage index adjustments between and 

within metropolitan statistical areas and statewide rural 

areas; 

(C) includes methods to minimize the volatility of 

wage index adjustments that result from implementation 

of policy, while maintaining budget neutrality in applying 

such adjustments; 

(D) takes into account the effect that implementation 

of the system would have on health care providers and on 

each region of the country; 

(E) addresses issues related to occupational mix, such 

as staffing practices and ratios, and any evidence on the 

effect on quality of care or patient safety as a result of the 

implementation of the system; and 

(F) provides for a transition. 

(3) CONSULTATION.—In developing the plan under paragraph (1), the Secretary shall consult with relevant affected 

parties. 

(c) USE OF PARTICULAR CRITERIA FOR DETERMINING RECLASSIFICATIONS.—Notwithstanding any other provision of law, in making 

decisions on applications for reclassification of a subsection (d) hospital (as defined in paragraph (1)(B) of section 1886(d) of the Social 

Security Act (42 U.S.C. 1395ww(d)) for the purposes described in 

paragraph (10)(D)(v) of such section for fiscal year 2011 and each 

subsequent fiscal year (until the first fiscal year beginning on or 

after the date that is 1 year after the Secretary of Health and 

Human Services submits the report to Congress under subsection 

(b)), the Geographic Classification Review Board established under 

paragraph (10) of such section shall use the average hourly wage 

comparison criteria used in making such decisions as of September 
Sec. 3138 PPACA (Consolidated) 362 

30, 2008. The preceding sentence shall be effected in a budget neutral manner. 

SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS. 

Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) 

is amended by adding at the end the following new paragraph: 

‘‘(18) AUTHORIZATION OF ADJUSTMENT FOR CANCER HOSPITALS.— 

‘‘(A) STUDY.—The Secretary shall conduct a study to 

determine if, under the system under this subsection, costs 

incurred by hospitals described in section 1886(d)(1)(B)(v) 

with respect to ambulatory payment classification groups 

exceed those costs incurred by other hospitals furnishing 

services under this subsection (as determined appropriate 

by the Secretary). In conducting the study under this subparagraph, the Secretary shall take into consideration the 

cost of drugs and biologicals incurred by such hospitals. 

‘‘(B) AUTHORIZATION OF ADJUSTMENT.—Insofar as the 

Secretary determines under subparagraph (A) that costs 

incurred by hospitals described in section 1886(d)(1)(B)(v) 

exceed those costs incurred by other hospitals furnishing 

services under this subsection, the Secretary shall provide 

for an appropriate adjustment under paragraph (2)(E) to 

reflect those higher costs effective for services furnished on 

or after January 1, 2011.’’. 

øSection 10324(b) of PPACA, p. 869, provided for amendments 

to section 1833(t) of Social Security Act providing a floor on area 

wage adjustment factor for hospital outpatient department services 

in frontier States¿ 

SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS. 

(a) IN GENERAL.—Section 1847A of the Social Security Act (42 

U.S.C. 1395w–3a) is amended— 

(1) in subsection (b)— 

(A) in paragraph (1)— 

(i) in subparagraph (A), by striking ‘‘or’’ at the 

end; 

(ii) in subparagraph (B), by striking the period at 

the end and inserting ‘‘; or’’; and 

(iii) by adding at the end the following new subparagraph: 

‘‘(C) in the case of a biosimilar biological product (as 

defined in subsection (c)(6)(H)), the amount determined 

under paragraph (8).’’; and 

(B) by adding at the end the following new paragraph: 

‘‘(8) BIOSIMILAR BIOLOGICAL PRODUCT.—The amount specified in this paragraph for a biosimilar biological product described in paragraph (1)(C) is the sum of— 

‘‘(A) the average sales price as determined using the 

methodology described under paragraph (6) applied to a 

biosimilar biological product for all National Drug Codes 

assigned to such product in the same manner as such 

paragraph is applied to drugs described in such paragraph; 

and 
363 Sec. 3140 PPACA (Consolidated) 

‘‘(B) 6 percent of the amount determined under paragraph (4) for the reference biological product (as defined in 

subsection (c)(6)(I)).’’; and 

(2) in subsection (c)(6), by adding at the end the following 

new subparagraph: 

‘‘(H) BIOSIMILAR BIOLOGICAL PRODUCT.—The term ‘biosimilar biological product’ means a biological product approved under an abbreviated application for a license of a 

biological product that relies in part on data or information in an application for another biological product licensed under section 351 of the Public Health Service Act. 

‘‘(I) REFERENCE BIOLOGICAL PRODUCT.—The term ‘reference biological product’ means the biological product licensed under such section 351 that is referred to in the application described in subparagraph (H) of the biosimilar 

biological product.’’. 

(b) EFFECTIVE DATE.—The amendments made by subsection (a) 

shall apply to payments for biosimilar biological products beginning 

with the first day of the second calendar quarter after enactment 

of legislation providing for a biosimilar pathway (as determined by 

the Secretary). 

SEC. 3140. ø42 U.S.C. 1395d note¿ MEDICARE HOSPICE CONCURRENT 

CARE DEMONSTRATION PROGRAM. 

(a) ESTABLISHMENT.— (1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as the ‘‘Secretary’’) shall establish a Medicare Hospice Concurrent Care demonstration 

program at participating hospice programs under which Medicare beneficiaries are furnished, during the same period, hospice care and any other items or services covered under title 

XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) from 

funds otherwise paid under such title to such hospice programs. 

(2) DURATION.—The demonstration program under this 

section shall be conducted for a 3-year period. 

(3) SITES.—The Secretary shall select not more than 15 

hospice programs at which the demonstration program under 

this section shall be conducted. Such hospice programs shall be 

located in urban and rural areas. 

(b) INDEPENDENT EVALUATION AND REPORTS.— (1) INDEPENDENT EVALUATION.—The Secretary shall provide for the conduct of an independent evaluation of the demonstration program under this section. Such independent evaluation shall determine whether the demonstration program 

has improved patient care, quality of life, and cost-effectiveness 

for Medicare beneficiaries participating in the demonstration 

program. 

(2) REPORTS.—The Secretary shall submit to Congress a 

report containing the results of the evaluation conducted under 

paragraph (1), together with such recommendations as the Secretary determines appropriate. 

(c) BUDGET NEUTRALITY.—With respect to the 3-year period of 

the demonstration program under this section, the Secretary shall 

ensure that the aggregate expenditures under title XVIII for such 
Sec. 3141 PPACA (Consolidated) 364 

period shall not exceed the aggregate expenditures that would have 

been expended under such title if the demonstration program 

under this section had not been implemented. 

SEC. 3141. ø42 U.S.C. 1395ww note¿ APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL BASIS IN THE CALCULATION OF 

THE MEDICARE HOSPITAL WAGE INDEX FLOOR. 

In the case of discharges occurring on or after October 1, 2010, 

for purposes of applying section 4410 of the Balanced Budget Act 

of 1997 (42 U.S.C. 1395ww note) and paragraph (h)(4) of section 

412.64 of title 42, Code of Federal Regulations, the Secretary of 

Health and Human Services shall administer subsection (b) of such 

section 4410 and paragraph (e) of such section 412.64 in the same 

manner as the Secretary administered such subsection (b) and 

paragraph (e) for discharges occurring during fiscal year 2008 

(through a uniform, national adjustment to the area wage index). 

SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS. 

(a) STUDY.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as the ‘‘Secretary’’) shall 

conduct a study on the need for an additional payment for 

urban Medicare-dependent hospitals for inpatient hospital 

services under section 1886 of the Social Security Act (42 

U.S.C. 1395ww). Such study shall include an analysis of— 

(A) the Medicare inpatient margins of urban Medicaredependent hospitals, as compared to other hospitals which 

receive 1 or more additional payments or adjustments 

under such section (including those payments or adjustments described in paragraph (2)(A)); and 

(B) whether payments to medicare-dependent, small 

rural hospitals under subsection (d)(5)(G) of such section 

should be applied to urban Medicare-dependent hospitals. 

(2) URBAN MEDICARE-DEPENDENT HOSPITAL DEFINED.—For 

purposes of this section, the term ‘‘urban Medicare-dependent 

hospital’’ means a subsection (d) hospital (as defined in subsection (d)(1)(B) of such section) that— 

(A) does not receive any additional payment or adjustment under such section, such as payments for indirect 

medical education costs under subsection (d)(5)(B) of such 

section, disproportionate share payments under subsection 

(d)(5)(A) of such section, payments to a rural referral center under subsection (d)(5)(C) of such section, payments to 

a critical access hospital under section 1814(l) of such Act 

(42 U.S.C. 1395f(l)), payments to a sole community hospital under subsection (d)(5)(D) of such section 1886, or 

payments to a medicare-dependent, small rural hospital 

under subsection (d)(5)(G) of such section 1886; and 

(B) for which more than 60 percent of its inpatient 

days or discharges during 2 of the 3 most recently audited 

cost reporting periods for which the Secretary has a settled 

cost report were attributable to inpatients entitled to benefits under part A of title XVIII of such Act. 

(b) REPORT.—Not later than 9 months after the date of enactment of this Act, the Secretary shall submit to Congress a report 
365 Sec. 3201 PPACA (Consolidated) 

containing the results of the study conducted under subsection (a), 

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

SEC. 3143. PROTECTING HOME HEALTH BENEFITS. 

Nothing in the provisions of, or amendments made by, this Act 

shall result in the reduction of guaranteed home health benefits 

under title XVIII of the Social Security Act. 

Subtitle C—Provisions Relating to Part C 

SEC. 3201. øMEDICARE ADVANTAGE PAYMENT¿øREPEALED & REPLACED¿. 

øSection 3201 (and the amendments made by such section, as 

previously amended by section 10318) was repealed by section 

1102(a) of HCERA. Section 1102(b) of HCERA amended section 

1853 of SSA to provide for a phase-in of modified MA benchmarks 

under a blended benchmark amount under a new subsection (n); 

section 1102(c) of HCERA further amended section 1853 of SSA to 

apply a percentage quality increase under a new subsection (o). Sections 1102(b)-(c) of HCERA shown below¿ 

(b) øSec. 1102(b) of HCERA:¿ Phase-in of Modified Benchmarks.—Section 1853 of the Social Security Act (42 U.S.C. 1395w– 

23) is amended— 

(1) in subsection (j)(1)(A), by striking ‘‘(or, beginning with 

2007, 1⁄12 of the applicable amount determined under subsection (k)(1)) for the area for the year’’ and inserting ‘‘for the 

area for the year (or, for 2007, 2008, 2009, and 2010, 1⁄12 of the 

applicable amount determined under subsection (k)(1) for the 

area for the year; for 2011, 1⁄12 of the applicable amount determined under subsection (k)(1) for the area for 2010; and, beginning with 2012, 1⁄12 of the blended benchmark amount determined under subsection (n)(1) for the area for the year)’’; and 

(2) by adding at the end the following new subsection: 

‘‘(n) DETERMINATION OF BLENDED BENCHMARK AMOUNT.— 

‘‘(1) IN GENERAL.—For purposes of subsection (j), subject to 

paragraphs (3), (4), and (5), the term ‘blended benchmark 

amount’ means for an area— 

‘‘(A) for 2012 the sum of— 

‘‘(i) 1⁄2 of the applicable amount for the area and 

year; and 

‘‘(ii) 1⁄2 of the amount specified in paragraph (2)(A) 

for the area and year; and 

‘‘(B) for a subsequent year the amount specified in 

paragraph (2)(A) for the area and year. 

‘‘(2) SPECIFIED AMOUNT.— 

‘‘(A) IN GENERAL.—The amount specified in this subparagraph for an area and year is the product of— 

‘‘(i) the base payment amount specified in subparagraph (E) for the area and year adjusted to take 

into account the phase-out in the indirect costs of medical education from capitation rates described in subsection (k)(4); and 
Sec. 3201 PPACA (Consolidated) 366 

‘‘(ii) the applicable percentage for the area for the 

year specified under subparagraph (B). 

‘‘(B) APPLICABLE PERCENTAGE.—Subject to subparagraph (D), the applicable percentage specified in this subparagraph for an area for a year in the case of an area 

that is ranked— 

‘‘(i) in the highest quartile under subparagraph 

(C) for the previous year is 95 percent; 

‘‘(ii) in the second highest quartile under such 

subparagraph for the previous year is 100 percent; 

‘‘(iii) in the third highest quartile under such subparagraph for the previous year is 107.5 percent; or 

‘‘(iv) in the lowest quartile under such subparagraph for the previous year is 115 percent. 

‘‘(C) PERIODIC RANKING.—For purposes of this paragraph in the case of an area located— 

‘‘(i) in 1 of the 50 States or the District of Columbia, the Secretary shall rank such area in each year 

specified under subsection (c)(1)(D)(ii) based upon the 

level of the amount specified in subparagraph (A)(i) for 

such areas; or 

‘‘(ii) in a territory, the Secretary shall rank such 

areas in each such year based upon the level of the 

amount specified in subparagraph (A)(i) for such area 

relative to quartile rankings computed under clause 

(i). 

‘‘(D) 1-YEAR TRANSITION FOR CHANGES IN APPLICABLE

PERCENTAGE.—If, for a year after 2012, there is a change 

in the quartile in which an area is ranked compared to the 

previous year, the applicable percentage for the area in the 

year shall be the average of— 

‘‘(i) the applicable percentage for the area for the 

previous year; and 

‘‘(ii) the applicable percentage that would otherwise apply for the area for the year. 

‘‘(E) BASE PAYMENT AMOUNT.—Subject to subparagraph (F), the base payment amount specified in this subparagraph— 

‘‘(i) for 2012 is the amount specified in subsection 

(c)(1)(D) for the area for the year; or 

‘‘(ii) for a subsequent year that— 

‘‘(I) is not specified under subsection 

(c)(1)(D)(ii), is the base amount specified in this 

subparagraph for the area for the previous year, 

increased by the national per capita MA growth 

percentage, described in subsection (c)(6) for that 

succeeding year, but not taking into account any 

adjustment under subparagraph (C) of such subsection for a year before 2004; and 

‘‘(II) is specified under subsection (c)(1)(D)(ii), 

is the amount specified in subsection (c)(1)(D) for 

the area for the year. 

‘‘(F) APPLICATION OF INDIRECT MEDICAL EDUCATION

PHASE-OUT.—The base payment amount specified in sub-
367 Sec. 3201 PPACA (Consolidated) 

paragraph (E) for a year shall be adjusted in the same 

manner under paragraph (4) of subsection (k) as the applicable amount is adjusted under such subsection. 

‘‘(3) ALTERNATIVE PHASE-INS.— ‘‘(A) 4-YEAR PHASE-IN FOR CERTAIN AREAS.—If the difference between the applicable amount (as defined in subsection (k)) for an area for 2010 and the projected 2010 

benchmark amount (as defined in subparagraph (C)) for 

the area is at least $30 but less than $50, the blended 

benchmark amount for the area is— 

‘‘(i) for 2012 the sum of— 

‘‘(I) 3⁄4 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄4 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(ii) for 2013 the sum of— 

‘‘(I) 1⁄2 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄2 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(iii) for 2014 the sum of— 

‘‘(I) 1⁄4 of the applicable amount for the area 

and year; and 

‘‘(II) 3⁄4 of the amount specified in paragraph 

(2)(A) for the area and year; and 

‘‘(iv) for a subsequent year the amount specified in 

paragraph (2)(A) for the area and year. 

‘‘(B) 6-YEAR PHASE-IN FOR CERTAIN AREAS.—If the difference between the applicable amount (as defined in subsection (k)) for an area for 2010 and the projected 2010 

benchmark amount (as defined in subparagraph (C)) for 

the area is at least $50, the blended benchmark amount 

for the area is— 

‘‘(i) for 2012 the sum of— 

‘‘(I) 5⁄6 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄6 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(ii) for 2013 the sum of— 

‘‘(I) 2⁄3 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄3 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(iii) for 2014 the sum of— 

‘‘(I) 1⁄2 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄2 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(iv) for 2015 the sum of— 

‘‘(I) 1⁄3 of the applicable amount for the area 

and year; and 

‘‘(II) 2⁄3 of the amount specified in paragraph 

(2)(A) for the area and year; and 

‘‘(v) for 2016 the sum of— 
Sec. 3201 PPACA (Consolidated) 368 

‘‘(I) 1⁄6 of the applicable amount for the area 

and year; and 

‘‘(II) 5⁄6 of the amount specified in paragraph 

(2)(A) for the area and year; and 

‘‘(vi) for a subsequent year the amount specified in 

paragraph (2)(A) for the area and year. 

‘‘(C) PROJECTED 2010 BENCHMARK AMOUNT.—The projected 2010 benchmark amount described in this subparagraph for an area is equal to the sum of— 

‘‘(i) 1⁄2 of the applicable amount (as defined in subsection (k)) for the area for 2010; and 

‘‘(ii) 1⁄2 of the amount specified in paragraph (2)(A) 

for the area for 2010 but determined as if there were 

substituted for the applicable percentage specified in 

clause (ii) of such paragraph the sum of— 

‘‘(I) the applicable percent that would be specified under subparagraph (B) of paragraph (2) (determined without regard to subparagraph (D) of 

such paragraph) for the area for 2010 if any reference in such paragraph to ‘the previous year’ 

were deemed a reference to 2010; and 

‘‘(II) the applicable percentage increase that 

would apply to a qualifying plan in the area under 

subsection (o) as if any reference in such subsection to 2012 were deemed a reference to 2010 

and as if the determination of a qualifying county 

under paragraph (3)(B) of such subsection were 

made for 2010. 

‘‘(4) CAP ON BENCHMARK AMOUNT.—In no case shall the 

blended benchmark amount for an area for a year (determined 

taking into account subsection (o)) be greater than the applicable amount that would (but for the application of this subsection) be determined under subsection (k)(1) for the area for 

the year. 

‘‘(5) NON-APPLICATION TO PACE PLANS.—This subsection 

shall not apply to payments to a PACE program under section 

1894.’’. 

(c) øSec. 1102(c) of HCERA:¿ Applicable Percentage Quality Increases.—Section 1853 of such Act (42 U.S.C. 1395w–23), as 

amended by subsection (b), is amended— 

(1) in subsection (j), by inserting ‘‘subject to subsection (o),’’ 

after ‘‘For purposes of this part,’’; 

(2) in subsection (n)(2)(B), as added by subsection (b), by 

inserting ‘‘, subject to subsection (o)’’ after ‘‘as follows’’; and 

(3) by adding at the end the following new subsection: 

‘‘(o) APPLICABLE PERCENTAGE QUALITY INCREASES.— 

‘‘(1) IN GENERAL.—Subject to the succeeding paragraphs, in 

the case of a qualifying plan with respect to a year beginning 

with 2012, the applicable percentage under subsection (n)(2)(B) 

shall be increased on a plan or contract level, as determined 

by the Secretary— 

‘‘(A) for 2012, by 1.5 percentage points; 

‘‘(B) for 2013, by 3.0 percentage points; and 
369 Sec. 3201 PPACA (Consolidated) 

‘‘(C) for 2014 or a subsequent year, by 5.0 percentage 

points. 

‘‘(2) INCREASE FOR QUALIFYING PLANS IN QUALIFYING COUNTIES.—The increase applied under paragraph (1) for a qualifying plan located in a qualifying county for a year shall be 

doubled. 

‘‘(3) QUALIFYING PLANS AND QUALIFYING COUNTY DEFINED; 

APPLICATION OF INCREASES TO LOW ENROLLMENT AND NEW

PLANS.—For purposes of this subsection: 

‘‘(A) QUALIFYING PLAN.— 

‘‘(i) IN GENERAL.—The term ‘qualifying plan’ 

means, for a year and subject to paragraph (4), a plan 

that had a quality rating under paragraph (4) of 4 

stars or higher based on the most recent data available for such year. 

‘‘(ii) APPLICATION OF INCREASES TO LOW ENROLLMENT PLANS.— 

‘‘(I) 2012.—For 2012, the term ‘qualifying 

plan’ includes an MA plan that the Secretary determines is not able to have a quality rating 

under paragraph (4) because of low enrollment. 

‘‘(II) 2013 AND SUBSEQUENT YEARS.—For 2013 

and subsequent years, for purposes of determining 

whether an MA plan with low enrollment (as defined by the Secretary) is included as a qualifying 

plan, the Secretary shall establish a method to 

apply to MA plans with low enrollment (as defined 

by the Secretary) the computation of quality rating and the rating system under paragraph (4). 

‘‘(iii) APPLICATION OF INCREASES TO NEW PLANS.— 

‘‘(I) IN GENERAL.—A new MA plan that meets 

criteria specified by the Secretary shall be treated 

as a qualifying plan, except that in applying paragraph (1), the applicable percentage under subsection (n)(2)(B) shall be increased— 

‘‘(aa) for 2012, by 1.5 percentage points; 

‘‘(bb) for 2013, by 2.5 percentage points; 

and 

‘‘(cc) for 2014 or a subsequent year, by 3.5 

percentage points. 

‘‘(II) NEW MA PLAN DEFINED.—The term ‘new 

MA plan’ means, with respect to a year, a plan offered by an organization or sponsor that has not 

had a contract as a Medicare Advantage organization in the preceding 3-year period. 

‘‘(B) QUALIFYING COUNTY.—The term ‘qualifying county’ means, for a year, a county— 

‘‘(i) that has an MA capitation rate that, in 2004, 

was based on the amount specified in subsection 

(c)(1)(B) for a Metropolitan Statistical Area with a 

population of more than 250,000; 

‘‘(ii) for which, as of December 2009, of the Medicare Advantage eligible individuals residing in the 
Sec. 3202 PPACA (Consolidated) 370 

county at least 25 percent of such individuals were enrolled in Medicare Advantage plans; and 

‘‘(iii) that has per capita fee-for-service spending 

that is lower than the national monthly per capita cost 

for expenditures for individuals enrolled under the 

original medicare fee-for-service program for the year. 

‘‘(4) QUALITY DETERMINATIONS FOR APPLICATION OF INCREASE.— 

‘‘(A) QUALITY DETERMINATION.—The quality rating for 

a plan shall be determined according to a 5-star rating system (based on the data collected under section 1852(e)). 

‘‘(B) PLANS THAT FAILED TO REPORT.—An MA plan 

which does not report data that enables the Secretary to 

rate the plan for purposes of this paragraph shall be 

counted as having a rating of fewer than 3.5 stars. 

‘‘(5) EXCEPTION FOR PACE PLANS.—This subsection shall not 

apply to payments to a PACE program under section 1894.’’. 

(4) DETERMINATION OF MEDICARE PART D LOW-INCOME

BENCHMARK PREMIUM.—øAmended section 1860D– 

14(b)(2)(B)(iii) of SSA, as amended by section 3302¿ 

SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION. 

(a) LIMITATION ON VARIATION OF COST SHARING FOR CERTAIN

BENEFITS.— 

(1) IN GENERAL.—Section 1852(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w–22(a)(1)(B)) is amended— 

(A) in clause (i), by inserting ‘‘, subject to clause (iii),’’ 

after ‘‘and B or’’; and 

(B) by adding at the end the following new clauses: 

‘‘(iii) LIMITATION ON VARIATION OF COST SHARING

FOR CERTAIN BENEFITS.—Subject to clause (v), costsharing for services described in clause (iv) shall not 

exceed the cost-sharing required for those services 

under parts A and B. 

‘‘(iv) SERVICES DESCRIBED.—The following services 

are described in this clause: 

‘‘(I) Chemotherapy administration services. 

‘‘(II) Renal dialysis services (as defined in section 1881(b)(14)(B)). 

‘‘(III) Skilled nursing care. 

‘‘(IV) Such other services that the Secretary 

determines appropriate (including services that 

the Secretary determines require a high level of 

predictability and transparency for beneficiaries). 

‘‘(v) EXCEPTION.—In the case of services described 

in clause (iv) for which there is no cost-sharing required under parts A and B, cost-sharing may be required for those services in accordance with clause 

(i).’’. 

(2) EFFECTIVE DATE.—The amendments made by this subsection shall apply to plan years beginning on or after January 

1, 2011. 

(b) APPLICATION OF REBATES, PERFORMANCE BONUSES, AND

PREMIUMS.— 
371 Sec. 3202 PPACA (Consolidated) 

(1) APPLICATION OF REBATES.—Section 1854(b)(1)(C) of the 

Social Security Act (42 U.S.C. 1395w–24(b)(1)(C)) is amended— 

(A) in clause (ii), by striking ‘‘REBATE.—A rebate’’ and 

inserting ‘‘REBATE FOR PLAN YEARS BEFORE 2012.—For plan 

years before 2012, a rebate’’; 

(B) by redesignating clauses (iii) and (iv) as clauses 

(vii) and (viii) øReflects subsequent redesignation made by 

section 1102(d)(2) of HCERA¿; and 

(C) by inserting after clause (ii) the following new 

clause: øAs revised by section 1102(d)(2) of HCERA¿ 

‘‘(iii) APPLICABLE REBATE PERCENTAGE.—The applicable rebate percentage specified in this clause for a 

plan for a year, based on the system under section 

1853(o)(4)(A), is the sum of— 

‘‘(I) the product of the old phase-in proportion 

for the year under clause (iv) and 75 percent; and 

‘‘(II) the product of the new phase-in proportion for the year under clause (iv) and the final 

applicable rebate percentage under clause (v). 

‘‘(iv) OLD AND NEW PHASE-IN PROPORTIONS.—For 

purposes of clause (iv)— 

‘‘(I) for 2012, the old phase-in proportion is 2⁄3

and the new phase-in proportion is 1⁄3; 

‘‘(II) for 2013, the old phase-in proportion is 1⁄3 and the new phase-in proportion is 2⁄3; and 

‘‘(III) for 2014 and any subsequent year, the 

old phase-in proportion is 0 and the new phase-in 

proportion is 1. 

‘‘(v) FINAL APPLICABLE REBATE PERCENTAGE.—Subject to clause (vi), the final applicable rebate percentage under this clause is— 

‘‘(I) in the case of a plan with a quality rating 

under such system of at least 4.5 stars, 70 percent; 

‘‘(II) in the case of a plan with a quality rating 

under such system of at least 3.5 stars and less 

than 4.5 stars, 65 percent; and 

‘‘(III) in the case of a plan with a quality rating under such system of less than 3.5 stars, 50 

percent. 

‘‘(vi) TREATMENT OF LOW ENROLLMENT AND NEW

PLANS.—For purposes of clause (v)— 

‘‘(I) for 2012, in the case of a plan described 

in subclause (I) of subsection (o)(3)(A)(ii), the plan 

shall be treated as having a rating of 4.5 stars; 

and 

‘‘(II) for 2012 or a subsequent year, in the 

case of a new MA plan (as defined under subclause (III) of subsection (o)(3)(A)(iii)) that is 

treated as a qualifying plan pursuant to subclause 

(I) of such subsection, the plan shall be treated as 

having a rating of 3.5 stars.’’. 

(2) APPLICATION OF PERFORMANCE BONUSES.—Section 

1853(n) of the Social Security Act, as added by section 3201(f), 
Sec. 3203 PPACA (Consolidated) 372 

is amended by adding at the end the following new paragraph: 

øamendment obsolete; section 3201 and its amendments were 

subsequently repealed by section 1102(a) of HCERA¿ 

‘‘(6) APPLICATION OF PERFORMANCE BONUSES.—For plan 

years beginning on or after January 1, 2014, any performance 

bonus paid to an MA plan under this subsection shall be used 

for the purposes, and in the priority order, described in subclauses (I) through (III) of section 1854(b)(1)(C)(iii).’’. 

(3) APPLICATION OF MA MONTHLY SUPPLEMENTARY BENE- FICIARY PREMIUM.—Section 1854(b)(2)(C) of the Social Security 

Act (42 U.S.C. 1395w–24(b)(2)(C)) is amended— 

(A) by striking ‘‘PREMIUM.—The term’’ and inserting ‘‘PREMIUM.— 

‘‘(i) IN GENERAL.—The term’’; and 

(B) by adding at the end the following new clause: 

‘‘(ii) APPLICATION OF MA MONTHLY SUPPLEMENTARY

BENEFICIARY PREMIUM.—For plan years beginning on 

or after January 1, 2012, any MA monthly supplementary beneficiary premium charged to an individual 

enrolled in an MA plan shall be used for the purposes, 

and in the priority order, described in subclauses (I) 

through (III) of paragraph (1)(C)(iii).’’. 

SEC. 3203. øAPPLICATION OF CODING INTENSITY ADJUSTMENT DURING MA PAYMENT TRANSITION¿øREPEALED AND REPLACED¿. 

øSection 3203 (and the amendments made by such section) was 

repealed by section 1102(a) of HCERA.¿ 

øSection 1102(e) of HCERA amended section 1853(a)(1)(C)(ii) of 

the Social Security Act with respect to the coding intensity adjustment, shown below¿ 

(e) ƒSEC. 1102(E) OF HCERA≈ Coding Intensity Adjustment.— 

Section 1853(a)(1)(C)(ii) of such Act (42 U.S.C. 1395w– 

23(a)(1)(C)(ii)) is amended— 

(1) in the heading, by striking ‘‘DURING PHASEOUT OF BUDGET NEUTRALITY FACTOR’’ and inserting ‘‘OF CODING ADJUSTMENT’’; 

(2) in the matter before subclause (I), by striking ‘‘through 

2010’’ and inserting ‘‘and each subsequent year’’; and 

(3) in subclause (II)— 

(A) in the first sentence, by inserting ‘‘annually’’ before 

‘‘conduct an analysis’’; 

(B) in the second sentence— 

(i) by inserting ‘‘on a timely basis’’ after ‘‘are incorporated’’; and 

(ii) by striking ‘‘only for 2008, 2009, and 2010’’ 

and inserting ‘‘for 2008 and subsequent years’’; 

(C) in the third sentence, by inserting ‘‘and updated as 

appropriate’’ before the period at the end; and 

(D) by adding at the end the following new subclauses: 

‘‘(III) In calculating each year’s adjustment, 

the adjustment factor shall be for 2014, not less 

than the adjustment factor applied for 2010, plus 

1.3 percentage points; for each of years 2015 

through 2018, not less than the adjustment factor 
373 Sec. 3205 PPACA (Consolidated) 

applied for the previous year, plus 0.25 percentage 

point; and for 2019 and each subsequent year, not 

less than 5.7 percent. 

‘‘(IV) Such adjustment shall be applied to risk 

scores until the Secretary implements risk adjustment using Medicare Advantage diagnostic, cost, 

and use data.’’. 

SEC. 3204. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS. 

(a) ANNUAL 45-DAY PERIOD FOR DISENROLLMENT FROM MA 

PLANS TO ELECT TO RECEIVE BENEFITS UNDER THE ORIGINAL

MEDICARE FEE-FOR-SERVICE PROGRAM.— 

(1) IN GENERAL.—Section 1851(e)(2)(C) of the Social Security Act (42 U.S.C. 1395w–1(e)(2)(C)) is amended to read as follows: 

‘‘(C) ANNUAL 45-DAY PERIOD FOR DISENROLLMENT FROM

MA PLANS TO ELECT TO RECEIVE BENEFITS UNDER THE

ORIGINAL MEDICARE FEE-FOR-SERVICE PROGRAM.—Subject 

to subparagraph (D), at any time during the first 45 days 

of a year (beginning with 2011), an individual who is enrolled in a Medicare Advantage plan may change the election under subsection (a)(1), but only with respect to coverage under the original medicare fee-for-service program 

under parts A and B, and may elect qualified prescription 

drug coverage in accordance with section 1860D–1.’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall apply with respect to 2011 and succeeding years. 

(b) TIMING OF THE ANNUAL, COORDINATED ELECTION PERIOD

UNDER PARTS C AND D.—Section 1851(e)(3)(B) of the Social Security Act (42 U.S.C. 1395w–1(e)(3)(B)) is amended— 

(1) in clause (iii), by striking ‘‘and’’ at the end; 

(2) in clause (iv)— 

(A) by striking ‘‘and succeeding years’’ and inserting ‘‘, 

2008, 2009, and 2010’’; and 

(B) by striking the period at the end and inserting ‘‘; 

and’’; and 

(3) by adding at the end the following new clause: 

‘‘(v) with respect to 2012 and succeeding years, the 

period beginning on October 15 and ending on December 7 of the year before such year.’’. 

SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL 

NEEDS INDIVIDUALS. 

(a) EXTENSION OF SNP AUTHORITY.—Section 1859(f)(1) of the 

Social Security Act (42 U.S.C. 1395w–28(f)(1)), as amended by section 164(a) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275), is amended by striking 

‘‘2011’’ and inserting ‘‘2014’’. 

(b) AUTHORITY TO APPLY FRAILTY ADJUSTMENT UNDER PACE 

PAYMENT RULES.—Section 1853(a)(1)(B) of the Social Security Act 

(42 U.S.C. 1395w–23(a)(1)(B)) is amended by adding at the end the 

following new clause: 
Sec. 3205 PPACA (Consolidated) 374 

‘‘(iv) AUTHORITY TO APPLY FRAILTY ADJUSTMENT

UNDER PACE PAYMENT RULES FOR CERTAIN SPECIALIZED

MA PLANS FOR SPECIAL NEEDS INDIVIDUALS.— ‘‘(I) IN GENERAL.—Notwithstanding the preceding provisions of this paragraph, for plan year 

2011 and subsequent plan years, in the case of a 

plan described in subclause (II), the Secretary 

may apply the payment rules under section 

1894(d) (other than paragraph (3) of such section) 

rather than the payment rules that would otherwise apply under this part, but only to the extent 

necessary to reflect the costs of treating high concentrations of frail individuals. 

‘‘(II) PLAN DESCRIBED.—A plan described in 

this subclause is a specialized MA plan for special 

needs individuals described in section 

1859(b)(6)(B)(ii) that is fully integrated with 

capitated contracts with States for Medicaid benefits, including long-term care, and that have similar average levels of frailty (as determined by the 

Secretary) as the PACE program.’’. 

(c) TRANSITION AND EXCEPTION REGARDING RESTRICTION ON

ENROLLMENT.—Section 1859(f) of the Social Security Act (42 U.S.C. 

1395w–28(f)) is amended by adding at the end the following new 

paragraph: 

‘‘(6) TRANSITION AND EXCEPTION REGARDING RESTRICTION

ON ENROLLMENT.— ‘‘(A) IN GENERAL.—Subject to subparagraph (C), the 

Secretary shall establish procedures for the transition of 

applicable individuals to— 

‘‘(i) a Medicare Advantage plan that is not a specialized MA plan for special needs individuals (as defined in subsection (b)(6)); or 

‘‘(ii) the original medicare fee-for-service program 

under parts A and B. 

‘‘(B) APPLICABLE INDIVIDUALS.—For purposes of clause 

(i), the term ‘applicable individual’ means an individual 

who— 

‘‘(i) is enrolled under a specialized MA plan for 

special needs individuals (as defined in subsection 

(b)(6)); and 

‘‘(ii) is not within the 1 or more of the classes of 

special needs individuals to which enrollment under 

the plan is restricted to. 

‘‘(C) EXCEPTION.—The Secretary shall provide for an 

exception to the transition described in subparagraph (A) 

for a limited period of time for individuals enrolled under 

a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) who are no longer eligible 

for medical assistance under title XIX. 

‘‘(D) TIMELINE FOR INITIAL TRANSITION.—The Secretary 

shall ensure that applicable individuals enrolled in a specialized MA plan for special needs individuals (as defined 

in subsection (b)(6)) prior to January 1, 2010, are 
375 Sec. 3205 PPACA (Consolidated) 

transitioned to a plan or the program described in subparagraph (A) by not later than January 1, 2013.’’. 

(d) TEMPORARY EXTENSION OF AUTHORITY TO OPERATE BUT NO

SERVICE AREA EXPANSION FOR DUAL SPECIAL NEEDS PLANS THAT

DO NOT MEET CERTAIN REQUIREMENTS.—Section 164(c)(2) of the 

Medicare Improvements for Patients and Providers Act of 2008 

(Public Law 110–275) is amended by striking ‘‘December 31, 2010’’ 

and inserting ‘‘December 31, 2012’’. 

(e) AUTHORITY TO REQUIRE SPECIAL NEEDS PLANS BE NCQA 

APPROVED.—Section 1859(f) of the Social Security Act (42 U.S.C. 

1395w–28(f)), as amended by subsections (a) and (c), is amended— 

(1) in paragraph (2), by adding at the end the following 

new subparagraph: 

‘‘(C) If applicable, the plan meets the requirement described in paragraph (7).’’; 

(2) in paragraph (3), by adding at the end the following 

new subparagraph: 

‘‘(E) If applicable, the plan meets the requirement described in paragraph (7).’’; 

(3) in paragraph (4), by adding at the end the following 

new subparagraph: 

‘‘(C) If applicable, the plan meets the requirement described in paragraph (7).’’; and 

(4) by adding at the end the following new paragraph: 

‘‘(7) AUTHORITY TO REQUIRE SPECIAL NEEDS PLANS BE NCQA

APPROVED.—For 2012 and subsequent years, the Secretary 

shall require that a Medicare Advantage organization offering 

a specialized MA plan for special needs individuals be approved by the National Committee for Quality Assurance 

(based on standards established by the Secretary).’’. 

(f) RISK ADJUSTMENT.—Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395i–23(a)(1)(C)) is amended by adding at 

the end the following new clause: 

‘‘(iii) IMPROVEMENTS TO RISK ADJUSTMENT FOR SPECIAL NEEDS INDIVIDUALS WITH CHRONIC HEALTH CONDITIONS.— 

‘‘(I) IN GENERAL.—For 2011 and subsequent 

years, for purposes of the adjustment under clause 

(i) with respect to individuals described in subclause (II), the Secretary shall use a risk score 

that reflects the known underlying risk profile 

and chronic health status of similar individuals. 

Such risk score shall be used instead of the default risk score for new enrollees in Medicare Advantage plans that are not specialized MA plans 

for special needs individuals (as defined in section 

1859(b)(6)). 

‘‘(II) INDIVIDUALS DESCRIBED.—An individual 

described in this subclause is a special needs individual described in subsection (b)(6)(B)(iii) who 

enrolls in a specialized MA plan for special needs 

individuals on or after January 1, 2011. 

‘‘(III) EVALUATION.—For 2011 and periodically 

thereafter, the Secretary shall evaluate and revise 
Sec. 3206 PPACA (Consolidated) 376 

the risk adjustment system under this subparagraph in order to, as accurately as possible, account for higher medical and care coordination 

costs associated with frailty, individuals with multiple, comorbid chronic conditions, and individuals 

with a diagnosis of mental illness, and also to account for costs that may be associated with higher 

concentrations of beneficiaries with those conditions. 

‘‘(IV) PUBLICATION OF EVALUATION AND REVISIONS.—The Secretary shall publish, as part of an 

announcement under subsection (b), a description 

of any evaluation conducted under subclause (III) 

during the preceding year and any revisions made 

under such subclause as a result of such evaluation.’’. 

(g) TECHNICAL CORRECTION.—Section 1859(f)(5) of the Social 

Security Act (42 U.S.C. 1395w–28(f)(5)) is amended, in the matter 

preceding subparagraph (A), by striking ‘‘described in subsection 

(b)(6)(B)(i)’’. 

SEC. 3206. EXTENSION OF REASONABLE COST CONTRACTS. 

Section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C. 

1395mm(h)(5)(C)(ii)) is amended, in the matter preceding subclause 

(I), by striking ‘‘January 1, 2010’’ and inserting ‘‘January 1, 2013’’. 

SEC. 3207. TECHNICAL CORRECTION TO MA PRIVATE FEE-FOR-SERVICE PLANS. 

For plan year 2011 and subsequent plan years, to the extent 

that the Secretary of Health and Human Services is applying the 

2008 service area extension waiver policy (as modified in the April 

11, 2008, Centers for Medicare & Medicaid Services’ memorandum 

with the subject ‘‘2009 Employer Group Waiver-Modification of the 

2008 Service Area Extension Waiver Granted to Certain MA Local 

Coordinated Care Plans’’) to Medicare Advantage coordinated care 

plans, the Secretary shall extend the application of such waiver 

policy to employers who contract directly with the Secretary as a 

Medicare Advantage private fee-for-service plan under section 

1857(i)(2) of the Social Security Act (42 U.S.C. 1395w–27(i)(2)) and 

that had enrollment as of October 1, 2009. 

SEC. 3208. MAKING SENIOR HOUSING FACILITY DEMONSTRATION PERMANENT. 

(a) IN GENERAL.—Section 1859 of the Social Security Act (42 

U.S.C. 1395w–28) is amended by adding at the end the following 

new subsection: 

‘‘(g) SPECIAL RULES FOR SENIOR HOUSING FACILITY PLANS.— 

‘‘(1) IN GENERAL.—In the case of a Medicare Advantage 

senior housing facility plan described in paragraph (2), notwithstanding any other provision of this part to the contrary 

and in accordance with regulations of the Secretary, the service 

area of such plan may be limited to a senior housing facility 

in a geographic area. 

‘‘(2) MEDICARE ADVANTAGE SENIOR HOUSING FACILITY PLAN

DESCRIBED.—For purposes of this subsection, a Medicare Ad-
377 Sec. 3210 PPACA (Consolidated) 

vantage senior housing facility plan is a Medicare Advantage 

plan that— 

‘‘(A) restricts enrollment of individuals under this part 

to individuals who reside in a continuing care retirement 

community (as defined in section 1852(l)(4)(B)); 

‘‘(B) provides primary care services onsite and has a 

ratio of accessible physicians to beneficiaries that the Secretary determines is adequate; 

‘‘(C) provides transportation services for beneficiaries 

to specialty providers outside of the facility; and 

‘‘(D) has participated (as of December 31, 2009) in a 

demonstration project established by the Secretary under 

which such a plan was offered for not less than 1 year.’’. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall take effect on January 1, 2010, and shall apply to plan years 

beginning on or after such date. 

SEC. 3209. AUTHORITY TO DENY PLAN BIDS. 

(a) IN GENERAL.—Section 1854(a)(5) of the Social Security Act 

(42 U.S.C. 1395w–24(a)(5)) is amended by adding at the end the 

following new subparagraph: 

‘‘(C) REJECTION OF BIDS.— ‘‘(i) IN GENERAL.—Nothing in this section shall be 

construed as requiring the Secretary to accept any or 

every bid submitted by an MA organization under this 

subsection. 

‘‘(ii) AUTHORITY TO DENY BIDS THAT PROPOSE SIG- NIFICANT INCREASES IN COST SHARING OR DECREASES IN

BENEFITS.—The Secretary may deny a bid submitted 

by an MA organization for an MA plan if it proposes 

significant increases in cost sharing or decreases in 

benefits offered under the plan.’’. 

(b) APPLICATION UNDER PART D.—Section 1860D–11(d) of such 

Act (42 U.S.C. 1395w–111(d)) is amended by adding at the end the 

following new paragraph: 

‘‘(3) REJECTION OF BIDS.—Paragraph (5)(C) of section 

1854(a) shall apply with respect to bids submitted by a PDP 

sponsor under subsection (b) in the same manner as such paragraph applies to bids submitted by an MA organization under 

such section 1854(a).’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to bids submitted for contract years beginning on or 

after January 1, 2011. 

SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN 

MEDIGAP PLANS. 

(a) IN GENERAL.—Section 1882 of the Social Security Act (42 

U.S.C. 1395ss) is amended by adding at the end the following new 

subsection: 

‘‘(y) DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDICARE

SUPPLEMENTAL POLICIES.— 

‘‘(1) IN GENERAL.—The Secretary shall request the National Association of Insurance Commissioners to review and 

revise the standards for benefit packages described in paragraph (2) under subsection (p)(1), to otherwise update stand-
Sec. 3301 PPACA (Consolidated) 378 

ards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under part 

B. Such revisions shall be based on evidence published in peerreviewed journals or current examples used by integrated delivery systems and made consistent with the rules applicable 

under subsection (p)(1)(E) with the reference to the ‘1991 NAIC 

Model Regulation’ deemed a reference to the NAIC Model Regulation as published in the Federal Register on December 4, 

1998, and as subsequently updated by the National Association 

of Insurance Commissioners to reflect previous changes in law 

and the reference to ‘date of enactment of this subsection’ 

deemed a reference to the date of enactment of the Patient 

Protection and Affordable Care Act. To the extent practicable, 

such revision shall provide for the implementation of revised 

standards for benefit packages as of January 1, 2015. 

‘‘(2) BENEFIT PACKAGES DESCRIBED.—The benefit packages 

described in this paragraph are benefit packages classified as 

‘C’ and ‘F’.’’. 

(b) CONFORMING AMENDMENT.—Section 1882(o)(1) of the Social 

Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking ‘‘, and 

(w)’’ and inserting ‘‘(w), and (y)’’. 

Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and 

MA–PD Plans 

SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM. 

(a) CONDITION FOR COVERAGE OF DRUGS UNDER PART D.—Part 

D of Title XVIII of the Social Security Act (42 U.S.C. 1395w–101 

et seq.), is amended by adding at the end the following new section: 

‘‘CONDITION FOR COVERAGE OF DRUGS UNDER THIS PART

‘‘SEC. 1860D–43. ø42 U.S.C. 1395w–153¿ (a) IN GENERAL.—In 

order for coverage to be available under this part for covered part 

D drugs (as defined in section 1860D–2(e)) of a manufacturer, the 

manufacturer must— 

‘‘(1) participate in the Medicare coverage gap discount program under section 1860D–14A; 

‘‘(2) have entered into and have in effect an agreement described in subsection (b) of such section with the Secretary; 

and 

‘‘(3) have entered into and have in effect, under terms and 

conditions specified by the Secretary, a contract with a third 

party that the Secretary has entered into a contract with 

under subsection (d)(3) of such section. 

‘‘(b) EFFECTIVE DATE.—Subsection (a) shall apply to covered 

part D drugs dispensed under this part on or after January 1, 

2011. øAs revised by section 1101(b)(1)(A) of HCERA¿ 

‘‘(c) AUTHORIZING COVERAGE FOR DRUGS NOT COVERED UNDER

AGREEMENTS.—Subsection (a) shall not apply to the dispensing of 

a covered part D drug if— 
379 Sec. 3301 PPACA (Consolidated) \1860D–14A SSA 

‘‘(1) the Secretary has made a determination that the 

availability of the drug is essential to the health of beneficiaries under this part; or 

‘‘(2) the Secretary determines that in the period beginning 

on January 1, 2011, and December 31, 2011, there were extenuating circumstances. øAs revised by section 1101(b)(1)(B) of 

HCERA; should have ‘‘ending on’’ before ‘‘December’’¿ 

‘‘(d) DEFINITION OF MANUFACTURER.—In this section, the term 

‘manufacturer’ has the meaning given such term in section 1860D– 

14A(g)(5).’’. 

(b) MEDICARE COVERAGE GAP DISCOUNT PROGRAM.—Part D of 

title XVIII of the Social Security Act (42 U.S.C. 1395w–101) is 

amended by inserting after section 1860D–14 the following new 

section: 

‘‘MEDICARE COVERAGE GAP DISCOUNT PROGRAM

‘‘SEC. 1860D–14A. ø42 U.S.C. 1395w–114a¿ (a) ESTABLISH- MENT.—The Secretary shall establish a Medicare coverage gap discount program (in this section referred to as the ‘program’) by not 

later than January 1, 2011. Under the program, the Secretary shall 

enter into agreements described in subsection (b) with manufacturers and provide for the performance of the duties described in subsection (c)(1). The Secretary shall establish a model agreement for 

use under the program by not later than 180 days after the date 

of the enactment of this section, in consultation with manufacturers, and allow for comment on such model agreement. øAs revised 

by section 1101(b)(2)(A) of HCERA¿ 

‘‘(b) TERMS OF AGREEMENT.— ‘‘(1) IN GENERAL.— ‘‘(A) AGREEMENT.—An agreement under this section 

shall require the manufacturer to provide applicable beneficiaries access to discounted prices for applicable drugs of 

the manufacturer. 

‘‘(B) PROVISION OF DISCOUNTED PRICES AT THE POINT- OF-SALE.—Except as provided in subsection (c)(1)(A)(iii), 

such discounted prices shall be provided to the applicable 

beneficiary at the pharmacy or by the mail order service 

at the point-of-sale of an applicable drug. 

‘‘(C) TIMING OF AGREEMENT.—øAs revised by section 

1011(b)(2)(B) of HCERA; executed as if had amended subsection (b)(1)(C)(i)¿ 

‘‘(i) SPECIAL RULE FOR 2011.—In order for an agreement with a manufacturer to be in effect under this 

section with respect to the period beginning on January 1, 2011, and ending on December 31, 2011, the 

manufacturer shall enter into such agreement not 

later than not later than øsic; duplicate ‘‘not later 

than’’¿ 30 days after the date of the establishment of 

a model agreement under subsection (a). 

‘‘(ii) 2012 AND SUBSEQUENT YEARS.—In order for 

an agreement with a manufacturer to be in effect 

under this section with respect to plan year 2012 or a 

subsequent plan year, the manufacturer shall enter 

into such agreement (or such agreement shall be re-
Sec. 3301\1860D–14A SSA PPACA (Consolidated) 380 

newed under paragraph (4)(A)) not later than January 

30 of the preceding year. 

‘‘(2) PROVISION OF APPROPRIATE DATA.—Each manufacturer 

with an agreement in effect under this section shall collect and 

have available appropriate data, as determined by the Secretary, to ensure that it can demonstrate to the Secretary compliance with the requirements under the program. 

‘‘(3) COMPLIANCE WITH REQUIREMENTS FOR ADMINISTRATION

OF PROGRAM.—Each manufacturer with an agreement in effect 

under this section shall comply with requirements imposed by 

the Secretary or a third party with a contract under subsection 

(d)(3), as applicable, for purposes of administering the program, including any determination under clause (i) of subsection (c)(1)(A) or procedures established under such subsection (c)(1)(A). 

‘‘(4) LENGTH OF AGREEMENT.— ‘‘(A) IN GENERAL.—An agreement under this section 

shall be effective for an initial period of not less than 18 

months and shall be automatically renewed for a period of 

not less than 1 year unless terminated under subparagraph (B). 

‘‘(B) TERMINATION.— ‘‘(i) BY THE SECRETARY.—The Secretary may provide for termination of an agreement under this section for a knowing and willful violation of the requirements of the agreement or other good cause shown. 

Such termination shall not be effective earlier than 30 

days after the date of notice to the manufacturer of 

such termination. The Secretary shall provide, upon 

request, a manufacturer with a hearing concerning 

such a termination, and such hearing shall take place 

prior to the effective date of the termination with sufficient time for such effective date to be repealed if the 

Secretary determines appropriate. 

‘‘(ii) BY A MANUFACTURER.—A manufacturer may 

terminate an agreement under this section for any 

reason. Any such termination shall be effective, with 

respect to a plan year— 

‘‘(I) if the termination occurs before January 

30 of a plan year, as of the day after the end of 

the plan year; and 

‘‘(II) if the termination occurs on or after January 30 of a plan year, as of the day after the end 

of the succeeding plan year. 

‘‘(iii) EFFECTIVENESS OF TERMINATION.—Any termination under this subparagraph shall not affect discounts for applicable drugs of the manufacturer that 

are due under the agreement before the effective date 

of its termination. 

‘‘(iv) NOTICE TO THIRD PARTY.—The Secretary shall 

provide notice of such termination to a third party 

with a contract under subsection (d)(3) within not less 

than 30 days before the effective date of such termination. 
381 Sec. 3301 PPACA (Consolidated) \1860D–14A SSA 

‘‘(c) DUTIES DESCRIBED AND SPECIAL RULE FOR SUPPLEMENTAL

BENEFITS.— 

‘‘(1) DUTIES DESCRIBED.—The duties described in this subsection are the following: 

‘‘(A) ADMINISTRATION OF PROGRAM.—Administering the 

program, including— 

‘‘(i) the determination of the amount of the discounted price of an applicable drug of a manufacturer; 

‘‘(ii) except as provided in clause (iii), the establishment of procedures under which discounted prices 

are provided to applicable beneficiaries at pharmacies 

or by mail order service at the point-of-sale of an applicable drug; 

‘‘(iii) in the case where, during the period beginning on January 1, 2011, and ending on December 31, 

2011, it is not practicable to provide such discounted 

prices at the point-of-sale (as described in clause (ii)), 

the establishment of procedures to provide such discounted prices as soon as practicable after the pointof-sale; øAs revised by section 1011(b)(2)(C)(i) of 

HCERA¿ 

‘‘(iv) the establishment of procedures to ensure 

that, not later than the applicable number of calendar 

days after the dispensing of an applicable drug by a 

pharmacy or mail order service, the pharmacy or mail 

order service is reimbursed for an amount equal to the 

difference between— 

‘‘(I) the negotiated price of the applicable 

drug; and 

‘‘(II) the discounted price of the applicable 

drug; 

‘‘(v) the establishment of procedures to ensure 

that the discounted price for an applicable drug under 

this section is applied before any coverage or financial 

assistance under other health benefit plans or programs that provide coverage or financial assistance for 

the purchase or provision of prescription drug coverage on behalf of applicable beneficiaries as the Secretary may specify; 

‘‘(vi) the establishment of procedures to implement 

the special rule for supplemental benefits under paragraph (2); and 

‘‘(vii) providing a reasonable dispute resolution 

mechanism to resolve disagreements between manufacturers, applicable beneficiaries, and the third party 

with a contract under subsection (d)(3). 

‘‘(B) MONITORING COMPLIANCE.— 

‘‘(i) IN GENERAL.—The Secretary shall monitor 

compliance by a manufacturer with the terms of an 

agreement under this section. 

‘‘(ii) NOTIFICATION.—If a third party with a contract under subsection (d)(3) determines that the manufacturer is not in compliance with such agreement, 

the third party shall notify the Secretary of such non-
Sec. 3301\1860D–14A SSA PPACA (Consolidated) 382 

compliance for appropriate enforcement under subsection (e). 

‘‘(C) COLLECTION OF DATA FROM PRESCRIPTION DRUG

PLANS AND MA–PD PLANS.—The Secretary may collect appropriate data from prescription drug plans and MA–PD 

plans in a timeframe that allows for discounted prices to 

be provided for applicable drugs under this section. 

‘‘(2) SPECIAL RULE FOR SUPPLEMENTAL BENEFITS.—For plan 

year 2011 and each subsequent plan year, in the case where 

an applicable beneficiary has supplemental benefits with respect to applicable drugs under the prescription drug plan or 

MA–PD plan that the applicable beneficiary is enrolled in, the 

applicable beneficiary shall not be provided a discounted price 

for an applicable drug under this section until after such supplemental benefits have been applied with respect to the applicable drug. øAs revised by section 1011(b)(2)(C)(ii) of HCERA¿ 

‘‘(d) ADMINISTRATION.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary 

shall provide for the implementation of this section, including 

the performance of the duties described in subsection (c)(1). 

‘‘(2) LIMITATION.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B), in providing for such implementation, the Secretary shall not receive or distribute any funds of a manufacturer under the 

program. 

‘‘(B) EXCEPTION.—The limitation under subparagraph 

(A) shall not apply to the Secretary with respect to drugs 

dispensed during the period beginning on January 1, 2011, 

and ending on December 31, 2011, but only if the Secretary determines that the exception to such limitation 

under this subparagraph is necessary in order for the Secretary to begin implementation of this section and provide 

applicable beneficiaries timely access to discounted prices 

during such period. øAs revised by section 1011(b)(2)(D) of 

HCERA¿ 

‘‘(3) CONTRACT WITH THIRD PARTIES.—The Secretary shall 

enter into a contract with 1 or more third parties to administer 

the requirements established by the Secretary in order to carry 

out this section. At a minimum, the contract with a third party 

under the preceding sentence shall require that the third 

party— 

‘‘(A) receive and transmit information between the 

Secretary, manufacturers, and other individuals or entities 

the Secretary determines appropriate; 

‘‘(B) receive, distribute, or facilitate the distribution of 

funds of manufacturers to appropriate individuals or entities in order to meet the obligations of manufacturers 

under agreements under this section; 

‘‘(C) provide adequate and timely information to manufacturers, consistent with the agreement with the manufacturer under this section, as necessary for the manufacturer to fulfill its obligations under this section; and 

‘‘(D) permit manufacturers to conduct periodic audits, 

directly or through contracts, of the data and information 
383 Sec. 3301 PPACA (Consolidated) \1860D–14A SSA 

used by the third party to determine discounts for applicable drugs of the manufacturer under the program. 

‘‘(4) PERFORMANCE REQUIREMENTS.—The Secretary shall 

establish performance requirements for a third party with a 

contract under paragraph (3) and safeguards to protect the 

independence and integrity of the activities carried out by the 

third party under the program under this section. 

‘‘(5) IMPLEMENTATION.—The Secretary may implement the 

program under this section by program instruction or otherwise. 

‘‘(6) ADMINISTRATION.—Chapter 35 of title 44, United 

States Code, shall not apply to the program under this section. 

‘‘(e) ENFORCEMENT.— 

‘‘(1) AUDITS.—Each manufacturer with an agreement in effect under this section shall be subject to periodic audit by the 

Secretary. 

‘‘(2) CIVIL MONEY PENALTY.— 

‘‘(A) IN GENERAL.—The Secretary shall impose a civil 

money penalty on a manufacturer that fails to provide applicable beneficiaries discounts for applicable drugs of the 

manufacturer in accordance with such agreement for each 

such failure in an amount the Secretary determines is 

commensurate with the sum of— 

‘‘(i) the amount that the manufacturer would have 

paid with respect to such discounts under the agreement, which will then be used to pay the discounts 

which the manufacturer had failed to provide; and 

‘‘(ii) 25 percent of such amount. 

‘‘(B) APPLICATION.—The provisions of section 1128A 

(other than subsections (a) and (b)) shall apply to a civil 

money penalty under this paragraph in the same manner 

as such provisions apply to a penalty or proceeding under 

section 1128A(a). 

‘‘(f) CLARIFICATION REGARDING AVAILABILITY OF OTHER COVERED PART D DRUGS.—Nothing in this section shall prevent an applicable beneficiary from purchasing a covered part D drug that is 

not an applicable drug (including a generic drug or a drug that is 

not on the formulary of the prescription drug plan or MA–PD plan 

that the applicable beneficiary is enrolled in). 

‘‘(g) DEFINITIONS.—In this section: 

‘‘(1) APPLICABLE BENEFICIARY.—The term ‘applicable beneficiary’ means an individual who, on the date of dispensing a 

covered part D drug—øAs revised by section 1101(b)(2)(E) of 

HCERA¿ 

‘‘(A) is enrolled in a prescription drug plan or an MA– 

PD plan; 

‘‘(B) is not enrolled in a qualified retiree prescription 

drug plan; 

‘‘(C) is not entitled to an income-related subsidy under 

section 1860D–14(a); and 

øprevious subparagraph (D) stricken by section 1101(b)(2)(E) of 

HCERA¿ 

‘‘(D) who— 
Sec. 3301\1860D–14A SSA PPACA (Consolidated) 384 

‘‘(i) has reached or exceeded the initial coverage 

limit under section 1860D–2(b)(3) during the year; and 

‘‘(ii) has not incurred costs for covered part D 

drugs in the year equal to the annual out-of-pocket 

threshold specified in section 1860D–2(b)(4)(B). 

‘‘(2) APPLICABLE DRUG.—The term ‘applicable drug’ means, 

with respect to an applicable beneficiary, a covered part D 

drug— 

‘‘(A) approved under a new drug application under section 505(b) of the Federal Food, Drug, and Cosmetic Act or, 

in the case of a biologic product, licensed under section 351 

of the Public Health Service Act (other than a product licensed under subsection (k) of such section 351); and 

‘‘(B)(i) if the PDP sponsor of the prescription drug plan 

or the MA organization offering the MA–PD plan uses a 

formulary, which is on the formulary of the prescription 

drug plan or MA–PD plan that the applicable beneficiary 

is enrolled in; 

‘‘(ii) if the PDP sponsor of the prescription drug plan 

or the MA organization offering the MA–PD plan does not 

use a formulary, for which benefits are available under the 

prescription drug plan or MA–PD plan that the applicable 

beneficiary is enrolled in; or 

‘‘(iii) is provided through an exception or appeal. 

‘‘(3) APPLICABLE NUMBER OF CALENDAR DAYS.—The term 

‘applicable number of calendar days’ means— 

‘‘(A) with respect to claims for reimbursement submitted electronically, 14 days; and 

‘‘(B) with respect to claims for reimbursement submitted otherwise, 30 days. 

‘‘(4) DISCOUNTED PRICE.— 

‘‘(A) IN GENERAL.—The term ‘discounted price’ means 

50 percent of the negotiated price of the applicable drug of 

a manufacturer. 

‘‘(B) CLARIFICATION.—Nothing in this section shall be 

construed as affecting the responsibility of an applicable 

beneficiary for payment of a dispensing fee for an applicable drug. 

‘‘(C) SPECIAL CASE FOR CERTAIN CLAIMS.—In the case 

where the entire amount of the negotiated price of an individual claim for an applicable drug with respect to an applicable beneficiary does not fall at or above the initial coverage limit under section 1860D–2(b)(3) and below the annual out-of-pocket threshold specified in section 1860D– 

2(b)(4)(B) for the year, the manufacturer of the applicable 

drug shall provide the discounted price under this section 

on only the portion of the negotiated price of the applicable 

drug that falls at or above such initial coverage limit and 

below such annual out-of-pocket threshold. 

‘‘(5) MANUFACTURER.—The term ‘manufacturer’ means any 

entity which is engaged in the production, preparation, propagation, compounding, conversion, or processing of prescription 

drug products, either directly or indirectly by extraction from 

substances of natural origin, or independently by means of 
385 Sec. 3301 PPACA (Consolidated) 

chemical synthesis, or by a combination of extraction and 

chemical synthesis. Such term does not include a wholesale 

distributor of drugs or a retail pharmacy licensed under State 

law. 

‘‘(6) NEGOTIATED PRICE.—The term ‘negotiated price’ has 

the meaning given such term in section 423.100 of title 42, 

Code of Federal Regulations (as in effect on the date of enactment of this section), except that such negotiated price shall 

not include any dispensing fee for the applicable drug. 

‘‘(7) QUALIFIED RETIREE PRESCRIPTION DRUG PLAN.—The 

term ‘qualified retiree prescription drug plan’ has the meaning 

given such term in section 1860D–22(a)(2).’’. 

(c) INCLUSION IN INCURRED COSTS.— (1) IN GENERAL.—Section 1860D–2(b)(4) of the Social Security Act (42 U.S.C. 1395w–102(b)(4)) is amended— 

(A) in subparagraph (C), in the matter preceding 

clause (i), by striking ‘‘In applying’’ and inserting ‘‘Except 

as provided in subparagraph (E), in applying’’; and 

(B) by adding at the end the following new subparagraph: 

‘‘(E) INCLUSION OF COSTS OF APPLICABLE DRUGS UNDER

MEDICARE COVERAGE GAP DISCOUNT PROGRAM.—In applying 

subparagraph (A), incurred costs shall include the negotiated price (as defined in paragraph (6) of section 1860D– 

14A(g)) of an applicable drug (as defined in paragraph (2) 

of such section) of a manufacturer that is furnished to an 

applicable beneficiary (as defined in paragraph (1) of such 

section) under the Medicare coverage gap discount program under section 1860D–14A, regardless of whether part 

of such costs were paid by a manufacturer under such program, except that incurred costs shall not include the portion of the negotiated price that represents the reduction 

in coinsurance resulting from the application of paragraph 

(2)(D). øAs revised by section 1101(b)(3)(E) of HCERA¿’’. 

(2) EFFECTIVE DATE.—The amendments made by this subsection shall apply to costs incurred on or after July 1, 2010. 

øSection 1101(b)(3) of HCERA amended section 1860D–2(b)(2) 

of the SSA to add subparagraphs (C) and (D) that provide coverage 

for generic drugs and applicable drugs in the coverage gap; and section 1101(b)(4) of HCERA amends section 1860D–22(a)(2)(A) in relation to not taking into account value of discounts or coverage in 

gap¿ 

øSection 1101(d) of HCERA amended section 1860D– 

2(b)(4)(B)(i) and (7) of SSA to reduce growth rate of out-of-pocket 

cost threshold¿ 

(d) CONFORMING AMENDMENT PERMITTING PRESCRIPTION DRUG

DISCOUNTS.— 

(1) IN GENERAL.—Section 1128B(b)(3) of the Social Security 

Act (42 U.S.C. 1320a–7b(b)(3)) is amended— 

(A) by striking ‘‘and’’ at the end of subparagraph (G); 

(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)— 
Sec. 3302 PPACA (Consolidated) 386 

(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) a discount in the price of an applicable drug (as 

defined in paragraph (2) of section 1860D–14A(g)) of a 

manufacturer that is furnished to an applicable beneficiary 

(as defined in paragraph (1) of such section) under the 

Medicare coverage gap discount program under section 

1860D–14A.’’. 

(2) CONFORMING AMENDMENT TO DEFINITION OF BEST PRICE

UNDER MEDICAID.—Section 1927(c)(1)(C)(i)(VI) of the Social Security Act (42 U.S.C. 1396r–8(c)(1)(C)(i)(VI)) is amended by inserting ‘‘, or any discounts provided by manufacturers under 

the Medicare coverage gap discount program under section 

1860D–14A’’ before the period at the end. 

(3) EFFECTIVE DATE.—The amendments made by this subsection shall apply to drugs dispensed on or after July 1, 2010. 

SEC. 3302. IMPROVEMENT IN DETERMINATION OF MEDICARE PART D 

LOW-INCOME BENCHMARK PREMIUM. 

(a) IN GENERAL.—Section 1860D–14(b)(2)(B)(iii) of the Social 

Security Act (42 U.S.C. 1395w–114(b)(2)(B)(iii)) is amended by inserting ‘‘and determined before the application of the monthly rebate computed under section 1854(b)(1)(C)(i) for that plan and year 

involved and, in the case of a qualifying plan, before the application of the increase under section 1853(o) for that plan and year 

involved’’ before the period at the end. øAs revised by section 

1103(c) of HCERA¿ 

(b) EFFECTIVE DATE.—The amendment made by subsection (a) 

shall apply to premiums for months beginning on or after January 

1, 2011. 

SEC. 3303. VOLUNTARY DE MINIMIS POLICY FOR SUBSIDY ELIGIBLE 

INDIVIDUALS UNDER PRESCRIPTION DRUG PLANS AND 

MA–PD PLANS. 

(a) IN GENERAL.—Section 1860D–14(a) of the Social Security 

Act (42 U.S.C. 1395w–114(a)) is amended by adding at the end the 

following new paragraph: 

‘‘(5) WAIVER OF DE MINIMIS PREMIUMS.—The Secretary 

shall, under procedures established by the Secretary, permit a 

prescription drug plan or an MA–PD plan to waive the monthly beneficiary premium for a subsidy eligible individual if the 

amount of such premium is de minimis. If such premium is 

waived under the plan, the Secretary shall not reassign subsidy eligible individuals enrolled in the plan to other plans 
387 Sec. 3305 PPACA (Consolidated) 

based on the fact that the monthly beneficiary premium under 

the plan was greater than the low-income benchmark premium 

amount.’’. 

(b) AUTHORIZING THE SECRETARY TO AUTO-ENROLL SUBSIDY

ELIGIBLE INDIVIDUALS IN PLANS THAT WAIVE DE MINIMIS PRE- MIUMS.—Section 1860D–1(b)(1) of the Social Security Act (42 

U.S.C. 1395w–101(b)(1)) is amended— 

(1) in subparagraph (C), by inserting ‘‘except as provided 

in subparagraph (D),’’ after ‘‘shall include,’’ 

(2) by adding at the end the following new subparagraph: 

‘‘(D) SPECIAL RULE FOR PLANS THAT WAIVE DE MINIMIS

PREMIUMS.—The process established under subparagraph 

(A) may include, in the case of a part D eligible individual 

who is a subsidy eligible individual (as defined in section 

1860D–14(a)(3)) who has failed to enroll in a prescription 

drug plan or an MA–PD plan, for the enrollment in a prescription drug plan or MA–PD plan that has waived the 

monthly beneficiary premium for such subsidy eligible individual under section 1860D–14(a)(5). If there is more 

than one such plan available, the Secretary shall enroll 

such an individual under the preceding sentence on a random basis among all such plans in the PDP region. Nothing in the previous sentence shall prevent such an individual from declining or changing such enrollment.’’. 

(c) EFFECTIVE DATE.—The amendments made by this subsection shall apply to premiums for months, and enrollments for 

plan years, beginning on or after January 1, 2011. 

SEC. 3304. SPECIAL RULE FOR WIDOWS AND WIDOWERS REGARDING 

ELIGIBILITY FOR LOW-INCOME ASSISTANCE. 

(a) IN GENERAL.—Section 1860D–14(a)(3)(B) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)(B)) is amended by adding at 

the end the following new clause: 

‘‘(vi) SPECIAL RULE FOR WIDOWS AND WIDOWERS.— Notwithstanding the preceding provisions of this subparagraph, in the case of an individual whose spouse 

dies during the effective period for a determination or 

redetermination that has been made under this subparagraph, such effective period shall be extended 

through the date that is 1 year after the date on which 

the determination or redetermination would (but for 

the application of this clause) otherwise cease to be effective.’’. 

(b) EFFECTIVE DATE.—The amendment made by subsection (a) 

shall take effect on January 1, 2011. 

SEC. 3305. IMPROVED INFORMATION FOR SUBSIDY ELIGIBLE INDIVIDUALS REASSIGNED TO PRESCRIPTION DRUG PLANS AND 

MA–PD PLANS. 

Section 1860D–14 of the Social Security Act (42 U.S.C. 1395w– 

114) is amended— 

(1) by redesignating subsection (d) as subsection (e); and 

(2) by inserting after subsection (c) the following new subsection: 

‘‘(d) FACILITATION OF REASSIGNMENTS.—Beginning not later 

than January 1, 2011, the Secretary shall, in the case of a subsidy 
Sec. 3306 PPACA (Consolidated) 388 

eligible individual who is enrolled in one prescription drug plan 

and is subsequently reassigned by the Secretary to a new prescription drug plan, provide the individual, within 30 days of such reassignment, with— 

‘‘(1) information on formulary differences between the individual’s former plan and the plan to which the individual is reassigned with respect to the individual’s drug regimens; and 

‘‘(2) a description of the individual’s right to request a coverage determination, exception, or reconsideration under section 1860D–4(g), bring an appeal under section 1860D–4(h), or 

resolve a grievance under section 1860D–4(f).’’. 

SEC. 3306. FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME 

PROGRAMS. 

(a) ADDITIONAL FUNDING FOR STATE HEALTH INSURANCE PRO- GRAMS.—Subsection (a)(1)(B) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 

1395b–3 note) is amended by striking ‘‘(42 U.S.C. 1395w–23(f))’’ 

and all that follows through the period at the end and inserting 

‘‘(42 U.S.C. 1395w–23(f)), to the Centers for Medicare & Medicaid 

Services Program Management Account— ‘‘(i) for fiscal year 2009, of $7,500,000; and 

‘‘(ii) for the period of fiscal years 2010 through 2012, of $15,000,000. 

Amounts appropriated under this subparagraph shall remain available until expended.’’. 

(b) ADDITIONAL FUNDING FOR AREA AGENCIES ON AGING.—Subsection (b)(1)(B) of such section 119 is amended by striking ‘‘(42 

U.S.C. 1395w–23(f))’’ and all that follows through the period at the 

end and inserting ‘‘(42 U.S.C. 1395w–23(f)), to the Administration 

on Aging— ‘‘(i) for fiscal year 2009, of $7,500,000; and 

‘‘(ii) for the period of fiscal years 2010 through 2012, of $15,000,000. 

Amounts appropriated under this subparagraph shall remain available until expended.’’. 

(c) ADDITIONAL FUNDING FOR AGING AND DISABILITY RESOURCE

CENTERS.—Subsection (c)(1)(B) of such section 119 is amended by 

striking ‘‘(42 U.S.C. 1395w–23(f))’’ and all that follows through the 

period at the end and inserting ‘‘(42 U.S.C. 1395w–23(f)), to the Administration on Aging— ‘‘(i) for fiscal year 2009, of $5,000,000; and 

‘‘(ii) for the period of fiscal years 2010 through 

2012, of $10,000,000. 

Amounts appropriated under this subparagraph shall remain available until expended.’’. 

(d) ADDITIONAL FUNDING FOR CONTRACT WITH THE NATIONAL

CENTER FOR BENEFITS AND OUTREACH ENROLLMENT.—Subsection 

(d)(2) of such section 119 is amended by striking ‘‘(42 U.S.C. 

1395w–23(f))’’ and all that follows through the period at the end 

and inserting ‘‘(42 U.S.C. 1395w–23(f)), to the Administration on 

Aging— 

‘‘(i) for fiscal year 2009, of $5,000,000; and 

‘‘(ii) for the period of fiscal years 2010 through 2012, of $5,000,000. 
389 Sec. 3307 PPACA (Consolidated) 

Amounts appropriated under this subparagraph shall remain available until expended.’’. 

(e) SECRETARIAL AUTHORITY TO ENLIST SUPPORT IN CON- DUCTING CERTAIN OUTREACH ACTIVITIES.—Such section 119 is 

amended by adding at the end the following new subsection: 

‘‘(g) SECRETARIAL AUTHORITY TO ENLIST SUPPORT IN CON- DUCTING CERTAIN OUTREACH ACTIVITIES.—The Secretary may request that an entity awarded a grant under this section support 

the conduct of outreach activities aimed at preventing disease and 

promoting wellness. Notwithstanding any other provision of this 

section, an entity may use a grant awarded under this subsection 

to support the conduct of activities described in the preceding sentence.’’. 

SEC. 3307. IMPROVING FORMULARY REQUIREMENTS FOR PRESCRIPTION DRUG PLANS AND MA–PD PLANS WITH RESPECT TO 

CERTAIN CATEGORIES OR CLASSES OF DRUGS. 

(a) IMPROVING FORMULARY REQUIREMENTS.—Section 1860D– 

4(b)(3)(G) of the Social Security Act is amended to read as follows: 

‘‘(G) REQUIRED INCLUSION OF DRUGS IN CERTAIN CAT- EGORIES AND CLASSES.— ‘‘(i) FORMULARY REQUIREMENTS.— ‘‘(I) IN GENERAL.—Subject to subclause (II), a 

PDP sponsor offering a prescription drug plan 

shall be required to include all covered part D 

drugs in the categories and classes identified by 

the Secretary under clause (ii)(I). 

‘‘(II) EXCEPTIONS.—The Secretary may establish exceptions that permit a PDP sponsor offering 

a prescription drug plan to exclude from its formulary a particular covered part D drug in a category or class that is otherwise required to be included in the formulary under subclause (I) (or to 

otherwise limit access to such a drug, including 

through prior authorization or utilization management). 

‘‘(ii) IDENTIFICATION OF DRUGS IN CERTAIN CATEGORIES AND CLASSES.— 

‘‘(I) IN GENERAL.—Subject to clause (iv), the 

Secretary shall identify, as appropriate, categories 

and classes of drugs for which the Secretary determines are of clinical concern. 

‘‘(II) CRITERIA.—The Secretary shall use criteria established by the Secretary in making any 

determination under subclause (I). 

‘‘(iii) IMPLEMENTATION.—The Secretary shall establish the criteria under clause (ii)(II) and any exceptions under clause (i)(II) through the promulgation of 

a regulation which includes a public notice and comment period. 

‘‘(iv) REQUIREMENT FOR CERTAIN CATEGORIES AND

CLASSES UNTIL CRITERIA ESTABLISHED.—Until such 

time as the Secretary establishes the criteria under 

clause (ii)(II) the following categories and classes of 

drugs shall be identified under clause (ii)(I): 
Sec. 3308 PPACA (Consolidated) 390 

‘‘(I) Anticonvulsants. 

‘‘(II) Antidepressants. 

‘‘(III) Antineoplastics. 

‘‘(IV) Antipsychotics. 

‘‘(V) Antiretrovirals. 

‘‘(VI) Immunosuppressants for the treatment 

of transplant rejection.’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to plan year 2011 and subsequent plan years. 

SEC. 3308. REDUCING PART D PREMIUM SUBSIDY FOR HIGH-INCOME 

BENEFICIARIES. 

(a) INCOME-RELATED INCREASE IN PART D PREMIUM.— (1) 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) INCREASE IN BASE BENEFICIARY PREMIUM BASED ON IN- COME.— ‘‘(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 beneficiary 

premium applicable under this section for a month after 

December 2010 shall 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 increase in the base beneficiary premium under this 

paragraph. 

‘‘(E) PROCEDURES TO ASSURE CORRECT INCOME-RELATED INCREASE IN BASE BENEFICIARY PREMIUM.— 

‘‘(i) DISCLOSURE OF BASE BENEFICIARY PREMIUM.— 

Not later than September 15 of each year beginning 

with 2010, the Secretary shall disclose to the Commis-
391 Sec. 3308 PPACA (Consolidated) 

sioner of Social Security the amount of the base beneficiary premium (as computed under paragraph (2)) for 

the purpose of carrying out the income-related increase in the base beneficiary premium 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 increase in the base beneficiary premium 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 increase in the base beneficiary premium 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.’’. 

(2) COLLECTION OF MONTHLY ADJUSTMENT AMOUNT.—Section 1860D–13(c) of the Social Security Act (42 U.S.C. 1395w– 

113(c)) is amended— 

(A) in paragraph (1), by striking ‘‘(2) and (3)’’ and inserting ‘‘(2), (3), and (4)’’; and 

(B) 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 increase in 

the base beneficiary premium 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.’’. 
Sec. 3308 PPACA (Consolidated) 392 

(b) CONFORMING AMENDMENTS.— (1) MEDICARE.—Section 1860D–13(a)(1) of the Social Security Act (42 U.S.C. 1395w–113(a)(1)) is amended— 

(A) by redesignating subparagraph (F) as subparagraph (G); 

(B) in subparagraph (G), as redesignated by subparagraph (A), by striking ‘‘(D) and (E)’’ and inserting ‘‘(D), (E), 

and (F)’’; and 

(C) 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).’’. 

(2) 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— 

(A) in the heading, by inserting ‘‘AND PART D BASE

BENEFICIARY PREMIUM INCREASE’’ after ‘‘PART B PREMIUM

SUBSIDY ADJUSTMENT’’; 

(B) in subparagraph (A)— 

(i) in the matter preceding clause (i), by inserting 

‘‘or increase under section 1860D–13(a)(7)’’ after 

‘‘1839(i)’’; and 

(ii) in clause (vii), by inserting after ‘‘subsection (i) 

of such section’’ the following: ‘‘or increase under section 1860D–13(a)(7) of such Act’’; and 

(C) in subparagraph (B)— 

(i) by striking ‘‘Return information’’ and inserting 

the following: 

‘‘(i) IN GENERAL.—Return information’’; 

(ii) by inserting ‘‘or increase under such section 

1860D–13(a)(7)’’ before the period at the end; 

(iii) as amended by clause (i), by inserting ‘‘or for 

the purpose of resolving taxpayer appeals with respect 

to any such premium adjustment or increase’’ before 

the period at the end; and 

(iv) by adding at the end the following new clause: 

‘‘(ii) DISCLOSURE TO OTHER AGENCIES.—Officers, 

employees, and contractors of the Social Security Administration may disclose— 

‘‘(I) the taxpayer identity information and the 

amount of the premium subsidy adjustment or 

premium increase with respect to a taxpayer described in subparagraph (A) to officers, employees, 

and contractors of the Centers for Medicare and 

Medicaid Services, to the extent that such disclosure is necessary for the collection of the premium 

subsidy amount or the increased premium 

amount, 

‘‘(II) the taxpayer identity information and the 

amount of the premium subsidy adjustment or the 

increased premium amount with respect to a taxpayer described in subparagraph (A) to officers 
393 Sec. 3310 PPACA (Consolidated) 

and employees of the Office of Personnel Management and the Railroad Retirement Board, to the 

extent that such disclosure is necessary for the 

collection of the premium subsidy amount or the 

increased premium amount, 

‘‘(III) return information with respect to a taxpayer described in subparagraph (A) to officers 

and employees of the Department of Health and 

Human Services to the extent necessary to resolve 

administrative appeals of such premium subsidy 

adjustment or increased premium, and 

‘‘(IV) return information with respect to a taxpayer described in subparagraph (A) to officers 

and employees of the Department of Justice for 

use in judicial proceedings to the extent necessary 

to carry out the purposes described in clause (i).’’. 

SEC. 3309. ELIMINATION OF COST SHARING FOR CERTAIN DUAL ELIGIBLE INDIVIDUALS. 

Section 1860D–14(a)(1)(D)(i) of the Social Security Act (42 

U.S.C. 1395w–114(a)(1)(D)(i)) is amended by inserting ‘‘or, effective 

on a date specified by the Secretary (but in no case earlier than 

January 1, 2012), who would be such an institutionalized individual or couple, if the full-benefit dual eligible individual were not 

receiving services under a home and community-based waiver authorized for a State under section 1115 or subsection (c) or (d) of 

section 1915 or under a State plan amendment under subsection (i) 

of such section or services provided through enrollment in a medicaid managed care organization with a contract under section 

1903(m) or under section 1932’’ after ‘‘1902(q)(1)(B))’’. 

SEC. 3310. REDUCING WASTEFUL DISPENSING OF OUTPATIENT PRESCRIPTION DRUGS IN LONG-TERM CARE FACILITIES 

UNDER PRESCRIPTION DRUG PLANS AND MA–PD PLANS. 

(a) IN GENERAL.—Section 1860D–4(c) of the Social Security Act 

(42 U.S.C. 1395w–104(c)) is amended by adding at the end the following new paragraph: 

‘‘(3) REDUCING WASTEFUL DISPENSING OF OUTPATIENT PRESCRIPTION DRUGS IN LONG-TERM CARE FACILITIES.—The Secretary shall require PDP sponsors of prescription drug plans to 

utilize specific, uniform dispensing techniques, as determined 

by the Secretary, in consultation with relevant stakeholders 

(including representatives of nursing facilities, residents of 

nursing facilities, pharmacists, the pharmacy industry (including retail and long-term care pharmacy), prescription drug 

plans, MA–PD plans, and any other stakeholders the Secretary 

determines appropriate), such as weekly, daily, or automated 

dose dispensing, when dispensing covered part D drugs to enrollees who reside in a long-term care facility in order to reduce waste associated with 30-day fills.’’. 

(b) EFFECTIVE DATE.—The amendment made by subsection (a) 

shall apply to plan years beginning on or after January 1, 2012. 
Sec. 3311 PPACA (Consolidated) 394 

SEC. 3311. ø42 U.S.C. 1395w–154¿ IMPROVED MEDICARE PRESCRIPTION 

DRUG PLAN AND MA–PD PLAN COMPLAINT SYSTEM. 

(a) IN GENERAL.—The Secretary shall develop and maintain a 

complaint system, that is widely known and easy to use, to collect 

and maintain information on MA–PD plan and prescription drug 

plan complaints that are received (including by telephone, letter, email, or any other means) by the Secretary (including by a regional 

office of the Department of Health and Human Services, the Medicare Beneficiary Ombudsman, a subcontractor, a carrier, a fiscal 

intermediary, and a Medicare administrative contractor under section 1874A of the Social Security Act (42 U.S.C. 1395kk)) through 

the date on which the complaint is resolved. The system shall be 

able to report and initiate appropriate interventions and monitoring based on substantial complaints and to guide quality improvement. 

(b) MODEL ELECTRONIC COMPLAINT FORM.—The Secretary 

shall develop a model electronic complaint form to be used for reporting plan complaints under the system. Such form shall be 

prominently displayed on the front page of the Medicare.gov Internet website and on the Internet website of the Medicare Beneficiary Ombudsman. 

(c) ANNUAL REPORTS BY THE SECRETARY.—The Secretary shall 

submit to Congress annual reports on the system. Such reports 

shall include an analysis of the number and types of complaints reported in the system, geographic variations in such complaints, the 

timeliness of agency or plan responses to such complaints, and the 

resolution of such complaints. 

(d) DEFINITIONS.—In this section: 

(1) MA–PD PLAN.—The term ‘‘MA–PD plan’’ has the meaning given such term in section 1860D–41(a)(9) of such Act (42 

U.S.C. 1395w–151(a)(9)). 

(2) PRESCRIPTION DRUG PLAN.—The term ‘‘prescription 

drug plan’’ has the meaning given such term in section 1860D– 

41(a)(14) of such Act (42 U.S.C. 1395w–151(a)(14)). 

(3) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health and Human Services. 

(4) SYSTEM.—The term ‘‘system’’ means the plan complaint 

system developed and maintained under subsection (a). 

SEC. 3312. UNIFORM EXCEPTIONS AND APPEALS PROCESS FOR PRESCRIPTION DRUG PLANS AND MA–PD PLANS. 

(a) IN GENERAL.—Section 1860D–4(b)(3) of the Social Security 

Act (42 U.S.C. 1395w–104(b)(3)) is amended by adding at the end 

the following new subparagraph: 

‘‘(H) USE OF SINGLE, UNIFORM EXCEPTIONS AND APPEALS PROCESS.—Notwithstanding any other provision of 

this part, each PDP sponsor of a prescription drug plan 

shall— 

‘‘(i) use a single, uniform exceptions and appeals 

process (including, to the extent the Secretary determines feasible, a single, uniform model form for use 

under such process) with respect to the determination 

of prescription drug coverage for an enrollee under the 

plan; and 
395 Sec. 3313 PPACA (Consolidated) 

‘‘(ii) provide instant access to such process by enrollees through a toll-free telephone number and an 

Internet website.’’. 

(b) EFFECTIVE DATE.—The amendment made by subsection (a) 

shall apply to exceptions and appeals on or after January 1, 2012. 

SEC. 3313. ø42 U.S.C. 1395w–101 note¿ OFFICE OF THE INSPECTOR GENERAL STUDIES AND REPORTS. 

(a) STUDY AND ANNUAL REPORT ON PART D FORMULARIES’ INCLUSION OF DRUGS COMMONLY USED BY DUAL ELIGIBLES.— 

(1) STUDY.—The Inspector General of the Department of 

Health and Human Services shall conduct a study of the extent 

to which formularies used by prescription drug plans and MA– 

PD plans under part D include drugs commonly used by fullbenefit dual eligible individuals (as defined in section 

1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6))). 

(2) ANNUAL REPORTS.—Not later than July 1 of each year 

(beginning with 2011), the Inspector General shall submit to 

Congress a report on the study conducted under paragraph (1), 

together with such recommendations as the Inspector General 

determines appropriate. 

(b) STUDY AND REPORT ON PRESCRIPTION DRUG PRICES UNDER

MEDICARE PART D AND MEDICAID.— 

(1) STUDY.— 

(A) IN GENERAL.—The Inspector General of the Department of Health and Human Services shall conduct a 

study on prices for covered part D drugs under the Medicare prescription drug program under part D of title XVIII 

of the Social Security Act and for covered outpatient drugs 

under title XIX. Such study shall include the following: 

(i) A comparison, with respect to the 200 most frequently dispensed covered part D drugs under such 

program and covered outpatient drugs under such title 

(as determined by the Inspector General based on volume and expenditures), of— 

(I) the prices paid for covered part D drugs by 

PDP sponsors of prescription drug plans and 

Medicare Advantage organizations offering MA– 

PD plans; and 

(II) the prices paid for covered outpatient 

drugs by a State plan under title XIX. 

(ii) An assessment of— 

(I) the financial impact of any discrepancies in 

such prices on the Federal Government; and 

(II) the financial impact of any such discrepancies on enrollees under part D or individuals eligible for medical assistance under a State plan 

under title XIX. 

(B) PRICE.—For purposes of subparagraph (A), the 

price of a covered part D drug or a covered outpatient drug 

shall include any rebate or discount under such program 

or such title, respectively, including any negotiated price 

concession described in section 1860D–2(d)(1)(B) of the Social Security Act (42 U.S.C. 1395w–102(d)(1)(B)) or rebate 
Sec. 3314 PPACA (Consolidated) 396 

under an agreement under section 1927 of the Social Security Act (42 U.S.C. 1396r–8). 

(C) AUTHORITY TO COLLECT ANY NECESSARY INFORMATION.—Notwithstanding any other provision of law, the Inspector General of the Department of Health and Human 

Services shall be able to collect any information related to 

the prices of covered part D drugs under such program and 

covered outpatient drugs under such title XIX necessary to 

carry out the comparison under subparagraph (A). 

(2) REPORT.— 

(A) IN GENERAL.—Not later than October 1, 2011, subject to subparagraph (B), the Inspector General shall submit to Congress a report containing the results of the 

study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Inspector General determines appropriate. 

(B) LIMITATION ON INFORMATION CONTAINED IN REPORT.—The report submitted under subparagraph (A) shall 

not include any information that the Inspector General determines is proprietary or is likely to negatively impact the 

ability of a PDP sponsor or a State plan under title XIX 

to negotiate prices for covered part D drugs or covered outpatient drugs, respectively. 

(3) DEFINITIONS.—In this section: 

(A) COVERED PART D DRUG.—The term ‘‘covered part D 

drug’’ has the meaning given such term in section 1860D– 

2(e) of the Social Security Act (42 U.S.C. 1395w–102(e)). 

(B) COVERED OUTPATIENT DRUG.—The term ‘‘covered 

outpatient drug’’ has the meaning given such term in section 1927(k) of such Act (42 U.S.C. 1396r(k)). 

(C) MA–PD PLAN.—The term ‘‘MA–PD plan’’ has the 

meaning given such term in section 1860D–41(a)(9) of such 

Act (42 U.S.C. 1395w–151(a)(9)). 

(D) MEDICARE ADVANTAGE ORGANIZATION.—The term 

‘‘Medicare Advantage organization’’ has the meaning given 

such term in section 1859(a)(1) of such Act (42 U.S.C. 

1395w–28)(a)(1)). 

(E) PDP SPONSOR.—The term ‘‘PDP sponsor’’ has the 

meaning given such term in section 1860D–41(a)(13) of 

such Act (42 U.S.C. 1395w–151(a)(13)). 

(F) PRESCRIPTION DRUG PLAN.—The term ‘‘prescription 

drug plan’’ has the meaning given such term in section 

1860D–41(a)(14) of such Act (42 U.S.C. 1395w–151(a)(14)). 

SEC. 3314. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE 

PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING 

PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OFPOCKET THRESHOLD UNDER PART D. 

(a) IN GENERAL.—Section 1860D–2(b)(4)(C) of the Social Security Act (42 U.S.C. 1395w–102(b)(4)(C)) is amended— 

(1) in clause (i), by striking ‘‘and’’ at the end; 

(2) in clause (ii)— 

(A) by striking ‘‘such costs shall be treated as incurred 

only if’’ and inserting ‘‘subject to clause (iii), such costs 

shall be treated as incurred only if’’; 
397 Sec. 3315 PPACA (Consolidated) 

(B) by striking ‘‘, under section 1860D–14, or under a 

State Pharmaceutical Assistance Program’’; and 

(C) by striking the period at the end and inserting ‘‘; 

and’’; and 

(3) by inserting after clause (ii) the following new clause: 

‘‘(iii) such costs shall be treated as incurred and 

shall not be considered to be reimbursed under clause 

(ii) if such costs are borne or paid— 

‘‘(I) under section 1860D–14; 

‘‘(II) under a State Pharmaceutical Assistance 

Program; 

‘‘(III) by the Indian Health Service, an Indian 

tribe or tribal organization, or an urban Indian organization (as defined in section 4 of the Indian 

Health Care Improvement Act); or 

‘‘(IV) under an AIDS Drug Assistance Program under part B of title XXVI of the Public 

Health Service Act.’’. 

(b) EFFECTIVE DATE.—The amendments made by subsection (a) 

shall apply to costs incurred on or after January 1, 2011. 

SEC. 3315. øIMMEDIATE REDUCTION IN COVERAGE GAP IN 

2010¿øREPEALED AND REPLACED¿. 

øThis section (and the amendments made by this section) repealed by section 1101(a)(2) of HCERA. Section 1101(a)(1) of 

HCERA provided for the following immediate reduction in the coverage gap in 2010:¿ 

(a) øSec. 1101(a)(1) of HCERA:¿Coverage Gap Rebate for 

2010.— 

(1) IN GENERAL.—Section 1860D–42 of the Social Security 

Act (42 U.S.C. 1395w–152) is amended by adding at the end 

the following new subsection: 

‘‘(c) COVERAGE GAP REBATE FOR 2010.— 

‘‘(1) IN GENERAL.—In the case of an individual described in 

subparagraphs (A) through (D) of section 1860D–14A(g)(1) who 

as of the last day of a calendar quarter in 2010 has incurred 

costs for covered part D drugs so that the individual has exceeded the initial coverage limit under section 1860D–2(b)(3) 

for 2010, the Secretary shall provide for payment from the 

Medicare Prescription Drug Account of $250 to the individual 

by not later than the 15th day of the third month following the 

end of such quarter. 

‘‘(2) LIMITATION.—The Secretary shall provide only 1 payment under this subsection with respect to any individual.’’. 
Sec. 3401 PPACA (Consolidated) 398 

Subtitle E—Ensuring Medicare 

Sustainability 

SEC. 3401. REVISION OF CERTAIN MARKET BASKET UPDATES AND INCORPORATION OF PRODUCTIVITY IMPROVEMENTS INTO 

MARKET BASKET UPDATES THAT DO NOT ALREADY INCORPORATE SUCH IMPROVEMENTS. 

(a) INPATIENT ACUTE HOSPITALS.—Section 1886(b)(3)(B) of the 

Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended by 

section 3001(a)(3), is further amended— 

(1) in clause (i)(XX), by striking ‘‘clause (viii)’’ and inserting ‘‘clauses (viii), (ix), (xi), and (xii)’’; 

(2) in the first sentence of clause (viii), by inserting ‘‘of 

such applicable percentage increase (determined without regard to clause (ix), (xi), or (xii))’’ after ‘‘one-quarter’’; 

(3) in the first sentence of clause (ix)(I), by inserting ‘‘(determined without regard to clause (viii), (xi), or (xii))’’ after 

‘‘clause (i)’’ the second time it appears; and 

(4) by adding at the end the following new clauses: 

‘‘(xi)(I) For 2012 and each subsequent fiscal year, after determining the applicable percentage increase described in clause (i) 

and after application of clauses (viii) and (ix), such percentage increase shall be reduced by the productivity adjustment described in 

subclause (II). 

‘‘(II) The productivity adjustment described in this subclause, 

with respect to a percentage, factor, or update for a fiscal year, 

year, cost reporting period, or other annual period, is a productivity 

adjustment equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity (as projected by the Secretary for the 10-year period ending 

with the applicable fiscal year, year, cost reporting period, or other 

annual period). 

‘‘(III) The application of subclause (I) may result in the applicable percentage increase described in clause (i) being less than 0.0 

for a fiscal year, and may result in payment rates under this section for a fiscal year being less than such payment rates for the 

preceding fiscal year. 

‘‘(xii) After determining the applicable percentage increase described in clause (i), and after application of clauses (viii), (ix), and 

(xi), the Secretary shall reduce such applicable percentage increase—øAs revised by section 10319(a)¿ 

‘‘(I) for each of fiscal years 2010 and 2011, by 0.25 percentage point; 

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

‘‘(III) for fiscal year 2014, by 0.3 percentage point; 

‘‘(IV) for each of fiscal years 2015 and 2016, by 0.2 percentage point; and 

‘‘(V) for each of fiscal years 2017, 2018, and 2019, by 0.75 

percentage point. 

The application of this clause may result in the applicable percentage increase described in clause (i) being less than 0.0 for a fiscal 

year, and may result in payment rates under this section for a fis-
399 Sec. 3401 PPACA (Consolidated) 

cal year being less than such payment rates for the preceding fiscal 

year. øAs revised by section 1105(a)(2) of HCERA¿’’. 

(b) SKILLED NURSING FACILITIES.—Section 1888(e)(5)(B) of the 

Social Security Act (42 U.S.C. 1395yy(e)(5)(B)) is amended— 

(1) by striking ‘‘PERCENTAGE.—The term’’ and inserting ‘‘PERCENTAGE.— 

‘‘(i) IN GENERAL.—Subject to clause (ii), the term’’; 

and 

(2) by adding at the end the following new clause: 

‘‘(ii) ADJUSTMENT.—For fiscal year 2012 and each 

subsequent fiscal year, after determining the percentage described in clause (i), the Secretary shall reduce 

such percentage by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). The application 

of the preceding sentence may result in such percentage being less than 0.0 for a fiscal year, and may result in payment rates under this subsection for a fiscal 

year being less than such payment rates for the preceding fiscal year.’’. 

(c) LONG-TERM CARE HOSPITALS.—Section 1886(m) of the Social 

Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the 

end the following new paragraphs: 

‘‘(3) IMPLEMENTATION FOR RATE YEAR 2010 AND SUBSEQUENT

YEARS.— ‘‘(A) IN GENERAL.—In implementing the system described in paragraph (1) for rate year 2010 and each subsequent rate year, any annual update to a standard Federal 

rate for discharges for the hospital during the rate year, 

shall be reduced— 

‘‘(i) for rate year 2012 and each subsequent rate 

year, by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II); and 

‘‘(ii) for each of rate years 2010 through 2019, by 

the other adjustment described in paragraph (4). 

‘‘(B) SPECIAL RULE.—The application of this paragraph 

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. 

‘‘(4) OTHER ADJUSTMENT.—øAs revised by section 10319(b) 

and section 1105(b) of HCERA¿ For purposes of paragraph 

(3)(A)(ii), the other adjustment described in this paragraph is— 

‘‘(A) for rate year 2010, 0.25 percentage point; 

‘‘(B) for rate year 2011, 0.50 percentage point; 

‘‘(C) for each of the rate years beginning in 2012 and 

2013, 0.1 percentage point; 

‘‘(D) for rate year 2014, 0.3 percentage point; 

‘‘(E) for each of rate years 2015 and 2016, 0.2 percentage point; and 

‘‘(F) for each of rate years 2017, 2018, and 2019, 0.75 

percentage point.’’. 

(d) INPATIENT REHABILITATION FACILITIES.—Section 1886(j)(3) 

of the Social Security Act (42 U.S.C. 1395ww(j)(3)) is amended— 

(1) in subparagraph (C)— 
Sec. 3401 PPACA (Consolidated) 400 

(A) by striking ‘‘FACTOR.—For purposes’’ and inserting ‘‘FACTOR.— 

‘‘(i) IN GENERAL.—For purposes’’; 

(B) by inserting ‘‘subject to clause (ii)’’ before the period at the end of the first sentence of clause (i), as added 

by paragraph (1); and 

(C) by adding at the end the following new clause: 

‘‘(ii) PRODUCTIVITY AND OTHER ADJUSTMENT.— After establishing the increase factor described in 

clause (i) for a fiscal year, the Secretary shall reduce 

such increase factor— 

‘‘(I) for fiscal year 2012 and each subsequent 

fiscal year, by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II); and 

‘‘(II) for each of fiscal years 2010 through 

2019, by the other adjustment described in subparagraph (D). 

The application of this clause may result in the increase factor under this subparagraph being less than 

0.0 for a fiscal year, and may result in payment rates 

under this subsection for a fiscal year being less than 

such payment rates for the preceding fiscal year.’’; and 

(2) by adding at the end the following new subparagraph: 

‘‘(D) OTHER ADJUSTMENT.—øAs revised by section 

10319(b) and section 1105(b) of HCERA¿ For purposes of 

subparagraph (C)(ii)(II), the other adjustment described in 

this subparagraph is— 

‘‘(i) for each of fiscal years 2010 and 2011, 0.25 

percentage point; 

‘‘(ii) for each of fiscal years 2012 and 2013, 0.1 

percentage point; 

‘‘(iii) for fiscal year 2014, 0.3 percentage point; 

‘‘(iv) for each of fiscal years 2015 and 2016, 0.2 

percentage point; and 

‘‘(v) for each of fiscal years 2017, 2018, and 2019, 

0.75 percentage point.’’. 

(e) HOME HEALTH AGENCIES.—Section 1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended— 

(1) in clause (ii)(V), by striking ‘‘clause (v)’’ and inserting 

‘‘clauses (v) and (vi)’’; and 

(2) by adding at the end the following new clause: 

‘‘(vi) ADJUSTMENTS.—After determining the home 

health market basket percentage increase under 

clause (iii), and after application of clause (v), the Secretary shall reduce such percentage— 

‘‘(I) for 2015 and each subsequent year, by the 

productivity adjustment described in section 

1886(b)(3)(B)(xi)(II); and 

‘‘(II) for each of 2011, 2012, and 2013, by 1 

percentage point. øAs revised by section 10319(d)¿ 

The application of this clause may result in the home 

health market basket percentage increase under 

clause (iii) being less than 0.0 for a year, and may result in payment rates under the system under this 
401 Sec. 3401 PPACA (Consolidated) 

subsection for a year being less than such payment 

rates for the preceding year.’’. 

(f) PSYCHIATRIC HOSPITALS.—Section 1886 of the Social Security Act, as amended by sections 3001, 3008, 3025, and 3133, is 

amended by adding at the end the following new subsection: 

‘‘(s) PROSPECTIVE PAYMENT FOR PSYCHIATRIC HOSPITALS.— ‘‘(1) REFERENCE TO ESTABLISHMENT AND IMPLEMENTATION

OF SYSTEM.—For provisions related to the establishment and 

implementation of a prospective payment system for payments 

under this title for inpatient hospital services furnished by psychiatric hospitals (as described in clause (i) of subsection 

(d)(1)(B)) and psychiatric units (as described in the matter following clause (v) of such subsection), see section 124 of the 

Medicare, Medicaid, and SCHIP Balanced Budget Refinement 

Act of 1999. 

‘‘(2) IMPLEMENTATION FOR RATE YEAR BEGINNING IN 2010

AND SUBSEQUENT RATE YEARS.— ‘‘(A) IN GENERAL.—In implementing the system described in paragraph (1) for the rate year beginning in 

2010 and any subsequent rate year, any update to a base 

rate for days during the rate year for a psychiatric hospital 

or unit, respectively, shall be reduced— 

‘‘(i) for the rate year beginning in 2012 and each 

subsequent rate year, by the productivity adjustment 

described in section 1886(b)(3)(B)(xi)(II); and 

‘‘(ii) for each of the rate years beginning in 2010 

through 2019, by the other adjustment described in 

paragraph (3). 

‘‘(B) SPECIAL RULE.—The application of this paragraph 

may result in such 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. 

‘‘(3) OTHER ADJUSTMENT.—øAs revised by section 10319(e) 

and section 1105(d) of HCERA¿ For purposes of paragraph 

(2)(A)(ii), the other adjustment described in this paragraph is— 

‘‘(A) for each of the rate years beginning in 2010 and 

2011, 0.25 percentage point; 

‘‘(B) for each of the rate years beginning in 2012 and 

2013, 0.1 percentage point; 

‘‘(C) for the rate year beginning in 2014, 0.3 percentage point; 

‘‘(D) for each of the rate years beginning in 2015 and 

2016, 0.2 percentage point; and 

‘‘(E) for each of the rate years beginning in 2017, 2018, 

and 2019, 0.75 percentage point. 

‘‘(4) QUALITY REPORTING.—øAs added by section 10322(a)¿ 

‘‘(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 
Sec. 3401 PPACA (Consolidated) 402 

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.’’. 

(g) HOSPICE CARE.—Section 1814(i)(1)(C) of the Social Security 

Act (42 U.S.C. 1395f(i)(1)(C)), as amended by section 3132, is 
403 Sec. 3401 PPACA (Consolidated) 

amended by adding at the end the following new clauses: øAs revised by section 10319(f)¿ 

‘‘(iv) After determining the market basket percentage increase 

under clause (ii)(VII) or (iii), as applicable, with respect to fiscal 

year 2013 and each subsequent fiscal year, the Secretary shall reduce such percentage— 

‘‘(I) for 2013 and each subsequent fiscal year, by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II); 

and 

‘‘(II) subject to clause (v), for each of fiscal years 2013 

through 2019, by 0.3 percentage point. 

The application of this clause may result in the market basket percentage increase under clause (ii)(VII) or (iii), as applicable, being 

less than 0.0 for a fiscal year, and may result in payment rates 

under this subsection for a fiscal year being less than such payment rates for the preceding fiscal year. 

‘‘(v) Clause (iv)(II) shall be applied with respect to any of fiscal 

years 2014 through 2019 by substituting ‘0.0 percentage points’ for 

‘0.3 percentage point’, if for such fiscal year— 

‘‘(I) the excess (if any) of— 

‘‘(aa) the total percentage of the non-elderly insured 

population for the preceding fiscal year (based on the most 

recent estimates available from the Director of the Congressional Budget Office before a vote in either House on 

the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over 

‘‘(bb) the total percentage of the non-elderly insured 

population for such preceding fiscal year (as estimated by 

the Secretary); exceeds 

‘‘(II) 5 percentage points.’’. 

(h) DIALYSIS.—Section 1881(b)(14)(F) of the Social Security Act 

(42 U.S.C. 1395rr(b)(14)(F)) is amended— 

(1) in clause (i)— 

(A) by inserting ‘‘(I)’’ after ‘‘(F)(i)’’ 

(B) in subclause (I), as inserted by subparagraph (A)— 

(i) by striking ‘‘clause (ii)’’ and inserting ‘‘subclause (II) and clause (ii)’’; and 

(ii) by striking ‘‘minus 1.0 percentage point’’; and 

(C) by adding at the end the following new subclause: 

‘‘(II) For 2012 and each subsequent year, after determining the 

increase factor described in subclause (I), the Secretary shall reduce such increase factor by the productivity adjustment described 

in section 1886(b)(3)(B)(xi)(II). The application of the preceding sentence may result in such increase factor being less than 0.0 for a 

year, and may result in payment rates under the payment system 

under this paragraph for a year being less than such payment 

rates for the preceding year.’’; and 

(2) in clause (ii)(II)— 

(A) by striking ‘‘The’’ and inserting ‘‘Subject to clause 

(i)(II), the’’; and 

(B) by striking ‘‘clause (i) minus 1.0 percentage point’’ 

and inserting ‘‘clause (i)(I)’’. 
Sec. 3401 PPACA (Consolidated) 404 

(i) OUTPATIENT HOSPITALS.—Section 1833(t)(3) of the Social Security Act (42 U.S.C. 1395l(t)(3)) is amended— 

(1) in subparagraph (C)(iv), by inserting ‘‘and subparagraph (F) of this paragraph’’ after ‘‘(17)’’; and 

(2) by adding at the end the following new subparagraphs: 

‘‘(F) PRODUCTIVITY AND OTHER ADJUSTMENT.—After determining the OPD fee schedule increase factor under subparagraph (C)(iv), the Secretary shall reduce such increase 

factor— 

‘‘(i) for 2012 and subsequent years, by the productivity adjustment described in section 

1886(b)(3)(B)(xi)(II); and 

‘‘(ii) for each of 2010 through 2019, by the adjustment described in subparagraph (G). 

The application of this subparagraph may result in the increase factor under subparagraph (C)(iv) being less than 

0.0 for a year, and may result in payment rates under the 

payment system under this subsection for a year being less 

than such payment rates for the preceding year. 

‘‘(G) OTHER ADJUSTMENT.—øAs revised by section 

10319(g) and section 1105(e) of HCERA¿ For purposes of 

subparagraph (F)(ii), the adjustment described in this subparagraph is— 

‘‘(i) for each of 2010 and 2011, 0.25 percentage 

point; 

‘‘(ii) for each of 2012 and 2013, 0.1 percentage 

point; 

‘‘(iii) for 2014, 0.3 percentage point; 

‘‘(iv) for each of 2015 and 2016, 0.2 percentage 

point; and 

‘‘(v) for each of 2017, 2018, and 2019, 0.75 percentage point.’’. 

(j) AMBULANCE SERVICES.—Section 1834(l)(3) of the Social Security Act (42 U.S.C. 1395m(l)(3)) is amended— 

(1) in subparagraph (A), by striking ‘‘and’’ at the end; 

(2) in subparagraph (B)— 

(A) by inserting ‘‘, subject to subparagraph (C) and the 

succeeding sentence of this paragraph,’’ after ‘‘increased’’; 

and 

(B) by striking the period at the end and inserting ‘‘; 

and’’; 

(3) by adding at the end the following new subparagraph: 

‘‘(C) for 2011 and each subsequent year, after determining the percentage increase under subparagraph (B) 

for the year, reduce such percentage increase by the productivity adjustment described in section 

1886(b)(3)(B)(xi)(II).’’; and 

(4) by adding at the end the following flush sentence: 

‘‘The application of subparagraph (C) may result in the percentage increase under subparagraph (B) being less than 0.0 

for a year, and may result in payment rates under the fee 

schedule under this subsection for a year being less than such 

payment rates for the preceding year.’’. 
405 Sec. 3401 PPACA (Consolidated) 

(k) AMBULATORY SURGICAL CENTER SERVICES.—Section 

1833(i)(2)(D) of the Social Security Act (42 U.S.C. 1395l(i)(2)(D)) is 

amended— 

(1) by redesignating clause (v) as clause (vi); and 

(2) by inserting after clause (iv) the following new clause: 

‘‘(v) In implementing the system described in 

clause (i) for 2011 and each subsequent year, any annual update under such system for the year, after application of clause (iv), shall be reduced by the productivity adjustment described in section 

1886(b)(3)(B)(xi)(II). The application of the preceding 

sentence may result in such update being less than 0.0 

for a year, and may result in payment rates under the 

system described in clause (i) for a year being less 

than such payment rates for the preceding year.’’. 

(l) LABORATORY SERVICES.—Section 1833(h)(2)(A) of the Social 

Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended— 

(1) in clause (i)— 

(A) by inserting ‘‘, subject to clause (iv),’’ after ‘‘year) 

by’’; and 

(B) by striking ‘‘through 2013’’ and inserting ‘‘and 

2010’’; and 

(2) by adding at the end the following new clause: 

‘‘(iv) After determining the adjustment to the fee 

schedules under clause (i), the Secretary shall reduce 

such adjustment— 

‘‘(I) for 2011 and each subsequent year, by the 

productivity adjustment described in section 

1886(b)(3)(B)(xi)(II); and 

‘‘(II) for each of 2011 through 2015, by 1.75 

percentage points. 

Subclause (I) shall not apply in a year where the adjustment to the fee schedules determined under clause 

(i) is 0.0 or a percentage decrease for a year. The application of the productivity adjustment under subclause (I) shall not result in an adjustment to the fee 

schedules under clause (i) being less than 0.0 for a 

year. The application of subclause (II) may result in 

an adjustment to the fee schedules under clause (i) 

being less than 0.0 for a year, and may result in payment rates for a year being less than such payment 

rates for the preceding year.’’. 

(m) CERTAIN DURABLE MEDICAL EQUIPMENT.—Section 

1834(a)(14) of the Social Security Act (42 U.S.C. 1395m(a)(14)) is 

amended— 

(1) in subparagraph (K)— 

(A) by striking ‘‘2011, 2012, and 2013,’’; and 

(B) by inserting ‘‘and’’ after the semicolon at the end; 

(2) by striking subparagraphs (L) and (M) and inserting 

the following new subparagraph: 

‘‘(L) for 2011 and each subsequent year— 

‘‘(i) the percentage increase in the consumer price 

index for all urban consumers (United States city av-
Sec. 3401 PPACA (Consolidated) 406 

erage) for the 12-month period ending with June of 

the previous year, reduced by— 

‘‘(ii) the productivity adjustment described in section 1886(b)(3)(B)(xi)(II).’’; and 

(3) by adding at the end the following flush sentence: 

‘‘The application of subparagraph (L)(ii) may result in the covered item update under this paragraph being less than 0.0 for 

a year, and may result in payment rates under this subsection 

for a year being less than such payment rates for the preceding 

year.’’. 

(n) PROSTHETIC DEVICES, ORTHOTICS, AND PROSTHETICS.—Section 1834(h)(4) of the Social Security Act (42 U.S.C. 1395m(h)(4)) 

is amended— 

(1) in subparagraph (A)— 

(A) in clause (ix), by striking ‘‘and’’ at the end; 

(B) in clause (x)— 

(i) by striking ‘‘a subsequent year’’ and inserting 

‘‘for each of 2007 through 2010’’; and 

(ii) by inserting ‘‘and’’ after the semicolon at the 

end; 

(C) by adding at the end the following new clause: 

‘‘(xi) for 2011 and each subsequent year— 

‘‘(I) the percentage increase in the consumer 

price index for all urban consumers (United States 

city average) for the 12-month period ending with 

June of the previous year, reduced by— 

‘‘(II) the productivity adjustment described in 

section 1886(b)(3)(B)(xi)(II).’’; and 

(D) by adding at the end the following flush sentence: 

‘‘The application of subparagraph (A)(xi)(II) may result in the 

applicable percentage increase under subparagraph (A) being 

less than 0.0 for a year, and may result in payment rates 

under this subsection for a year being less than such payment 

rates for the preceding year.’’. 

(o) OTHER ITEMS.—Section 1842(s)(1) of the Social Security Act 

(42 U.S.C. 1395u(s)(1)) is amended— 

(1) in the first sentence, by striking ‘‘Subject to’’ and inserting ‘‘(A) Subject to’’; 

(2) by striking the second sentence and inserting the following new subparagraph: 

‘‘(B) Any fee schedule established under this paragraph for such item or service shall be updated— 

‘‘(i) for years before 2011— 

‘‘(I) subject to subclause (II), by the percentage increase in the consumer price index for all 

urban consumers (United States city average) for 

the 12-month period ending with June of the preceding year; and 

‘‘(II) for items and services described in paragraph (2)(D) for 2009, section 1834(a)(14)(J) shall 

apply under this paragraph instead of the percentage increase otherwise applicable; and 

‘‘(ii) for 2011 and subsequent years— 
407 Sec. 3403 PPACA (Consolidated) \1899A SSA 

‘‘(I) the percentage increase in the consumer 

price index for all urban consumers (United States 

city average) for the 12-month period ending with 

June of the previous year, reduced by— 

‘‘(II) the productivity adjustment described in 

section 1886(b)(3)(B)(xi)(II).’’; and 

(3) by adding at the end the following flush sentence: 

‘‘The application of subparagraph (B)(ii)(II) may result in the 

update under this paragraph being less than 0.0 for a year, 

and may result in payment rates under any fee schedule established under this paragraph for a year being less than such 

payment rates for the preceding year.’’. 

(p) NO APPLICATION PRIOR TO APRIL 1, 2010.—Notwithstanding 

the preceding provisions of this section, the amendments made by 

subsections (a), (c), and (d) shall not apply to discharges occurring 

before April 1, 2010. 

SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART 

B PREMIUMS. 

Section 1839(i) of the Social Security Act (42 U.S.C. 1395r(i)) 

is amended— 

(1) in paragraph (2), in the matter preceding subparagraph 

(A), by inserting ‘‘subject to paragraph (6),’’ after ‘‘subsection,’’; 

(2) in paragraph (3)(A)(i), by striking ‘‘The applicable’’ and 

inserting ‘‘Subject to paragraph (6), the applicable’’; 

(3) by redesignating paragraph (6) as paragraph (7); and 

(4) by inserting after paragraph (5) the following new 

paragraph: 

‘‘(6) TEMPORARY ADJUSTMENT TO INCOME THRESHOLDS.— 

Notwithstanding any other provision of this subsection, during 

the period beginning on January 1, 2011, and ending on December 31, 2019— 

‘‘(A) the threshold amount otherwise applicable under 

paragraph (2) shall be equal to such amount for 2010; and 

‘‘(B) the dollar amounts otherwise applicable under 

paragraph (3)(C)(i) shall be equal to such dollar amounts 

for 2010.’’. 

SEC. 3403. INDEPENDENT øMEDICARE¿ [PAYMENT] ADVISORY BOARD. 

øSection 10320(b) provides the following 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’ ’’¿ 

(a) BOARD.— 

(1) IN GENERAL.—Title XVIII of the Social Security Act (42 

U.S.C. 1395 et seq.), as amended by section 3022, is amended 

by adding at the end the following new section: øAs revised by 

section 10320(a)¿ 

‘‘INDEPENDENT MEDICARE ADVISORY BOARD

‘‘SEC. 1899A. ø42 U.S.C. 1395kkk¿ (a) ESTABLISHMENT.—There 

is established an independent board to be known as the ‘Independent Medicare Advisory Board’ øNote: Referred to as the ‘‘Independent Payment Advisory Board’’¿. 
Sec. 3403\1899A SSA PPACA (Consolidated) 408 

‘‘(b) PURPOSE.—It is the purpose of this section to, in accordance with the following provisions of this section, reduce the per 

capita rate of growth in Medicare spending— 

‘‘(1) by requiring the Chief Actuary of the Centers for 

Medicare & Medicaid Services to determine in each year to 

which this section applies (in this section referred to as ‘a determination year’) the projected per capita growth rate under 

Medicare for the second year following the determination year 

(in this section referred to as ‘an implementation year’); 

‘‘(2) if the projection for the implementation year exceeds 

the target growth rate for that year, by requiring the Board to 

develop and submit during the first year following the determination year (in this section referred to as ‘a proposal year’) 

a proposal containing recommendations to reduce the Medicare 

per capita growth rate to the extent required by this section; 

and 

‘‘(3) by requiring the Secretary to implement such proposals unless Congress enacts legislation pursuant to this section. 

‘‘(c) BOARD PROPOSALS.— ‘‘(1) DEVELOPMENT.— ‘‘(A) IN GENERAL.—The Board shall develop detailed 

and specific proposals related to the Medicare program in 

accordance with the succeeding provisions of this section. 

‘‘(B) ADVISORY REPORTS.—Beginning January 15, 2014, 

the Board may develop and submit to Congress advisory 

reports on matters related to the Medicare program, regardless of whether or not the Board submitted a proposal 

for such year. Such a report may, for years prior to 2020, 

include recommendations regarding improvements to payment systems for providers of services and suppliers who 

are not otherwise subject to the scope of the Board’s recommendations in a proposal under this section. Any advisory report submitted under this subparagraph shall not 

be subject to the rules for congressional consideration 

under subsection (d). 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. 

øAs revised by section 10320(a)(1)(A)¿ 

‘‘(2) PROPOSALS.— 

‘‘(A) REQUIREMENTS.—Each proposal submitted under 

this section in a proposal year shall meet each of the following requirements: 

‘‘(i) If the Chief Actuary of the Centers for Medicare & Medicaid Services has made a determination 

under paragraph (7)(A) in the determination year, the 

proposal shall include recommendations so that the 

proposal as a whole (after taking into account recommendations under clause (v)) will result in a net reduction in total Medicare program spending in the implementation year that is at least equal to the applicable savings target established under paragraph (7)(B) 

for such implementation year. In determining whether 
409 Sec. 3403 PPACA (Consolidated) \1899A SSA 

a proposal meets the requirement of the preceding 

sentence, reductions in Medicare program spending 

during the 3-month period immediately preceding the 

implementation year shall be counted to the extent 

that such reductions are a result of the implementation of recommendations contained in the proposal for 

a change in the payment rate for an item or service 

that was effective during such period pursuant to subsection (e)(2)(A). 

‘‘(ii) The proposal shall not include any recommendation to ration health care, raise revenues or 

Medicare beneficiary premiums under section 1818, 

1818A, or 1839, increase Medicare beneficiary costsharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria. 

‘‘(iii) In the case of proposals submitted prior to 

December 31, 2018, the proposal shall not include any 

recommendation that would reduce payment rates for 

items and services furnished, prior to December 31, 

2019, by providers of services (as defined in section 

1861(u)) and suppliers (as defined in section 1861(d)) 

scheduled, pursuant to the amendments made by section 3401 of the Patient Protection and Affordable 

Care Act, to receive a reduction to the inflationary 

payment updates of such providers of services and 

suppliers in excess of a reduction due to productivity 

in a year in which such recommendations would take 

effect. 

‘‘(iv) As appropriate, the proposal shall include 

recommendations to reduce Medicare payments under 

parts C and D, such as reductions in direct subsidy 

payments to Medicare Advantage and prescription 

drug plans specified under paragraph (1) and (2) of 

section 1860D–15(a) that are related to administrative 

expenses (including profits) for basic coverage, denying 

high bids or removing high bids for prescription drug 

coverage from the calculation of the national average 

monthly bid amount under section 1860D–13(a)(4), 

and reductions in payments to Medicare Advantage 

plans under clauses (i) and (ii) of section 1853(a)(1)(B) 

that are related to administrative expenses (including 

profits) and performance bonuses for Medicare Advantage plans under section 1853(n). Any such recommendation shall not affect the base beneficiary premium percentage specified under 1860D–13(a) or the 

full premium subsidy under section 1860D–14(a). øAs 

revised by section 10320(a)(1)(B)¿ 

‘‘(v) The proposal shall include recommendations 

with respect to administrative funding for the Secretary to carry out the recommendations contained in 

the proposal. 

‘‘(vi) The proposal shall only include recommendations related to the Medicare program. 
Sec. 3403\1899A SSA PPACA (Consolidated) 410 

‘‘(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. øAs added by section 

10320(a)(1)(B)(ii)¿ 

‘‘(B) ADDITIONAL CONSIDERATIONS.—In developing and 

submitting each proposal under this section in a proposal 

year, the Board shall, to the extent feasible— 

‘‘(i) give priority to recommendations that extend 

Medicare solvency; 

‘‘(ii) include recommendations that— 

‘‘(I) improve the health care delivery system 

and health outcomes, including by promoting integrated care, care coordination, prevention and 

wellness, and quality and efficiency improvement; 

and 

‘‘(II) protect and improve Medicare beneficiaries’ access to necessary and evidence-based 

items and services, including in rural and frontier 

areas; 

‘‘(iii) include recommendations that target reductions in Medicare program spending to sources of excess cost growth; 

‘‘(iv) consider the effects on Medicare beneficiaries 

of changes in payments to providers of services (as defined in section 1861(u)) and suppliers (as defined in 

section 1861(d)); 

‘‘(v) consider the effects of the recommendations 

on providers of services and suppliers with actual or 

projected negative cost margins or payment updates; 

‘‘(vi) consider the unique needs of Medicare beneficiaries who are dually eligible for Medicare and the 

Medicaid program under title XIX; and 

‘‘(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. øAs added by section 

10320(a)(1)(C)¿ 

‘‘(C) NO INCREASE IN TOTAL MEDICARE PROGRAM SPENDING.—Each proposal submitted under this section shall be 

designed in such a manner that implementation of the recommendations contained in the proposal would not be expected to result, over the 10-year period starting with the 

implementation year, in any increase in the total amount 

of net Medicare program spending relative to the total 

amount of net Medicare program spending that would 

have occurred absent such implementation. 

‘‘(D) CONSULTATION WITH MEDPAC.—The Board shall 

submit a draft copy of each proposal to be submitted under 

this section to the Medicare Payment Advisory Commis-
411 Sec. 3403 PPACA (Consolidated) \1899A SSA 

sion established under section 1805 for its review. The 

Board shall submit such draft copy by not later than September 1 of the determination year. 

‘‘(E) REVIEW AND COMMENT BY THE SECRETARY.—The 

Board shall submit a draft copy of each proposal to be submitted to Congress under this section to the Secretary for 

the Secretary’s review and comment. The Board shall submit such draft copy by not later than September 1 of the 

determination year. Not later than March 1 of the submission year, the Secretary shall submit a report to Congress 

on the results of such review, unless the Secretary submits 

a proposal under paragraph (5)(A) in that year. 

‘‘(F) CONSULTATIONS.—In carrying out its duties under 

this section, the Board shall engage in regular consultations with the Medicaid and CHIP Payment and Access 

Commission under section 1900. 

‘‘(3) SUBMISSION OF BOARD PROPOSAL TO CONGRESS AND

THE PRESIDENT.—øAs revised by section 10320(a)(1)(D)¿ 

‘‘(A) IN GENERAL.— 

‘‘(i) IN GENERAL.—Except as provided in clause (ii) 

and subsection (f)(3)(B), the Board shall submit a proposal under this section to Congress and the President 

on January 15 of each year (beginning with 2014). 

‘‘(ii) EXCEPTION.—The Board shall not submit a 

proposal under clause (i) in a proposal year if the year 

is— 

‘‘(I) a year for which the Chief Actuary of the 

Centers for Medicare & Medicaid Services makes 

a determination in the determination year under 

paragraph (6)(A) that the growth rate described in 

clause (i) of such paragraph does not exceed the 

growth rate described in clause (ii) of such paragraph; or 

‘‘(II) a year in which the Chief Actuary of the 

Centers for Medicare & Medicaid Services makes 

a determination in the determination year that 

the projected percentage increase (if any) for the 

medical care expenditure category of the Consumer Price Index for All Urban Consumers 

(United States city average) for the implementation year is less than the projected percentage increase (if any) in the Consumer Price Index for All 

Urban Consumers (all items; United States city 

average) for such implementation year. 

‘‘(iii) START-UP PERIOD.—The Board may not submit a proposal under clause (i) prior to January 15, 

2014. 

‘‘(B) REQUIRED INFORMATION.—Each proposal submitted by the Board under subparagraph (A)(i) shall include— 

‘‘(i) the recommendations described in paragraph 

(2)(A)(i); 
Sec. 3403\1899A SSA PPACA (Consolidated) 412 

‘‘(ii) an explanation of each recommendation contained in the proposal and the reasons for including 

such recommendation; 

‘‘(iii) an actuarial opinion by the Chief Actuary of 

the Centers for Medicare & Medicaid Services certifying that the proposal meets the requirements of subparagraphs (A)(i) and (C) of paragraph (2); 

‘‘(iv) a legislative proposal that implements the 

recommendations; and 

‘‘(v) other information determined appropriate by 

the Board. 

‘‘(4) PRESIDENTIAL SUBMISSION TO CONGRESS.—Upon receiving a proposal from the Secretary under paragraph (5), the 

President shall within 2 days submit such proposal to Congress. øAs revised by section 10320(a)(1)(E)¿ 

‘‘(5) CONTINGENT SECRETARIAL DEVELOPMENT OF PRO- POSAL.—øAs revised by section 10320(a)(1)(F)¿ If, with respect 

to a proposal year, the Board is required, but fails, to submit 

a proposal to Congress and the President by the deadline applicable under paragraph (3)(A)(i), the Secretary shall develop 

a detailed and specific proposal that satisfies the requirements 

of subparagraphs (A) and (C) (and, to the extent feasible, subparagraph (B)) of paragraph (2) and contains the information 

required paragraph (3)(B)). By not later than January 25 of the 

year, the Secretary shall transmit— 

‘‘(A) such proposal to the President; and 

‘‘(B) a copy of such proposal to the Medicare Payment 

Advisory Commission for its review. 

‘‘(6) PER CAPITA GROWTH RATE PROJECTIONS BY CHIEF ACTUARY.— 

‘‘(A) IN GENERAL.—Subject to subsection (f)(3)(A), not 

later than April 30, 2013, and annually thereafter, the 

Chief Actuary of the Centers for Medicare & Medicaid 

Services shall determine in each such year whether— 

‘‘(i) the projected Medicare per capita growth rate 

for the implementation year (as determined under 

subparagraph (B)); exceeds 

‘‘(ii) the projected Medicare per capita target 

growth rate for the implementation year (as determined under subparagraph (C)). 

‘‘(B) MEDICARE PER CAPITA GROWTH RATE.— 

‘‘(i) IN GENERAL.—øAs revised by section 

10320(a)(1)(G)¿ For purposes of this section, the Medicare per capita growth rate for an implementation 

year shall be calculated as the projected 5-year average (ending with such year) of the growth in Medicare 

program spending (calculated as the sum of per capita 

spending under each of parts A, B, and D). 

‘‘(ii) REQUIREMENT.—The projection under clause 

(i) shall— 

‘‘(I) to the extent that there is projected to be 

a negative update to the single conversion factor 

applicable to payments for physicians’ services 

under section 1848(d) furnished in the proposal 
413 Sec. 3403 PPACA (Consolidated) \1899A SSA 

year or the implementation year, assume that 

such update for such services is 0 percent rather 

than the negative percent that would otherwise 

apply; and 

‘‘(II) take into account any delivery system reforms or other payment changes that have been 

enacted or published in final rules but not yet implemented as of the making of such calculation. 

‘‘(C) MEDICARE PER CAPITA TARGET GROWTH RATE.—For 

purposes of this section, the Medicare per capita target 

growth rate for an implementation year shall be calculated 

as the projected 5-year average (ending with such year) 

percentage increase in— 

‘‘(i) with respect to a determination year that is 

prior to 2018, the average of the projected percentage 

increase (if any) in— 

‘‘(I) the Consumer Price Index for All Urban 

Consumers (all items; United States city average); 

and 

‘‘(II) the medical care expenditure category of 

the Consumer Price Index for All Urban Consumers (United States city average); and 

‘‘(ii) with respect to a determination year that is 

after 2017, the nominal gross domestic product per 

capita plus 1.0 percentage point. 

‘‘(7) SAVINGS REQUIREMENT.— 

‘‘(A) IN GENERAL.—If, with respect to a determination 

year, the Chief Actuary of the Centers for Medicare & 

Medicaid Services makes a determination under paragraph 

(6)(A) that the growth rate described in clause (i) of such 

paragraph exceeds the growth rate described in clause (ii) 

of such paragraph, the Chief Actuary shall establish an applicable savings target for the implementation year. 

‘‘(B) APPLICABLE SAVINGS TARGET.—For purposes of 

this section, the applicable savings target for an implementation year shall be an amount equal to the product of— 

‘‘(i) the total amount of projected Medicare program spending for the proposal year; and 

‘‘(ii) the applicable percent for the implementation 

year. 

‘‘(C) APPLICABLE PERCENT.—For purposes of subparagraph (B), the applicable percent for an implementation 

year is the lesser of— 

‘‘(i) in the case of— 

‘‘(I) implementation year 2015, 0.5 percent; 

‘‘(II) implementation year 2016, 1.0 percent; 

‘‘(III) implementation year 2017, 1.25 percent; 

and 

‘‘(IV) implementation year 2018 or any subsequent implementation year, 1.5 percent; and 

‘‘(ii) the projected excess for the implementation 

year (expressed as a percent) determined under subparagraph (A). 
Sec. 3403\1899A SSA PPACA (Consolidated) 414 

‘‘(8) PER CAPITA RATE OF GROWTH IN NATIONAL HEALTH EX- PENDITURES.—In each determination year (beginning in 2018), 

the Chief Actuary of the Centers for Medicare & Medicaid 

Services shall project the per capita rate of growth in national 

health expenditures for the implementation year. Such rate of 

growth for an implementation year shall be calculated as the 

projected 5-year average (ending with such year) percentage increase in national health care expenditures. 

‘‘(d) CONGRESSIONAL CONSIDERATION.—øAs revised by section 

10320(a)(2)¿ 

‘‘(1) INTRODUCTION.— ‘‘(A) IN GENERAL.—On the day on which a proposal is 

submitted by the Board or the President to the House of 

Representatives and the Senate under subsection 

(c)(3)(A)(i) or subsection (c)(4), the legislative proposal (described in subsection (c)(3)(B)(iv)) contained in the proposal shall be introduced (by request) in the Senate by the 

majority leader of the Senate or by Members of the Senate 

designated by the majority leader of the Senate and shall 

be introduced (by request) in the House by the majority 

leader of the House or by Members of the House designated by the majority leader of the House. 

‘‘(B) NOT IN SESSION.—If either House is not in session 

on the day on which such legislative proposal is submitted, 

the legislative proposal shall be introduced in that House, 

as provided in subparagraph (A), on the first day thereafter on which that House is in session. 

‘‘(C) ANY MEMBER.—If the legislative proposal is not 

introduced in either House within 5 days on which that 

House is in session after the day on which the legislative 

proposal is submitted, then any Member of that House 

may introduce the legislative proposal. 

‘‘(D) REFERRAL.—The legislation introduced under this 

paragraph shall be referred by the Presiding Officers of 

the respective Houses to the Committee on Finance in the 

Senate and to the Committee on Energy and Commerce 

and the Committee on Ways and Means in the House of 

Representatives. 

‘‘(2) COMMITTEE CONSIDERATION OF PROPOSAL.— 

‘‘(A) REPORTING BILL.—Not later than April 1 of any 

proposal year in which a proposal is submitted by the 

Board or the President to Congress under this section, the 

Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and 

the Committee on Finance of the Senate may report the 

bill referred to the Committee under paragraph (1)(D) with 

committee amendments related to the Medicare program. 

‘‘(B) CALCULATIONS.—In determining whether a committee amendment meets the requirement of subparagraph 

(A), the reductions in Medicare program spending during 

the 3-month period immediately preceding the implementation year shall be counted to the extent that such reductions are a result of the implementation provisions in the 

committee amendment for a change in the payment rate 
415 Sec. 3403 PPACA (Consolidated) \1899A SSA 

for an item or service that was effective during such period 

pursuant to such amendment. 

‘‘(C) COMMITTEE JURISDICTION.—Notwithstanding rule 

XV of the Standing Rules of the Senate, a committee 

amendment described in subparagraph (A) may include 

matter not within the jurisdiction of the Committee on Finance if that matter is relevant to a proposal contained in 

the bill submitted under subsection (c)(3). 

‘‘(D) DISCHARGE.—If, with respect to the House involved, the committee has not reported the bill by the date 

required by subparagraph (A), the committee shall be discharged from further consideration of the proposal. 

‘‘(3) LIMITATION ON CHANGES TO THE BOARD RECOMMENDA- TIONS.— ‘‘(A) IN GENERAL.—It shall not be in order in the Senate or the House of Representatives to consider any bill, 

resolution, or amendment, pursuant to this subsection or 

conference report thereon, that fails to satisfy the requirements of subparagraphs (A)(i) and (C) of subsection (c)(2). 

‘‘(B) LIMITATION ON CHANGES TO THE BOARD REC- OMMENDATIONS IN OTHER LEGISLATION.—It shall not be in 

order in the Senate or the House of Representatives to consider any bill, resolution, amendment, or conference report 

(other than pursuant to this section) that would repeal or 

otherwise change the recommendations of the Board if 

that change would fail to satisfy the requirements of subparagraphs (A)(i) and (C) of subsection (c)(2). 

‘‘(C) LIMITATION ON CHANGES TO THIS SUBSECTION.—It 

shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment, 

or conference report that would repeal or otherwise change 

this subsection. 

‘‘(D) WAIVER.—This paragraph may be waived or suspended in the Senate only by the affirmative vote of threefifths of the Members, duly chosen and sworn. 

‘‘(E) APPEALS.—An affirmative vote of three-fifths of 

the Members of the Senate, duly chosen and sworn, shall 

be required in the Senate to sustain an appeal of the ruling of the Chair on a point of order raised under this paragraph. 

‘‘(4) EXPEDITED PROCEDURE.— 

‘‘(A) CONSIDERATION.—A motion to proceed to the consideration of the bill in the Senate is not debatable. 

‘‘(B) AMENDMENT.— 

‘‘(i) TIME LIMITATION.—Debate in the Senate on 

any amendment to a bill under this section shall be 

limited to 1 hour, to be equally divided between, and 

controlled by, the mover and the manager of the bill, 

and debate on any amendment to an amendment, debatable motion, or appeal shall be limited to 30 minutes, to be equally divided between, and controlled by, 

the mover and the manager of the bill, except that in 

the event the manager of the bill is in favor of any 

such amendment, motion, or appeal, the time in oppo-
Sec. 3403\1899A SSA PPACA (Consolidated) 416 

sition thereto shall be controlled by the minority leader or such leader’s designee. 

‘‘(ii) GERMANE.—No amendment that is not germane to the provisions of such bill shall be received. 

‘‘(iii) ADDITIONAL TIME.—The leaders, or either of 

them, may, from the time under their control on the 

passage of the bill, allot additional time to any Senator during the consideration of any amendment, debatable motion, or appeal. 

‘‘(iv) AMENDMENT NOT IN ORDER.—It shall not be 

in order to consider an amendment that would cause 

the bill to result in a net reduction in total Medicare 

program spending in the implementation year that is 

less than the applicable savings target established 

under subsection (c)(7)(B) for such implementation 

year. 

‘‘(v) WAIVER AND APPEALS.—This paragraph may 

be waived or suspended in the Senate only by the affirmative vote of three-fifths of the Members, duly chosen and sworn. An affirmative vote of three-fifths of 

the Members of the Senate, duly chosen and sworn, 

shall be required in the Senate to sustain an appeal 

of the ruling of the Chair on a point of order raised 

under this section. 

‘‘(C) CONSIDERATION BY THE OTHER HOUSE.— 

‘‘(i) IN GENERAL.—The expedited procedures provided in this subsection for the consideration of a bill 

introduced pursuant to paragraph (1) shall not apply 

to such a bill that is received by one House from the 

other House if such a bill was not introduced in the 

receiving House. 

‘‘(ii) BEFORE PASSAGE.—If a bill that is introduced 

pursuant to paragraph (1) is received by one House 

from the other House, after introduction but before 

disposition of such a bill in the receiving House, then 

the following shall apply: 

‘‘(I) The receiving House shall consider the bill 

introduced in that House through all stages of 

consideration up to, but not including, passage. 

‘‘(II) The question on passage shall be put on 

the bill of the other House as amended by the language of the receiving House. 

‘‘(iii) AFTER PASSAGE.—If a bill introduced pursuant to paragraph (1) is received by one House from the 

other House, after such a bill is passed by the receiving House, then the vote on passage of the bill that 

originates in the receiving House shall be considered 

to be the vote on passage of the bill received from the 

other House as amended by the language of the receiving House. 

‘‘(iv) DISPOSITION.—Upon disposition of a bill introduced pursuant to paragraph (1) that is received by 

one House from the other House, it shall no longer be 
417 Sec. 3403 PPACA (Consolidated) \1899A SSA 

in order to consider the bill that originates in the receiving House. 

‘‘(v) LIMITATION.—Clauses (ii), (iii), and (iv) shall 

apply only to a bill received by one House from the 

other House if the bill— 

‘‘(I) is related only to the program under this 

title; and 

‘‘(II) satisfies the requirements of subparagraphs (A)(i) and (C) of subsection (c)(2). 

‘‘(D) SENATE LIMITS ON DEBATE.— 

‘‘(i) IN GENERAL.—In the Senate, consideration of 

the bill and on all debatable motions and appeals in 

connection therewith shall not exceed a total of 30 

hours, which shall be divided equally between the majority and minority leaders or their designees. 

‘‘(ii) MOTION TO FURTHER LIMIT DEBATE.—A motion to further limit debate on the bill is in order and 

is not debatable. 

‘‘(iii) MOTION OR APPEAL.—Any debatable motion 

or appeal is debatable for not to exceed 1 hour, to be 

divided equally between those favoring and those opposing the motion or appeal. 

‘‘(iv) FINAL DISPOSITION.—After 30 hours of consideration, the Senate shall proceed, without any further 

debate on any question, to vote on the final disposition 

thereof to the exclusion of all amendments not then 

pending before the Senate at that time and to the exclusion of all motions, except a motion to table, or to 

reconsider and one quorum call on demand to establish the presence of a quorum (and motions required 

to establish a quorum) immediately before the final 

vote begins. 

‘‘(E) CONSIDERATION IN CONFERENCE.— 

‘‘(i) IN GENERAL.—Consideration in the Senate and 

the House of Representatives on the conference report 

or any messages between Houses shall be limited to 

10 hours, equally divided and controlled by the majority and minority leaders of the Senate or their designees and the Speaker of the House of Representatives and the minority leader of the House of Representatives or their designees. 

‘‘(ii) TIME LIMITATION.—Debate in the Senate on 

any amendment under this subparagraph shall be limited to 1 hour, to be equally divided between, and controlled by, the mover and the manager of the bill, and 

debate on any amendment to an amendment, debatable motion, or appeal shall be limited to 30 minutes, 

to be equally divided between, and controlled by, the 

mover and the manager of the bill, except that in the 

event the manager of the bill is in favor of any such 

amendment, motion, or appeal, the time in opposition 

thereto shall be controlled by the minority leader or 

such leader’s designee. 
Sec. 3403\1899A SSA PPACA (Consolidated) 418 

‘‘(iii) FINAL DISPOSITION.—After 10 hours of consideration, the Senate shall proceed, without any further debate on any question, to vote on the final disposition thereof to the exclusion of all motions not 

then pending before the Senate at that time or necessary to resolve the differences between the Houses 

and to the exclusion of all other motions, except a motion to table, or to reconsider and one quorum call on 

demand to establish the presence of a quorum (and 

motions required to establish a quorum) immediately 

before the final vote begins. 

‘‘(iv) LIMITATION.—Clauses (i) through (iii) shall 

only apply to a conference report, message or the 

amendments thereto if the conference report, message, 

or an amendment thereto— 

‘‘(I) is related only to the program under this 

title; and 

‘‘(II) satisfies the requirements of subparagraphs (A)(i) and (C) of subsection (c)(2). 

‘‘(F) VETO.—If the President vetoes the bill debate on 

a veto message in the Senate under this subsection shall 

be 1 hour equally divided between the majority and minority leaders or their designees. 

‘‘(5) RULES OF THE SENATE AND HOUSE OF REPRESENTA- TIVES.—This subsection and subsection (f)(2) are enacted by 

Congress— 

‘‘(A) as an exercise of the rulemaking power of the 

Senate and the House of Representatives, respectively, and 

is deemed to be part of the rules of each House, respectively, but applicable only with respect to the procedure to 

be followed in that House in the case of bill under this section, and it supersedes other rules only to the extent that 

it is inconsistent with such rules; and 

‘‘(B) with full recognition of the constitutional right of 

either House to change the rules (so far as they relate to 

the procedure of that House) at any time, in the same 

manner, and to the same extent as in the case of any other 

rule of that House. 

‘‘(e) IMPLEMENTATION OF PROPOSAL.— 

‘‘(1) IN GENERAL.—Notwithstanding any other provision of 

law, the Secretary shall, except as provided in paragraph (3), 

implement the recommendations contained in a proposal submitted by the Board or the President to Congress pursuant to 

this section on August 15 of the year in which the proposal is 

so submitted. 

‘‘(2) APPLICATION.— 

‘‘(A) IN GENERAL.—A recommendation described in 

paragraph (1) shall apply as follows: 

‘‘(i) In the case of a recommendation that is a 

change in the payment rate for an item or service 

under Medicare in which payment rates change on a 

fiscal year basis (or a cost reporting period basis that 

relates to a fiscal year), on a calendar year basis (or 

a cost reporting period basis that relates to a calendar 
419 Sec. 3403 PPACA (Consolidated) \1899A SSA 

year), or on a rate year basis (or a cost reporting period basis that relates to a rate year), such recommendation shall apply to items and services furnished on the first day of the first fiscal year, calendar 

year, or rate year (as the case may be) that begins 

after such August 15. 

‘‘(ii) In the case of a recommendation relating to 

payments to plans under parts C and D, such recommendation shall apply to plan years beginning on 

the first day of the first calendar year that begins 

after such August 15. 

‘‘(iii) In the case of any other recommendation, 

such recommendation shall be addressed in the regular regulatory process timeframe and shall apply as 

soon as practicable. 

‘‘(B) INTERIM FINAL RULEMAKING.—The Secretary may 

use interim final rulemaking to implement any recommendation described in paragraph (1). 

‘‘(3) EXCEPTIONS.— ‘‘(A) IN GENERAL.—The Secretary shall not implement 

the recommendations contained in a proposal submitted in 

a proposal year by the Board or the President to Congress 

pursuant to this section if— 

‘‘(i) prior to August 15 of the proposal year, Federal legislation is enacted that includes the following 

provision: ‘This Act supercedes the recommendations 

of the Board contained in the proposal submitted, in 

the year which includes the date of enactment of this 

Act, to Congress under section 1899A of the Social Security Act.’; and 

‘‘(ii) in the case of implementation year 2020 and 

subsequent implementation years, a joint resolution 

described in subsection (f)(1) is enacted not later than 

August 15, 2017. 

‘‘(B) LIMITED ADDITIONAL EXCEPTION.—øAs added by 

section 10320(a)(3)(B)¿ 

‘‘(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 
Sec. 3403\1899A SSA PPACA (Consolidated) 420 

year preceding the proposal year were not required to 

be implemented by reason of this subparagraph. 

‘‘(iii) NO AFFECT ON REQUIREMENT TO SUBMIT PRO- POSALS OR FOR CONGRESSIONAL CONSIDERATION OF

PROPOSALS.—Clause (i) and (ii) shall not affect— 

‘‘(I) the requirement of the Board or the President to submit a proposal to Congress in a proposal year in accordance with the provisions of 

this section; or 

‘‘(II) Congressional consideration of a legislative proposal (described in subsection (c)(3)(B)(iv)) 

contained such a proposal in accordance with subsection (d). 

‘‘(4) NO AFFECT ON AUTHORITY TO IMPLEMENT CERTAIN PRO- VISIONS.—Nothing in paragraph (3) shall be construed to affect 

the authority of the Secretary to implement any recommendation contained in a proposal or advisory report under this section to the extent that the Secretary otherwise has the authority to implement such recommendation administratively. 

‘‘(5) LIMITATION ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or 

otherwise of the implementation by the Secretary under this 

subsection of the recommendations contained in a proposal. 

‘‘(f) JOINT RESOLUTION REQUIRED TO DISCONTINUE THE

BOARD.— 

‘‘(1) IN GENERAL.—For purposes of subsection (e)(3)(B), a 

joint resolution described in this paragraph means only a joint 

resolution— 

‘‘(A) that is introduced in 2017 by not later than February 1 of such year; 

‘‘(B) which does not have a preamble; 

‘‘(C) the title of which is as follows: ‘Joint resolution 

approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under 

section 1899A of the Social Security Act’; and 

‘‘(D) the matter after the resolving clause of which is 

as follows: ‘That Congress approves the discontinuation of 

the process for consideration and automatic implementation of the annual proposal of the Independent Medicare 

Advisory Board under section 1899A of the Social Security 

Act.’. 

‘‘(2) PROCEDURE.— 

‘‘(A) REFERRAL.—A joint resolution described in paragraph (1) shall be referred to the Committee on Ways and 

Means and the Committee on Energy and Commerce of the 

House of Representatives and the Committee on Finance 

of the Senate. 

‘‘(B) DISCHARGE.—In the Senate, if the committee to 

which is referred a joint resolution described in paragraph 

(1) has not reported such joint resolution (or an identical 

joint resolution) at the end of 20 days after the joint resolution described in paragraph (1) is introduced, such committee may be discharged from further consideration of 
421 Sec. 3403 PPACA (Consolidated) \1899A SSA 

such joint resolution upon a petition supported in writing 

by 30 Members of the Senate, and such joint resolution 

shall be placed on the calendar. 

‘‘(C) CONSIDERATION.— ‘‘(i) IN GENERAL.—In the Senate, when the committee to which a joint resolution is referred has reported, or when a committee is discharged (under subparagraph (C)) from further consideration of a joint 

resolution described in paragraph (1), it is at any time 

thereafter in order (even though a previous motion to 

the same effect has been disagreed to) for a motion to 

proceed to the consideration of the joint resolution to 

be made, and all points of order against the joint resolution (and against consideration of the joint resolution) are waived, except for points of order under the 

Congressional Budget act of 1974 or under budget resolutions pursuant to that Act. The motion is not debatable. A motion to reconsider the vote by which the motion is agreed to or disagreed to shall not be in order. 

If a motion to proceed to the consideration of the joint 

resolution is agreed to, the joint resolution shall remain the unfinished business of the Senate until disposed of. 

‘‘(ii) DEBATE LIMITATION.—In the Senate, consideration of the joint resolution, and on all debatable motions and appeals in connection therewith, shall be 

limited to not more than 10 hours, which shall be divided equally between the majority leader and the minority leader, or their designees. A motion further to 

limit debate is in order and not debatable. An amendment to, or a motion to postpone, or a motion to proceed to the consideration of other business, or a motion to recommit the joint resolution is not in order. 

‘‘(iii) PASSAGE.—In the Senate, immediately following the conclusion of the debate on a joint resolution described in paragraph (1), and a single quorum 

call at the conclusion of the debate if requested in accordance with the rules of the Senate, the vote on passage of the joint resolution shall occur. 

‘‘(iv) APPEALS.—Appeals from the decisions of the 

Chair relating to the application of the rules of the 

Senate to the procedure relating to a joint resolution 

described in paragraph (1) shall be decided without 

debate. 

‘‘(D) OTHER HOUSE ACTS FIRST.—If, before the passage 

by 1 House of a joint resolution of that House described in 

paragraph (1), that House receives from the other House 

a joint resolution described in paragraph (1), then the following procedures shall apply: 

‘‘(i) The joint resolution of the other House shall 

not be referred to a committee. 

‘‘(ii) With respect to a joint resolution described in 

paragraph (1) of the House receiving the joint resolution— 
Sec. 3403\1899A SSA PPACA (Consolidated) 422 

‘‘(I) the procedure in that House shall be the 

same as if no joint resolution had been received 

from the other House; but 

‘‘(II) the vote on final passage shall be on the 

joint resolution of the other House. 

‘‘(E) EXCLUDED DAYS.—For purposes of determining 

the period specified in subparagraph (B), there shall be excluded any days either House of Congress is adjourned for 

more than 3 days during a session of Congress. 

‘‘(F) MAJORITY REQUIRED FOR ADOPTION.—A joint resolution considered under this subsection shall require an affirmative vote of three-fifths of the Members, duly chosen 

and sworn, for adoption. 

‘‘(3) TERMINATION.—If a joint resolution described in paragraph (1) is enacted not later than August 15, 2017— 

‘‘(A) the Chief Actuary of the Medicare & Medicaid 

Services shall not— 

‘‘(i) make any determinations under subsection 

(c)(6) after May 1, 2017; or 

‘‘(ii) provide any opinion pursuant to subsection 

(c)(3)(B)(iii) after January 16, 2018; 

‘‘(B) the Board shall not submit any proposals, advisory reports, or advisory recommendations under this section or produce the public report under subsection (n) after 

January 16, 2018; and 

øSubparagraph (B) amended by section 10320(a)(4); section 

10320(c) provides: ‘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).’¿ 

‘‘(C) the Board and the consumer advisory council 

under subsection (k) shall terminate on August 16, 2018. 

‘‘(g) BOARD MEMBERSHIP; TERMS OF OFFICE; CHAIRPERSON; REMOVAL.— 

‘‘(1) MEMBERSHIP.— 

‘‘(A) IN GENERAL.—The Board shall be composed of— 

‘‘(i) 15 members appointed by the President, by 

and with the advice and consent of the Senate; and 

‘‘(ii) the Secretary, the Administrator of the Center for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration, all of whom shall serve ex officio as nonvoting 

members of the Board. 

‘‘(B) QUALIFICATIONS.— 

‘‘(i) IN GENERAL.—The appointed membership of 

the Board shall include individuals with national recognition for their expertise in health finance and economics, actuarial science, health facility management, 

health plans and integrated delivery systems, reimbursement of health facilities, allopathic and osteopathic physicians, and other providers of health services, and other related fields, who provide a mix of different professionals, broad geographic representation, 
423 Sec. 3403 PPACA (Consolidated) \1899A SSA 

and a balance between urban and rural representatives. 

‘‘(ii) INCLUSION.—The appointed membership of 

the Board shall include (but not be limited to) physicians and other health professionals, experts in the 

area of pharmaco-economics or prescription drug benefit programs, employers, third-party payers, individuals skilled in the conduct and interpretation of biomedical, health services, and health economics research and expertise in outcomes and effectiveness research and technology assessment. Such membership 

shall also include representatives of consumers and 

the elderly. 

‘‘(iii) MAJORITY NONPROVIDERS.—Individuals who 

are directly involved in the provision or management 

of the delivery of items and services covered under 

this title shall not constitute a majority of the appointed membership of the Board. 

‘‘(C) ETHICAL DISCLOSURE.—The President shall establish a system for public disclosure by appointed members 

of the Board of financial and other potential conflicts of interest relating to such members. Appointed members of 

the Board shall be treated as officers in the executive 

branch for purposes of applying title I of the Ethics in Government Act of 1978 (Public Law 95–521). 

‘‘(D) CONFLICTS OF INTEREST.—No individual may 

serve as an appointed member if that individual engages 

in any other business, vocation, or employment. 

‘‘(E) CONSULTATION WITH CONGRESS.—In selecting individuals for nominations for appointments to the Board, 

the President shall consult with— 

‘‘(i) the majority leader of the Senate concerning 

the appointment of 3 members; 

‘‘(ii) the Speaker of the House of Representatives 

concerning the appointment of 3 members; 

‘‘(iii) the minority leader of the Senate concerning 

the appointment of 3 members; and 

‘‘(iv) the minority leader of the House of Representatives concerning the appointment of 3 members. 

‘‘(2) TERM OF OFFICE.—Each appointed member shall hold 

office for a term of 6 years except that— 

‘‘(A) a member may not serve more than 2 full consecutive terms (but may be reappointed to 2 full consecutive terms after being appointed to fill a vacancy on the 

Board); 

‘‘(B) a member appointed to fill a vacancy occurring 

prior to the expiration of the term for which that member’s 

predecessor was appointed shall be appointed for the remainder of such term; 

‘‘(C) a member may continue to serve after the expiration of the member’s term until a successor has taken office; and 
Sec. 3403\1899A SSA PPACA (Consolidated) 424 

‘‘(D) of the members first appointed under this section, 

5 shall be appointed for a term of 1 year, 5 shall be appointed for a term of 3 years, and 5 shall be appointed for 

a term of 6 years, the term of each to be designated by the 

President at the time of nomination. 

‘‘(3) CHAIRPERSON.— ‘‘(A) IN GENERAL.—The Chairperson shall be appointed 

by the President, by and with the advice and consent of 

the Senate, from among the members of the Board. 

‘‘(B) DUTIES.—The Chairperson shall be the principal 

executive officer of the Board, and shall exercise all of the 

executive and administrative functions of the Board, including functions of the Board with respect to— 

‘‘(i) the appointment and supervision of personnel 

employed by the Board; 

‘‘(ii) the distribution of business among personnel 

appointed and supervised by the Chairperson and 

among administrative units of the Board; and 

‘‘(iii) the use and expenditure of funds. 

‘‘(C) GOVERNANCE.—In carrying out any of the functions under subparagraph (B), the Chairperson shall be 

governed by the general policies established by the Board 

and by the decisions, findings, and determinations the 

Board shall by law be authorized to make. 

‘‘(D) REQUESTS FOR APPROPRIATIONS.—Requests or estimates for regular, supplemental, or deficiency appropriations on behalf of the Board may not be submitted by the 

Chairperson without the prior approval of a majority vote 

of the Board. 

‘‘(4) REMOVAL.—Any appointed member may be removed 

by the President for neglect of duty or malfeasance in office, 

but for no other cause. 

‘‘(h) VACANCIES; QUORUM; SEAL; VICE CHAIRPERSON; VOTING

ON REPORTS.— 

‘‘(1) VACANCIES.—No vacancy on the Board shall impair 

the right of the remaining members to exercise all the powers 

of the Board. 

‘‘(2) QUORUM.—A majority of the appointed members of the 

Board shall constitute a quorum for the transaction of business, but a lesser number of members may hold hearings. 

‘‘(3) SEAL.—The Board shall have an official seal, of which 

judicial notice shall be taken. 

‘‘(4) VICE CHAIRPERSON.—The Board shall annually elect a 

Vice Chairperson to act in the absence or disability of the 

Chairperson or in case of a vacancy in the office of the Chairperson. 

‘‘(5) VOTING ON PROPOSALS.—Any proposal of the Board 

must be approved by the majority of appointed members 

present. 

‘‘(i) POWERS OF THE BOARD.— 

‘‘(1) HEARINGS.—The Board may hold such hearings, sit 

and act at such times and places, take such testimony, and receive such evidence as the Board considers advisable to carry 

out this section. 
425 Sec. 3403 PPACA (Consolidated) \1899A SSA 

‘‘(2) AUTHORITY TO INFORM RESEARCH PRIORITIES FOR DATA

COLLECTION.—The Board may advise the Secretary on priorities for health services research, particularly as such priorities 

pertain to necessary changes and issues regarding payment reforms under Medicare. 

‘‘(3) OBTAINING OFFICIAL DATA.—The Board may secure directly from any department or agency of the United States information necessary to enable it to carry out this section. Upon 

request of the Chairperson, the head of that department or 

agency shall furnish that information to the Board on an 

agreed upon schedule. 

‘‘(4) POSTAL SERVICES.—The Board may use the United 

States mails in the same manner and under the same conditions as other departments and agencies of the Federal Government. 

‘‘(5) GIFTS.—The Board may accept, use, and dispose of 

gifts or donations of services or property. 

‘‘(6) OFFICES.—The Board shall maintain a principal office 

and such field offices as it determines necessary, and may meet 

and exercise any of its powers at any other place. 

‘‘(j) PERSONNEL MATTERS.— ‘‘(1) COMPENSATION OF MEMBERS AND CHAIRPERSON.—Each 

appointed member, other than the Chairperson, shall be compensated at a rate equal to the annual rate of basic pay prescribed for level III of the Executive Schedule under section 

5315 of title 5, United States Code. The Chairperson shall be 

compensated at a rate equal to the daily equivalent of the annual rate of basic pay prescribed for level II of the Executive 

Schedule under section 5315 of title 5, United States Code. 

‘‘(2) TRAVEL EXPENSES.—The appointed members shall be 

allowed 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 in the performance of services for the Board. 

‘‘(3) STAFF.— 

‘‘(A) IN GENERAL.—The Chairperson may, without regard to the civil service laws and regulations, appoint and 

terminate an executive director and such other additional 

personnel as may be necessary to enable the Board to perform its duties. The employment of an executive director 

shall be subject to confirmation by the Board. 

‘‘(B) COMPENSATION.—The Chairperson may fix the 

compensation of the executive director and other personnel 

without regard to chapter 51 and subchapter III of chapter 

53 of title 5, United States Code, relating to classification 

of positions and General Schedule pay rates, except that 

the rate of pay for the executive director and other personnel may not exceed the rate payable for level V of the 

Executive Schedule under section 5316 of such title. 

‘‘(4) DETAIL OF GOVERNMENT EMPLOYEES.—Any Federal 

Government employee may be detailed to the Board without 

reimbursement, and such detail shall be without interruption 

or loss of civil service status or privilege. 
Sec. 3403\1899A SSA PPACA (Consolidated) 426 

‘‘(5) PROCUREMENT OF TEMPORARY AND INTERMITTENT

SERVICES.—The Chairperson may procure temporary and intermittent services under section 3109(b) of title 5, United States 

Code, at rates for individuals which do not exceed the daily 

equivalent of the annual rate of basic pay prescribed for level 

V of the Executive Schedule under section 5316 of such title. 

‘‘(k) CONSUMER ADVISORY COUNCIL.— ‘‘(1) IN GENERAL.—There is established a consumer advisory council to advise the Board on the impact of payment policies under this title on consumers. 

‘‘(2) MEMBERSHIP.— ‘‘(A) NUMBER AND APPOINTMENT.—The consumer advisory council shall be composed of 10 consumer representatives appointed by the Comptroller General of the United 

States, 1 from among each of the 10 regions established by 

the Secretary as of the date of enactment of this section. 

‘‘(B) QUALIFICATIONS.—The membership of the council 

shall represent the interests of consumers and particular 

communities. 

‘‘(3) DUTIES.—The consumer advisory council shall, subject 

to the call of the Board, meet not less frequently than 2 times 

each year in the District of Columbia. 

‘‘(4) OPEN MEETINGS.—Meetings of the consumer advisory 

council shall be open to the public. 

‘‘(5) ELECTION OF OFFICERS.—Members of the consumer advisory council shall elect their own officers. 

‘‘(6) APPLICATION OF FACA.—The Federal Advisory Committee Act (5 U.S.C. App.) shall apply to the consumer advisory 

council except that section 14 of such Act shall not apply. 

‘‘(l) DEFINITIONS.—In this section: 

‘‘(1) BOARD; CHAIRPERSON; MEMBER.—The terms ‘Board’, 

‘Chairperson’, and ‘Member’ mean the Independent Medicare 

Advisory Board established under subsection (a) and the 

Chairperson and any Member thereof, respectively. 

‘‘(2) MEDICARE.—The term ‘Medicare’ means the program 

established under this title, including parts A, B, C, and D. 

‘‘(3) MEDICARE BENEFICIARY.—The term ‘Medicare beneficiary’ means an individual who is entitled to, or enrolled for, 

benefits under part A or enrolled for benefits under part B. 

‘‘(4) MEDICARE PROGRAM SPENDING.—The term ‘Medicare 

program spending’ means program spending under parts A, B, 

and D net of premiums. 

‘‘(m) FUNDING.— 

‘‘(1) IN GENERAL.—There are appropriated to the Board to 

carry out its duties and functions— 

‘‘(A) for fiscal year 2012, $15,000,000; and 

‘‘(B) for each subsequent fiscal year, the amount appropriated under this paragraph for the previous fiscal 

year increased by the annual percentage increase in the 

Consumer Price Index for All Urban Consumers (all items; 

United States city average) as of June of the previous fiscal year. 

‘‘(2) FROM TRUST FUNDS.—Sixty percent of amounts appropriated under paragraph (1) shall be derived by transfer from 
427 Sec. 3403 PPACA (Consolidated) \1899A SSA 

the Federal Hospital Insurance Trust Fund under section 1817 

and 40 percent of amounts appropriated under such paragraph 

shall be derived by transfer from the Federal Supplementary 

Medical Insurance Trust Fund under section 1841. 

‘‘(n) ANNUAL PUBLIC REPORT.—øAs added by section 

10320(a)(5)¿ 

‘‘(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.—øAs added by section 10320(a)(5)¿ 

‘‘(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). 
Sec. 3403 PPACA (Consolidated) 428 

‘‘(3) AVAILABLE TO PUBLIC.—The Board shall make recommendations submitted to Congress and the President under 

this subsection available to the public.’’. 

(2) LOBBYING COOLING-OFF PERIOD FOR MEMBERS OF THE

INDEPENDENT MEDICARE ADVISORY BOARD.—Section 207(c) of 

title 18, United States Code, is amended by inserting at the 

end the following: 

‘‘(3) MEMBERS OF THE INDEPENDENT MEDICARE ADVISORY

BOARD.— ‘‘(A) IN GENERAL.—Paragraph (1) shall apply to a 

member of the Independent Medicare Advisory Board 

under section 1899A. 

‘‘(B) AGENCIES AND CONGRESS.—For purposes of paragraph (1), the agency in which the individual described in 

subparagraph (A) served shall be considered to be the 

Independent Medicare Advisory Board, the Department of 

Health and Human Services, and the relevant committees 

of jurisdiction of Congress, including the Committee on 

Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee 

on Finance of the Senate.’’. 

(b) GAO STUDY AND REPORT ON DETERMINATION AND IMPLE- MENTATION OF PAYMENT AND COVERAGE POLICIES UNDER THE

MEDICARE PROGRAM.— (1) INITIAL STUDY AND REPORT.— (A) STUDY.—The Comptroller General of the United 

States (in this section referred to as the ‘‘Comptroller General’’) shall conduct a study on changes to payment policies, methodologies, and rates and coverage policies and 

methodologies under the Medicare program under title 

XVIII of the Social Security Act as a result of the recommendations contained in the proposals made by the 

Independent Medicare Advisory Board under section 

1899A of such Act (as added by subsection (a)), including 

an analysis of the effect of such recommendations on— 

(i) Medicare beneficiary access to providers and 

items and services; 

(ii) the affordability of Medicare premiums and 

cost-sharing (including deductibles, coinsurance, and 

copayments); 

(iii) the potential impact of changes on other government or private-sector purchasers and payers of 

care; and 

(iv) quality of patient care, including patient experience, outcomes, and other measures of care. 

(B) REPORT.—Not later than July 1, 2015, the Comptroller General shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General 

determines appropriate. 

(2) SUBSEQUENT STUDIES AND REPORTS.—The Comptroller 

General shall periodically conduct such additional studies and 

submit reports to Congress on changes to Medicare payments 
429 Sec. 3501 PPACA (Consolidated) \933 PHSA 

policies, methodologies, and rates and coverage policies and 

methodologies as the Comptroller General determines appropriate, in consultation with the Committee on Ways and Means 

and the Committee on Energy and Commerce of the House of 

Representatives and the Committee on Finance of the Senate. 

(c) CONFORMING AMENDMENTS.—Section 1805(b) of the Social 

Security Act (42 U.S.C. 1395b–6(b)) is amended— 

(1) by redesignating paragraphs (4) through (8) as paragraphs (5) through (9), respectively; and 

(2) by inserting after paragraph (3) the following: 

‘‘(4) REVIEW AND COMMENT ON THE INDEPENDENT MEDICARE ADVISORY BOARD OR SECRETARIAL PROPOSAL.—If the Independent Medicare Advisory Board (as established under subsection (a) of section 1899A) or the Secretary submits a proposal to the Commission under such section in a year, the 

Commission shall review the proposal and, not later than 

March 1 of that year, submit to the Committee on Ways and 

Means and the Committee on Energy and Commerce of the 

House of Representatives and the Committee on Finance of the 

Senate written comments on such proposal. Such comments 

may include such recommendations as the Commission deems 

appropriate.’’. 

Subtitle F—Health Care Quality 

Improvements 

SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY IMPROVEMENT TECHNICAL ASSISTANCE. 

Part D of title IX of the Public Health Service Act, as amended 

by section 3013, is further amended by adding at the end the following: 

‘‘Subpart II—Health Care Quality Improvement 

Programs 

‘‘SEC. 933. ø42 U.S.C. 299b–33¿ HEALTH CARE DELIVERY SYSTEM RESEARCH. 

‘‘(a) PURPOSE.—The purposes of this section are to— 

‘‘(1) enable the Director to identify, develop, evaluate, disseminate, and provide training in innovative methodologies 

and strategies for quality improvement practices in the delivery of health care services that represent best practices (referred to as ‘best practices’) in health care quality, safety, and 

value; and 

‘‘(2) ensure that the Director is accountable for implementing a model to pursue such research in a collaborative 

manner with other related Federal agencies. 

‘‘(b) GENERAL FUNCTIONS OF THE CENTER.—The Center for 

Quality Improvement and Patient Safety of the Agency for 

Healthcare Research and Quality (referred to in this section as the 

‘Center’), or any other relevant agency or department designated by 

the Director, shall— 
Sec. 3501\933 PHSA PPACA (Consolidated) 430 

‘‘(1) carry out its functions using research from a variety 

of disciplines, which may include epidemiology, health services, 

sociology, psychology, human factors engineering, biostatistics, 

health economics, clinical research, and health informatics; 

‘‘(2) conduct or support activities consistent with the purposes described in subsection (a), and for— 

‘‘(A) best practices for quality improvement practices 

in the delivery of health care services; and 

‘‘(B) that include changes in processes of care and the 

redesign of systems used by providers that will reliably result in intended health outcomes, improve patient safety, 

and reduce medical errors (such as skill development for 

health care providers in team-based health care delivery 

and rapid cycle process improvement) and facilitate adoption of improved workflow; 

‘‘(3) identify health care providers, including health care 

systems, single institutions, and individual providers, that— 

‘‘(A) deliver consistently high-quality, efficient health 

care services (as determined by the Secretary); and 

‘‘(B) employ best practices that are adaptable and scalable to diverse health care settings or effective in improving care across diverse settings; 

‘‘(4) assess research, evidence, and knowledge about what 

strategies and methodologies are most effective in improving 

health care delivery; 

‘‘(5) find ways to translate such information rapidly and effectively into practice, and document the sustainability of those 

improvements; 

‘‘(6) create strategies for quality improvement through the 

development of tools, methodologies, and interventions that 

can successfully reduce variations in the delivery of health 

care; 

‘‘(7) identify, measure, and improve organizational, human, 

or other causative factors, including those related to the culture and system design of a health care organization, that contribute to the success and sustainability of specific quality improvement and patient safety strategies; 

‘‘(8) provide for the development of best practices in the delivery of health care services that— 

‘‘(A) have a high likelihood of success, based on structured review of empirical evidence; 

‘‘(B) are specified with sufficient detail of the individual processes, steps, training, skills, and knowledge required for implementation and incorporation into workflow 

of health care practitioners in a variety of settings; 

‘‘(C) are designed to be readily adapted by health care 

providers in a variety of settings; and 

‘‘(D) where applicable, assist health care providers in 

working with other health care providers across the continuum of care and in engaging patients and their families 

in improving the care and patient health outcomes; 

‘‘(9) provide for the funding of the activities of organizations with recognized expertise and excellence in improving the 

delivery of health care services, including children’s health 
431 Sec. 3501 PPACA (Consolidated) \933 PHSA 

care, by involving multiple disciplines, managers of health care 

entities, broad development and training, patients, caregivers 

and families, and frontline health care workers, including activities for the examination of strategies to share best quality 

improvement practices and to promote excellence in the delivery of health care services; and 

‘‘(10) build capacity at the State and community level to 

lead quality and safety efforts through education, training, and 

mentoring programs to carry out the activities under paragraphs (1) through (9). 

‘‘(c) RESEARCH FUNCTIONS OF CENTER.— ‘‘(1) IN GENERAL.—The Center shall support, such as 

through a contract or other mechanism, research on health 

care delivery system improvement and the development of 

tools to facilitate adoption of best practices that improve the 

quality, safety, and efficiency of health care delivery services. 

Such support may include establishing a Quality Improvement 

Network Research Program for the purpose of testing, scaling, 

and disseminating of interventions to improve quality and efficiency in health care. Recipients of funding under the Program 

may include national, State, multi-State, or multi-site quality 

improvement networks. 

‘‘(2) RESEARCH REQUIREMENTS.—The research conducted 

pursuant to paragraph (1) shall— 

‘‘(A) address the priorities identified by the Secretary 

in the national strategic plan established under section 

399HH; 

‘‘(B) identify areas in which evidence is insufficient to 

identify strategies and methodologies, taking into consideration areas of insufficient evidence identified by the entity 

with a contract under section 1890(a) of the Social Security 

Act in the report required under section 399JJ; 

‘‘(C) address concerns identified by health care institutions and providers and communicated through the Center 

pursuant to subsection (d); 

‘‘(D) reduce preventable morbidity, mortality, and associated costs of morbidity and mortality by building capacity for patient safety research; 

‘‘(E) support the discovery of processes for the reliable, 

safe, efficient, and responsive delivery of health care, taking into account discoveries from clinical research and 

comparative effectiveness research; 

‘‘(F) allow communication of research findings and 

translate evidence into practice recommendations that are 

adaptable to a variety of settings, and which, as soon as 

practicable after the establishment of the Center, shall include— 

‘‘(i) the implementation of a national application of 

Intensive Care Unit improvement projects relating to 

the adult (including geriatric), pediatric, and neonatal 

patient populations; 

‘‘(ii) practical methods for addressing health care 

associated infections, including Methicillin-Resistant 

Staphylococcus Aureus and Vancomycin-Resistant 
Sec. 3501\933 PHSA PPACA (Consolidated) 432 

Entercoccus infections and other emerging infections; 

and 

‘‘(iii) practical methods for reducing preventable 

hospital admissions and readmissions; 

‘‘(G) expand demonstration projects for improving the 

quality of children’s health care and the use of health information technology, such as through Pediatric Quality 

Improvement Collaboratives and Learning Networks, consistent with provisions of section 1139A of the Social Security Act for assessing and improving quality, where applicable; 

‘‘(H) identify and mitigate hazards by— 

‘‘(i) analyzing events reported to patient safety reporting systems and patient safety organizations; and 

‘‘(ii) using the results of such analyses to develop 

scientific methods of response to such events; 

‘‘(I) include the conduct of systematic reviews of existing practices that improve the quality, safety, and efficiency of health care delivery, as well as new research on 

improving such practices; and 

‘‘(J) include the examination of how to measure and 

evaluate the progress of quality and patient safety activities. 

‘‘(d) DISSEMINATION OF RESEARCH FINDINGS.— ‘‘(1) PUBLIC AVAILABILITY.—The Director shall make the research findings of the Center available to the public through 

multiple media and appropriate formats to reflect the varying 

needs of health care providers and consumers and diverse levels of health literacy. 

‘‘(2) LINKAGE TO HEALTH INFORMATION TECHNOLOGY.—The 

Secretary shall ensure that research findings and results generated by the Center are shared with the Office of the National 

Coordinator of Health Information Technology and used to inform the activities of the health information technology extension program under section 3012, as well as any relevant 

standards, certification criteria, or implementation specifications. 

‘‘(e) PRIORITIZATION.—The Director shall identify and regularly 

update a list of processes or systems on which to focus research 

and dissemination activities of the Center, taking into account— 

‘‘(1) the cost to Federal health programs; 

‘‘(2) consumer assessment of health care experience; 

‘‘(3) provider assessment of such processes or systems and 

opportunities to minimize distress and injury to the health 

care workforce; 

‘‘(4) the potential impact of such processes or systems on 

health status and function of patients, including vulnerable 

populations including children; 

‘‘(5) the areas of insufficient evidence identified under subsection (c)(2)(B); and 

‘‘(6) the evolution of meaningful use of health information 

technology, as defined in section 3000. 

‘‘(f) COORDINATION.—The Center shall coordinate its activities 

with activities conducted by the Center for Medicare and Medicaid 
433 Sec. 3503 PPACA (Consolidated) \934 PHSA 

Innovation established under section 1115A of the Social Security 

Act. 

‘‘(g) FUNDING.—There is authorized to be appropriated to carry out this section $20,000,000 for fiscal years 2010 through 2014. 

‘‘SEC. 934. ø42 U.S.C. 299b–34¿ QUALITY IMPROVEMENT TECHNICAL ASSISTANCE AND IMPLEMENTATION. 

‘‘(a) IN GENERAL.—The Director, through the Center for Quality Improvement and Patient Safety of the Agency for Healthcare 

Research and Quality (referred to in this section as the ‘Center’), 

shall award— 

‘‘(1) technical assistance grants or contracts to eligible entities to provide technical support to institutions that deliver 

health care and health care providers (including rural and 

urban providers of services and suppliers with limited infrastructure and financial resources to implement and support 

quality improvement activities, providers of services and suppliers with poor performance scores, and providers of services 

and suppliers for which there are disparities in care among 

subgroups of patients) so that such institutions and providers 

understand, adapt, and implement the models and practices 

identified in the research conducted by the Center, including 

the Quality Improvement Networks Research Program; and 

‘‘(2) implementation grants or contracts to eligible entities 

to implement the models and practices described under paragraph (1). 

‘‘(b) ELIGIBLE ENTITIES.— ‘‘(1) TECHNICAL ASSISTANCE AWARD.—To be eligible to receive a technical assistance grant or contract under subsection 

(a)(1), an entity— 

‘‘(A) may be a health care provider, health care provider association, professional society, health care worker 

organization, Indian health organization, quality improvement organization, patient safety organization, local quality improvement collaborative, the Joint Commission, academic health center, university, physician-based research 

network, primary care extension program established 

under section 399V–1, a Federal Indian Health Service 

program or a health program operated by an Indian tribe 

(as defined in section 4 of the Indian Health Care Improvement Act), or any other entity identified by the Secretary; 

and øAs revised by section 10501(f)(2)¿ 

‘‘(B) shall have demonstrated expertise in providing information and technical support and assistance to health 

care providers regarding quality improvement. 

‘‘(2) IMPLEMENTATION AWARD.—To be eligible to receive an 

implementation grant or contract under subsection (a)(2), an 

entity— 

‘‘(A) may be a hospital or other health care provider or 

consortium or providers, as determined by the Secretary; 

and 

‘‘(B) shall have demonstrated expertise in providing information and technical support and assistance to health 

care providers regarding quality improvement. 

‘‘(c) APPLICATION.— 
Sec. 3503\934 PHSA PPACA (Consolidated) 434 

‘‘(1) TECHNICAL ASSISTANCE AWARD.—To receive a technical 

assistance grant or contract under subsection (a)(1), an eligible 

entity shall submit an application to the Secretary at such 

time, in such manner, and containing— 

‘‘(A) a plan for a sustainable business model that may 

include a system of— 

‘‘(i) charging fees to institutions and providers 

that receive technical support from the entity; and 

‘‘(ii) reducing or eliminating such fees for such institutions and providers that serve low-income populations; and 

‘‘(B) such other information as the Director may require. 

‘‘(2) IMPLEMENTATION AWARD.—To receive a grant or contract under subsection (a)(2), an eligible entity shall submit an 

application to the Secretary at such time, in such manner, and 

containing— 

‘‘(A) a plan for implementation of a model or practice 

identified in the research conducted by the Center including— 

‘‘(i) financial cost, staffing requirements, and 

timeline for implementation; and 

‘‘(ii) pre- and projected post-implementation quality measure performance data in targeted improvement areas identified by the Secretary; and 

‘‘(B) such other information as the Director may require. 

‘‘(d) MATCHING FUNDS.—The Director 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. 

‘‘(e) EVALUATION.— 

‘‘(1) IN GENERAL.—The Director shall evaluate the performance of each entity that receives a grant or contract under this 

section. The evaluation of an entity shall include a study of— 

‘‘(A) the success of such entity in achieving the implementation, by the health care institutions and providers 

assisted by such entity, of the models and practices identified in the research conducted by the Center under section 

933; 

‘‘(B) the perception of the health care institutions and 

providers assisted by such entity regarding the value of 

the entity; and 

‘‘(C) where practicable, better patient health outcomes 

and lower cost resulting from the assistance provided by 

such entity. 

‘‘(2) EFFECT OF EVALUATION.—Based on the outcome of the 

evaluation of the entity under paragraph (1), the Director shall 
435 Sec. 3502 PPACA (Consolidated) 

determine whether to renew a grant or contract with such entity under this section. 

‘‘(f) COORDINATION.—The entities that receive a grant or contract under this section shall coordinate with health information 

technology regional extension centers under section 3012(c) and the 

primary care extension program established under section 399V–1 

regarding the dissemination of quality improvement, system delivery reform, and best practices information.øAs revised by section 

10501(f)(2)¿’’. 

SEC. 3502. ø42 U.S.C. 256a–1¿ ESTABLISHING COMMUNITY HEALTH 

TEAMS TO SUPPORT THE PATIENT-CENTERED MEDICAL 

HOME. 

(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’) shall establish 

a program to provide grants to or enter into contracts with eligible 

entities to establish community-based interdisciplinary, interprofessional teams (referred to in this section as ‘‘health teams’’) to support primary care practices, including obstetrics and gynecology 

practices, within the hospital service areas served by the eligible 

entities. Grants or contracts shall be used to— 

(1) establish health teams to provide support services to 

primary care providers; and 

(2) provide capitated payments to primary care providers 

as determined by the Secretary. 

(b) ELIGIBLE ENTITIES.—To be eligible to receive a grant or 

contract under subsection (a), an entity shall— 

(1)(A) be a State or State-designated entity; or 

(B) be an Indian tribe or tribal organization, as defined in 

section 4 of the Indian Health Care Improvement Act; 

(2) submit a plan for achieving long-term financial sustainability within 3 years; 

(3) submit a plan for incorporating prevention initiatives 

and patient education and care management resources into the 

delivery of health care that is integrated with communitybased prevention and treatment resources, where available; 

(4) ensure that the health team established by the entity 

includes an interdisciplinary, interprofessional team of health 

care providers, as determined by the Secretary; such team may 

include medical specialists, nurses, pharmacists, nutritionists, 

dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians’ assistants; 

(5) agree to provide services to eligible individuals with 

chronic conditions, as described in section 1945 of the Social 

Security Act (as added by section 2703), in accordance with the 

payment methodology established under subsection (c) of such 

section; and 

(6) submit to the Secretary an application at such time, in 

such manner, and containing such information as the Secretary may require. 

(c) REQUIREMENTS FOR HEALTH TEAMS.—A health team established pursuant to a grant or contract under subsection (a) shall— 
Sec. 3502 PPACA (Consolidated) 436 

(1) establish contractual agreements with primary care 

providers to provide support services; 

(2) support patient-centered medical homes, defined as a 

mode of care that includes— 

(A) personal physicians or other primary care providers; øAs revised by section 10321¿ 

(B) whole person orientation; 

(C) coordinated and integrated care; 

(D) safe and high-quality care through evidence-informed medicine, appropriate use of health information 

technology, and continuous quality improvements; 

(E) expanded access to care; and 

(F) payment that recognizes added value from additional components of patient-centered care; 

(3) collaborate with local primary care providers and existing State and community based resources to coordinate disease 

prevention, chronic disease management, transitioning between health care providers and settings and case management for patients, including children, with priority given to 

those amenable to prevention and with chronic diseases or conditions identified by the Secretary; 

(4) in collaboration with local health care providers, develop and implement interdisciplinary, interprofessional care 

plans that integrate clinical and community preventive and 

health promotion services for patients, including children, with 

a priority given to those amenable to prevention and with 

chronic diseases or conditions identified by the Secretary; 

(5) incorporate health care providers, patients, caregivers, 

and authorized representatives in program design and oversight; 

(6) provide support necessary for local primary care providers to— 

(A) coordinate and provide access to high-quality 

health care services; 

(B) coordinate and provide access to preventive and 

health promotion services; 

(C) provide access to appropriate specialty care and inpatient services; 

(D) provide quality-driven, cost-effective, culturally appropriate, and patient- and family-centered health care; 

(E) provide access to pharmacist-delivered medication 

management services, including medication reconciliation; 

(F) provide coordination of the appropriate use of complementary and alternative (CAM) services to those who 

request such services; 

(G) promote effective strategies for treatment planning, monitoring health outcomes and resource use, sharing information, treatment decision support, and organizing care to avoid duplication of service and other medical management approaches intended to improve quality 

and value of health care services; 

(H) provide local access to the continuum of health 

care services in the most appropriate setting, including access to individuals that implement the care plans of pa-
437 Sec. 3502 PPACA (Consolidated) 

tients and coordinate care, such as integrative health care 

practitioners; 

(I) collect and report data that permits evaluation of 

the success of the collaborative effort on patient outcomes, 

including collection of data on patient experience of care, 

and identification of areas for improvement; and 

(J) establish a coordinated system of early identification and referral for children at risk for developmental or 

behavioral problems such as through the use of infolines, 

health information technology, or other means as determined by the Secretary; 

(7) provide 24-hour care management and support during 

transitions in care settings including— 

(A) a transitional care program that provides onsite 

visits from the care coordinator, assists with the development of discharge plans and medication reconciliation 

upon admission to and discharge from the hospitals, nursing home, or other institution setting; 

(B) discharge planning and counseling support to providers, patients, caregivers, and authorized representatives; 

(C) assuring that post-discharge care plans include 

medication management, as appropriate; 

(D) referrals for mental and behavioral health services, which may include the use of infolines; and 

(E) transitional health care needs from adolescence to 

adulthood; 

(8) serve as a liaison to community prevention and treatment programs; 

(9) demonstrate a capacity to implement and maintain 

health information technology that meets the requirements of 

certified EHR technology (as defined in section 3000 of the 

Public Health Service Act (42 U.S.C. 300jj)) to facilitate coordination among members of the applicable care team and affiliated primary care practices; and 

(10) where applicable, report to the Secretary information 

on quality measures used under section 399JJ of the Public 

Health Service Act. 

(d) REQUIREMENT FOR PRIMARY CARE PROVIDERS.—A provider 

who contracts with a care team shall— 

(1) provide a care plan to the care team for each patient 

participant; 

(2) provide access to participant health records; and 

(3) meet regularly with the care team to ensure integration 

of care. 

(e) REPORTING TO SECRETARY.—An entity that receives a grant 

or contract under subsection (a) shall submit to the Secretary a report that describes and evaluates, as requested by the Secretary, 

the activities carried out by the entity under subsection (c). 

(f) DEFINITION OF PRIMARY CARE.—In this section, the term 

‘‘primary care’’ means the provision of integrated, accessible health 

care services by clinicians who are accountable for addressing a 

large majority of personal health care needs, developing a sus-
Sec. 3503 PPACA (Consolidated) 438 

tained partnership with patients, and practicing in the context of 

family and community. 

SEC. 3503. MEDICATION MANAGEMENT SERVICES IN TREATMENT OF 

CHRONIC DISEASE. 

Title IX of the Public Health Service Act (42 U.S.C. 299 et 

seq.), as amended by section 3501, is further amended by inserting 

after section 934 the following: 

‘‘SEC. 935. ø42 U.S.C. 299b–35¿ GRANTS OR CONTRACTS TO IMPLEMENT 

MEDICATION MANAGEMENT SERVICES IN TREATMENT OF 

CHRONIC DISEASES. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Patient 

Safety Research Center established in section 933 (referred to in 

this section as the ‘Center’), shall establish a program to provide 

grants or contracts to eligible entities to implement medication 

management (referred to in this section as ‘MTM’) services provided by licensed pharmacists, as a collaborative, multidisciplinary, 

inter-professional approach to the treatment of chronic diseases for 

targeted individuals, to improve the quality of care and reduce 

overall cost in the treatment of such diseases. The Secretary shall 

commence the program under this section not later than May 1, 

2010. 

‘‘(b) ELIGIBLE ENTITIES.—To be eligible to receive a grant or 

contract under subsection (a), an entity shall— 

‘‘(1) provide a setting appropriate for MTM services, as recommended by the experts described in subsection (e); 

‘‘(2) submit to the Secretary a plan for achieving long-term 

financial sustainability; 

‘‘(3) where applicable, submit a plan for coordinating MTM 

services through local community health teams established in 

section 3502 of the Patient Protection and Affordable Care Act 

or in collaboration with primary care extension programs established in section 399V–1; øAs revised by section 10501(f)(3)¿ 

‘‘(4) submit a plan for meeting the requirements under 

subsection (c); and 

‘‘(5) submit to the Secretary such other information as the 

Secretary may require. 

‘‘(c) MTM SERVICES TO TARGETED INDIVIDUALS.—The MTM 

services provided with the assistance of a grant or contract awarded under subsection (a) shall, as allowed by State law including applicable collaborative pharmacy practice agreements, include— 

‘‘(1) performing or obtaining necessary assessments of the 

health and functional status of each patient receiving such 

MTM services; 

‘‘(2) formulating a medication treatment plan according to 

therapeutic goals agreed upon by the prescriber and the patient or caregiver or authorized representative of the patient; 

‘‘(3) selecting, initiating, modifying, recommending changes 

to, or administering medication therapy; 

‘‘(4) monitoring, which may include access to, ordering, or 

performing laboratory assessments, and evaluating the response of the patient to therapy, including safety and effectiveness; 

‘‘(5) performing an initial comprehensive medication review 

to identify, resolve, and prevent medication-related problems, 
439 Sec. 3503 PPACA (Consolidated) \935 PHSA 

including adverse drug events, quarterly targeted medication 

reviews for ongoing monitoring, and additional followup interventions on a schedule developed collaboratively with the prescriber; 

‘‘(6) documenting the care delivered and communicating essential information about such care, including a summary of 

the medication review, and the recommendations of the pharmacist to other appropriate health care providers of the patient 

in a timely fashion; 

‘‘(7) providing education and training designed to enhance 

the understanding and appropriate use of the medications by 

the patient, caregiver, and other authorized representative; 

‘‘(8) providing information, support services, and resources 

and strategies designed to enhance patient adherence with 

therapeutic regimens; 

‘‘(9) coordinating and integrating MTM services within the 

broader health care management services provided to the patient; and 

‘‘(10) such other patient care services allowed under pharmacist scopes of practice in use in other Federal programs that 

have implemented MTM services. 

‘‘(d) TARGETED INDIVIDUALS.—MTM services provided by licensed pharmacists under a grant or contract awarded under subsection (a) shall be offered to targeted individuals who— 

‘‘(1) take 4 or more prescribed medications (including overthe-counter medications and dietary supplements); 

‘‘(2) take any ‘high risk’ medications; 

‘‘(3) have 2 or more chronic diseases, as identified by the 

Secretary; or 

‘‘(4) have undergone a transition of care, or other factors, 

as determined by the Secretary, that are likely to create a high 

risk of medication-related problems. 

‘‘(e) CONSULTATION WITH EXPERTS.—In designing and implementing MTM services provided under grants or contracts awarded 

under subsection (a), the Secretary shall consult with Federal, 

State, private, public-private, and academic entities, pharmacy and 

pharmacist organizations, health care organizations, consumer advocates, chronic disease groups, and other stakeholders involved 

with the research, dissemination, and implementation of pharmacist-delivered MTM services, as the Secretary determines appropriate. The Secretary, in collaboration with this group, shall determine whether it is possible to incorporate rapid cycle process improvement concepts in use in other Federal programs that have implemented MTM services. 

‘‘(f) REPORTING TO THE SECRETARY.—An entity that receives a 

grant or contract under subsection (a) shall submit to the Secretary 

a report that describes and evaluates, as requested by the Secretary, the activities carried out under subsection (c), including 

quality measures endorsed by the entity with a contract under section 1890 of the Social Security Act, as determined by the Secretary. 

‘‘(g) EVALUATION AND REPORT.—The Secretary shall submit to 

the relevant committees of Congress a report which shall— 
Sec. 3504 PPACA (Consolidated) 440 

‘‘(1) assess the clinical effectiveness of pharmacist-provided 

services under the MTM services program, as compared to 

usual care, including an evaluation of whether enrollees maintained better health with fewer hospitalizations and emergency 

room visits than similar patients not enrolled in the program; 

‘‘(2) assess changes in overall health care resource use by 

targeted individuals; 

‘‘(3) assess patient and prescriber satisfaction with MTM 

services; 

‘‘(4) assess the impact of patient-cost sharing requirements 

on medication adherence and recommendations for modifications; 

‘‘(5) identify and evaluate other factors that may impact 

clinical and economic outcomes, including demographic characteristics, clinical characteristics, and health services use of the 

patient, as well as characteristics of the regimen, pharmacy 

benefit, and MTM services provided; and 

‘‘(6) evaluate the extent to which participating pharmacists 

who maintain a dispensing role have a conflict of interest in 

the provision of MTM services, and if such conflict is found, 

provide recommendations on how such a conflict might be appropriately addressed. 

‘‘(h) GRANTS OR CONTRACTS TO FUND DEVELOPMENT OF PERFORMANCE MEASURES.—The Secretary may, through the quality 

measure development program under section 931 of the Public 

Health Service Act, award grants or contracts to eligible entities for 

the purpose of funding the development of performance measures 

that assess the use and effectiveness of medication therapy management services.’’. 

SEC. 3504. DESIGN AND IMPLEMENTATION OF REGIONALIZED SYSTEMS FOR EMERGENCY CARE. 

(a) IN GENERAL.—Title XII of the Public Health Service Act (42 

U.S.C. 300d et seq.) is amended— 

(1) in section 1203— 

(A) in the section heading, by inserting ‘‘FOR TRAUMA SYSTEMS’’ after ‘‘GRANTS’’; and 

(B) in subsection (a), by striking ‘‘Administrator of the 

Health Resources and Services Administration’’ and inserting ‘‘Assistant Secretary for Preparedness and Response’’; 

(2) by inserting after section 1203 the following: 

‘‘SEC. 1204. ø42 U.S.C. 300d–6¿ COMPETITIVE GRANTS FOR REGIONALIZED SYSTEMS FOR EMERGENCY CARE RESPONSE. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Assistant 

Secretary for Preparedness and Response, shall award not fewer 

than 4 multiyear contracts or competitive grants to eligible entities 

to support pilot projects that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable 

emergency care and trauma systems. 

‘‘(b) ELIGIBLE ENTITY; REGION.—In this section: 

‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means— 

‘‘(A) a State or a partnership of 1 or more States and 

1 or more local governments; or 
441 Sec. 3504 PPACA (Consolidated) \1204 PHSA 

‘‘(B) an Indian tribe (as defined in section 4 of the Indian Health Care Improvement Act) or a partnership of 1 

or more Indian tribes. 

‘‘(2) REGION.—The term ‘region’ means an area within a 

State, an area that lies within multiple States, or a similar 

area (such as a multicounty area), as determined by the Secretary. 

‘‘(3) EMERGENCY SERVICES.—The term ‘emergency services’ 

includes acute, prehospital, and trauma care. 

‘‘(c) PILOT PROJECTS.—The Secretary shall award a contract or 

grant under subsection (a) to an eligible entity that proposes a pilot 

project to design, implement, and evaluate an emergency medical 

and trauma system that— 

‘‘(1) coordinates with public health and safety services, 

emergency medical services, medical facilities, trauma centers, 

and other entities in a region to develop an approach to emergency medical and trauma system access throughout the region, including 9–1–1 Public Safety Answering Points and 

emergency medical dispatch; 

‘‘(2) includes a mechanism, such as a regional medical direction or transport communications system, that operates 

throughout the region to ensure that the patient is taken to 

the medically appropriate facility (whether an initial facility or 

a higher-level facility) in a timely fashion; 

‘‘(3) allows for the tracking of prehospital and hospital resources, including inpatient bed capacity, emergency department capacity, trauma center capacity, on-call specialist coverage, ambulance diversion status, and the coordination of 

such tracking with regional communications and hospital destination decisions; and 

‘‘(4) includes a consistent region-wide prehospital, hospital, 

and interfacility data management system that— 

‘‘(A) submits data to the National EMS Information 

System, the National Trauma Data Bank, and others; 

‘‘(B) reports data to appropriate Federal and State 

databanks and registries; and 

‘‘(C) contains information sufficient to evaluate key 

elements of prehospital care, hospital destination decisions, including initial hospital and interfacility decisions, 

and relevant health outcomes of hospital care. 

‘‘(d) APPLICATION.— 

‘‘(1) IN GENERAL.—An eligible entity that seeks a contract 

or grant described in subsection (a) shall submit to the Secretary an application at such time and in such manner as the 

Secretary may require. 

‘‘(2) APPLICATION INFORMATION.—Each application shall include— 

‘‘(A) an assurance from the eligible entity that the proposed system— 

‘‘(i) has been coordinated with the applicable State 

Office of Emergency Medical Services (or equivalent 

State office); 
Sec. 3504\1204 PHSA PPACA (Consolidated) 442 

‘‘(ii) includes consistent indirect and direct medical 

oversight of prehospital, hospital, and interfacility 

transport throughout the region; 

‘‘(iii) coordinates prehospital treatment and triage, 

hospital destination, and interfacility transport 

throughout the region; 

‘‘(iv) includes a categorization or designation system for special medical facilities throughout the region 

that is integrated with transport and destination protocols; 

‘‘(v) includes a regional medical direction, patient 

tracking, and resource allocation system that supports 

day-to-day emergency care and surge capacity and is 

integrated with other components of the national and 

State emergency preparedness system; and 

‘‘(vi) addresses pediatric concerns related to integration, planning, preparedness, and coordination of 

emergency medical services for infants, children and 

adolescents; and 

‘‘(B) such other information as the Secretary may require. 

‘‘(e) REQUIREMENT OF MATCHING FUNDS.— 

‘‘(1) IN GENERAL.—The Secretary may not make a grant 

under this section unless the State (or consortia of States) involved agrees, with respect to the costs to be incurred by the 

State (or consortia) in carrying out the purpose for which such 

grant was made, to make available non-Federal contributions 

(in cash or in kind under paragraph (2)) toward such costs in 

an amount equal to not less than $1 for each $3 of Federal 

funds provided in the grant. Such contributions may be made 

directly or through donations from public or private entities. 

‘‘(2) NON-FEDERAL CONTRIBUTIONS.—Non-Federal contributions required in paragraph (1) may be in cash or in kind, fairly evaluated, including equipment or services (and excluding 

indirect or overhead costs). Amounts provided by the Federal 

Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included 

in determining the amount of such non-Federal contributions. 

‘‘(f) PRIORITY.—The Secretary shall give priority for the award 

of the contracts or grants described in subsection (a) to any eligible 

entity that serves a population in a medically underserved area (as 

defined in section 330(b)(3)). 

‘‘(g) REPORT.—Not later than 90 days after the completion of 

a pilot project under subsection (a), the recipient of such contract 

or grant described in shall submit to the Secretary a report containing the results of an evaluation of the program, including an 

identification of— 

‘‘(1) the impact of the regional, accountable emergency care 

and trauma system on patient health outcomes for various critical care categories, such as trauma, stroke, cardiac emergencies, neurological emergencies, and pediatric emergencies; 

‘‘(2) the system characteristics that contribute to the effectiveness and efficiency of the program (or lack thereof); 
443 Sec. 3504 PPACA (Consolidated) \498D PHSA 

‘‘(3) methods of assuring the long-term financial sustainability of the emergency care and trauma system; 

‘‘(4) the State and local legislation necessary to implement 

and to maintain the system; 

‘‘(5) the barriers to developing regionalized, accountable 

emergency care and trauma systems, as well as the methods 

to overcome such barriers; and 

‘‘(6) recommendations on the utilization of available funding for future regionalization efforts. 

‘‘(h) DISSEMINATION OF FINDINGS.—The Secretary shall, as appropriate, disseminate to the public and to the appropriate Committees of the Congress, the information contained in a report 

made under subsection (g).’’; and 

(3) in section 1232— 

(A) in subsection (a), by striking ‘‘appropriated’’ and 

all that follows through the period at the end and inserting 

‘‘appropriated $24,000,000 for each of fiscal years 2010 

through 2014.’’; and 

(B) by inserting after subsection (c) the following: 

‘‘(d) AUTHORITY.—For the purpose of carrying out parts A 

through C, beginning on the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall transfer authority in administering grants and related authorities under such 

parts from the Administrator of the Health Resources and Services 

Administration to the Assistant Secretary for Preparedness and Response.’’. 

(b) SUPPORT FOR EMERGENCY MEDICINE RESEARCH.—Part H of 

title IV of the Public Health Service Act (42 U.S.C. 289 et seq.) is 

amended by inserting after the section 498C the following: 

‘‘SEC. 498D. ø42 U.S.C. 289g–4¿ SUPPORT FOR EMERGENCY MEDICINE 

RESEARCH. 

‘‘(a) EMERGENCY MEDICAL RESEARCH.—The Secretary shall 

support Federal programs administered by the National Institutes 

of Health, the Agency for Healthcare Research and Quality, the 

Health Resources and Services Administration, the Centers for Disease Control and Prevention, and other agencies involved in improving the emergency care system to expand and accelerate research in emergency medical care systems and emergency medicine, including— 

‘‘(1) the basic science of emergency medicine; 

‘‘(2) the model of service delivery and the components of 

such models that contribute to enhanced patient health outcomes; 

‘‘(3) the translation of basic scientific research into improved practice; and 

‘‘(4) the development of timely and efficient delivery of 

health services. 

‘‘(b) PEDIATRIC EMERGENCY MEDICAL RESEARCH.—The Secretary shall support Federal programs administered by the National Institutes of Health, the Agency for Healthcare Research and 

Quality, the Health Resources and Services Administration, the 

Centers for Disease Control and Prevention, and other agencies to 

coordinate and expand research in pediatric emergency medical 

care systems and pediatric emergency medicine, including— 
Sec. 3505 PPACA (Consolidated) 444 

‘‘(1) an examination of the gaps and opportunities in pediatric emergency care research and a strategy for the optimal 

organization and funding of such research; 

‘‘(2) the role of pediatric emergency services as an integrated component of the overall health system; 

‘‘(3) system-wide pediatric emergency care planning, preparedness, coordination, and funding; 

‘‘(4) pediatric training in professional education; and 

‘‘(5) research in pediatric emergency care, specifically on 

the efficacy, safety, and health outcomes of medications used 

for infants, children, and adolescents in emergency care settings in order to improve patient safety. 

‘‘(c) IMPACT RESEARCH.—The Secretary shall support research 

to determine the estimated economic impact of, and savings that 

result from, the implementation of coordinated emergency care systems. 

‘‘(d) 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 2010 through 2014.’’. 

SEC. 3505. TRAUMA CARE CENTERS AND SERVICE AVAILABILITY. 

(a) TRAUMA CARE CENTERS.— 

(1) GRANTS FOR TRAUMA CARE CENTERS.—Section 1241 of 

the Public Health Service Act (42 U.S.C. 300d–41) is amended 

by striking subsections (a) and (b) and inserting the following: 

‘‘(a) IN GENERAL.—The Secretary shall establish 3 programs to 

award grants to qualified public, nonprofit Indian Health Service, 

Indian tribal, and urban Indian trauma centers— 

‘‘(1) to assist in defraying substantial uncompensated care 

costs; 

‘‘(2) to further the core missions of such trauma centers, 

including by addressing costs associated with patient stabilization and transfer, trauma education and outreach, coordination 

with local and regional trauma systems, essential personnel 

and other fixed costs, and expenses associated with employee 

and non-employee physician services; and 

‘‘(3) to provide emergency relief to ensure the continued 

and future availability of trauma services. 

‘‘(b) MINIMUM QUALIFICATIONS OF TRAUMA CENTERS.— 

‘‘(1) PARTICIPATION IN TRAUMA CARE SYSTEM OPERATING

UNDER CERTAIN PROFESSIONAL GUIDELINES.—Except as provided in paragraph (2), the Secretary may not award a grant 

to a trauma center under subsection (a) unless the trauma center is a participant in a trauma system that substantially complies with section 1213. 

‘‘(2) EXEMPTION.—Paragraph (1) shall not apply to trauma 

centers that are located in States with no existing trauma care 

system. 

‘‘(3) QUALIFICATION FOR SUBSTANTIAL UNCOMPENSATED

CARE COSTS.—The Secretary shall award substantial uncompensated care grants under subsection (a)(1) only to trauma 

centers meeting at least 1 of the criteria in 1 of the following 

3 categories: 
445 Sec. 3505 PPACA (Consolidated) 

‘‘(A) CATEGORY A.—The criteria for category A are as 

follows: 

‘‘(i) At least 40 percent of the visits in the emergency department of the hospital in which the trauma 

center is located were charity or self-pay patients. 

‘‘(ii) At least 50 percent of the visits in such emergency department were Medicaid (under title XIX of 

the Social Security Act (42 U.S.C. 1396 et seq.)) and 

charity and self-pay patients combined. 

‘‘(B) CATEGORY B.—The criteria for category B are as 

follows: 

‘‘(i) At least 35 percent of the visits in the emergency department were charity or self-pay patients. 

‘‘(ii) At least 50 percent of the visits in the emergency department were Medicaid and charity and selfpay patients combined. 

‘‘(C) CATEGORY C.—The criteria for category C are as 

follows: 

‘‘(i) At least 20 percent of the visits in the emergency department were charity or self-pay patients. 

‘‘(ii) At least 30 percent of the visits in the emergency department were Medicaid and charity and selfpay patients combined. 

‘‘(4) TRAUMA CENTERS IN 1115 WAIVER STATES.—Notwithstanding paragraph (3), the Secretary may award a substantial 

uncompensated care grant to a trauma center under subsection 

(a)(1) if the trauma center qualifies for funds under a Low Income Pool or Safety Net Care Pool established through a waiver approved under section 1115 of the Social Security Act (42 

U.S.C. 1315). 

‘‘(5) DESIGNATION.—The Secretary may not award a grant 

to a trauma center unless such trauma center is verified by the 

American College of Surgeons or designated by an equivalent 

State or local agency. 

‘‘(c) ADDITIONAL REQUIREMENTS.—The Secretary may not 

award a grant to a trauma center under subsection (a)(1) unless 

such trauma center— 

‘‘(1) submits to the Secretary a plan satisfactory to the Secretary that demonstrates a continued commitment to serving 

trauma patients regardless of their ability to pay; and 

‘‘(2) has policies in place to assist patients who cannot pay 

for part or all of the care they receive, including a sliding fee 

scale, and to ensure fair billing and collection practices.’’. 

(2) CONSIDERATIONS IN MAKING GRANTS.—Section 1242 of 

the Public Health Service Act (42 U.S.C. 300d–42) is amended 

by striking subsections (a) and (b) and inserting the following: 

‘‘(a) SUBSTANTIAL UNCOMPENSATED CARE AWARDS.— 

‘‘(1) IN GENERAL.—The Secretary shall establish an award 

basis for each eligible trauma center for grants under section 

1241(a)(1) according to the percentage described in paragraph 

(2), subject to the requirements of section 1241(b)(3). 

‘‘(2) PERCENTAGES.—The applicable percentages are as follows: 
Sec. 3505 PPACA (Consolidated) 446 

‘‘(A) With respect to a category A trauma center, 100 

percent of the uncompensated care costs. 

‘‘(B) With respect to a category B trauma center, not 

more than 75 percent of the uncompensated care costs. 

‘‘(C) With respect to a category C trauma center, not 

more than 50 percent of the uncompensated care costs. 

‘‘(b) CORE MISSION AWARDS.— ‘‘(1) IN GENERAL.—In awarding grants under section 

1241(a)(2), the Secretary shall— 

‘‘(A) reserve 25 percent of the amount allocated for 

core mission awards for Level III and Level IV trauma 

centers; and 

‘‘(B) reserve 25 percent of the amount allocated for 

core mission awards for large urban Level I and II trauma 

centers— 

‘‘(i) that have at least 1 graduate medical education fellowship in trauma or trauma related specialties for which demand is exceeding supply; 

‘‘(ii) for which— 

‘‘(I) annual uncompensated care costs exceed $10,000,000; or 

‘‘(II) at least 20 percent of emergency department visits are charity or self-pay or Medicaid patients; and 

‘‘(iii) that are not eligible for substantial uncompensated care awards under section 1241(a)(1). 

‘‘(c) EMERGENCY AWARDS.—In awarding grants under section 

1241(a)(3), the Secretary shall— 

‘‘(1) give preference to any application submitted by a trauma center that provides trauma care in a geographic area in 

which the availability of trauma care has significantly decreased or will significantly decrease if the center is forced to 

close or downgrade service or growth in demand for trauma 

services exceeds capacity; and 

‘‘(2) reallocate any emergency awards funds not obligated 

due to insufficient, or a lack of qualified, applications to the 

significant uncompensated care award program.’’. 

(3) CERTAIN AGREEMENTS.—Section 1243 of the Public 

Health Service Act (42 U.S.C. 300d–43) is amended by striking 

subsections (a), (b), and (c) and inserting the following: 

‘‘(a) MAINTENANCE OF FINANCIAL SUPPORT.—The Secretary 

may require a trauma center receiving a grant under section 

1241(a) to maintain access to trauma services at comparable levels 

to the prior year during the grant period. 

‘‘(b) TRAUMA CARE REGISTRY.—The Secretary may require the 

trauma center receiving a grant under section 1241(a) to provide 

data to a national and centralized registry of trauma cases, in accordance with guidelines developed by the American College of Surgeons, and as the Secretary may otherwise require.’’. 

(4) GENERAL PROVISIONS.—Section 1244 of the Public 

Health Service Act (42 U.S.C. 300d–44) is amended by striking 

subsections (a), (b), and (c) and inserting the following: 

‘‘(a) APPLICATION.—The Secretary may not award a grant to a 

trauma center under section 1241(a) unless such center submits an 
447 Sec. 3505 PPACA (Consolidated) \1245 PHSA 

application for the grant to the Secretary and the application is in 

such form, is made in such manner, and contains such agreements, 

assurances, and information as the Secretary determines to be necessary to carry out this part. 

‘‘(b) LIMITATION ON DURATION OF SUPPORT.—The period during 

which a trauma center receives payments under a grant under section 1241(a)(3) shall be for 3 fiscal years, except that the Secretary 

may waive such requirement for a center and authorize such center 

to receive such payments for 1 additional fiscal year. 

‘‘(c) LIMITATION ON AMOUNT OF GRANT.—Notwithstanding section 1242(a), a grant under section 1241 may not be made in an 

amount exceeding $2,000,000 for each fiscal year. 

‘‘(d) ELIGIBILITY.—Except as provided in section 

1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under section 1241(a) shall not preclude a trauma center from being eligible 

for other grants described in such section. 

‘‘(e) FUNDING DISTRIBUTION.—Of the total amount appropriated 

for a fiscal year under section 1245, 70 percent shall be used for 

substantial uncompensated care awards under section 1241(a)(1), 

20 percent shall be used for core mission awards under section 

1241(a)(2), and 10 percent shall be used for emergency awards 

under section 1241(a)(3). 

‘‘(f) MINIMUM ALLOWANCE.—Notwithstanding subsection (e), if 

the amount appropriated for a fiscal year under section 1245 is less 

than $25,000,000, all available funding for such fiscal year shall be 

used for substantial uncompensated care awards under section 

1241(a)(1). 

‘‘(g) SUBSTANTIAL UNCOMPENSATED CARE AWARD DISTRIBUTION

AND PROPORTIONAL SHARE.—Notwithstanding section 1242(a), of 

the amount appropriated for substantial uncompensated care 

grants for a fiscal year, the Secretary shall— 

‘‘(1) make available— 

‘‘(A) 50 percent of such funds for category A trauma 

center grantees; 

‘‘(B) 35 percent of such funds for category B trauma 

center grantees; and 

‘‘(C) 15 percent of such funds for category C trauma 

center grantees; and 

‘‘(2) provide available funds within each category in a manner proportional to the award basis specified in section 

1242(a)(2) to each eligible trauma center. 

‘‘(h) REPORT.—Beginning 2 years after the date of enactment of 

the Patient Protection and Affordable Care Act, and every 2 years 

thereafter, the Secretary shall biennially report to Congress regarding the status of the grants made under section 1241 and on the 

overall financial stability of trauma centers.’’. 

(5) AUTHORIZATION OF APPROPRIATIONS.—Section 1245 of 

the Public Health Service Act (42 U.S.C. 300d–45) is amended 

to read as follows: 

‘‘SEC. 1245. AUTHORIZATION OF APPROPRIATIONS. 

‘‘For the purpose of carrying out this part, there are authorized 

to be appropriated $100,000,000 for fiscal year 2009, and such 

sums as may be necessary for each of fiscal years 2010 through 
Sec. 3505 PPACA (Consolidated) 448 

2015. Such authorization of appropriations is in addition to any 

other authorization of appropriations or amounts that are available 

for such purpose.’’. 

(6) DEFINITION.—Part D of title XII of the Public Health 

Service Act (42 U.S.C. 300d–41 et seq.) is amended by adding 

at the end the following: 

‘‘SEC. 1246. ø42 U.S.C. 300d–46¿ DEFINITION. 

‘‘In this part, the term ‘uncompensated care costs’ means unreimbursed costs from serving self-pay, charity, or Medicaid patients, 

without regard to payment under section 1923 of the Social Security Act, all of which are attributable to emergency care and trauma care, including costs related to subsequent inpatient admissions 

to the hospital.’’. 

(b) TRAUMA SERVICE AVAILABILITY.—Title XII of the Public 

Health Service Act (42 U.S.C. 300d et seq.) is amended by adding 

at the end the following: 

‘‘PART H—TRAUMA SERVICE AVAILABILITY 

‘‘SEC. 1281. ø42 U.S.C. 300d–81¿ GRANTS TO STATES. 

‘‘(a) ESTABLISHMENT.—To promote universal access to trauma 

care services provided by trauma centers and trauma-related physician specialties, the Secretary shall provide funding to States to enable such States to award grants to eligible entities for the purposes described in this section. 

‘‘(b) AWARDING OF GRANTS BY STATES.—Each State may award 

grants to eligible entities within the State for the purposes described in subparagraph (d). 

‘‘(c) ELIGIBILITY.— 

‘‘(1) IN GENERAL.—To be eligible to receive a grant under 

subsection (b) an entity shall— 

‘‘(A) be— 

‘‘(i) a public or nonprofit trauma center or consortium thereof that meets that requirements of paragraphs (1), (2), and (5) of section 1241(b); 

‘‘(ii) a safety net public or nonprofit trauma center 

that meets the requirements of paragraphs (1) through 

(5) of section 1241(b); or 

‘‘(iii) a hospital in an underserved area (as defined 

by the State) that seeks to establish new trauma services; and 

‘‘(B) submit to the State an application at such time, 

in such manner, and containing such information as the 

State may require. 

‘‘(2) LIMITATION.—A State shall use at least 40 percent of 

the amount available to the State under this part for a fiscal 

year to award grants to safety net trauma centers described in 

paragraph (1)(A)(ii). 

‘‘(d) USE OF FUNDS.—The recipient of a grant under subsection 

(b) shall carry out 1 or more of the following activities consistent 

with subsection (b): 

‘‘(1) Providing trauma centers with funding to support physician compensation in trauma-related physician specialties 
449 Sec. 3505 PPACA (Consolidated) \1281 PHSA 

where shortages exist in the region involved, with priority provided to safety net trauma centers described in subsection 

(c)(1)(A)(ii). 

‘‘(2) Providing for individual safety net trauma center fiscal stability and costs related to having service that is available 24 hours a day, 7 days a week, with priority provided to 

safety net trauma centers described in subsection (c)(1)(A)(ii) 

located in urban, border, and rural areas. 

‘‘(3) Reducing trauma center overcrowding at specific trauma centers related to throughput of trauma patients. 

‘‘(4) Establishing new trauma services in underserved 

areas as defined by the State. 

‘‘(5) Enhancing collaboration between trauma centers and 

other hospitals and emergency medical services personnel related to trauma service availability. 

‘‘(6) Making capital improvements to enhance access and 

expedite trauma care, including providing helipads and associated safety infrastructure. 

‘‘(7) Enhancing trauma surge capacity at specific trauma 

centers. 

‘‘(8) Ensuring expedient receipt of trauma patients transported by ground or air to the appropriate trauma center. 

‘‘(9) Enhancing interstate trauma center collaboration. 

‘‘(e) LIMITATION.— 

‘‘(1) IN GENERAL.—A State may use not more than 20 percent of the amount available to the State under this part for 

a fiscal year for administrative costs associated with awarding 

grants and related costs. 

‘‘(2) MAINTENANCE OF EFFORT.—The Secretary may not 

provide funding to a State under this part unless the State 

agrees that such funds will be used to supplement and not supplant State funding otherwise available for the activities and 

costs described in this part. 

‘‘(f) DISTRIBUTION OF FUNDS.—The following shall apply with 

respect to grants provided in this part: 

‘‘(1) LESS THAN $10,000,000.—If the amount of appropriations for this part in a fiscal year is less than $10,000,000, the 

Secretary shall divide such funding evenly among only those 

States that have 1 or more trauma centers eligible for funding 

under section 1241(b)(3)(A). 

‘‘(2) LESS THAN $20,000,000.—If the amount of appropriations in a fiscal year is less than $20,000,000, the Secretary 

shall divide such funding evenly among only those States that 

have 1 or more trauma centers eligible for funding under subparagraphs (A) and (B) of section 1241(b)(3). 

‘‘(3) LESS THAN $30,000,000.—If the amount of appropriations for this part in a fiscal year is less than $30,000,000, the 

Secretary shall divide such funding evenly among only those 

States that have 1 or more trauma centers eligible for funding 

under section 1241(b)(3). 

‘‘(4) $30,000,000 OR MORE.—If the amount of appropriations for this part in a fiscal year is $30,000,000 or more, the 

Secretary shall divide such funding evenly among all States. 
Sec. 3506 PPACA (Consolidated) 450 

‘‘SEC. 1282. ø42 U.S.C. 300d–82¿ AUTHORIZATION OF APPROPRIATIONS. 

‘‘For the purpose of carrying out this part, there is authorized 

to be appropriated $100,000,000 for each of fiscal years 2010 

through 2015.’’. 

SEC. 3506. PROGRAM TO FACILITATE SHARED DECISIONMAKING. 

Part D of title IX of the Public Health Service Act, as amended 

by section 3503, is further amended by adding at the end the following: 

‘‘SEC. 936. ø42 U.S.C. 299b–36¿ PROGRAM TO FACILITATE SHARED DECISIONMAKING. 

‘‘(a) PURPOSE.—The purpose of this section is to facilitate collaborative processes between patients, caregivers or authorized representatives, and clinicians that engages the patient, caregiver or 

authorized representative in decisionmaking, provides patients, 

caregivers or authorized representatives with information about 

trade-offs among treatment options, and facilitates the incorporation of patient preferences and values into the medical plan. 

‘‘(b) DEFINITIONS.—In this section: 

‘‘(1) PATIENT DECISION AID.—The term ‘patient decision aid’ 

means an educational tool that helps patients, caregivers or 

authorized representatives understand and communicate their 

beliefs and preferences related to their treatment options, and 

to decide with their health care provider what treatments are 

best for them based on their treatment options, scientific evidence, circumstances, beliefs, and preferences. 

‘‘(2) PREFERENCE SENSITIVE CARE.—The term ‘preference 

sensitive care’ means medical care for which the clinical evidence does not clearly support one treatment option such that 

the appropriate course of treatment depends on the values of 

the patient or the preferences of the patient, caregivers or authorized representatives regarding the benefits, harms and scientific evidence for each treatment option, the use of such care 

should depend on the informed patient choice among clinically 

appropriate treatment options. 

‘‘(c) ESTABLISHMENT OF INDEPENDENT STANDARDS FOR PATIENT

DECISION AIDS FOR PREFERENCE SENSITIVE CARE.— 

‘‘(1) CONTRACT WITH ENTITY TO ESTABLISH STANDARDS AND

CERTIFY PATIENT DECISION AIDS.— 

‘‘(A) IN GENERAL.—For purposes of supporting consensus-based standards for patient decision aids for preference sensitive care and a certification process for patient 

decision aids for use in the Federal health programs and 

by other interested parties, the Secretary shall have in effect a contract with the entity with a contract under section 1890 of the Social Security Act. Such contract shall 

provide that the entity perform the duties described in 

paragraph (2). 

‘‘(B) TIMING FOR FIRST CONTRACT.—As soon as practicable after the date of the enactment of this section, the 

Secretary shall enter into the first contract under subparagraph (A). 

‘‘(C) PERIOD OF CONTRACT.—A contract under subparagraph (A) shall be for a period of 18 months (except such 
451 Sec. 3506 PPACA (Consolidated) \936 PHSA 

contract may be renewed after a subsequent bidding process). 

‘‘(2) DUTIES.—The following duties are described in this 

paragraph: 

‘‘(A) DEVELOP AND IDENTIFY STANDARDS FOR PATIENT

DECISION AIDS.—The entity shall synthesize evidence and 

convene a broad range of experts and key stakeholders to 

develop and identify consensus-based standards to evaluate patient decision aids for preference sensitive care. 

‘‘(B) ENDORSE PATIENT DECISION AIDS.—The entity 

shall review patient decision aids and develop a certification process whether patient decision aids meet the 

standards developed and identified under subparagraph 

(A). The entity shall give priority to the review and certification of patient decision aids for preference sensitive care. 

‘‘(d) PROGRAM TO DEVELOP, UPDATE AND PATIENT DECISION

AIDS TO ASSIST HEALTH CARE PROVIDERS AND PATIENTS.— ‘‘(1) IN GENERAL.—The Secretary, acting through the Director, and in coordination with heads of other relevant agencies, 

such as the Director of the Centers for Disease Control and 

Prevention and the Director of the National Institutes of 

Health, shall establish a program to award grants or contracts— 

‘‘(A) to develop, update, and produce patient decision 

aids for preference sensitive care to assist health care providers in educating patients, caregivers, and authorized 

representatives concerning the relative safety, relative effectiveness (including possible health outcomes and impact 

on functional status), and relative cost of treatment or, 

where appropriate, palliative care options; 

‘‘(B) to test such materials to ensure such materials 

are balanced and evidence based in aiding health care providers and patients, caregivers, and authorized representatives to make informed decisions about patient care and 

can be easily incorporated into a broad array of practice 

settings; and 

‘‘(C) to educate providers on the use of such materials, 

including through academic curricula. 

‘‘(2) REQUIREMENTS FOR PATIENT DECISION AIDS.—Patient 

decision aids developed and produced pursuant to a grant or 

contract under paragraph (1)— 

‘‘(A) shall be designed to engage patients, caregivers, 

and authorized representatives in informed decisionmaking with health care providers; 

‘‘(B) shall present up-to-date clinical evidence about 

the risks and benefits of treatment options in a form and 

manner that is age-appropriate and can be adapted for patients, caregivers, and authorized representatives from a 

variety of cultural and educational backgrounds to reflect 

the varying needs of consumers and diverse levels of 

health literacy; 

‘‘(C) shall, where appropriate, explain why there is a 

lack of evidence to support one treatment option over another; and 
Sec. 3506\936 PHSA PPACA (Consolidated) 452 

‘‘(D) shall address health care decisions across the age 

span, including those affecting vulnerable populations including children. 

‘‘(3) DISTRIBUTION.—The Director shall ensure that patient 

decision aids produced with grants or contracts under this section are available to the public. 

‘‘(4) NONDUPLICATION OF EFFORTS.—The Director shall ensure that the activities under this section of the Agency and 

other agencies, including the Centers for Disease Control and 

Prevention and the National Institutes of Health, are free of 

unnecessary duplication of effort. 

‘‘(e) GRANTS TO SUPPORT SHARED DECISIONMAKING IMPLEMENTATION.— 

‘‘(1) IN GENERAL.—The Secretary shall establish a program 

to provide for the phased-in development, implementation, and 

evaluation of shared decisionmaking using patient decision 

aids to meet the objective of improving the understanding of 

patients of their medical treatment options. 

‘‘(2) SHARED DECISIONMAKING RESOURCE CENTERS.— 

‘‘(A) IN GENERAL.—The Secretary shall provide grants 

for the establishment and support of Shared Decisionmaking Resource Centers (referred to in this subsection as 

‘Centers’) to provide technical assistance to providers and 

to develop and disseminate best practices and other information to support and accelerate adoption, implementation, and effective use of patient decision aids and shared 

decisionmaking by providers. 

‘‘(B) OBJECTIVES.—The objective of a Center is to enhance and promote the adoption of patient decision aids 

and shared decisionmaking through— 

‘‘(i) providing assistance to eligible providers with 

the implementation and effective use of, and training 

on, patient decision aids; and 

‘‘(ii) the dissemination of best practices and research on the implementation and effective use of patient decision aids. 

‘‘(3) SHARED DECISIONMAKING PARTICIPATION GRANTS.— 

‘‘(A) IN GENERAL.—The Secretary shall provide grants 

to health care providers for the development and implementation of shared decisionmaking techniques and to assess the use of such techniques. 

‘‘(B) PREFERENCE.—In order to facilitate the use of 

best practices, the Secretary shall provide a preference in 

making grants under this subsection to health care providers who participate in training by Shared Decisionmaking Resource Centers or comparable training. 

‘‘(C) LIMITATION.—Funds under this paragraph shall 

not be used to purchase or implement use of patient decision aids other than those certified under the process identified in subsection (c). 

‘‘(4) GUIDANCE.—The Secretary may issue guidance to eligible grantees under this subsection on the use of patient decision aids. 
453 Sec. 3508 PPACA (Consolidated) 

‘‘(f) FUNDING.—For purposes of carrying out this section there 

are authorized to be appropriated such sums as may be necessary 

for fiscal year 2010 and each subsequent fiscal year.’’. 

SEC. 3507. ø21 U.S.C. 352 note¿ PRESENTATION OF PRESCRIPTION 

DRUG BENEFIT AND RISK INFORMATION. 

(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’), acting through 

the Commissioner of Food and Drugs, shall determine whether the 

addition of quantitative summaries of the benefits and risks of prescription drugs in a standardized format (such as a table or drug 

facts box) to the promotional labeling or print advertising of such 

drugs would improve health care decisionmaking by clinicians and 

patients and consumers. 

(b) REVIEW AND CONSULTATION.—In making the determination 

under subsection (a), the Secretary shall review all available scientific evidence and research on decisionmaking and social and cognitive psychology and consult with drug manufacturers, clinicians, 

patients and consumers, experts in health literacy, representatives 

of racial and ethnic minorities, and experts in women’s and pediatric health. 

(c) REPORT.—Not later than 1 year after the date of enactment 

of this Act, the Secretary shall submit to Congress a report that 

provides— 

(1) the determination by the Secretary under subsection 

(a); and 

(2) the reasoning and analysis underlying that determination. 

(d) AUTHORITY.—If the Secretary determines under subsection 

(a) that the addition of quantitative summaries of the benefits and 

risks of prescription drugs in a standardized format (such as a 

table or drug facts box) to the promotional labeling or print advertising of such drugs would improve health care decisionmaking by 

clinicians and patients and consumers, then the Secretary, not 

later than 3 years after the date of submission of the report under 

subsection (c), shall promulgate proposed regulations as necessary 

to implement such format. 

(e) CLARIFICATION.—Nothing in this section shall be construed 

to restrict the existing authorities of the Secretary with respect to 

benefit and risk information. 

SEC. 3508. ø42 U.S.C. 294j note¿ DEMONSTRATION PROGRAM TO INTEGRATE QUALITY IMPROVEMENT AND PATIENT SAFETY 

TRAINING INTO CLINICAL EDUCATION OF HEALTH PROFESSIONALS. 

(a) IN GENERAL.—The Secretary may award grants to eligible 

entities or consortia under this section to carry out demonstration 

projects to develop and implement academic curricula that integrates quality improvement and patient safety in the clinical education of health professionals. Such awards shall be made on a 

competitive basis and pursuant to peer review. 

(b) ELIGIBILITY.—To be eligible to receive a grant under subsection (a), an entity or consortium shall— 

(1) submit to the Secretary an application at such time, in 

such manner, and containing such information as the Secretary may require; 
Sec. 3509 PPACA (Consolidated) 454 

(2) be or include— 

(A) a health professions school; 

(B) a school of public health; 

(C) a school of social work; 

(D) a school of nursing; 

(E) a school of pharmacy; 

(F) an institution with a graduate medical education 

program; or 

(G) a school of health care administration; 

(3) collaborate in the development of curricula described in 

subsection (a) with an organization that accredits such school 

or institution; 

(4) provide for the collection of data regarding the effectiveness of the demonstration project; and 

(5) provide matching funds in accordance with subsection 

(c). 

(c) MATCHING FUNDS.— 

(1) IN GENERAL.—The Secretary may award a grant to an 

entity or consortium under this section only if the entity or 

consortium agrees to make available non-Federal contributions 

toward the costs of the program to be funded under the grant 

in an amount that is not less than $1 for each $5 of Federal 

funds provided under the grant. 

(2) DETERMINATION OF AMOUNT CONTRIBUTED.—Non-Federal contributions under paragraph (1) may be in cash or inkind, fairly evaluated, including equipment or services. 

Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal 

Government, may not be included in determining the amount 

of such contributions. 

(d) EVALUATION.—The Secretary shall take such action as may 

be necessary to evaluate the projects funded under this section and 

publish, make publicly available, and disseminate the results of 

such evaluations on as wide a basis as is practicable. 

(e) REPORTS.—Not later than 2 years after the date of enactment of this section, and annually thereafter, the Secretary 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 that— 

(1) describes the specific projects supported under this section; and 

(2) contains recommendations for Congress based on the 

evaluation conducted under subsection (d). 

SEC. 3509. IMPROVING WOMEN’S HEALTH. 

(a) HEALTH AND HUMAN SERVICES OFFICE ON WOMEN’S

HEALTH.— 

(1) ESTABLISHMENT.—Part A of title II of the Public Health 

Service Act (42 U.S.C. 202 et seq.) is amended by adding at the 

end the following: 
455 Sec. 3509 PPACA (Consolidated) \229 PHSA 

‘‘SEC. 229. ø42 U.S.C. 237a¿ HEALTH AND HUMAN SERVICES OFFICE ON 

WOMEN’S HEALTH. 

‘‘(a) ESTABLISHMENT OF OFFICE.—There is established within 

the Office of the Secretary, an Office on Women’s Health (referred 

to in this section as the ‘Office’). The Office shall be headed by a 

Deputy Assistant Secretary for Women’s Health who may report to 

the Secretary. 

‘‘(b) DUTIES.—The Secretary, acting through the Office, with 

respect to the health concerns of women, shall— 

‘‘(1) establish short-range and long-range goals and objectives within the Department of Health and Human Services 

and, as relevant and appropriate, coordinate with other appropriate offices on activities within the Department that relate to 

disease prevention, health promotion, service delivery, research, and public and health care professional education, for 

issues of particular concern to women throughout their lifespan; 

‘‘(2) provide expert advice and consultation to the Secretary concerning scientific, legal, ethical, and policy issues relating to women’s health; 

‘‘(3) monitor the Department of Health and Human Services’ offices, agencies, and regional activities regarding women’s health and identify needs regarding the coordination of activities, including intramural and extramural multidisciplinary 

activities; 

‘‘(4) establish a Department of Health and Human Services 

Coordinating Committee on Women’s Health, which shall be 

chaired by the Deputy Assistant Secretary for Women’s Health 

and composed of senior level representatives from each of the 

agencies and offices of the Department of Health and Human 

Services; 

‘‘(5) establish a National Women’s Health Information Center to— 

‘‘(A) facilitate the exchange of information regarding 

matters relating to health information, health promotion, 

preventive health services, research advances, and education in the appropriate use of health care; 

‘‘(B) facilitate access to such information; 

‘‘(C) assist in the analysis of issues and problems relating to the matters described in this paragraph; and 

‘‘(D) provide technical assistance with respect to the 

exchange of information (including facilitating the development of materials for such technical assistance); 

‘‘(6) coordinate efforts to promote women’s health programs 

and policies with the private sector; and 

‘‘(7) through publications and any other means appropriate, provide for the exchange of information between the Office and recipients of grants, contracts, and agreements under 

subsection (c), and between the Office and health professionals 

and the general public. 

‘‘(c) GRANTS AND CONTRACTS REGARDING DUTIES.— 

‘‘(1) AUTHORITY.—In carrying out subsection (b), the Secretary may make grants to, and enter into cooperative agree-
Sec. 3509 PPACA (Consolidated) 456 

ments, contracts, and interagency agreements with, public and 

private entities, agencies, and organizations. 

‘‘(2) EVALUATION AND DISSEMINATION.—The Secretary shall 

directly or through contracts with public and private entities, 

agencies, and organizations, provide for evaluations of projects 

carried out with financial assistance provided under paragraph 

(1) and for the dissemination of information developed as a result of such projects. 

‘‘(d) REPORTS.—Not later than 1 year after the date of enactment of this section, and every second year thereafter, the Secretary shall prepare and submit to the appropriate committees of 

Congress a report describing the activities carried out under this 

section during the period for which the report is being prepared. 

‘‘(e) 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 the fiscal years 2010 

through 2014.’’. 

(2) TRANSFER OF FUNCTIONS.—There are transferred to the 

Office on Women’s Health (established under section 229 of the 

Public Health Service Act, as added by this section), all functions exercised by the Office on Women’s Health of the Public 

Health Service prior to the date of enactment of this section, 

including all personnel and compensation authority, all delegation and assignment authority, and all remaining appropriations. All orders, determinations, rules, regulations, permits, 

agreements, grants, contracts, certificates, licenses, registrations, privileges, and other administrative actions that— 

(A) have been issued, made, granted, or allowed to become effective by the President, any Federal agency or official thereof, or by a court of competent jurisdiction, in the 

performance of functions transferred under this paragraph; 

and 

(B) are in effect at the time this section takes effect, 

or were final before the date of enactment of this section 

and are to become effective on or after such date, 

shall continue in effect according to their terms until modified, 

terminated, superseded, set aside, or revoked in accordance 

with law by the President, the Secretary, or other authorized 

official, a court of competent jurisdiction, or by operation of 

law. 

(b) CENTERS FOR DISEASE CONTROL AND PREVENTION OFFICE

OF WOMEN’S HEALTH.—Part A of title III of the Public Health Service Act (42 U.S.C. 241 et seq.) is amended by adding at the end the 

following: 

‘‘SEC. 310A. ø42 U.S.C. 242s¿ CENTERS FOR DISEASE CONTROL AND 

PREVENTION OFFICE OF WOMEN’S HEALTH. 

‘‘(a) ESTABLISHMENT.—There is established within the Office of 

the Director of the Centers for Disease Control and Prevention, an 

office to be known as the Office of Women’s Health (referred to in 

this section as the ‘Office’). The Office shall be headed by a director 

who shall be appointed by the Director of such Centers. 

‘‘(b) PURPOSE.—The Director of the Office shall— 

‘‘(1) report to the Director of the Centers for Disease Control and Prevention on the current level of the Centers’ activity 
457 Sec. 3509 PPACA (Consolidated) 

regarding women’s health conditions across, where appropriate, age, biological, and sociocultural contexts, in all aspects 

of the Centers’ work, including prevention programs, public 

and professional education, services, and treatment; 

‘‘(2) establish short-range and long-range goals and objectives within the Centers for women’s health and, as relevant 

and appropriate, coordinate with other appropriate offices on 

activities within the Centers that relate to prevention, research, education and training, service delivery, and policy development, for issues of particular concern to women; 

‘‘(3) identify projects in women’s health that should be conducted or supported by the Centers; 

‘‘(4) consult with health professionals, nongovernmental organizations, consumer organizations, women’s health professionals, and other individuals and groups, as appropriate, on 

the policy of the Centers with regard to women; and 

‘‘(5) serve as a member of the Department of Health and 

Human Services Coordinating Committee on Women’s Health 

(established under section 229(b)(4)). 

‘‘(c) DEFINITION.—As used in this section, the term ‘women’s 

health conditions’, with respect to women of all age, ethnic, and racial groups, means diseases, disorders, and conditions— 

‘‘(1) unique to, significantly more serious for, or significantly more prevalent in women; and 

‘‘(2) for which the factors of medical risk or type of medical 

intervention are different for women, or for which there is reasonable evidence that indicates that such factors or types may 

be different for women. 

‘‘(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 the fiscal years 2010 

through 2014.’’. 

(c) OFFICE OF WOMEN’S HEALTH RESEARCH.—Section 486(a) of 

the Public Health Service Act (42 U.S.C. 287d(a)) is amended by inserting ‘‘and who shall report directly to the Director’’ before the 

period at the end thereof. 

(d) SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION.—Section 501(f) of the Public Health Service Act (42 

U.S.C. 290aa(f)) is amended— 

(1) in paragraph (1), by inserting ‘‘who shall report directly 

to the Administrator’’ before the period; 

(2) by redesignating paragraph (4) as paragraph (5); and 

(3) by inserting after paragraph (3), the following: 

‘‘(4) OFFICE.—Nothing in this subsection shall be construed 

to preclude the Secretary from establishing within the Substance Abuse and Mental Health Administration an Office of 

Women’s Health.’’. 

(e) AGENCY FOR HEALTHCARE RESEARCH AND QUALITY ACTIVITIES REGARDING WOMEN’S HEALTH.—Part C of title IX of the Public 

Health Service Act (42 U.S.C. 299c et seq.) is amended— 

(1) by redesignating sections 925 and 926 as sections 926 

and 927, respectively; and 

(2) by inserting after section 924 the following: 
Sec. 3509\925 PHSA PPACA (Consolidated) 458 

‘‘SEC. 925. ø42 U.S.C. 299b–24a¿ ACTIVITIES REGARDING WOMEN’S 

HEALTH. 

‘‘(a) ESTABLISHMENT.—There is established within the Office of 

the Director, an Office of Women’s Health and Gender-Based Research (referred to in this section as the ‘Office’). The Office shall 

be headed by a director who shall be appointed by the Director of 

Healthcare and Research Quality. 

‘‘(b) PURPOSE.—The official designated under subsection (a) 

shall— 

‘‘(1) report to the Director on the current Agency level of 

activity regarding women’s health, across, where appropriate, 

age, biological, and sociocultural contexts, in all aspects of 

Agency work, including the development of evidence reports 

and clinical practice protocols and the conduct of research into 

patient outcomes, delivery of health care services, quality of 

care, and access to health care; 

‘‘(2) establish short-range and long-range goals and objectives within the Agency for research important to women’s 

health and, as relevant and appropriate, coordinate with other 

appropriate offices on activities within the Agency that relate 

to health services and medical effectiveness research, for issues 

of particular concern to women; 

‘‘(3) identify projects in women’s health that should be conducted or supported by the Agency; 

‘‘(4) consult with health professionals, nongovernmental organizations, consumer organizations, women’s health professionals, and other individuals and groups, as appropriate, on 

Agency policy with regard to women; and 

‘‘(5) serve as a member of the Department of Health and 

Human Services Coordinating Committee on Women’s Health 

(established under section 229(b)(4)).’’. 

‘‘(c) 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 the fiscal years 2010 

through 2014.’’. 

(f) HEALTH RESOURCES AND SERVICES ADMINISTRATION OFFICE

OF WOMEN’S HEALTH.—Title VII of the Social Security Act (42 

U.S.C. 901 et seq.) is amended by adding at the end the following: 

‘‘SEC. 713. ø42 U.S.C. 914¿ OFFICE OF WOMEN’S HEALTH. 

‘‘(a) ESTABLISHMENT.—The Secretary shall establish within the 

Office of the Administrator of the Health Resources and Services 

Administration, an office to be known as the Office of Women’s 

Health. The Office shall be headed by a director who shall be appointed by the Administrator. 

‘‘(b) PURPOSE.—The Director of the Office shall— 

‘‘(1) report to the Administrator on the current Administration level of activity regarding women’s health across, where 

appropriate, age, biological, and sociocultural contexts; 

‘‘(2) establish short-range and long-range goals and objectives within the Health Resources and Services Administration 

for women’s health and, as relevant and appropriate, coordinate with other appropriate offices on activities within the Administration that relate to health care provider training, 
459 Sec. 3509 PPACA (Consolidated) \1011 FFDCA 

health service delivery, research, and demonstration projects, 

for issues of particular concern to women; 

‘‘(3) identify projects in women’s health that should be conducted or supported by the bureaus of the Administration; 

‘‘(4) consult with health professionals, nongovernmental organizations, consumer organizations, women’s health professionals, and other individuals and groups, as appropriate, on 

Administration policy with regard to women; and 

‘‘(5) serve as a member of the Department of Health and 

Human Services Coordinating Committee on Women’s Health 

(established under section 229(b)(4) of the Public Health Service Act). 

‘‘(c) CONTINUED ADMINISTRATION OF EXISTING PROGRAMS.—The 

Director of the Office shall assume the authority for the development, implementation, administration, and evaluation of any 

projects carried out through the Health Resources and Services Administration relating to women’s health on the date of enactment 

of this section. 

‘‘(d) DEFINITIONS.—For purposes of this section: 

‘‘(1) ADMINISTRATION.—The term ‘Administration’ means 

the Health Resources and Services Administration. 

‘‘(2) ADMINISTRATOR.—The term ‘Administrator’ means the 

Administrator of the Health Resources and Services Administration. 

‘‘(3) OFFICE.—The term ‘Office’ means the Office of Women’s Health established under this section in the Administration. 

‘‘(e) 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 the fiscal years 2010 

through 2014.’’. 

(g) FOOD AND DRUG ADMINISTRATION OFFICE OF WOMEN’S

HEALTH.—Chapter X of the Federal Food, Drug, and Cosmetic Act 

(21 U.S.C. 391 et seq.) is amended by adding at the end the following: 

‘‘SEC. 1011. ø21 U.S.C. 399b¿ OFFICE OF WOMEN’S HEALTH. 

‘‘(a) ESTABLISHMENT.—There is established within the Office of 

the Commissioner, an office to be known as the Office of Women’s 

Health (referred to in this section as the ‘Office’). The Office shall 

be headed by a director who shall be appointed by the Commissioner of Food and Drugs. 

‘‘(b) PURPOSE.—The Director of the Office shall— 

‘‘(1) report to the Commissioner of Food and Drugs on current Food and Drug Administration (referred to in this section 

as the ‘Administration’) levels of activity regarding women’s 

participation in clinical trials and the analysis of data by sex 

in the testing of drugs, medical devices, and biological products 

across, where appropriate, age, biological, and sociocultural 

contexts; 

‘‘(2) establish short-range and long-range goals and objectives within the Administration for issues of particular concern 

to women’s health within the jurisdiction of the Administration, including, where relevant and appropriate, adequate in-
Sec. 3509 PPACA (Consolidated) 460 

clusion of women and analysis of data by sex in Administration 

protocols and policies; 

‘‘(3) provide information to women and health care providers on those areas in which differences between men and 

women exist; 

‘‘(4) consult with pharmaceutical, biologics, and device 

manufacturers, health professionals with expertise in women’s 

issues, consumer organizations, and women’s health professionals on Administration policy with regard to women; 

‘‘(5) make annual estimates of funds needed to monitor 

clinical trials and analysis of data by sex in accordance with 

needs that are identified; and 

‘‘(6) serve as a member of the Department of Health and 

Human Services Coordinating Committee on Women’s Health 

(established under section 229(b)(4) of the Public Health Service Act). 

‘‘(c) 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 the fiscal years 2010 

through 2014.’’. 

(h) NO NEW REGULATORY AUTHORITY.—Nothing in this section 

and the amendments made by this section may be construed as establishing regulatory authority or modifying any existing regulatory authority. 

(i) LIMITATION ON TERMINATION.—Notwithstanding any other 

provision of law, a Federal office of women’s health (including the 

Office of Research on Women’s Health of the National Institutes of 

Health) or Federal appointive position with primary responsibility 

over women’s health issues (including the Associate Administrator 

for Women’s Services under the Substance Abuse and Mental 

Health Services Administration) that is in existence on the date of 

enactment of this section shall not be terminated, reorganized, or 

have any of it’s powers or duties transferred unless such termination, reorganization, or transfer is approved by Congress through 

the adoption of a concurrent resolution of approval. 

(j) RULE OF CONSTRUCTION.—Nothing in this section (or the 

amendments made by this section) shall be construed to limit the 

authority of the Secretary of Health and Human Services with respect to women’s health, or with respect to activities carried out 

through the Department of Health and Human Services on the 

date of enactment of this section. 

SEC. 3510. PATIENT NAVIGATOR PROGRAM. 

Section 340A of the Public Health Service Act (42 U.S.C. 256a) 

is amended— 

(1) by striking subsection (d)(3) and inserting the following: 

‘‘(3) LIMITATIONS ON GRANT PERIOD.—In carrying out this 

section, the Secretary shall ensure that the total period of a 

grant does not exceed 4 years.’’; 

(2) in subsection (e), by adding at the end the following: 

‘‘(3) MINIMUM CORE PROFICIENCIES.—The Secretary shall 

not award a grant to an entity under this section unless such 

entity provides assurances that patient navigators recruited, 
461 Sec. 3512 PPACA (Consolidated) 

assigned, trained, or employed using grant funds meet minimum core proficiencies, as defined by the entity that submits 

the application, that are tailored for the main focus or intervention of the navigator involved.’’; and 

(3) in subsection (m)— 

(A) in paragraph (1), by striking ‘‘and $3,500,000 for 

fiscal year 2010.’’ and inserting ‘‘$3,500,000 for fiscal year 

2010, and such sums as may be necessary for each of fiscal 

years 2011 through 2015.’’; and 

(B) in paragraph (2), by striking ‘‘2010’’ and inserting 

‘‘2015’’. 

SEC. 3511. AUTHORIZATION OF APPROPRIATIONS. 

Except where otherwise provided in this subtitle (or an amendment made by this subtitle), there is authorized to be appropriated 

such sums as may be necessary to carry out this subtitle (and such 

amendments made by this subtitle). 

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

øSection added by section 10201(j)¿ 

(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 
Sec. 3601 PPACA (Consolidated) 462 

shall submit to the appropriate committees of Congress, a report 

containing the findings made by the Comptroller General under the 

study under subsection (a). 

Subtitle G—Protecting and Improving 

Guaranteed Medicare Benefits 

SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE 

BENEFITS. 

(a) PROTECTING GUARANTEED MEDICARE BENEFITS.—Nothing 

in the provisions of, or amendments made by, this Act shall result 

in a reduction of guaranteed benefits under title XVIII of the Social 

Security Act. 

(b) ENSURING THAT MEDICARE SAVINGS BENEFIT THE MEDICARE PROGRAM AND MEDICARE BENEFICIARIES.—Savings generated 

for the Medicare program under title XVIII of the Social Security 

Act under the provisions of, and amendments made by, this Act 

shall extend the solvency of the Medicare trust funds, reduce Medicare premiums and other cost-sharing for beneficiaries, and improve or expand guaranteed Medicare benefits and protect access 

to Medicare providers. 

SEC. 3602. NO CUTS IN GUARANTEED BENEFITS. 

Nothing in this Act shall result in the reduction or elimination 

of any benefits guaranteed by law to participants in Medicare Advantage plans. 
463 Sec. 4001 PPACA (Consolidated) 

TITLE IV—PREVENTION OF CHRONIC 

DISEASE AND IMPROVING PUBLIC 

HEALTH 

Subtitle A—Modernizing Disease 

Prevention and Public Health Systems 

SEC. 4001. ø42 U.S.C. 300u–10¿ NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH COUNCIL. 

(a) ESTABLISHMENT.—The President shall establish, within the 

Department of Health and Human Services, a council to be known 

as the ‘‘National Prevention, Health Promotion and Public Health 

Council’’ (referred to in this section as the ‘‘Council’’). 

(b) CHAIRPERSON.—The President shall appoint the Surgeon 

General to serve as the chairperson of the Council. 

(c) COMPOSITION.—The Council shall be composed of— 

(1) the Secretary of Health and Human Services; 

(2) the Secretary of Agriculture; 

(3) the Secretary of Education; 

(4) the Chairman of the Federal Trade Commission; 

(5) the Secretary of Transportation; 

(6) the Secretary of Labor; 

(7) the Secretary of Homeland Security; 

(8) the Administrator of the Environmental Protection 

Agency; 

(9) the Director of the Office of National Drug Control Policy; 

(10) the Director of the Domestic Policy Council; 

(11) the Assistant Secretary for Indian Affairs; 

(12) the Chairman of the Corporation for National and 

Community Service; and 

(13) the head of any other Federal agency that the chairperson determines is appropriate. 

(d) PURPOSES AND DUTIES.—The Council shall— 

(1) provide coordination and leadership at the Federal 

level, and among all Federal departments and agencies, with 

respect to prevention, wellness and health promotion practices, 

the public health system, and integrative health care in the 

United States; 

(2) after obtaining input from relevant stakeholders, develop a national prevention, health promotion, public health, 

and integrative health care strategy that incorporates the most 

effective and achievable means of improving the health status 

of Americans and reducing the incidence of preventable illness 

and disability in the United States; 

(3) provide recommendations to the President and Congress concerning the most pressing health issues confronting 

the United States and changes in Federal policy to achieve national wellness, health promotion, and public health goals, including the reduction of tobacco use, sedentary behavior, and 

poor nutrition; 
Sec. 4001 PPACA (Consolidated) 464 

(4) consider and propose evidence-based models, policies, 

and innovative approaches for the promotion of transformative 

models of prevention, integrative health, and public health on 

individual and community levels across the United States; 

(5) establish processes for continual public input, including 

input from State, regional, and local leadership communities 

and other relevant stakeholders, including Indian tribes and 

tribal organizations; 

(6) submit the reports required under subsection (g); and 

(7) carry out other activities determined appropriate by the 

President. 

(e) MEETINGS.—The Council shall meet at the call of the Chairperson. 

(f) ADVISORY GROUP.— (1) IN GENERAL.—The President shall establish an Advisory Group to the Council to be known as the ‘‘Advisory Group 

on Prevention, Health Promotion, and Integrative and Public 

Health’’ (hereafter referred to in this section as the ‘‘Advisory 

Group’’). The Advisory Group shall be within the Department 

of Health and Human Services and report to the Surgeon General. 

(2) COMPOSITION.— (A) IN GENERAL.—The Advisory Group shall be composed of not more than 25 non-Federal members to be appointed by the President. 

(B) REPRESENTATION.—In appointing members under 

subparagraph (A), the President shall ensure that the Advisory Group includes a diverse group of licensed health 

professionals, including integrative health practitioners 

who have expertise in— 

(i) worksite health promotion; 

(ii) community services, including community 

health centers; 

(iii) preventive medicine; 

(iv) health coaching; 

(v) public health education; 

(vi) geriatrics; and 

(vii) rehabilitation medicine. 

(3) PURPOSES AND DUTIES.—The Advisory Group shall develop policy and program recommendations and advise the 

Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion. 

(g) NATIONAL PREVENTION AND HEALTH PROMOTION STRATEGY.—Not later than 1 year after the date of enactment of this Act, 

the Chairperson, in consultation with the Council, shall develop 

and make public a national prevention, health promotion and public health strategy, and shall review and revise such strategy periodically. Such strategy shall— 

(1) set specific goals and objectives for improving the 

health of the United States through federally-supported prevention, health promotion, and public health programs, consistent with ongoing goal setting efforts conducted by specific 

agencies; 
465 Sec. 4001 PPACA (Consolidated) 

(2) establish specific and measurable actions and timelines 

to carry out the strategy, and determine accountability for 

meeting those timelines, within and across Federal departments and agencies; and 

(3) make recommendations to improve Federal efforts relating to prevention, health promotion, public health, and integrative health care practices to ensure Federal efforts are consistent with available standards and evidence. 

(h) REPORT.—Not later than July 1, 2010, and annually thereafter through January 1, 2015, the Council shall submit to the 

President and the relevant committees of Congress, a report that— 

(1) describes the activities and efforts on prevention, 

health promotion, and public health and activities to develop 

a national strategy conducted by the Council during the period 

for which the report is prepared; 

(2) describes the national progress in meeting specific prevention, health promotion, and public health goals defined in 

the strategy and further describes corrective actions recommended by the Council and taken by relevant agencies and 

organizations to meet these goals; 

(3) contains a list of national priorities on health promotion and disease prevention to address lifestyle behavior 

modification (smoking cessation, proper nutrition, appropriate 

exercise, mental health, behavioral health, substance use disorder, and domestic violence screenings) and the prevention 

measures for the 5 leading disease killers in the United States; 

(4) contains specific science-based initiatives to achieve the 

measurable goals of Healthy People 2020 regarding nutrition, 

exercise, and smoking cessation, and targeting the 5 leading 

disease killers in the United States; øAs revised by section 

10401(a)¿ 

(5) contains 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 2020); øAs revised by section 10401(a)¿ 

(6) contains specific plans to ensure that all Federal health 

care programs are fully coordinated with science-based prevention recommendations by the Director of the Centers for Disease Control and Prevention; and 

(7) contains 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 paragraph (4). 

(i) PERIODIC REVIEWS.—The Secretary and the Comptroller 

General of the United States shall jointly conduct periodic reviews, 

not less than every 5 years, and evaluations of every Federal disease prevention and health promotion initiative, program, and 

agency. Such reviews shall be evaluated based on effectiveness in 

meeting metrics-based goals with an analysis posted on such agencies’ public Internet websites. 
Sec. 4002 PPACA (Consolidated) 466 

SEC. 4002. ø42 U.S.C. 300u–11¿ PREVENTION AND PUBLIC HEALTH 

FUND. 

(a) PURPOSE.—It is the purpose of this section to establish a 

Prevention and Public Health Fund (referred to in this section as 

the ‘‘Fund’’), to be administered through the Department of Health 

and Human Services, Office of the Secretary, to provide for expanded and sustained national investment in prevention and public 

health programs to improve health and help restrain the rate of 

growth in private and public sector health care costs. 

(b) FUNDING.—There are hereby authorized to be appropriated, 

and appropriated, to the Fund, out of any monies in the Treasury 

not otherwise appropriated— (1) for fiscal year 2010, $500,000,000; 

(2) for fiscal year 2011, $750,000,000; 

(3) for fiscal year 2012, $1,000,000,000; 

(4) for fiscal year 2013, $1,250,000,000; 

(5) for fiscal year 2014, $1,500,000,000; and 

(6) for fiscal year 2015, and each fiscal year thereafter, $2,000,000,000. 

(c) USE OF FUND.—The Secretary shall transfer amounts in the 

Fund to accounts within the Department of Health and Human 

Services to increase funding, over the fiscal year 2008 level, for programs authorized by the Public Health Service Act, for prevention, 

wellness, and public health activities including prevention research, health screenings, and initiatives, such as the Community 

Transformation grant program, the Education and Outreach Campaign Regarding Preventive Benefits, and immunization programs. 

øAs revised by section 10401(b)¿ 

(d) TRANSFER AUTHORITY.—The Committee on Appropriations 

of the Senate and the Committee on Appropriations of the House 

of Representatives may provide for the transfer of funds in the 

Fund to eligible activities under this section, subject to subsection 

(c). 

SEC. 4003. CLINICAL AND COMMUNITY PREVENTIVE SERVICES. 

(a) PREVENTIVE SERVICES TASK FORCE.—Section 915 of the 

Public Health Service Act (42 U.S.C. 299b–4) is amended by striking subsection (a) and inserting the following: 

‘‘(a) PREVENTIVE SERVICES TASK FORCE.— 

‘‘(1) ESTABLISHMENT AND PURPOSE.—The Director shall 

convene an independent Preventive Services Task Force (referred to in this subsection as the ‘Task Force’) to be composed 

of individuals with appropriate expertise. Such Task Force 

shall review the scientific evidence related to the effectiveness, 

appropriateness, and cost-effectiveness of clinical preventive 

services for the purpose of developing recommendations for the 

health care community, and updating previous clinical preventive recommendations, to be published in the Guide to Clinical 

Preventive Services (referred to in this section as the ‘Guide’), 

for individuals and organizations delivering clinical services, 

including primary care professionals, health care systems, professional societies, employers, community organizations, nonprofit organizations, Congress and other policy-makers, governmental public health agencies, health care quality organizations, and organizations developing national health objectives. 
467 Sec. 4003 PPACA (Consolidated) 

Such recommendations shall consider clinical preventive best 

practice recommendations from the Agency for Healthcare Research and Quality, the National Institutes of Health, the Centers for Disease Control and Prevention, the Institute of Medicine, specialty medical associations, patient groups, and scientific societies. 

‘‘(2) DUTIES.—The duties of the Task Force shall include— 

‘‘(A) the development of additional topic areas for new 

recommendations and interventions related to those topic 

areas, including those related to specific sub-populations 

and age groups; 

‘‘(B) at least once during every 5-year period, review 

interventions and update recommendations related to existing topic areas, including new or improved techniques to 

assess the health effects of interventions; 

‘‘(C) improved integration with Federal Government 

health objectives and related target setting for health improvement; 

‘‘(D) the enhanced dissemination of recommendations; 

‘‘(E) the provision of technical assistance to those 

health care professionals, agencies and organizations that 

request help in implementing the Guide recommendations; 

and 

‘‘(F) the submission of yearly reports to Congress and 

related agencies identifying gaps in research, such as preventive services that receive an insufficient evidence statement, and recommending priority areas that deserve further examination, including areas related to populations 

and age groups not adequately addressed by current recommendations. 

‘‘(3) ROLE OF AGENCY.—The Agency shall provide ongoing 

administrative, research, and technical support for the operations of the Task Force, including coordinating and supporting the dissemination of the recommendations of the Task 

Force, ensuring adequate staff resources, and assistance to 

those organizations requesting it for implementation of the 

Guide’s recommendations. 

‘‘(4) COORDINATION WITH COMMUNITY PREVENTIVE SERVICES

TASK FORCE.—The Task Force shall take appropriate steps to 

coordinate its work with the Community Preventive Services 

Task Force and the Advisory Committee on Immunization 

Practices, including the examination of how each task force’s 

recommendations interact at the nexus of clinic and community. 

‘‘(5) OPERATION.—Operation. In carrying out the duties 

under paragraph (2), the Task Force is not subject to the provisions of Appendix 2 of title 5, United States Code. 

‘‘(6) INDEPENDENCE.—All members of the Task Force convened under this subsection, and any recommendations made 

by such members, shall be independent and, to the extent practicable, not subject to political pressure. 

‘‘(7) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as may be necessary for 

each fiscal year to carry out the activities of the Task Force.’’. 
Sec. 4003\399U PHSA PPACA (Consolidated) 468 

(b) COMMUNITY PREVENTIVE SERVICES TASK FORCE.— 

(1) IN GENERAL.—Part P of title III of the Public Health 

Service Act, as amended by paragraph (2), is amended by adding at the end the following: 

‘‘SEC. 399U. ø42 U.S.C. 280g–10¿ COMMUNITY PREVENTIVE SERVICES 

TASK FORCE. 

‘‘(a) ESTABLISHMENT AND PURPOSE.—The Director of the Centers for Disease Control and Prevention shall convene an independent Community Preventive Services Task Force (referred to in 

this subsection as the ‘Task Force’) to be composed of individuals 

with appropriate expertise. Such Task Force shall review the scientific evidence related to the effectiveness, appropriateness, and 

cost-effectiveness of community preventive interventions for the 

purpose of developing recommendations, to be published in the 

Guide to Community Preventive Services (referred to in this section as the ‘Guide’), for individuals and organizations delivering 

population-based services, including primary care professionals, 

health care systems, professional societies, employers, community 

organizations, non-profit organizations, schools, governmental public health agencies, Indian tribes, tribal organizations and urban 

Indian organizations, medical groups, Congress and other policymakers. Community preventive services include any policies, programs, processes or activities designed to affect or otherwise affecting health at the population level. 

‘‘(b) DUTIES.—The duties of the Task Force shall include— 

‘‘(1) the development of additional topic areas for new recommendations and interventions related to those topic areas, 

including those related to specific populations and age groups, 

as well as the social, economic and physical environments that 

can have broad effects on the health and disease of populations 

and health disparities among sub-populations and age groups; 

‘‘(2) at least once during every 5-year period, review interventions and update recommendations related to existing topic 

areas, including new or improved techniques to assess the 

health effects of interventions, including health impact assessment and population health modeling; 

‘‘(3) improved integration with Federal Government health 

objectives and related target setting for health improvement; 

‘‘(4) the enhanced dissemination of recommendations; 

‘‘(5) the provision of technical assistance to those health 

care professionals, agencies, and organizations that request 

help in implementing the Guide recommendations; and 

‘‘(6) providing yearly reports to Congress and related agencies identifying gaps in research and recommending priority 

areas that deserve further examination, including areas related to populations and age groups not adequately addressed 

by current recommendations. 

‘‘(c) ROLE OF AGENCY.—The Director shall provide ongoing administrative, research, and technical support for the operations of 

the Task Force, including coordinating and supporting the dissemination of the recommendations of the Task Force, ensuring adequate staff resources, and assistance to those organizations requesting it for implementation of Guide recommendations. 
469 Sec. 4004 PPACA (Consolidated) 

‘‘(d) COORDINATION WITH PREVENTIVE SERVICES TASK FORCE.— The Task Force shall take appropriate steps to coordinate its work 

with the U.S. Preventive Services Task Force and the Advisory 

Committee on Immunization Practices, including the examination 

of how each task force’s recommendations interact at the nexus of 

clinic and community. 

‘‘(e) OPERATION.—In carrying out the duties under subsection 

(b), the Task Force shall not be subject to the provisions of Appendix 2 of title 5, United States Code. 

‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated such sums as may be necessary for each fiscal 

year to carry out the activities of the Task Force.’’. 

(2) TECHNICAL AMENDMENTS.— (A) Section 399R of the Public Health Service Act (as 

added by section 2 of the ALS Registry Act (Public Law 

110–373; 122 Stat. 4047)) is redesignated as section 399S. 

(B) Section 399R of such Act (as added by section 3 of 

the Prenatally and Postnatally Diagnosed Conditions 

Awareness Act (Public Law 110–374; 122 Stat. 4051)) is 

redesignated as section 399T. 

SEC. 4004. ø42 U.S.C. 300u–12¿ EDUCATION AND OUTREACH CAMPAIGN 

REGARDING PREVENTIVE BENEFITS. 

(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’) shall provide for 

the planning and implementation of a national public–private partnership for a prevention and health promotion outreach and education campaign to raise public awareness of health improvement 

across the life span. Such campaign shall include the dissemination 

of information that— 

(1) describes the importance of utilizing preventive services to promote wellness, reduce health disparities, and mitigate chronic disease; 

(2) promotes the use of preventive services recommended 

by the United States Preventive Services Task Force and the 

Community Preventive Services Task Force; 

(3) encourages healthy behaviors linked to the prevention 

of chronic diseases; 

(4) explains the preventive services covered under health 

plans offered through an Exchange; øAs revised by section 

10401(c)¿ 

(5) describes additional preventive care supported by the 

Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Substance Abuse and 

Mental Health Services Administration, the Advisory Committee on Immunization Practices, and other appropriate agencies; and 

(6) includes general health promotion information. 

(b) CONSULTATION.—In coordinating the campaign under subsection (a), the Secretary shall consult with the Institute of Medicine to provide ongoing advice on evidence-based scientific information for policy, program development, and evaluation. 

(c) MEDIA CAMPAIGN.— 

(1) IN GENERAL.—Not later than 1 year after the date of 

enactment of this Act, the Secretary, acting through the Direc-
Sec. 4004 PPACA (Consolidated) 470 

tor of the Centers for Disease Control and Prevention, shall establish and implement a national science-based media campaign on health promotion and disease prevention. 

(2) REQUIREMENT OF CAMPAIGN.—The campaign implemented under paragraph (1)— 

(A) 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; 

(B) shall be carried out through competitively bid contracts awarded to entities providing for the professional 

production and design of such campaign; 

(C) 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; 

(D) shall not be duplicative of any other Federal efforts relating to health promotion and disease prevention; 

and 

(E) may include the use of humor and nationally recognized positive role models. 

(3) EVALUATION.—The Secretary shall ensure that the 

campaign implemented under paragraph (1) 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. 

(d) 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. 

(e) 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, 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 Medicare and Medicaid. 

(f) PERSONALIZED PREVENTION PLANS.— 

(1) 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. 

(2) USE.—The website developed under paragraph (1) shall 

be designed to be used as a source of the most up-to-date scientific evidence relating to disease prevention for 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 infor-
471 Sec. 4101 PPACA (Consolidated) 

mation) relating to the 5 leading diseases in the United States, 

and obtain personalized suggestions for preventing such diseases. 

(g) INTERNET PORTAL.—The Secretary shall establish an Internet portal for accessing risk-assessment tools developed and maintained by private and academic entities. 

(h) PRIORITY FUNDING.—Funding for the activities authorized 

under this section shall take priority over funding provided 

through the Centers for Disease Control and Prevention 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 section. 

(i) PUBLIC AWARENESS OF PREVENTIVE AND OBESITY-RELATED

SERVICES.— 

(1) INFORMATION TO STATES.—The Secretary of Health and 

Human Services shall provide guidance and relevant information to States and health care providers regarding preventive 

and obesity-related services that are available to Medicaid enrollees, including obesity screening and counseling for children 

and adults. 

(2) INFORMATION TO ENROLLEES.—Each State shall design 

a public awareness campaign to educate Medicaid enrollees regarding availability and coverage of such services, with the 

goal of reducing incidences of obesity. 

(3) REPORT.—Not later than January 1, 2011, and every 3 

years thereafter through January 1, 2017, the Secretary of 

Health and Human Services shall report to Congress on the 

status and effectiveness of efforts under paragraphs (1) and (2), 

including summaries of the States’ efforts to increase awareness of coverage of obesity-related services. 

(j) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated such sums as may be necessary to carry out this 

section. 

Subtitle B—Increasing Access to Clinical 

Preventive Services 

SEC. 4101. ø42 U.S.C. 280h–4¿ SCHOOL-BASED HEALTH CENTERS. 

(a) GRANTS FOR THE ESTABLISHMENT OF SCHOOL-BASED

HEALTH CENTERS.— 

(1) PROGRAM.—The Secretary of Health and Human Services (in this subsection referred to as the ‘‘Secretary’’) shall establish a program to award grants to eligible entities to support the operation of school-based health centers. 

(2) ELIGIBILITY.—To be eligible for a grant under this subsection, an entity shall— 

(A) be a school-based health center or a sponsoring facility of a school-based health center; and 

(B) submit an application at such time, in such manner, and containing such information as the Secretary may 

require, including at a minimum an assurance that funds 

awarded under the grant shall not be used to provide any 
Sec. 4101\399Z–1 PHSA PPACA (Consolidated) 472 

service that is not authorized or allowed by Federal, State, 

or local law. 

(3) PREFERENCE.—In awarding grants under this section, 

the Secretary shall give preference to awarding grants for 

school-based health centers that serve a large population of 

children eligible for medical assistance under the State Medicaid plan under title XIX of the Social Security Act or under 

a waiver of such plan or children eligible for child health assistance under the State child health plan under title XXI of 

that Act (42 U.S.C. 1397aa et seq.). 

(4) LIMITATION ON USE OF FUNDS.—An eligible entity shall 

use funds provided under a grant awarded under this subsection only for expenditures for facilities (including the acquisition or improvement of land, or the acquisition, construction, 

expansion, replacement, or other improvement of any building 

or other facility), equipment, or similar expenditures, as specified by the Secretary. No funds provided under a grant awarded under this section shall be used for expenditures for personnel or to provide health services. 

(5) APPROPRIATIONS.—Out of any funds in the Treasury 

not otherwise appropriated, there is appropriated for each of 

fiscal years 2010 through 2013, $50,000,000 for the purpose of 

carrying out this subsection. Funds appropriated under this 

paragraph shall remain available until expended. 

(6) DEFINITIONS.—In this subsection, the terms ‘‘schoolbased health center’’ and ‘‘sponsoring facility’’ have the meanings given those terms in section 2110(c)(9) of the Social Security Act (42 U.S.C. 1397jj(c)(9)). 

(b) GRANTS FOR THE OPERATION OF SCHOOL-BASED HEALTH

CENTERS.—Part Q of title III of the Public Health Service Act (42 

U.S.C. 280h et seq.) is amended by adding at the end the following: 

‘‘SEC. 399Z–1. ø42 U.S.C. 280h–5¿ SCHOOL-BASED HEALTH CENTERS. 

‘‘(a) DEFINITIONS; ESTABLISHMENT OF CRITERIA.—In this section: 

‘‘(1) COMPREHENSIVE PRIMARY HEALTH SERVICES.—The 

term ‘comprehensive primary health services’ means the core 

services offered by school-based health centers, which shall include the following: 

‘‘(A) PHYSICAL.—Comprehensive health assessments, 

diagnosis, and treatment of minor, acute, and chronic medical conditions, and referrals to, and follow-up for, specialty care and oral and vision health services. øAs revised 

by section 10402(a)¿ 

‘‘(B) MENTAL HEALTH.—Mental health and substance 

use disorder assessments, crisis intervention, counseling, 

treatment, and referral to a continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs. 

‘‘(2) MEDICALLY UNDERSERVED CHILDREN AND ADOLESCENTS.— 

‘‘(A) IN GENERAL.—The term ‘medically underserved 

children and adolescents’ means a population of children 

and adolescents who are residents of an area designated as 
473 Sec. 4101 PPACA (Consolidated) \399Z–1 PHSA 

a medically underserved area or a health professional 

shortage area by the Secretary. 

‘‘(B) CRITERIA.—The Secretary shall prescribe criteria 

for determining the specific shortages of personal health 

services for medically underserved children and adolescents under subparagraph (A) that shall— 

‘‘(i) take into account any comments received by 

the Secretary from the chief executive officer of a 

State and local officials in a State; and 

‘‘(ii) include factors indicative of the health status 

of such children and adolescents of an area, including 

the ability of the residents of such area to pay for 

health services, the accessibility of such services, the 

availability of health professionals to such children 

and adolescents, and other factors as determined appropriate by the Secretary. 

‘‘(3) SCHOOL-BASED HEALTH CENTER.—The term ‘schoolbased health center’ means a health clinic that— 

‘‘(A) meets the definition of a school-based health center under section 2110(c)(9)(A) of the Social Security Act 

and is administered by a sponsoring facility (as defined in 

section 2110(c)(9)(B) of the Social Security Act); 

‘‘(B) provides, at a minimum, comprehensive primary 

health services during school hours to children and adolescents by health professionals in accordance with established standards, community practice, reporting laws, and 

other State laws, including parental consent and notification laws that are not inconsistent with Federal law; and 

‘‘(C) does not perform abortion services. 

‘‘(b) AUTHORITY TO AWARD GRANTS.—The Secretary shall 

award grants for the costs of the operation of school-based health 

centers (referred to in this section as ‘SBHCs’) that meet the requirements of this section. 

‘‘(c) APPLICATIONS.—To be eligible to receive a grant under this 

section, an entity shall— 

‘‘(1) be an SBHC (as defined in subsection (a)(3)); and 

‘‘(2) submit to the Secretary an application at such time, 

in such manner, and containing— 

‘‘(A) evidence that the applicant meets all criteria necessary to be designated an SBHC; 

‘‘(B) evidence of local need for the services to be provided by the SBHC; 

‘‘(C) an assurance that— 

‘‘(i) SBHC services will be provided to those children and adolescents for whom parental or guardian 

consent has been obtained in cooperation with Federal, State, and local laws governing health care service provision to children and adolescents; 

‘‘(ii) the SBHC has made and will continue to 

make every reasonable effort to establish and maintain collaborative relationships with other health care 

providers in the catchment area of the SBHC; 

‘‘(iii) the SBHC will provide on-site access during 

the academic day when school is in session and 24- 
Sec. 4101\399Z–1 PHSA PPACA (Consolidated) 474 

hour coverage through an on-call system and through 

its backup health providers to ensure access to services on a year-round basis when the school or the 

SBHC is closed; 

‘‘(iv) the SBHC will be integrated into the school 

environment and will coordinate health services with 

school personnel, such as administrators, teachers, 

nurses, counselors, and support personnel, as well as 

with other community providers co-located at the 

school; 

‘‘(v) the SBHC sponsoring facility assumes all responsibility for the SBHC administration, operations, 

and oversight; and 

‘‘(vi) the SBHC will comply with Federal, State, 

and local laws concerning patient privacy and student 

records, including regulations promulgated under the 

Health Insurance Portability and Accountability Act of 

1996 and section 444 of the General Education Provisions Act; and 

‘‘(D) such other information as the Secretary may require. 

‘‘(d) PREFERENCES AND CONSIDERATION.—In reviewing applications: 

‘‘(1) The Secretary may give preference to applicants who 

demonstrate an ability to serve the following: 

‘‘(A) Communities that have evidenced barriers to primary health care and mental health and substance use 

disorder prevention services for children and adolescents. 

‘‘(B) Communities with high per capita numbers of 

children and adolescents who are uninsured, underinsured, 

or enrolled in public health insurance programs. 

‘‘(C) Populations of children and adolescents that have 

historically demonstrated difficulty in accessing health and 

mental health and substance use disorder prevention services. 

‘‘(2) The Secretary may give consideration to whether an 

applicant has received a grant under subsection (a) of section 

4101 of the Patient Protection and Affordable Care Act. 

‘‘(e) WAIVER OF REQUIREMENTS.—The Secretary may— 

‘‘(1) under appropriate circumstances, waive the application of all or part of the requirements of this subsection with 

respect to an SBHC for not to exceed 2 years; and 

‘‘(2) upon a showing of good cause, waive the requirement 

that the SBHC provide all required comprehensive primary 

health services for a designated period of time to be determined by the Secretary. 

‘‘(f) USE OF FUNDS.— 

‘‘(1) FUNDS.—Funds awarded under a grant under this section— 

‘‘(A) may be used for— 

‘‘(i) acquiring and leasing equipment (including 

the costs of amortizing the principle of, and paying interest on, loans for such equipment); 
475 Sec. 4101 PPACA (Consolidated) \399Z–1 PHSA 

‘‘(ii) providing training related to the provision of 

required comprehensive primary health services and 

additional health services; 

‘‘(iii) the management and operation of health center programs; 

‘‘(iv) the payment of salaries for physicians, 

nurses, and other personnel of the SBHC; and 

‘‘(B) may not be used to provide abortions. 

‘‘(2) CONSTRUCTION.—The Secretary may award grants 

which may be used to pay the costs associated with expanding 

and modernizing existing buildings for use as an SBHC, including the purchase of trailers or manufactured buildings to 

install on the school property. 

‘‘(3) LIMITATIONS.— 

‘‘(A) IN GENERAL.—Any provider of services that is determined by a State to be in violation of a State law described in subsection (a)(3)(B) with respect to activities 

carried out at a SBHC shall not be eligible to receive additional funding under this section. 

‘‘(B) NO OVERLAPPING GRANT PERIOD.—No entity that 

has received funding under section 330 for a grant period 

shall be eligible for a grant under this section for with respect to the same grant period. 

‘‘(g) MATCHING REQUIREMENT.— 

‘‘(1) IN GENERAL.—Each eligible entity that receives a 

grant under this section shall provide, from non-Federal 

sources, an amount equal to 20 percent of the amount of the 

grant (which may be provided in cash or in-kind) to carry out 

the activities supported by the grant. 

‘‘(2) WAIVER.—The Secretary may waive all or part of the 

matching requirement described in paragraph (1) for any fiscal 

year for the SBHC if the Secretary determines that applying 

the matching requirement to the SBHC would result in serious 

hardship or an inability to carry out the purposes of this section. 

‘‘(h) SUPPLEMENT, NOT SUPPLANT.—Grant funds provided 

under this section shall be used to supplement, not supplant, other 

Federal or State funds. 

‘‘(i) EVALUATION.—The Secretary shall develop and implement 

a plan for evaluating SBHCs and monitoring quality performance 

under the awards made under this section. 

‘‘(j) AGE APPROPRIATE SERVICES.—An eligible entity receiving 

funds under this section shall only provide age appropriate services 

through a SBHC funded under this section to an individual. 

‘‘(k) PARENTAL CONSENT.—An eligible entity receiving funds 

under this section shall not provide services through a SBHC funded under this section to an individual without the consent of the 

parent or guardian of such individual if such individual is considered a minor under applicable State law. 

‘‘(l) AUTHORIZATION OF APPROPRIATIONS.—For purposes of carrying out this section, there are authorized to be appropriated such 

sums as may be necessary for each of the fiscal years 2010 through 

2014.’’. 
Sec. 4102 PPACA (Consolidated) 476 

SEC. 4102. ORAL HEALTHCARE PREVENTION ACTIVITIES. 

(a) IN GENERAL.—Title III of the Public Health Service Act (42 

U.S.C. 241 et seq.), as amended by section 3025, is amended by 

adding at the end the following: 

‘‘PART T—ORAL HEALTHCARE PREVENTION 

ACTIVITIES 

‘‘SEC. 399LL. ø42 U.S.C. 280k¿ ORAL HEALTHCARE PREVENTION EDUCATION CAMPAIGN. 

‘‘(a) ESTABLISHMENT.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention and in consultation with professional oral health organizations, shall, subject 

to the availability of appropriations, establish a 5-year national, 

public education campaign (referred to in this section as the ‘campaign’) that is focused on oral healthcare prevention and education, 

including prevention of oral disease such as early childhood and 

other caries, periodontal disease, and oral cancer. 

‘‘(b) REQUIREMENTS.—In establishing the campaign, the Secretary shall— 

‘‘(1) ensure that activities are targeted towards specific 

populations such as children, pregnant women, parents, the elderly, individuals with disabilities, and ethnic and racial minority populations, including Indians, Alaska Natives and Native Hawaiians (as defined in section 4(c) of the Indian Health 

Care Improvement Act) in a culturally and linguistically appropriate manner; and 

‘‘(2) utilize science-based strategies to convey oral health 

prevention messages that include, but are not limited to, community water fluoridation and dental sealants. 

‘‘(c) PLANNING AND IMPLEMENTATION.—Not later than 2 years 

after the date of enactment of this section, the Secretary shall 

begin implementing the 5-year campaign. During the 2-year period 

referred to in the previous sentence, the Secretary shall conduct 

planning activities with respect to the campaign. 

‘‘SEC. 399LL–1. ø42 U.S.C. 280k–1¿ RESEARCH-BASED DENTAL CARIES 

DISEASE MANAGEMENT. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Director 

of the Centers for Disease Control and Prevention, shall award 

demonstration grants to eligible entities to demonstrate the effectiveness of research-based dental caries disease management activities. 

‘‘(b) ELIGIBILITY.—To be eligible for a grant under this section, 

an entity shall— 

‘‘(1) be a community-based provider of dental services (as 

defined by the Secretary), including a Federally-qualified 

health center, a clinic of a hospital owned or operated by a 

State (or by an instrumentality or a unit of government within 

a State), a State or local department of health, a dental program of the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization (as such terms are 

defined in section 4 of the Indian Health Care Improvement 

Act), a health system provider, a private provider of dental 
477 Sec. 4102 PPACA (Consolidated) 

services, medical, dental, public health, nursing, nutrition educational institutions, or national organizations involved in improving children’s oral health; and 

‘‘(2) submit to the Secretary an application at such time, 

in such manner, and containing such information as the Secretary may require. 

‘‘(c) USE OF FUNDS.—A grantee shall use amounts received 

under a grant under this section to demonstrate the effectiveness 

of research-based dental caries disease management activities. 

‘‘(d) USE OF INFORMATION.—The Secretary shall utilize information generated from grantees under this section in planning and 

implementing the public education campaign under section 399LL. 

‘‘SEC. 399LL–2. ø42 U.S.C. 280k–2¿ AUTHORIZATION OF APPROPRIATIONS. 

‘‘There is authorized to be appropriated to carry out this part, 

such sums as may be necessary.’’. 

(b) SCHOOL-BASED SEALANT PROGRAMS.—Section 317M(c)(1) of 

the Public Health Service Act (42 U.S.C. 247b–14(c)(1)) is amended 

by striking ‘‘may award grants to States and Indian tribes’’ and inserting ‘‘shall award a grant to each of the 50 States and territories 

and to Indians, Indian tribes, tribal organizations and urban Indian organizations (as such terms are defined in section 4 of the 

Indian Health Care Improvement Act)’’. 

(c) ORAL HEALTH INFRASTRUCTURE.—Section 317M of the Public Health Service Act (42 U.S.C. 247b–14) is amended— 

(1) by redesignating subsections (d) and (e) as subsections 

(e) and (f), respectively; and 

(2) by inserting after subsection (c), the following: 

‘‘(d) ORAL HEALTH INFRASTRUCTURE.— 

‘‘(1) COOPERATIVE AGREEMENTS.—The Secretary, acting 

through the Director of the Centers for Disease Control and 

Prevention, shall enter into cooperative agreements with State, 

territorial, and Indian tribes or tribal organizations (as those 

terms are defined in section 4 of the Indian Health Care Improvement Act) to establish oral health leadership and program guidance, oral health data collection and interpretation, 

(including determinants of poor oral health among vulnerable 

populations), a multi-dimensional delivery system for oral 

health, and to implement science-based programs (including 

dental sealants and community water fluoridation) to improve 

oral health. 

‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated such sums as necessary to carry out 

this subsection for fiscal years 2010 through 2014.’’. 

(d) UPDATING NATIONAL ORAL HEALTHCARE SURVEILLANCE ACTIVITIES.—ø42 U.S.C.280k–3¿ 

(1) PRAMS.— 

(A) IN GENERAL.—The Secretary of Health and Human 

Services (referred to in this subsection as the ‘‘Secretary’’) 

shall carry out activities to update and improve the Pregnancy Risk Assessment Monitoring System (referred to in 

this section as ‘‘PRAMS’’) as it relates to oral healthcare. 

(B) STATE REPORTS AND MANDATORY MEASUREMENTS.— 
Sec. 4103 PPACA (Consolidated) 478 

(i) IN GENERAL.—Not later than 5 years after the 

date of enactment of this Act, and every 5 years thereafter, a State shall submit to the Secretary a report 

concerning activities conducted within the State under 

PRAMS. 

(ii) MEASUREMENTS.—The oral healthcare measurements developed by the Secretary for use under 

PRAMS shall be mandatory with respect to States for 

purposes of the State reports under clause (i). 

(C) FUNDING.—There is authorized to be appropriated 

to carry out this paragraph, such sums as may be necessary. 

(2) NATIONAL HEALTH AND NUTRITION EXAMINATION SUR- VEY.—The Secretary shall develop oral healthcare components 

that shall include tooth-level surveillance for inclusion in the 

National Health and Nutrition Examination Survey. Such components shall be updated by the Secretary at least every 6 

years. For purposes of this paragraph, the term ‘‘tooth-level 

surveillance’’ means a clinical examination where an examiner 

looks at each dental surface, on each tooth in the mouth and 

as expanded by the Division of Oral Health of the Centers for 

Disease Control and Prevention. 

(3) MEDICAL EXPENDITURES PANEL SURVEY.—The Secretary 

shall ensure that the Medical Expenditures Panel Survey by 

the Agency for Healthcare Research and Quality includes the 

verification of dental utilization, expenditure, and coverage 

findings through conduct of a look-back analysis. 

(4) NATIONAL ORAL HEALTH SURVEILLANCE SYSTEM.— (A) APPROPRIATIONS.—There is authorized to be appropriated, such sums as may be necessary for each of fiscal 

years 2010 through 2014 to increase the participation of 

States in the National Oral Health Surveillance System 

from 16 States to all 50 States, territories, and District of 

Columbia. 

(B) REQUIREMENTS.—The Secretary shall ensure that 

the National Oral Health Surveillance System include the 

measurement of early childhood caries. 

SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT PROVIDING A PERSONALIZED PREVENTION PLAN. 

(a) COVERAGE OF PERSONALIZED PREVENTION PLAN SERVICES.— (1) IN GENERAL.—Section 1861(s)(2) of the Social Security 

Act (42 U.S.C. 1395x(s)(2)) is amended— 

(A) in subparagraph (DD), by striking ‘‘and’’ at the 

end; 

(B) in subparagraph (EE), by adding ‘‘and’’ at the end; 

and 

(C) by adding at the end the following new subparagraph: 

‘‘(FF) personalized prevention plan services (as defined in 

subsection (hhh));’’. 

(2) CONFORMING AMENDMENTS.—Clauses (i) and (ii) of section 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 

1395x(s)(2)(K)) are each amended by striking ‘‘subsection 

(ww)(1)’’ and inserting ‘‘subsections (ww)(1) and (hhh)’’. 
479 Sec. 4103 PPACA (Consolidated) 

(b) PERSONALIZED PREVENTION PLAN SERVICES DEFINED.—Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended 

by adding at the end the following new subsection: 

‘‘Annual Wellness Visit 

‘‘(hhh)(1) The term ‘personalized prevention plan services’ 

means the creation of a plan for an individual— 

‘‘(A) that includes a health risk assessment (that meets the 

guidelines established by the Secretary under paragraph 

(4)(A)) of the individual that is completed prior to or as part 

of the same visit with a health professional described in paragraph (3); and 

‘‘(B) that— 

‘‘(i) takes into account the results of the health risk assessment; and 

‘‘(ii) may contain the elements described in paragraph 

(2). 

‘‘(2) Subject to paragraph (4)(H), the elements described in this 

paragraph are the following: 

‘‘(A) The establishment of, or an update to, the individual’s 

medical and family history. 

‘‘(B) A list of current providers and suppliers that are regularly involved in providing medical care to the individual (including a list of all prescribed medications). 

‘‘(C) A measurement of height, weight, body mass index (or 

waist circumference, if appropriate), blood pressure, and other 

routine measurements. 

‘‘(D) Detection of any cognitive impairment. 

‘‘(E) The establishment of, or an update to, the following: 

‘‘(i) A screening schedule for the next 5 to 10 years, as 

appropriate, based on recommendations of the United 

States Preventive Services Task Force and the Advisory 

Committee on Immunization Practices, and the individual’s health status, screening history, and age-appropriate 

preventive services covered under this title. 

‘‘(ii) A list of risk factors and conditions for which primary, secondary, or tertiary prevention interventions are 

recommended or are underway, including any mental 

health conditions or any such risk factors or conditions 

that have been identified through an initial preventive 

physical examination (as described under subsection 

(ww)(1)), and a list of treatment options and their associated risks and benefits. 

‘‘(F) The furnishing of personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk 

factors and improving self-management, or community-based 

lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition. 

‘‘(G) Any other element determined appropriate by the Secretary. 

‘‘(3) A health professional described in this paragraph is— 
Sec. 4103 PPACA (Consolidated) 480 

‘‘(A) a physician; 

‘‘(B) a practitioner described in clause (i) of section 

1842(b)(18)(C); or 

‘‘(C) a medical professional (including a health educator, 

registered dietitian, or nutrition professional) or a team of 

medical professionals, as determined appropriate by the Secretary, under the supervision of a physician. 

‘‘(4)(A) For purposes of paragraph (1)(A), the Secretary, not 

later than 1 year after the date of enactment of this subsection, 

shall establish publicly available guidelines for health risk assessments. Such guidelines shall be developed in consultation with relevant groups and entities and shall provide that a health risk assessment— 

‘‘(i) identify chronic diseases, injury risks, modifiable risk 

factors, and urgent health needs of the individual; and 

‘‘(ii) may be furnished— 

‘‘(I) through an interactive telephonic or web-based 

program that meets the standards established under subparagraph (B); 

‘‘(II) during an encounter with a health care professional; 

‘‘(III) through community-based prevention programs; 

or 

‘‘(IV) through any other means the Secretary determines appropriate to maximize accessibility and ease of 

use by beneficiaries, while ensuring the privacy of such 

beneficiaries. 

‘‘(B) Not later than 1 year after the date of enactment of this 

subsection, the Secretary shall establish standards for interactive 

telephonic or web-based programs used to furnish health risk assessments under subparagraph (A)(ii)(I). The Secretary may utilize 

any health risk assessment developed under section 4004(f) of the 

Patient Protection and Affordable Care Act as part of the requirement to develop a personalized prevention plan to comply with this 

subparagraph. 

‘‘(C)(i) Not later than 18 months after the date of enactment 

of this subsection, the Secretary shall develop and make available 

to the public a health risk assessment model. Such model shall 

meet the guidelines under subparagraph (A) and may be used to 

meet the requirement under paragraph (1)(A). 

‘‘(ii) Any health risk assessment that meets the guidelines 

under subparagraph (A) and is approved by the Secretary may be 

used to meet the requirement under paragraph (1)(A). 

‘‘(D) The Secretary may coordinate with community-based entities (including State Health Insurance Programs, Area Agencies on 

Aging, Aging and Disability Resource Centers, and the Administration on Aging) to— 

‘‘(i) ensure that health risk assessments are accessible to 

beneficiaries; and 

‘‘(ii) provide appropriate support for the completion of 

health risk assessments by beneficiaries. 

‘‘(E) The Secretary shall establish procedures to make beneficiaries and providers aware of the requirement that a beneficiary 
481 Sec. 4103 PPACA (Consolidated) 

complete a health risk assessment prior to or at the same time as 

receiving personalized prevention plan services. 

‘‘(F) To the extent practicable, the Secretary shall encourage 

the use of, integration with, and coordination of health information 

technology (including use of technology that is compatible with 

electronic medical records and personal health records) and may 

experiment with the use of personalized technology to aid in the 

development of self-management skills and management of and adherence to provider recommendations in order to improve the 

health status of beneficiaries. 

‘‘(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. 

øReplaced by section 10402(b)¿ 

‘‘(H) The Secretary shall issue guidance that— 

‘‘(i) identifies elements under paragraph (2) that are required to be provided to a beneficiary as part of their first visit 

for personalized prevention plan services; and 

‘‘(ii) establishes a yearly schedule for appropriate provision 

of such elements thereafter.’’. 

(c) PAYMENT AND ELIMINATION OF COST-SHARING.— (1) PAYMENT AND ELIMINATION OF COINSURANCE.—Section 

1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is 

amended— 

(A) in subparagraph (N), by inserting ‘‘other than personalized prevention plan services (as defined in section 

1861(hhh)(1))’’ after ‘‘(as defined in section 1848(j)(3))’’; 

(B) by striking ‘‘and’’ before ‘‘(W)’’; and 

(C) by inserting before the semicolon at the end the 

following: ‘‘, and (X) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)), the 

amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined 

under the payment basis determined under section 1848’’. 

(2) PAYMENT UNDER PHYSICIAN FEE SCHEDULE.—Section 

1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) 

is amended by inserting ‘‘(2)(FF) (including administration of 

the health risk assessment) ,’’ after ‘‘(2)(EE),’’. 

(3) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL

SETTINGS.— 

(A) EXCLUSION FROM OPD FEE SCHEDULE.—Section 

1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 

1395l(t)(1)(B)(iv)) is amended by striking ‘‘and diagnostic 

mammography’’ and inserting ‘‘, diagnostic mammography, 

or personalized prevention plan services (as defined in section 1861(hhh)(1))’’. 

(B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of 

the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended— 
Sec. 4104 PPACA (Consolidated) 482 

(i) in subparagraph (F), by striking ‘‘and’’ at the 

end; 

(ii) in subparagraph (G)(ii), by striking the comma 

at the end and inserting ‘‘; and’’; and 

(iii) by inserting after subparagraph (G)(ii) the following new subparagraph: 

‘‘(H) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)) furnished by an 

outpatient department of a hospital, the amount determined under paragraph (1)(X),’’. 

(4) WAIVER OF APPLICATION OF DEDUCTIBLE.—The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 

1395l(b)) is amended— 

(A) by striking ‘‘and’’ before ‘‘(9)’’; and 

(B) by inserting before the period the following: ‘‘, and 

(10) such deductible shall not apply with respect to personalized prevention plan services (as defined in section 

1861(hhh)(1))’’. 

(d) FREQUENCY LIMITATION.—Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended— 

(1) in paragraph (1)— 

(A) in subparagraph (N), by striking ‘‘and’’ at the end; 

(B) in subparagraph (O), by striking the semicolon at 

the end and inserting ‘‘, and’’; and 

(C) by adding at the end the following new subparagraph: 

‘‘(P) in the case of personalized prevention plan services 

(as defined in section 1861(hhh)(1)), which are performed more 

frequently than is covered under such section;’’; and 

(2) in paragraph (7), by striking ‘‘or (K)’’ and inserting 

‘‘(K), or (P)’’. 

(e) EFFECTIVE DATE.—The amendments made by this section 

shall apply to services furnished on or after January 1, 2011. 

SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN 

MEDICARE. 

(a) DEFINITION OF PREVENTIVE SERVICES.—Section 1861(ddd) of 

the Social Security Act (42 U.S.C. 1395x(ddd)) is amended— 

(1) in the heading, by inserting ‘‘; Preventive Services’’ 

after ‘‘Services’’; 

(2) in paragraph (1), by striking ‘‘not otherwise described 

in this title’’ and inserting ‘‘not described in subparagraph (A) 

or (C) of paragraph (3)’’; and 

(3) by adding at the end the following new paragraph: 

‘‘(3) The term ‘preventive services’ means the following: 

‘‘(A) The screening and preventive services described in 

subsection (ww)(2) (other than the service described in subparagraph (M) of such subsection). 

‘‘(B) An initial preventive physical examination (as defined 

in subsection (ww)). 

‘‘(C) Personalized prevention plan services (as defined in 

subsection (hhh)(1)).’’. 

(b) PAYMENT AND ELIMINATION OF COINSURANCE IN ALL SETTINGS.—øReplaced by section 10406¿ Section 1833(a)(1) of the So-
483 Sec. 4105 PPACA (Consolidated) 

cial 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)’’. 

(c) WAIVER OF APPLICATION OF DEDUCTIBLE FOR PREVENTIVE

SERVICES AND COLORECTAL CANCER SCREENING TESTS.—Section 

1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended 

by section 4103(c)(4), is amended— 

(1) in paragraph (1), by striking ‘‘items and services described in section 1861(s)(10)(A)’’ and inserting ‘‘preventive 

services described in subparagraph (A) of section 1861(ddd)(3) 

that 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.’’; and 

(2) by adding at the end the following new sentence: ‘‘Paragraph (1) of the first sentence of this subsection shall apply 

with respect to a colorectal cancer screening test regardless of 

the code that is billed for the establishment of a diagnosis as 

a result of the test, or for the removal of tissue or other matter 

or other procedure that is furnished in connection with, as a 

result of, and in the same clinical encounter as the screening 

test.’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to items and services furnished on or after January 1, 

2011. 

SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES IN 

MEDICARE. 

(a) AUTHORITY TO MODIFY OR ELIMINATE COVERAGE OF CERTAIN PREVENTIVE SERVICES.—Section 1834 of the Social Security 

Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection: 
Sec. 4106 PPACA (Consolidated) 484 

‘‘(n) AUTHORITY TO MODIFY OR ELIMINATE COVERAGE OF CER- TAIN PREVENTIVE SERVICES.—Notwithstanding any other provision 

of this title, effective beginning on January 1, 2010, if the Secretary 

determines appropriate, the Secretary may— 

‘‘(1) modify— 

‘‘(A) the coverage of any preventive service described 

in subparagraph (A) of section 1861(ddd)(3) to the extent 

that such modification is consistent with the recommendations of the United States Preventive Services Task Force; 

and 

‘‘(B) the services included in the initial preventive 

physical examination described in subparagraph (B) of 

such section; and 

‘‘(2) provide that no payment shall be made under this title 

for a preventive service described in subparagraph (A) of such 

section that has not received a grade of A, B, C, or I by such 

Task Force.’’. 

(b) CONSTRUCTION.—Nothing in the amendment made by paragraph (1) shall be construed to affect the coverage of diagnostic or 

treatment services under title XVIII of the Social Security Act. 

SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR ELIGIBLE ADULTS IN MEDICAID. 

(a) CLARIFICATION OF INCLUSION OF SERVICES.—Section 

1905(a)(13) of the Social Security Act (42 U.S.C. 1396d(a)(13)) is 

amended to read as follows: 

‘‘(13) other diagnostic, screening, preventive, and rehabilitative services, including— 

‘‘(A) any clinical preventive services that are assigned 

a grade of A or B by the United States Preventive Services 

Task Force; 

‘‘(B) with respect to an adult individual, approved vaccines recommended by the Advisory Committee on Immunization Practices (an advisory committee established by 

the Secretary, acting through the Director of the Centers 

for Disease Control and Prevention) and their administration; and 

‘‘(C) any medical or remedial services (provided in a 

facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional 

level;’’. 

(b) INCREASED FMAP.—Section 1905(b) of the Social Security 

Act (42 U.S.C. 1396d(b)), as amended by sections 2001(a)(3)(A) and 

2004(c)(1), is amended in the first sentence— 

(1) by striking ‘‘, and (4)’’ and inserting ‘‘, (4)’’; and 

(2) by inserting before the period the following: ‘‘, and (5) 

in the case of a State that provides medical assistance for services and vaccines described in subparagraphs (A) and (B) of 

subsection (a)(13), and prohibits cost-sharing for such services 

and vaccines, the Federal medical assistance percentage, as determined under this subsection and subsection (y) (without regard to paragraph (1)(C) of such subsection), shall be increased 
485 Sec. 4107 PPACA (Consolidated) 

by 1 percentage point with respect to medical assistance for 

such services and vaccines and for items and services described 

in subsection (a)(4)(D)’’. 

(c) EFFECTIVE DATE.—The amendments made under this section shall take effect on January 1, 2013. 

SEC. 4107. COVERAGE OF COMPREHENSIVE TOBACCO CESSATION 

SERVICES FOR PREGNANT WOMEN IN MEDICAID. 

(a) REQUIRING COVERAGE OF COUNSELING AND

PHARMACOTHERAPY FOR CESSATION OF TOBACCO USE BY PREGNANT

WOMEN.—Section 1905 of the Social Security Act (42 U.S.C. 

1396d), as amended by sections 2001(a)(3)(B) and 2303, is further 

amended— 

(1) in subsection (a)(4)— 

(A) by striking ‘‘and’’ before ‘‘(C)’’; and 

(B) by inserting before the semicolon at the end the 

following new subparagraph: ‘‘; and (D) counseling and 

pharmacotherapy for cessation of tobacco use by pregnant 

women (as defined in subsection (bb))’’; and 

(2) by adding at the end the following: 

‘‘(bb)(1) For purposes of this title, the term ‘counseling and 

pharmacotherapy for cessation of tobacco use by pregnant women’ 

means diagnostic, therapy, and counseling services and 

pharmacotherapy (including the coverage of prescription and nonprescription tobacco cessation agents approved by the Food and 

Drug Administration) for cessation of tobacco use by pregnant 

women who use tobacco products or who are being treated for tobacco use that is furnished— 

‘‘(A) by or under the supervision of a physician; or 

‘‘(B) by any other health care professional who— 

‘‘(i) is legally authorized to furnish such services under 

State law (or the State regulatory mechanism provided by 

State law) of the State in which the services are furnished; 

and 

‘‘(ii) is authorized to receive payment for other services 

under this title or is designated by the Secretary for this 

purpose. 

‘‘(2) Subject to paragraph (3), such term is limited to— 

‘‘(A) services recommended with respect to pregnant 

women in ‘Treating Tobacco Use and Dependence: 2008 Update: A Clinical Practice Guideline’, published by the Public 

Health Service in May 2008, or any subsequent modification of 

such Guideline; and 

‘‘(B) such other services that the Secretary recognizes to be 

effective for cessation of tobacco use by pregnant women. 

‘‘(3) Such term shall not include coverage for drugs or 

biologicals that are not otherwise covered under this title.’’. 

(b) EXCEPTION FROM OPTIONAL RESTRICTION UNDER MEDICAID

PRESCRIPTION DRUG COVERAGE.—Section 1927(d)(2)(F) of the Social 

Security Act (42 U.S.C. 1396r–8(d)(2)(F)), as redesignated by section 2502(a), is amended by inserting before the period at the end 

the following: ‘‘, except, in the case of pregnant women when recommended in accordance with the Guideline referred to in section 

1905(bb)(2)(A), agents approved by the Food and Drug Administra-
Sec. 4108 PPACA (Consolidated) 486 

tion under the over-the-counter monograph process for purposes of 

promoting, and when used to promote, tobacco cessation’’. 

(c) REMOVAL OF COST-SHARING FOR COUNSELING AND

PHARMACOTHERAPY FOR CESSATION OF TOBACCO USE BY PREGNANT

WOMEN.— 

(1) GENERAL COST-SHARING LIMITATIONS.—Section 1916 of 

the Social Security Act (42 U.S.C. 1396o) is amended in each 

of subsections (a)(2)(B) and (b)(2)(B) by inserting ‘‘, and counseling and pharmacotherapy for cessation of tobacco use by 

pregnant women (as defined in section 1905(bb)) and covered 

outpatient drugs (as defined in subsection (k)(2) of section 1927 

and including nonprescription drugs described in subsection 

(d)(2) of such section) that are prescribed for purposes of promoting, and when used to promote, tobacco cessation by pregnant women in accordance with the Guideline referred to in 

section 1905(bb)(2)(A)’’ after ‘‘complicate the pregnancy’’. 

(2) APPLICATION TO ALTERNATIVE COST-SHARING.—Section 

1916A(b)(3)(B)(iii) of such Act (42 U.S.C. 1396o–1(b)(3)(B)(iii)) 

is amended by inserting ‘‘, and counseling and 

pharmacotherapy for cessation of tobacco use by pregnant 

women (as defined in section 1905(bb))’’ after ‘‘complicate the 

pregnancy’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall take effect on October 1, 2010. 

SEC. 4108. ø42 U.S.C. 1396a note¿ INCENTIVES FOR PREVENTION OF 

CHRONIC DISEASES IN MEDICAID. 

(a) INITIATIVES.— (1) ESTABLISHMENT.— (A) IN GENERAL.—The Secretary shall award grants to 

States to carry out initiatives to provide incentives to Medicaid beneficiaries who— 

(i) successfully participate in a program described 

in paragraph (3); and 

(ii) upon completion of such participation, demonstrate changes in health risk and outcomes, including the adoption and maintenance of healthy behaviors by meeting specific targets (as described in subsection (c)(2)). 

(B) PURPOSE.—The purpose of the initiatives under 

this section is to test approaches that may encourage behavior modification and determine scalable solutions. 

(2) DURATION.— 

(A) INITIATION OF PROGRAM; RESOURCES.—The Secretary shall awards grants to States beginning on January 

1, 2011, or beginning on the date on which the Secretary 

develops program criteria, whichever is earlier. The Secretary shall develop program criteria for initiatives under 

this section using relevant evidence-based research and resources, including the Guide to Community Preventive 

Services, the Guide to Clinical Preventive Services, and 

the National Registry of Evidence-Based Programs and 

Practices. 

(B) DURATION OF PROGRAM.—A State awarded a grant 

to carry out initiatives under this section shall carry out 
487 Sec. 4108 PPACA (Consolidated) 

such initiatives within the 5-year period beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. Initiatives under this section shall be carried out by a State 

for a period of not less than 3 years. 

(3) PROGRAM DESCRIBED.— 

(A) IN GENERAL.—A program described in this paragraph is a comprehensive, evidence-based, widely available, and easily accessible program, proposed by the State 

and approved by the Secretary, that is designed and 

uniquely suited to address the needs of Medicaid beneficiaries and has demonstrated success in helping individuals achieve one or more of the following: 

(i) Ceasing use of tobacco products. 

(ii) Controlling or reducing their weight. 

(iii) Lowering their cholesterol. 

(iv) Lowering their blood pressure. 

(v) Avoiding the onset of diabetes or, in the case 

of a diabetic, improving the management of that condition. 

(B) CO-MORBIDITIES.—A program under this section 

may also address co-morbidities (including depression) that 

are related to any of the conditions described in subparagraph (A). 

(C) WAIVER AUTHORITY.—The Secretary may waive the 

requirements of section 1902(a)(1) (relating to 

statewideness) of the Social Security Act for a State 

awarded a grant to conduct an initiative under this section 

and shall ensure that a State makes any program described in subparagraph (A) available and accessible to 

Medicaid beneficiaries. 

(D) FLEXIBILITY IN IMPLEMENTATION.—A State may 

enter into arrangements with providers participating in 

Medicaid, community-based organizations, faith-based organizations, public-private partnerships, Indian tribes, or 

similar entities or organizations to carry out programs described in subparagraph (A). 

(4) APPLICATION.—Following the development of program 

criteria by the Secretary, a State may submit an application, 

in such manner and containing such information as the Secretary may require, that shall include a proposal for programs 

described in paragraph (3)(A) and a plan to make Medicaid 

beneficiaries and providers participating in Medicaid who reside in the State aware and informed about such programs. 

(b) EDUCATION AND OUTREACH CAMPAIGN.— 

(1) STATE AWARENESS.—The Secretary shall conduct an 

outreach and education campaign to make States aware of the 

grants under this section. 

(2) PROVIDER AND BENEFICIARY EDUCATION.—A State 

awarded a grant to conduct an initiative under this section 

shall conduct an outreach and education campaign to make 

Medicaid beneficiaries and providers participating in Medicaid 

who reside in the State aware of the programs described in 
Sec. 4108 PPACA (Consolidated) 488 

subsection (a)(3) that are to be carried out by the State under 

the grant. 

(c) IMPACT.—A State awarded a grant to conduct an initiative 

under this section shall develop and implement a system to— 

(1) track Medicaid beneficiary participation in the program 

and validate changes in health risk and outcomes with clinical 

data, including the adoption and maintenance of health behaviors by such beneficiaries; 

(2) to the extent practicable, establish standards and 

health status targets for Medicaid beneficiaries participating in 

the program and measure the degree to which such standards 

and targets are met; 

(3) evaluate the effectiveness of the program and provide 

the Secretary with such evaluations; 

(4) report to the Secretary on processes that have been developed and lessons learned from the program; and 

(5) report on preventive services as part of reporting on 

quality measures for Medicaid managed care programs. 

(d) EVALUATIONS AND REPORTS.— (1) INDEPENDENT ASSESSMENT.—The Secretary shall enter 

into a contract with an independent entity or organization to 

conduct an evaluation and assessment of the initiatives carried 

out by States under this section, for the purpose of determining— 

(A) the effect of such initiatives on the use of health 

care services by Medicaid beneficiaries participating in the 

program; 

(B) the extent to which special populations (including 

adults with disabilities, adults with chronic illnesses, and 

children with special health care needs) are able to participate in the program; 

(C) the level of satisfaction of Medicaid beneficiaries 

with respect to the accessibility and quality of health care 

services provided through the program; and 

(D) the administrative costs incurred by State agencies 

that are responsible for administration of the program. 

(2) STATE REPORTING.—A State awarded a grant to carry 

out initiatives under this section shall submit reports to the 

Secretary, on a semi-annual basis, regarding the programs that 

are supported by the grant funds. Such report shall include information, as specified by the Secretary, regarding— 

(A) the specific uses of the grant funds; 

(B) an assessment of program implementation and lessons learned from the programs; 

(C) an assessment of quality improvements and clinical outcomes under such programs; and 

(D) estimates of cost savings resulting from such programs. 

(3) INITIAL REPORT.—Not later than January 1, 2014, the 

Secretary shall submit to Congress an initial report on such 

initiatives based on information provided by States through reports required under paragraph (2). The initial report shall include an interim evaluation of the effectiveness of the initiatives carried out with grants awarded under this section and 
489 Sec. 4201 PPACA (Consolidated) 

a recommendation regarding whether funding for expanding or 

extending the initiatives should be extended beyond January 1, 

2016. 

(4) FINAL REPORT.—Not later than July 1, 2016, the Secretary shall submit to Congress a final report on the program 

that includes the results of the independent assessment required under paragraph (1), together with recommendations 

for such legislation and administrative action as the Secretary 

determines appropriate. 

(e) NO EFFECT ON ELIGIBILITY FOR, OR AMOUNT OF, MEDICAID

OR OTHER BENEFITS.—Any incentives provided to a Medicaid beneficiary participating in a program described in subsection (a)(3) 

shall not be taken into account for purposes of determining the 

beneficiary’s eligibility for, or amount of, benefits under the Medicaid program or any program funded in whole or in part with Federal funds. 

(f) FUNDING.—Out of any funds in the Treasury not otherwise 

appropriated, there are appropriated for the 5-year period beginning on January 1, 2011, $100,000,000 to the Secretary to carry out 

this section. Amounts appropriated under this subsection shall remain available until expended. 

(g) DEFINITIONS.—In this section: 

(1) MEDICAID BENEFICIARY.—The term ‘‘Medicaid beneficiary’’ means an individual who is eligible for medical assistance under a State plan or waiver under title XIX of the Social 

Security Act (42 U.S.C. 1396 et seq.) and is enrolled in such 

plan or waiver. 

(2) STATE.—The term ‘‘State’’ has the meaning given that 

term for purposes of title XIX of the Social Security Act (42 

U.S.C. 1396 et seq.). 

Subtitle C—Creating Healthier 

Communities 

SEC. 4201. ø42 U.S.C. 300u–13¿ COMMUNITY TRANSFORMATION GRANTS. 

(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’), acting through 

the Director of the Centers for Disease Control and Prevention (referred to in this section as the ‘‘Director’’), shall award competitive 

grants to State and local governmental agencies and communitybased organizations for the implementation, evaluation, and dissemination of evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and develop a stronger evidence-base of effective prevention programming, with not less than 20 percent of such grants being awarded 

to rural and frontier areas. øAs revised by section 10403(1)¿ 

(b) ELIGIBILITY.—To be eligible to receive a grant under subsection (a), an entity shall— 

(1) be— 

(A) a State governmental agency; 

(B) a local governmental agency; 
Sec. 4201 PPACA (Consolidated) 490 

(C) a national network of community-based organizations; 

(D) a State or local non-profit organization; or 

(E) an Indian tribe; and 

(2) submit to the Director an application at such time, in 

such a manner, and containing such information as the Director may require, including a description of the program to be 

carried out under the grant; and 

(3) demonstrate a history or capacity, if funded, to develop 

relationships necessary to engage key stakeholders from multiple sectors within and beyond health care and across a community, such as healthy futures corps and health care providers. 

(c) USE OF FUNDS.— (1) IN GENERAL.—An eligible entity shall use amounts received under a grant under this section to carry out programs 

described in this subsection. 

(2) COMMUNITY TRANSFORMATION PLAN.— (A) IN GENERAL.—An eligible entity that receives a 

grant under this section shall submit to the Director (for 

approval) a detailed plan that includes the policy, environmental, programmatic, and as appropriate infrastructure 

changes needed to promote healthy living and reduce disparities. 

(B) ACTIVITIES.—Activities within the plan may focus 

on (but not be limited to)— 

(i) creating healthier school environments, including increasing healthy food options, physical activity 

opportunities, promotion of healthy lifestyle, emotional 

wellness, and prevention curricula, and activities to 

prevent chronic diseases; 

(ii) creating the infrastructure to support active 

living and access to nutritious foods in a safe environment; 

(iii) developing and promoting programs targeting 

a variety of age levels to increase access to nutrition, 

physical activity and smoking cessation, improve social 

and emotional wellness, enhance safety in a community, or address any other chronic disease priority area 

identified by the grantee; 

(iv) assessing and implementing worksite wellness 

programming and incentives; 

(v) working to highlight healthy options at restaurants and other food venues; 

(vi) prioritizing strategies to reduce racial and ethnic disparities, including social, economic, and geographic determinants of health; and 

(vii) addressing special populations needs, including all age groups and individuals with disabilities, 

and individuals in urban, rural, and frontier areas. 

øAs revised by section 10403(2)¿ 

(3) COMMUNITY-BASED PREVENTION HEALTH ACTIVITIES.— 

(A) IN GENERAL.—An eligible entity shall use amounts 

received under a grant under this section to implement a 
491 Sec. 4201 PPACA (Consolidated) 

variety of programs, policies, and infrastructure improvements to promote healthier lifestyles. 

(B) ACTIVITIES.—An eligible entity shall implement activities detailed in the community transformation plan 

under paragraph (2). 

(C) IN-KIND SUPPORT.—An eligible entity may provide 

in-kind resources such as staff, equipment, or office space 

in carrying out activities under this section. 

(4) EVALUATION.— 

(A) IN GENERAL.—An eligible entity shall use amounts 

provided under a grant under this section to conduct activities to measure changes in the prevalence of chronic 

disease risk factors among community members participating in preventive health activities 

(B) TYPES OF MEASURES.—In carrying out subparagraph (A), the eligible entity shall, with respect to residents in the community, measure— 

(i) changes in weight; 

(ii) changes in proper nutrition; 

(iii) changes in physical activity; 

(iv) changes in tobacco use prevalence; 

(v) changes in emotional well-being and overall 

mental health; 

(vi) other factors using community-specific data 

from the Behavioral Risk Factor Surveillance Survey; 

and 

(vii) other factors as determined by the Secretary. 

(C) REPORTING.—An eligible entity shall annually submit to the Director a report containing an evaluation of activities carried out under the grant. 

(5) DISSEMINATION.—A grantee under this section shall— 

(A) meet at least annually in regional or national 

meetings to discuss challenges, best practices, and lessons 

learned with respect to activities carried out under the 

grant; and 

(B) develop models for the replication of successful 

programs and activities and the mentoring of other eligible 

entities. 

(d) TRAINING.— 

(1) IN GENERAL.—The Director shall develop a program to 

provide training for eligible entities on effective strategies for 

the prevention and control of chronic disease and the link between physical, emotional, and social well-being. 

(2) COMMUNITY TRANSFORMATION PLAN.—The Director 

shall provide appropriate feedback and technical assistance to 

grantees to establish community transformation plans 

(3) EVALUATION.—The Director shall provide a literature 

review and framework for the evaluation of programs conducted as part of the grant program under this section, in addition to working with academic institutions or other entities 

with expertise in outcome evaluation. 

(e) PROHIBITION.—A grantee shall not use funds provided 

under a grant under this section to create video games or to carry 
Sec. 4202 PPACA (Consolidated) 492 

out any other activities that may lead to higher rates of obesity or 

inactivity. 

(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated to carry out this section, such sums as may be 

necessary for each of fiscal year 2010 through 2014. øAs revised by 

section 10403(3)¿ 

SEC. 4202. ø42 U.S.C. 300u–14¿ HEALTHY AGING, LIVING WELL; EVALUATION OF COMMUNITY-BASED PREVENTION AND 

WELLNESS PROGRAMS FOR MEDICARE BENEFICIARIES. 

(a) HEALTHY AGING, LIVING WELL.— (1) IN GENERAL.—The Secretary of Health and Human 

Services (referred to in this section as the ‘‘Secretary’’), acting 

through the Director of the Centers for Disease Control and 

Prevention, shall award grants to State or local health departments and Indian tribes to carry out 5-year pilot programs to 

provide public health community interventions, screenings, and 

where necessary, clinical referrals for individuals who are between 55 and 64 years of age. 

(2) ELIGIBILITY.—To be eligible to receive a grant under 

paragraph (1), an entity shall— 

(A) be— 

(i) a State health department; 

(ii) a local health department; or 

(iii) an Indian tribe; 

(B) 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 

program to be carried out under the grant; 

(C) design a strategy for improving the health of the 

55-to-64 year-old population through community-based 

public health interventions; and 

(D) demonstrate the capacity, if funded, to develop the 

relationships necessary with relevant health agencies, 

health care providers, community-based organizations, and 

insurers to carry out the activities described in paragraph 

(3), such relationships to include the identification of a 

community-based clinical partner, such as a community 

health center or rural health clinic. 

(3) USE OF FUNDS.— 

(A) IN GENERAL.—A State or local health department 

shall use amounts received under a grant under this subsection to carry out a program to provide the services described in this paragraph to individuals who are between 

55 and 64 years of age. 

(B) PUBLIC HEALTH INTERVENTIONS.— 

(i) IN GENERAL.—In developing and implementing 

such activities, a grantee shall collaborate with the 

Centers for Disease Control and Prevention and the 

Administration on Aging, and relevant local agencies 

and organizations. 

(ii) TYPES OF INTERVENTION ACTIVITIES.—Intervention activities conducted under this subparagraph may 

include efforts to improve nutrition, increase physical 

activity, reduce tobacco use and substance abuse, im-
493 Sec. 4202 PPACA (Consolidated) 

prove mental health, and promote healthy lifestyles 

among the target population. 

(C) COMMUNITY PREVENTIVE SCREENINGS.— (i) IN GENERAL.—In addition to community-wide 

public health interventions, a State or local health department shall use amounts received under a grant 

under this subsection to conduct ongoing health 

screening to identify risk factors for cardiovascular 

disease, cancer, stroke, and diabetes among individuals in both urban and rural areas who are between 

55 and 64 years of age. 

(ii) TYPES OF SCREENING ACTIVITIES.—Screening 

activities conducted under this subparagraph may include— 

(I) mental health/behavioral health and substance use disorders; 

(II) physical activity, smoking, and nutrition; 

and 

(III) any other measures deemed appropriate 

by the Secretary. 

(iii) MONITORING.—Grantees under this section 

shall maintain records of screening results under this 

subparagraph to establish the baseline data for monitoring the targeted population 

(D) CLINICAL REFERRAL/TREATMENT FOR CHRONIC DIS- EASES.— (i) IN GENERAL.—A State or local health department shall use amounts received under a grant under 

this subsection to ensure that individuals between 55 

and 64 years of age who are found to have chronic disease risk factors through the screening activities described in subparagraph (C)(ii), receive clinical referral/treatment for follow-up services to reduce such 

risk. 

(ii) MECHANISM.— 

(I) IDENTIFICATION AND DETERMINATION OF

STATUS.—With respect to each individual with risk 

factors for or having heart disease, stroke, diabetes, or any other condition for which such individual was screened under subparagraph (C), a 

grantee under this section shall determine whether or not such individual is covered under any 

public or private health insurance program. 

(II) INSURED INDIVIDUALS.—An individual determined to be covered under a health insurance 

program under subclause (I) shall be referred by 

the grantee to the existing providers under such 

program or, if such individual does not have a current provider, to a provider who is in-network 

with respect to the program involved. 

(III) UNINSURED INDIVIDUALS.—With respect 

to an individual determined to be uninsured 

under subclause (I), the grantee’s communitybased clinical partner described in paragraph 
Sec. 4202 PPACA (Consolidated) 494 

(4)(D) shall assist the individual in determining 

eligibility for available public coverage options and 

identify other appropriate community health care 

resources and assistance programs. 

(iii) PUBLIC HEALTH INTERVENTION PROGRAM.—A 

State or local health department shall use amounts received under a grant under this subsection to enter 

into contracts with community health centers or rural 

health clinics and mental health and substance use 

disorder service providers to assist in the referral/ 

treatment of at risk patients to community resources 

for clinical follow-up and help determine eligibility for 

other public programs. 

(E) GRANTEE EVALUATION.—An eligible entity shall 

use amounts provided under a grant under this subsection 

to conduct activities to measure changes in the prevalence 

of chronic disease risk factors among participants. 

(4) PILOT PROGRAM EVALUATION.—The Secretary shall conduct an annual evaluation of the effectiveness of the pilot program under this subsection. In determining such effectiveness, 

the Secretary shall consider changes in the prevalence of uncontrolled chronic disease risk factors among new Medicare enrollees (or individuals nearing enrollment, including those who 

are 63 and 64 years of age) who reside in States or localities 

receiving grants under this section as compared with national 

and historical data for those States and localities for the same 

population. 

(5) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection, such sums 

as may be necessary for each of fiscal years 2010 through 2014. 

(b) EVALUATION AND PLAN FOR COMMUNITY-BASED PREVENTION

AND WELLNESS PROGRAMS FOR MEDICARE BENEFICIARIES.— 

(1) IN GENERAL.—The Secretary shall conduct an evaluation of community-based prevention and wellness programs 

and develop a plan for promoting healthy lifestyles and chronic 

disease self-management for Medicare beneficiaries. 

(2) MEDICARE EVALUATION OF PREVENTION AND WELLNESS

PROGRAMS.— 

(A) IN GENERAL.—The Secretary shall evaluate community prevention and wellness programs including those 

that are sponsored by the Administration on Aging, are 

evidence-based, and have demonstrated potential to help 

Medicare beneficiaries (particularly beneficiaries that have 

attained 65 years of age) reduce their risk of disease, disability, and injury by making healthy lifestyle choices, including exercise, diet, and self-management of chronic diseases. 

(B) EVALUATION.—The evaluation under subparagraph 

(A) shall consist of the following: 

(i) EVIDENCE REVIEW.—The Secretary shall review 

available evidence, literature, best practices, and resources that are relevant to programs that promote 

healthy lifestyles and reduce risk factors for the Medicare population. The Secretary may determine the 
495 Sec. 4202 PPACA (Consolidated) 

scope of the evidence review and such issues to be considered, which shall include, at a minimum— 

(I) physical activity, nutrition, and obesity; 

(II) falls; 

(III) chronic disease self-management; and 

(IV) mental health. 

(ii) INDEPENDENT EVALUATION OF EVIDENCE-BASED

COMMUNITY PREVENTION AND WELLNESS PROGRAMS.— 

The Administrator of the Centers for Medicare & Medicaid Services, in consultation with the Assistant Secretary for Aging, shall, to the extent feasible and practicable, conduct an evaluation of existing community 

prevention and wellness programs that are sponsored 

by the Administration on Aging to assess the extent to 

which Medicare beneficiaries who participate in such 

programs— 

(I) reduce their health risks, improve their 

health outcomes, and adopt and maintain healthy 

behaviors; 

(II) improve their ability to manage their 

chronic conditions; and 

(III) reduce their utilization of health services 

and associated costs under the Medicare program 

for conditions that are amenable to improvement 

under such programs. 

(3) REPORT.—Not later than September 30, 2013, the Secretary shall submit to Congress a report that includes— 

(A) recommendations for such legislation and administrative action as the Secretary determines appropriate to 

promote healthy lifestyles and chronic disease self-management for Medicare beneficiaries; 

(B) any relevant findings relating to the evidence review under paragraph (2)(B)(i); and 

(C) the results of the evaluation under paragraph 

(2)(B)(ii). 

(4) FUNDING.—For purposes of carrying out this subsection, 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 Supplemental Medical Insurance Trust Fund under section 1841 of 

such Act (42 U.S.C. 1395t), in such proportion as the Secretary 

determines appropriate, of $50,000,000 to the Centers for 

Medicare & Medicaid Services Program Management Account. 

Amounts transferred under the preceding sentence shall remain available until expended. 

(5) ADMINISTRATION.—Chapter 35 of title 44, United States 

Code shall not apply to the this subsection. 

(6) MEDICARE BENEFICIARY.—In this subsection, the term 

‘‘Medicare beneficiary’’ means an individual who is entitled to 

benefits under part A of title XVIII of the Social Security Act 

and enrolled under part B of such title. 
Sec. 4203 PPACA (Consolidated) 496 

SEC. 4203. REMOVING BARRIERS AND IMPROVING ACCESS TO 

WELLNESS FOR INDIVIDUALS WITH DISABILITIES. 

Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et seq.) 

is amended by adding at the end of the following: 

‘‘SEC. 510. ø29 U.S.C. 794f¿ ESTABLISHMENT OF STANDARDS FOR ACCESSIBLE MEDICAL DIAGNOSTIC EQUIPMENT. 

‘‘(a) STANDARDS.—Not later than 24 months after the date of 

enactment of the Affordable Health Choices Act, the Architectural 

and Transportation Barriers Compliance Board shall, in consultation with the Commissioner of the Food and Drug Administration, 

promulgate regulatory standards in accordance with the Administrative Procedure Act (2 U.S.C. 551 et seq.) setting forth the minimum technical criteria for medical diagnostic equipment used in 

(or in conjunction with) physician’s offices, clinics, emergency 

rooms, hospitals, and other medical settings. The standards shall 

ensure that such equipment is accessible to, and usable by, individuals with accessibility needs, and shall allow independent entry to, 

use of, and exit from the equipment by such individuals to the 

maximum extent possible. 

‘‘(b) MEDICAL DIAGNOSTIC EQUIPMENT COVERED.—The standards issued under subsection (a) for medical diagnostic equipment 

shall apply to equipment that includes examination tables, examination chairs (including chairs used for eye examinations or procedures, and dental examinations or procedures), weight scales, 

mammography equipment, x-ray machines, and other radiological 

equipment commonly used for diagnostic purposes by health professionals. 

‘‘(c) REVIEW AND AMENDMENT.—The Architectural and Transportation Barriers Compliance Board, in consultation with the 

Commissioner of the Food and Drug Administration, shall periodically review and, as appropriate, amend the standards in accordance with the Administrative Procedure Act (2 U.S.C. 551 et seq.).’’. 

SEC. 4204. IMMUNIZATIONS. 

(a) STATE AUTHORITY TO PURCHASE RECOMMENDED VACCINES

FOR ADULTS.—Section 317 of the Public Health Service Act (42 

U.S.C. 247b) is amended by adding at the end the following: 

‘‘(l) AUTHORITY TO PURCHASE RECOMMENDED VACCINES FOR

ADULTS.— 

‘‘(1) IN GENERAL.—The Secretary may negotiate and enter 

into contracts with manufacturers of vaccines for the purchase 

and delivery of vaccines for adults as provided for under subsection (e). 

‘‘(2) STATE PURCHASE.—A State may obtain additional 

quantities of such adult vaccines (subject to amounts specified 

to the Secretary by the State in advance of negotiations) 

through the purchase of vaccines from manufacturers at the 

applicable price negotiated by the Secretary under this subsection.’’. 

(b) DEMONSTRATION PROGRAM TO IMPROVE IMMUNIZATION COV- ERAGE.—Section 317 of the Public Health Service Act (42 U.S.C. 

247b), as amended by subsection (a), is further amended by adding 

at the end the following: 

‘‘(m) DEMONSTRATION PROGRAM TO IMPROVE IMMUNIZATION

COVERAGE.— 
497 Sec. 4204 PPACA (Consolidated) 

‘‘(1) IN GENERAL.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish a demonstration program to award grants to States to 

improve the provision of recommended immunizations for children, adolescents, and adults through the use of evidencebased, population-based interventions for high-risk populations. 

‘‘(2) STATE PLAN.—To be eligible for a grant under paragraph (1), 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 State plan that describes the interventions to be implemented under the grant 

and how such interventions match with local needs and capabilities, as determined through consultation with local authorities. 

‘‘(3) USE OF FUNDS.—Funds received under a grant under 

this subsection shall be used to implement interventions that 

are recommended by the Task Force on Community Preventive 

Services (as established by the Secretary, acting through the 

Director of the Centers for Disease Control and Prevention) or 

other evidence-based interventions, including— 

‘‘(A) providing immunization reminders or recalls for 

target populations of clients, patients, and consumers; 

‘‘(B) educating targeted populations and health care 

providers concerning immunizations in combination with 

one or more other interventions; 

‘‘(C) reducing out-of-pocket costs for families for vaccines and their administration; 

‘‘(D) carrying out immunization-promoting strategies 

for participants or clients of public programs, including assessments of immunization status, referrals to health care 

providers, education, provision of on-site immunizations, or 

incentives for immunization; 

‘‘(E) providing for home visits that promote immunization through education, assessments of need, referrals, provision of immunizations, or other services; 

‘‘(F) providing reminders or recalls for immunization 

providers; 

‘‘(G) conducting assessments of, and providing feedback to, immunization providers; 

‘‘(H) any combination of one or more interventions described in this paragraph; or 

‘‘(I) immunization information systems to allow all 

States to have electronic databases for immunization 

records. 

‘‘(4) CONSIDERATION.—In awarding grants under this subsection, the Secretary shall consider any reviews or recommendations of the Task Force on Community Preventive 

Services. 

‘‘(5) EVALUATION.—Not later than 3 years after the date on 

which a State receives a grant under this subsection, the State 

shall submit to the Secretary an evaluation of progress made 

toward improving immunization coverage rates among highrisk populations within the State. 
Sec. 4204 PPACA (Consolidated) 498 

‘‘(6) REPORT TO CONGRESS.—Not later than 4 years after 

the date of enactment of the Affordable Health Choices Act, the 

Secretary shall submit to Congress a report concerning the effectiveness of the demonstration program established under 

this subsection together with recommendations on whether to 

continue and expand such program. 

‘‘(7) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this subsection, such sums 

as may be necessary for each of fiscal years 2010 through 

2014.’’. 

(c) REAUTHORIZATION OF IMMUNIZATION PROGRAM.—Section 

317(j) of the Public Health Service Act (42 U.S.C. 247b(j)) is 

amended— 

(1) in paragraph (1), by striking ‘‘for each of the fiscal 

years 1998 through 2005’’; and 

(2) in paragraph (2), by striking ‘‘after October 1, 1997,’’. 

(d) RULE OF CONSTRUCTION REGARDING ACCESS TO IMMUNIZATIONS.—Nothing in this section (including the amendments made 

by this section), or any other provision of this Act (including any 

amendments made by this Act) shall be construed to decrease children’s access to immunizations. 

(e) GAO STUDY AND REPORT ON MEDICARE BENEFICIARY ACCESS TO VACCINES.— 

(1) STUDY.—The Comptroller General of the United States 

(in this section referred to as the ‘‘Comptroller General’’) shall 

conduct a study on the ability of Medicare beneficiaries who 

were 65 years of age or older to access routinely recommended 

vaccines covered under the prescription drug program under 

part D of title XVIII of the Social Security Act over the period 

since the establishment of such program. Such study shall include the following: 

(A) An analysis and determination of— 

(i) the number of Medicare beneficiaries who were 

65 years of age or older and were eligible for a routinely recommended vaccination that was covered 

under part D; 

(ii) the number of such beneficiaries who actually 

received a routinely recommended vaccination that 

was covered under part D; and 

(iii) any barriers to access by such beneficiaries to 

routinely recommended vaccinations that were covered 

under part D. 

(B) A summary of the findings and recommendations 

by government agencies, departments, and advisory bodies 

(as well as relevant professional organizations) on the impact of coverage under part D of routinely recommended 

adult immunizations for access to such immunizations by 

Medicare beneficiaries. 

(2) REPORT.—Not later than June 1, 2011, the Comptroller 

General shall submit to the appropriate committees of jurisdiction of the House of Representatives and the Senate a report 

containing the results of the study conducted under paragraph 

(1), together with recommendations for such legislation and ad-
499 Sec. 4205 PPACA (Consolidated) 

ministrative action as the Comptroller General determines appropriate. 

(3) FUNDING.—Out of any funds in the Treasury not other- wise appropriated, there are appropriated $1,000,000 for fiscal 

year 2010 to carry out this subsection. 

SEC. 4205. NUTRITION LABELING OF STANDARD MENU ITEMS AT 

CHAIN RESTAURANTS. 

(a) TECHNICAL AMENDMENTS.—Section 403(q)(5)(A) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) is 

amended— 

(1) in subitem (i), by inserting at the beginning ‘‘except as 

provided in clause (H)(ii)(III),’’; and 

(2) in subitem (ii), by inserting at the beginning ‘‘except as 

provided in clause (H)(ii)(III),’’. 

(b) LABELING REQUIREMENTS.—Section 403(q)(5) of the Federal 

Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is amended by 

adding at the end the following: 

‘‘(H) RESTAURANTS, RETAIL FOOD ESTABLISHMENTS, AND VEND- ING MACHINES.— ‘‘(i) GENERAL REQUIREMENTS FOR RESTAURANTS AND SIMI- LAR RETAIL FOOD ESTABLISHMENTS.—Except for food described 

in subclause (vii), in the case of food that is a standard menu 

item that is offered for sale in a restaurant or similar retail 

food establishment that is part of a chain with 20 or more locations doing business under the same name (regardless of the 

type of ownership of the locations) and offering for sale substantially the same menu items, the restaurant or similar retail food establishment shall disclose the information described 

in subclauses (ii) and (iii). 

‘‘(ii) INFORMATION REQUIRED TO BE DISCLOSED BY RES- TAURANTS AND RETAIL FOOD ESTABLISHMENTS.—Except as provided in subclause (vii), the restaurant or similar retail food establishment shall disclose in a clear and conspicuous manner— 

‘‘(I)(aa) in a nutrient content disclosure statement adjacent to the name of the standard menu item, so as to be 

clearly associated with the standard menu item, on the 

menu listing the item for sale, the number of calories contained in the standard menu item, as usually prepared 

and offered for sale; and 

‘‘(bb) a succinct statement concerning suggested daily 

caloric intake, as specified by the Secretary by regulation 

and posted prominently on the menu and designed to enable the public to understand, in the context of a total 

daily diet, the significance of the caloric information that 

is provided on the menu; 

‘‘(II)(aa) in a nutrient content disclosure statement adjacent to the name of the standard menu item, so as to be 

clearly associated with the standard menu item, on the 

menu board, including a drive-through menu board, the 

number of calories contained in the standard menu item, 

as usually prepared and offered for sale; and 

‘‘(bb) a succinct statement concerning suggested daily 

caloric intake, as specified by the Secretary by regulation 

and posted prominently on the menu board, designed to 
Sec. 4205 PPACA (Consolidated) 500 

enable the public to understand, in the context of a total 

daily diet, the significance of the nutrition information 

that is provided on the menu board; 

‘‘(III) in a written form, available on the premises of the 

restaurant or similar retail establishment and to the consumer 

upon request, the nutrition information required under clauses 

(C) and (D) of subparagraph (1); and 

‘‘(IV) on the menu or menu board, a prominent, clear, and 

conspicuous statement regarding the availability of the information described in item (III). 

‘‘(iii) SELF-SERVICE FOOD AND FOOD ON DISPLAY.—Except as 

provided in subclause (vii), in the case of food sold at a salad 

bar, buffet line, cafeteria line, or similar self-service facility, 

and for self-service beverages or food that is on display and 

that is visible to customers, a restaurant or similar retail food 

establishment shall place adjacent to each food offered a sign 

that lists calories per displayed food item or per serving. 

‘‘(iv) REASONABLE BASIS.—For the purposes of this clause, 

a restaurant or similar retail food establishment shall have a 

reasonable basis for its nutrient content disclosures, including 

nutrient databases, cookbooks, laboratory analyses, and other 

reasonable means, as described in section 101.10 of title 21, 

Code of Federal Regulations (or any successor regulation) or in 

a related guidance of the Food and Drug Administration. 

‘‘(v) MENU VARIABILITY AND COMBINATION MEALS.—The 

Secretary shall establish by regulation standards for determining and disclosing the nutrient content for standard menu 

items that come in different flavors, varieties, or combinations, 

but which are listed as a single menu item, such as soft drinks, 

ice cream, pizza, doughnuts, or children’s combination meals, 

through means determined by the Secretary, including ranges, 

averages, or other methods. 

‘‘(vi) ADDITIONAL INFORMATION.—If the Secretary determines that a nutrient, other than a nutrient required under 

subclause (ii)(III), should be disclosed for the purpose of providing information to assist consumers in maintaining healthy 

dietary practices, the Secretary may require, by regulation, disclosure of such nutrient in the written form required under 

subclause (ii)(III). 

‘‘(vii) NONAPPLICABILITY TO CERTAIN FOOD.— 

‘‘(I) IN GENERAL.—Subclauses (i) through (vi) do not 

apply to— 

‘‘(aa) items that are not listed on a menu or menu 

board (such as condiments and other items placed on 

the table or counter for general use); 

‘‘(bb) daily specials, temporary menu items appearing on the menu for less than 60 days per calendar year, or custom orders; or 

‘‘(cc) such other food that is part of a customary 

market test appearing on the menu for less than 90 

days, under terms and conditions established by the 

Secretary. 
501 Sec. 4205 PPACA (Consolidated) 

‘‘(II) WRITTEN FORMS.—Subparagraph (5)(C) shall 

apply to any regulations promulgated under subclauses 

(ii)(III) and (vi). 

‘‘(viii) VENDING MACHINES.— ‘‘(I) IN GENERAL.—In the case of an article of food sold 

from a vending machine that— 

‘‘(aa) does not permit a prospective purchaser to 

examine the Nutrition Facts Panel before purchasing 

the article or does not otherwise provide visible nutrition information at the point of purchase; and 

‘‘(bb) is operated by a person who is engaged in 

the business of owning or operating 20 or more vending machines, 

the vending machine operator shall provide a sign in close 

proximity to each article of food or the selection button 

that includes a clear and conspicuous statement disclosing 

the number of calories contained in the article. 

‘‘(ix) VOLUNTARY PROVISION OF NUTRITION INFORMATION.— ‘‘(I) IN GENERAL.—An authorized official of any restaurant or similar retail food establishment or vending 

machine operator not subject to the requirements of this 

clause may elect to be subject to the requirements of such 

clause, by registering biannually the name and address of 

such restaurant or similar retail food establishment or 

vending machine operator with the Secretary, as specified 

by the Secretary by regulation. 

‘‘(II) REGISTRATION.—Within 120 days of enactment of 

this clause, the Secretary shall publish a notice in the Federal Register specifying the terms and conditions for implementation of item (I), pending promulgation of regulations. 

‘‘(III) RULE OF CONSTRUCTION.—Nothing in this subclause shall be construed to authorize the Secretary to require an application, review, or licensing process for any 

entity to register with the Secretary, as described in such 

item. 

‘‘(x) REGULATIONS.— 

‘‘(I) PROPOSED REGULATION.—Not later than 1 year 

after the date of enactment of this clause, the Secretary 

shall promulgate proposed regulations to carry out this 

clause. 

‘‘(II) CONTENTS.—In promulgating regulations, the 

Secretary shall— 

‘‘(aa) consider standardization of recipes and 

methods of preparation, reasonable variation in serving size and formulation of menu items, space on 

menus and menu boards, inadvertent human error, 

training of food service workers, variations in ingredients, and other factors, as the Secretary determines; 

and 

‘‘(bb) specify the format and manner of the nutrient content disclosure requirements under this subclause. 

‘‘(III) REPORTING.—The Secretary shall submit to the 

Committee on Health, Education, Labor, and Pensions of 
Sec. 4206 PPACA (Consolidated) 502 

the Senate and the Committee on Energy and Commerce 

of the House of Representatives a quarterly report that describes the Secretary’s progress toward promulgating final 

regulations under this subparagraph. 

‘‘(xi) DEFINITION.—In this clause, the term ‘menu’ or ‘menu 

board’ means the primary writing of the restaurant or other 

similar retail food establishment from which a consumer 

makes an order selection.’’ 

(c) NATIONAL UNIFORMITY.—Section 403A(a)(4) of the Federal 

Food, Drug, and Cosmetic Act (21 U.S.C. 343–1(a)(4)) is amended 

by striking ‘‘except a requirement for nutrition labeling of food 

which is exempt under subclause (i) or (ii) of section 403(q)(5)(A)’’ 

and inserting ‘‘except that this paragraph does not apply to food 

that is offered for sale in a restaurant or similar retail food establishment that is not part of a chain with 20 or more locations doing 

business under the same name (regardless of the type of ownership 

of the locations) and offering for sale substantially the same menu 

items unless such restaurant or similar retail food establishment 

complies with the voluntary provision of nutrition information requirements under section 403(q)(5)(H)(ix)’’. 

(d) RULE OF CONSTRUCTION.—Nothing in the amendments 

made by this section shall be construed— 

(1) to preempt any provision of State or local law, unless 

such provision establishes or continues into effect nutrient content disclosures of the type required under section 403(q)(5)(H) 

of the Federal Food, Drug, and Cosmetic Act (as added by subsection (b)) and is expressly preempted under subsection (a)(4) 

of such section; 

(2) to apply to any State or local requirement respecting a 

statement in the labeling of food that provides for a warning 

concerning the safety of the food or component of the food; or 

(3) except as provided in section 403(q)(5)(H)(ix) of the 

Federal Food, Drug, and Cosmetic Act (as added by subsection 

(b)), to apply to any restaurant or similar retail food establishment other than a restaurant or similar retail food establishment described in section 403(q)(5)(H)(i) of such Act. 

SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED 

WELLNESS PLAN. 

Section 330 of the Public Health Service Act (42 U.S.C. 245b) 

is amended by adding at the end the following: 

‘‘(s) DEMONSTRATION PROGRAM FOR INDIVIDUALIZED WELLNESS

PLANS.— 

‘‘(1) IN GENERAL.—The Secretary shall establish a pilot 

program to test the impact of providing at-risk populations 

who utilize community health centers funded under this section an individualized wellness plan that is designed to reduce 

risk factors for preventable conditions as identified by a comprehensive risk-factor assessment. 

‘‘(2) AGREEMENTS.—The Secretary shall enter into agreements with not more than 10 community health centers funded 

under this section to conduct activities under the pilot program 

under paragraph (1). 

‘‘(3) WELLNESS PLANS.— 
503 Sec. 4207 PPACA (Consolidated) 

‘‘(A) IN GENERAL.—An individualized wellness plan 

prepared under the pilot program under this subsection 

may include one or more of the following as appropriate to 

the individual’s identified risk factors: 

‘‘(i) Nutritional counseling. 

‘‘(ii) A physical activity plan. 

‘‘(iii) Alcohol and smoking cessation counseling 

and services. 

‘‘(iv) Stress management. 

‘‘(v) Dietary supplements that have health claims 

approved by the Secretary. 

‘‘(vi) Compliance assistance provided by a community health center employee. 

‘‘(B) RISK FACTORS.—Wellness plan risk factors shall 

include— 

‘‘(i) weight; 

‘‘(ii) tobacco and alcohol use; 

‘‘(iii) exercise rates; 

‘‘(iv) nutritional status; and 

‘‘(v) blood pressure. 

‘‘(C) COMPARISONS.—Individualized wellness plans 

shall make comparisons between the individual involved 

and a control group of individuals with respect to the risk 

factors described in subparagraph (B). 

‘‘(4) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this subsection, such sums 

as may be necessary.’’. 

SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS. 

Section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 

207) is amended by adding at the end the following: 

‘‘(r)(1) An employer shall provide— 

‘‘(A) a reasonable break time for an employee to express 

breast milk for her nursing child for 1 year after the child’s 

birth each time such employee has need to express the milk; 

and 

‘‘(B) a place, other than a bathroom, that is shielded from 

view and free from intrusion from coworkers and the public, 

which may be used by an employee to express breast milk. 

‘‘(2) An employer shall not be required to compensate an employee receiving reasonable break time under paragraph (1) for any 

work time spent for such purpose. 

‘‘(3) An employer that employs less than 50 employees shall not 

be subject to the requirements of this subsection, if such requirements would impose an undue hardship by causing the employer 

significant difficulty or expense when considered in relation to the 

size, financial resources, nature, or structure of the employer’s 

business. 

‘‘(4) Nothing in this subsection shall preempt a State law that 

provides greater protections to employees than the protections provided for under this subsection.’’. 
Sec. 4301 PPACA (Consolidated) 504 

Subtitle D—Support for Prevention and 

Public Health Innovation 

SEC. 4301. ø42 U.S.C. 300u–15¿ RESEARCH ON OPTIMIZING THE DELIVERY OF PUBLIC HEALTH SERVICES. 

(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’), acting through 

the Director of the Centers for Disease Control and Prevention, 

shall provide funding for research in the area of public health services and systems. 

(b) REQUIREMENTS OF RESEARCH.—Research supported under 

this section shall include— 

(1) examining evidence-based practices relating to prevention, with a particular focus on high priority areas as identified 

by the Secretary in the National Prevention Strategy or 

Healthy People 2020, and including comparing communitybased public health interventions in terms of effectiveness and 

cost; 

(2) analyzing the translation of interventions from academic settings to real world settings; and 

(3) identifying effective strategies for organizing, financing, 

or delivering public health services in real world community 

settings, including comparing State and local health department structures and systems in terms of effectiveness and cost. 

(c) EXISTING PARTNERSHIPS.—Research supported under this 

section shall be coordinated with the Community Preventive Services Task Force and carried out by building on existing partnerships within the Federal Government while also considering initiatives at the State and local levels and in the private sector. 

(d) ANNUAL REPORT.—The Secretary shall, on an annual basis, 

submit to Congress a report concerning the activities and findings 

with respect to research supported under this section. 

SEC. 4302. UNDERSTANDING HEALTH DISPARITIES: DATA COLLECTION AND ANALYSIS. 

(a) UNIFORM CATEGORIES AND COLLECTION REQUIREMENTS.— 

The Public Health Service Act (42 U.S.C. 201 et seq.) is amended 

by adding at the end the following: 

‘‘TITLE XXXI—DATA COLLECTION, 

ANALYSIS, AND QUALITY 

‘‘SEC. 3101. ø42 U.S.C. 300k¿ DATA COLLECTION, ANALYSIS, AND QUALITY. 

‘‘(a) DATA COLLECTION.— 

‘‘(1) IN GENERAL.—The Secretary shall ensure that, by not 

later than 2 years after the date of enactment of this title, any 

federally conducted or supported health care or public health 

program, activity or survey (including Current Population Surveys and American Community Surveys conducted by the Bureau of Labor Statistics and the Bureau of the Census) collects 

and reports, to the extent practicable— 
505 Sec. 4302 PPACA (Consolidated) \3101 PHSA 

‘‘(A) data on race, ethnicity, sex, primary language, 

and disability status for applicants, recipients, or participants; 

‘‘(B) data at the smallest geographic level such as 

State, local, or institutional levels if such data can be aggregated; 

‘‘(C) sufficient data to generate statistically reliable estimates by racial, ethnic, sex, primary language, and disability status subgroups for applicants, recipients or participants using, if needed, statistical oversamples of these 

subpopulations; and 

‘‘(D) any other demographic data as deemed appropriate by the Secretary regarding health disparities. 

‘‘(2) COLLECTION STANDARDS.—In collecting data described 

in paragraph (1), the Secretary or designee shall— 

‘‘(A) use Office of Management and Budget standards, 

at a minimum, for race and ethnicity measures; 

‘‘(B) develop standards for the measurement of sex, 

primary language, and disability status; 

‘‘(C) develop standards for the collection of data described in paragraph (1) that, at a minimum— 

‘‘(i) collects self-reported data by the applicant, recipient, or participant; and 

‘‘(ii) collects data from a parent or legal guardian 

if the applicant, recipient, or participant is a minor or 

legally incapacitated; 

‘‘(D) survey health care providers and establish other 

procedures in order to assess access to care and treatment 

for individuals with disabilities and to identify— 

‘‘(i) locations where individuals with disabilities 

access primary, acute (including intensive), and longterm care; 

‘‘(ii) the number of providers with accessible facilities and equipment to meet the needs of the individuals with disabilities, including medical diagnostic 

equipment that meets the minimum technical criteria 

set forth in section 510 of the Rehabilitation Act of 

1973; and 

‘‘(iii) the number of employees of health care providers trained in disability awareness and patient care 

of individuals with disabilities; and 

‘‘(E) require that any reporting requirement imposed 

for purposes of measuring quality under any ongoing or 

federally conducted or supported health care or public 

health program, activity, or survey includes requirements 

for the collection of data on individuals receiving health 

care items or services under such programs activities by 

race, ethnicity, sex, primary language, and disability status. 

‘‘(3) DATA MANAGEMENT.—In collecting data described in 

paragraph (1), the Secretary, acting through the National Coordinator for Health Information Technology shall— 

‘‘(A) develop national standards for the management of 

data collected; and 
Sec. 4302\3101 PHSA PPACA (Consolidated) 506 

‘‘(B) develop interoperability and security systems for 

data management. 

‘‘(b) DATA ANALYSIS.— ‘‘(1) IN GENERAL.—For each federally conducted or supported health care or public health program or activity, the 

Secretary shall analyze data collected under paragraph (a) to 

detect and monitor trends in health disparities (as defined for 

purposes of section 485E) at the Federal and State levels. 

‘‘(c) DATA REPORTING AND DISSEMINATION.— ‘‘(1) IN GENERAL.—The Secretary shall make the analyses 

described in (b) available to— 

‘‘(A) the Office of Minority Health; 

‘‘(B) the National Center on Minority Health and 

Health Disparities; 

‘‘(C) the Agency for Healthcare Research and Quality; 

‘‘(D) the Centers for Disease Control and Prevention; 

‘‘(E) the Centers for Medicare & Medicaid Services; 

‘‘(F) the Indian Health Service and epidemiology centers funded under the Indian Health Care Improvement 

Act; 

‘‘(G) the Office of Rural health; 

‘‘(H) other agencies within the Department of Health 

and Human Services; and 

‘‘(I) other entities as determined appropriate by the 

Secretary. 

‘‘(2) REPORTING OF DATA.—The Secretary shall report data 

and analyses described in (a) and (b) through— 

‘‘(A) public postings on the Internet websites of the Department of Health and Human Services; and 

‘‘(B) any other reporting or dissemination mechanisms 

determined appropriate by the Secretary. 

‘‘(3) AVAILABILITY OF DATA.—The Secretary may make data 

described in (a) and (b) available for additional research, analyses, and dissemination to other Federal agencies, non-governmental entities, and the public, in accordance with any Federal 

agency’s data user agreements. 

‘‘(d) LIMITATIONS ON USE OF DATA.—Nothing in this section 

shall be construed to permit the use of information collected under 

this section in a manner that would adversely affect any individual. 

‘‘(e) PROTECTION AND SHARING OF DATA.— 

‘‘(1) PRIVACY AND OTHER SAFEGUARDS.—The Secretary 

shall ensure (through the promulgation of regulations or otherwise) that— 

‘‘(A) all data collected pursuant to subsection (a) is 

protected— 

‘‘(i) under privacy protections that are at least as 

broad as those that the Secretary applies to other 

health data under the regulations promulgated under 

section 264(c) of the Health Insurance Portability and 

Accountability Act of 1996 (Public Law 104–191; 110 

Stat. 2033); and 

‘‘(ii) from all inappropriate internal use by any entity that collects, stores, or receives the data, including 

use of such data in determinations of eligibility (or 
507 Sec. 4302 PPACA (Consolidated) 

continued eligibility) in health plans, and from other 

inappropriate uses, as defined by the Secretary; and 

‘‘(B) all appropriate information security safeguards 

are used in the collection, analysis, and sharing of data 

collected pursuant to subsection (a). 

‘‘(2) DATA SHARING.—The Secretary shall establish procedures for sharing data collected pursuant to subsection (a), 

measures relating to such data, and analyses of such data, 

with other relevant Federal and State agencies including the 

agencies, centers, and entities within the Department of 

Health and Human Services specified in subsection (c)(1).. 

‘‘(f) DATA ON RURAL UNDERSERVED POPULATIONS.—The Secretary shall ensure that any data collected in accordance with this 

section regarding racial and ethnic minority groups are also collected regarding underserved rural and frontier populations. 

‘‘(g) 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) REQUIREMENT FOR IMPLEMENTATION.—Notwithstanding 

any other provision of this section, data may not be collected under 

this section unless funds are directly appropriated for such purpose 

in an appropriations Act. 

‘‘(i) CONSULTATION.—The Secretary shall consult with the Director of the Office of Personnel Management, the Secretary of Defense, the Secretary of Veterans Affairs, the Director of the Bureau 

of the Census, the Commissioner of Social Security, and the head 

of other appropriate Federal agencies in carrying out this section.’’. 

(b) ADDRESSING HEALTH CARE DISPARITIES IN MEDICAID AND

CHIP.— 

(1) STANDARDIZED COLLECTION REQUIREMENTS INCLUDED IN

STATE PLANS.— 

(A) MEDICAID.—Section 1902(a) of the Social Security 

Act (42 U.S.C. 1396a(a)), as amended by section 2001(d), 

is amended— 

(i) in paragraph 4), by striking ‘‘and’’ at the end; 

(ii) in paragraph (75), by striking the period at the 

end and inserting ‘‘; and’’; and 

(iii) by inserting after paragraph (75) the following 

new paragraph: 

‘‘(76) provide that any data collected under the State plan 

meets the requirements of section 3101 of the Public Health 

Service Act.’’. 

(B) CHIP.—Section 2108(e) of the Social Security Act 

(42 U.S.C. 1397hh(e)) is amended by adding at the end the 

following new paragraph: 

‘‘(7) Data collected and reported in accordance with section 

3101 of the Public Health Service Act, with respect to individuals enrolled in the State child health plan (and, in the case 

of enrollees under 19 years of age, their parents or legal guardians), including data regarding the primary language of such 

individuals, parents, and legal guardians.’’. 

(2) EXTENDING MEDICARE REQUIREMENT TO ADDRESS

HEALTH DISPARITIES DATA COLLECTION TO MEDICAID AND
Sec. 4302\1946 SSA PPACA (Consolidated) 508 

CHIP.—Title XIX of the Social Security Act (42 U.S.C. 1396 et 

seq.), as amended by section 2703 is amended by adding at the 

end the following new section: 

‘‘SEC. 1946. ø42 U.S.C. 1396w–5¿ ADDRESSING HEALTH CARE DISPARITIES. 

‘‘(a) EVALUATING DATA COLLECTION APPROACHES.—The Secretary shall evaluate approaches for the collection of data under 

this title and title XXI, to be performed in conjunction with existing 

quality reporting requirements and programs under this title and 

title XXI, that allow for the ongoing, accurate, and timely collection 

and evaluation of data on disparities in health care services and 

performance on the basis of race, ethnicity, sex, primary language, 

and disability status. In conducting such evaluation, the Secretary 

shall consider the following objectives: 

‘‘(1) Protecting patient privacy. 

‘‘(2) Minimizing the administrative burdens of data collection and reporting on States, providers, and health plans participating under this title or title XXI. 

‘‘(3) Improving program data under this title and title XXI 

on race, ethnicity, sex, primary language, and disability status. 

‘‘(b) REPORTS TO CONGRESS.— 

‘‘(1) REPORT ON EVALUATION.—Not later than 18 months 

after the date of the enactment of this section, the Secretary 

shall submit to Congress a report on the evaluation conducted 

under subsection (a). Such report shall, taking into consideration the results of such evaluation— 

‘‘(A) identify approaches (including defining methodologies) for identifying and collecting and evaluating 

data on health care disparities on the basis of race, ethnicity, sex, primary language, and disability status for the 

programs under this title and title XXI; and 

‘‘(B) include recommendations on the most effective 

strategies and approaches to reporting HEDIS quality 

measures as required under section 1852(e)(3) and other 

nationally recognized quality performance measures, as 

appropriate, on such bases. 

‘‘(2) REPORTS ON DATA ANALYSES.—Not later than 4 years 

after the date of the enactment of this section, and 4 years 

thereafter, the Secretary shall submit to Congress a report 

that includes recommendations for improving the identification 

of health care disparities for beneficiaries under this title and 

under title XXI based on analyses of the data collected under 

subsection (c). 

‘‘(c) IMPLEMENTING EFFECTIVE APPROACHES.—Not later than 24 

months after the date of the enactment of this section, the Secretary shall implement the approaches identified in the report submitted under subsection (b)(1) for the ongoing, accurate, and timely 

collection and evaluation of data on health care disparities on the 

basis of race, ethnicity, sex, primary language, and disability status.’’. 
509 Sec. 4303 PPACA (Consolidated) \399MM–1 PHSA 

SEC. 4303. CDC AND EMPLOYER-BASED WELLNESS PROGRAMS. 

Title III of the Public Health Service Act (42 U.S.C. 241 et 

seq.), by section 4102, is further amended by adding at the end the 

following: 

‘‘PART U—EMPLOYER-BASED WELLNESS 

PROGRAM 

‘‘SEC. 399MM. ø42 U.S.C. 280l¿ TECHNICAL ASSISTANCE FOR EMPLOYER-BASED WELLNESS PROGRAMS. 

‘‘In order to expand the utilization of evidence-based prevention and health promotion approaches in the workplace, the Director shall— 

‘‘(1) provide employers (including small, medium, and large 

employers, as determined by the Director) with technical assistance, consultation, tools, and other resources in evaluating 

such employers’ employer-based wellness programs, including— 

‘‘(A) measuring the participation and methods to increase participation of employees in such programs; 

‘‘(B) developing standardized measures that assess policy, environmental and systems changes necessary to have 

a positive health impact on employees’ health behaviors, 

health outcomes, and health care expenditures; and 

‘‘(C) evaluating such programs as they relate to 

changes in the health status of employees, the absenteeism 

of employees, the productivity of employees, the rate of 

workplace injury, and the medical costs incurred by employees; and 

‘‘(2) build evaluation capacity among workplace staff by 

training employers on how to evaluate employer-based 

wellness programs and ensuring evaluation resources, technical assistance, and consultation are available to workplace 

staff as needed through such mechanisms as web portals, call 

centers, or other means. øAs revised by section 10404¿ 

‘‘SEC. 399MM–1. ø42 U.S.C. 280l–1¿ NATIONAL WORKSITE HEALTH POLICIES AND PROGRAMS STUDY. 

‘‘(a) IN GENERAL.—In order to assess, analyze, and monitor 

over time data about workplace policies and programs, and to develop instruments to assess and evaluate comprehensive workplace 

chronic disease prevention and health promotion programs, policies 

and practices, not later than 2 years after the date of enactment 

of this part, and at regular intervals (to be determined by the Director) thereafter, the Director shall conduct a national worksite 

health policies and programs survey to assess employer-based 

health policies and programs. 

‘‘(b) REPORT.—Upon the completion of each study under subsection (a), the Director shall submit to Congress a report that includes the recommendations of the Director for the implementation 

of effective employer-based health policies and programs. 
Sec. 4303\399MM–2 PHSA PPACA (Consolidated) 510 

‘‘SEC. 399MM–2. ø42 U.S.C. 280l–2¿ PRIORITIZATION OF EVALUATION BY 

SECRETARY. 

‘‘The Secretary shall evaluate, in accordance with this part, all 

programs funded through the Centers for Disease Control and Prevention before conducting such an evaluation of privately funded 

programs unless an entity with a privately funded wellness program requests such an evaluation. 

‘‘SEC. 399MM–3. ø42 U.S.C. 280l–3¿ PROHIBITION OF FEDERAL WORKPLACE WELLNESS REQUIREMENTS. 

‘‘Notwithstanding any other provision of this part, any recommendations, data, or assessments carried out under this part 

shall not be used to mandate requirements for workplace wellness 

programs.’’. 

SEC. 4304. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS. 

Title XXVIII of the Public Health Service Act (42 U.S.C. 300hh 

et seq.) is amended by adding at the end the following: 

‘‘Subtitle C—Strengthening Public Health 

Surveillance Systems 

‘‘SEC. 2821. ø42 U.S.C. 300hh–31¿ EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS. 

‘‘(a) IN GENERAL.—Subject to the availability of appropriations, 

the Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish an Epidemiology and 

Laboratory Capacity Grant Program to award grants to State 

health departments as well as local health departments and tribal 

jurisdictions that meet such criteria as the Director determines appropriate. Academic centers that assist State and eligible local and 

tribal health departments may also be eligible for funding under 

this section as the Director determines appropriate. Grants shall be 

awarded under this section to assist public health agencies in improving surveillance for, and response to, infectious diseases and 

other conditions of public health importance by— 

‘‘(1) strengthening epidemiologic capacity to identify and 

monitor the occurrence of infectious diseases and other conditions of public health importance; 

‘‘(2) enhancing laboratory practice as well as systems to report test orders and results electronically; 

‘‘(3) improving information systems including developing 

and maintaining an information exchange using national 

guidelines and complying with capacities and functions determined by an advisory council established and appointed by the 

Director; and 

‘‘(4) developing and implementing prevention and control 

strategies. 

‘‘(b) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this section $190,000,000 for 

each of fiscal years 2010 through 2013, of which— 

‘‘(1) not less than $95,000,000 shall be made available each 

such fiscal year for activities under paragraphs (1) and (4) of 

subsection (a); 
511 Sec. 4305 PPACA (Consolidated) \409J PHSA 

‘‘(2) not less than $60,000,000 shall be made available each 

such fiscal year for activities under subsection (a)(3); and 

‘‘(3) not less than $32,000,000 shall be made available each 

such fiscal year for activities under subsection (a)(2).’’. 

SEC. 4305. ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE 

MANAGEMENT. 

(a) INSTITUTE OF MEDICINE CONFERENCE ON PAIN.— 

(1) CONVENING.—Not later than 1 year after funds are appropriated to carry out this subsection, the Secretary of Health 

and Human Services shall seek to enter into an agreement 

with the Institute of Medicine of the National Academies to 

convene a Conference on Pain (in this subsection referred to as 

‘‘the Conference’’). 

(2) PURPOSES.—The purposes of the Conference shall be 

to— 

(A) increase the recognition of pain as a significant 

public health problem in the United States; 

(B) evaluate the adequacy of assessment, diagnosis, 

treatment, and management of acute and chronic pain in 

the general population, and in identified racial, ethnic, 

gender, age, and other demographic groups that may be 

disproportionately affected by inadequacies in the assessment, diagnosis, treatment, and management of pain; 

(C) identify barriers to appropriate pain care; 

(D) establish an agenda for action in both the public 

and private sectors that will reduce such barriers and significantly improve the state of pain care research, education, and clinical care in the United States. 

(3) OTHER APPROPRIATE ENTITY.—If the Institute of Medicine declines to enter into an agreement under paragraph (1), 

the Secretary of Health and Human Services may enter into 

such agreement with another appropriate entity. 

(4) REPORT.—A report summarizing the Conference’s findings and recommendations shall be submitted to the Congress 

not later than June 30, 2011. 

(5) AUTHORIZATION OF APPROPRIATIONS.—For the purpose 

of carrying out this subsection, there is authorized to be appropriated such sums as may be necessary for each of fiscal years 

2010 and 2011. 

(b) PAIN RESEARCH AT NATIONAL INSTITUTES OF HEALTH.—Part 

B of title IV of the Public Health Service Act (42 U.S.C. 284 et seq.) 

is amended by adding at the end the following: 

‘‘SEC. 409J. ø42 U.S.C. 284q¿ PAIN RESEARCH. 

‘‘(a) RESEARCH INITIATIVES.— 

‘‘(1) IN GENERAL.—The Director of NIH is encouraged to 

continue and expand, through the Pain Consortium, an aggressive program of basic and clinical research on the causes of and 

potential treatments for pain. 

‘‘(2) ANNUAL RECOMMENDATIONS.—Not less than annually, 

the Pain Consortium, in consultation with the Division of Program Coordination, Planning, and Strategic Initiatives, shall 

develop and submit to the Director of NIH recommendations 

on appropriate pain research initiatives that could be under-
Sec. 4305\409J PHSA PPACA (Consolidated) 512 

taken with funds reserved under section 402A(c)(1) for the 

Common Fund or otherwise available for such initiatives. 

‘‘(3) DEFINITION.—In this subsection, the term ‘Pain Consortium’ means the Pain Consortium of the National Institutes 

of Health or a similar trans-National Institutes of Health coordinating entity designated by the Secretary for purposes of 

this subsection. 

‘‘(b) INTERAGENCY PAIN RESEARCH COORDINATING COM- MITTEE.— 

‘‘(1) ESTABLISHMENT.—The Secretary shall establish not 

later than 1 year after the date of the enactment of this section 

and as necessary maintain a committee, to be known as the 

Interagency Pain Research Coordinating Committee (in this 

section referred to as the ‘Committee’), to coordinate all efforts 

within the Department of Health and Human Services and 

other Federal agencies that relate to pain research. 

‘‘(2) MEMBERSHIP.— ‘‘(A) IN GENERAL.—The Committee shall be composed 

of the following voting members: 

‘‘(i) Not more than 7 voting Federal representatives appoint by the Secretary from agencies that conduct pain care research and treatment. 

‘‘(ii) 12 additional voting members appointed 

under subparagraph (B). 

‘‘(B) ADDITIONAL MEMBERS.—The Committee shall include additional voting members appointed by the Secretary as follows: 

‘‘(i) 6 non-Federal members shall be appointed 

from among scientists, physicians, and other health 

professionals. 

‘‘(ii) 6 members shall be appointed from members 

of the general public, who are representatives of leading research, advocacy, and service organizations for 

individuals with pain-related conditions. 

‘‘(C) NONVOTING MEMBERS.—The Committee shall include such nonvoting members as the Secretary determines to be appropriate. 

‘‘(3) CHAIRPERSON.—The voting members of the Committee 

shall select a chairperson from among such members. The selection of a chairperson shall be subject to the approval of the 

Director of NIH. 

‘‘(4) MEETINGS.—The Committee shall meet at the call of 

the chairperson of the Committee or upon the request of the 

Director of NIH, but in no case less often than once each year. 

‘‘(5) DUTIES.—The Committee shall— 

‘‘(A) develop a summary of advances in pain care research supported or conducted by the Federal agencies relevant to the diagnosis, prevention, and treatment of pain 

and diseases and disorders associated with pain; 

‘‘(B) identify critical gaps in basic and clinical research 

on the symptoms and causes of pain; 

‘‘(C) make recommendations to ensure that the activities of the National Institutes of Health and other Federal 

agencies are free of unnecessary duplication of effort; 
513 Sec. 4306 PPACA (Consolidated) 

‘‘(D) make recommendations on how best to disseminate information on pain care; and 

‘‘(E) make recommendations on how to expand partnerships between public entities and private entities to expand collaborative, cross-cutting research. 

‘‘(6) REVIEW.—The Secretary shall review the necessity of 

the Committee at least once every 2 years.’’. 

(c) PAIN CARE EDUCATION AND TRAINING.—Part D of title VII 

of the Public Health Service Act (42 U.S.C. 294 et seq.) is amended 

by adding at the end the following new section: 

‘‘SEC. 759. ø42 U.S.C. 294i¿ PROGRAM FOR EDUCATION AND TRAINING 

IN PAIN CARE. 

‘‘(a) IN GENERAL.—The Secretary may make awards of grants, 

cooperative agreements, and contracts to health professions 

schools, hospices, and other public and private entities for the development and implementation of programs to provide education 

and training to health care professionals in pain care. 

‘‘(b) CERTAIN TOPICS.—An award may be made under subsection (a) only if the applicant for the award agrees that the program carried out with the award will include information and education on— 

‘‘(1) recognized means for assessing, diagnosing, treating, 

and managing pain and related signs and symptoms, including 

the medically appropriate use of controlled substances; 

‘‘(2) applicable laws, regulations, rules, and policies on controlled substances, including the degree to which misconceptions and concerns regarding such laws, regulations, rules, and 

policies, or the enforcement thereof, may create barriers to patient access to appropriate and effective pain care; 

‘‘(3) interdisciplinary approaches to the delivery of pain 

care, including delivery through specialized centers providing 

comprehensive pain care treatment expertise; 

‘‘(4) cultural, linguistic, literacy, geographic, and other barriers to care in underserved populations; and 

‘‘(5) recent findings, developments, and improvements in 

the provision of pain care. 

‘‘(c) EVALUATION OF PROGRAMS.—The Secretary shall (directly 

or through grants or contracts) provide for the evaluation of programs implemented under subsection (a) in order to determine the 

effect of such programs on knowledge and practice of pain care. 

‘‘(d) PAIN CARE DEFINED.—For purposes of this section the 

term ‘pain care’ means the assessment, diagnosis, treatment, or 

management of acute or chronic pain regardless of causation or 

body location. 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated to carry out this section, such sums as may be 

necessary for each of the fiscal years 2010 through 2012. Amounts 

appropriated under this subsection shall remain available until expended.’’. 

SEC. 4306. FUNDING FOR CHILDHOOD OBESITY DEMONSTRATION 

PROJECT. 

Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 

1320b–9a(e)(8)) is amended to read as follows: 
Sec. 4401 PPACA (Consolidated) 514 

‘‘(8) APPROPRIATION.—Out of any funds in the Treasury not 

otherwise appropriated, there is appropriated to carry out this 

subsection, $25,000,000 for the period of fiscal years 2010 

through 2014.’’. 

Subtitle E—Miscellaneous Provisions 

øSEC. 4401. SENSE OF THE SENATE CONCERNING CBO SCORING.¿ 

øStricken by section 10405; subsequent section not redesignated¿ 

SEC. 4402. EFFECTIVENESS OF FEDERAL HEALTH AND WELLNESS INITIATIVES. 

To determine whether existing Federal health and wellness 

initiatives are effective in achieving their stated goals, the Secretary of Health and Human Services shall— 

(1) conduct an evaluation of such programs as they relate 

to changes in health status of the American public and specifically on the health status of the Federal workforce, including 

absenteeism of employees, the productivity of employees, the 

rate of workplace injury, and the medical costs incurred by employees, and health conditions, including workplace fitness, 

healthy food and beverages, and incentives in the Federal Employee Health Benefits Program; and 

(2) submit to Congress a report concerning such evaluation, which shall include conclusions concerning the reasons 

that such existing programs have proven successful or not successful and what factors contributed to such conclusions. 
515 Sec. 5002 PPACA (Consolidated) 

TITLE V—HEALTH CARE WORKFORCE 

Subtitle A—Purpose and Definitions 

SEC. 5001. PURPOSE. 

The purpose of this title is to improve access to and the delivery of health care services for all individuals, particularly low income, underserved, uninsured, minority, health disparity, and rural 

populations by— 

(1) gathering and assessing comprehensive data in order 

for the health care workforce to meet the health care needs of 

individuals, including research on the supply, demand, distribution, diversity, and skills needs of the health care workforce; 

(2) increasing the supply of a qualified health care workforce to improve access to and the delivery of health care services for all individuals; 

(3) enhancing health care workforce education and training to improve access to and the delivery of health care services for all individuals; and 

(4) providing support to the existing health care workforce 

to improve access to and the delivery of health care services for 

all individuals. 

SEC. 5002. ø42 U.S.C. 294q note¿ DEFINITIONS. 

(a) THIS TITLE.—In this title: 

(1) ALLIED HEALTH PROFESSIONAL.—The term ‘‘allied 

health professional’’ means an allied health professional as defined in section 799B(5) of the Public Heath Service Act (42 

U.S.C. 295p(5)) who— 

(A) has graduated and received an allied health professions degree or certificate from an institution of higher 

education; and 

(B) is employed with a Federal, State, local or tribal 

public health agency, or in a setting where patients might 

require health care services, including acute care facilities, 

ambulatory care facilities, personal residences, and other 

settings located in health professional shortage areas, 

medically underserved areas, or medically underserved 

populations, as recognized by the Secretary of Health and 

Human Services. 

(2) HEALTH CARE CAREER PATHWAY.—The term ‘‘healthcare 

career pathway’’ means a rigorous, engaging, and high quality 

set of courses and services that— 

(A) includes an articulated sequence of academic and 

career courses, including 21st century skills; 

(B) is aligned with the needs of healthcare industries 

in a region or State; 

(C) prepares students for entry into the full range of 

postsecondary education options, including registered apprenticeships, and careers; 
Sec. 5002 PPACA (Consolidated) 516 

(D) provides academic and career counseling in student-to-counselor ratios that allow students to make informed decisions about academic and career options; 

(E) meets State academic standards, State requirements for secondary school graduation and is aligned with 

requirements for entry into postsecondary education, and 

applicable industry standards; and 

(F) leads to 2 or more credentials, including— 

(i) a secondary school diploma; and 

(ii) a postsecondary degree, an apprenticeship or 

other occupational certification, a certificate, or a license. 

(3) INSTITUTION OF HIGHER EDUCATION.—The term ‘‘institution of higher education’’ has the meaning given the term in 

sections 101 and 102 of the Higher Education Act of 1965 (20 

U.S.C. 1001 and 1002). 

(4) LOW INCOME INDIVIDUAL, STATE WORKFORCE INVEST- MENT BOARD, AND LOCAL WORKFORCE INVESTMENT BOARD.— (A) LOW-INCOME INDIVIDUAL.—The term ‘‘low-income 

individual’’ has the meaning given that term in section 101 

of the Workforce investment Act of 1998 (29 U.S.C. 2801). 

(B) STATE WORKFORCE INVESTMENT BOARD; LOCAL

WORKFORCE INVESTMENT BOARD.—The terms ‘‘State workforce investment board’’ and ‘‘local workforce investment 

board’’, refer to a State workforce investment board established under section 111 of the Workforce Investment Act 

of 1998 (29 U.S.C. 2821) and a local workforce investment 

board established under section 117 of such Act (29 U.S.C. 

2832), respectively. 

(5) POSTSECONDARY EDUCATION.—The term ‘‘postsecondary 

education’’ means— 

(A) a 4-year program of instruction, or not less than 

a 1-year program of instruction that is acceptable for credit toward an associate or a baccalaureate degree, offered by 

an institution of higher education; or 

(B) a certificate or registered apprenticeship program 

at the postsecondary level offered by an institution of higher education or a non-profit educational institution. 

(6) REGISTERED APPRENTICESHIP PROGRAM.—The term ‘‘registered apprenticeship program’’ means an industry skills 

training program at the postsecondary level that combines 

technical and theoretical training through structure on the job 

learning with related instruction (in a classroom or through 

distance learning) while an individual is employed, working 

under the direction of qualified personnel or a mentor, and 

earning incremental wage increases aligned to enhance job proficiency, resulting in the acquisition of a nationally recognized 

and portable certificate, under a plan approved by the Office 

of Apprenticeship or a State agency recognized by the Department of Labor. 

(b) TITLE VII OF THE PUBLIC HEALTH SERVICE ACT.—Section 

799B of the Public Health Service Act (42 U.S.C. 295p) is amended— 

(1) by striking paragraph (3) and inserting the following: 
517 Sec. 5002 PPACA (Consolidated) 

‘‘(3) PHYSICIAN ASSISTANT EDUCATION PROGRAM.—The term 

‘physician assistant education program’ means an educational 

program in a public or private institution in a State that— 

‘‘(A) has as its objective the education of individuals 

who, upon completion of their studies in the program, be 

qualified to provide primary care medical services with the 

supervision of a physician; and 

‘‘(B) is accredited by the Accreditation Review Commission on Education for the Physician Assistant.’’; and 

(2) by adding at the end the following: 

‘‘(12) AREA HEALTH EDUCATION CENTER.—The term ‘area 

health education center’ means a public or nonprofit private organization that has a cooperative agreement or contract in effect with an entity that has received an award under subsection (a)(1) or (a)(2) of section 751, satisfies the requirements 

in section 751(d)(1), and has as one of its principal functions 

the operation of an area health education center. Appropriate 

organizations may include hospitals, health organizations with 

accredited primary care training programs, accredited physician assistant educational programs associated with a college 

or university, and universities or colleges not operating a 

school of medicine or osteopathic medicine. 

‘‘(13) AREA HEALTH EDUCATION CENTER PROGRAM.—The 

term ‘area health education center program’ means cooperative 

program consisting of an entity that has received an award 

under subsection (a)(1) or (a)(2) of section 751 for the purpose 

of planning, developing, operating, and evaluating an area 

health education center program and one or more area health 

education centers, which carries out the required activities described in section 751(c), satisfies the program requirements in 

such section, has as one of its principal functions identifying 

and implementing strategies and activities that address health 

care workforce needs in its service area, in coordination with 

the local workforce investment boards. 

‘‘(14) CLINICAL SOCIAL WORKER.—The term ‘clinical social 

worker’ has the meaning given the term in section 1861(hh)(1) 

of the Social Security Act (42 U.S.C. 1395x(hh)(1)). 

‘‘(15) CULTURAL COMPETENCY.—The term ‘cultural competency’ shall be defined by the Secretary in a manner consistent with section 1707(d)(3). 

‘‘(16) DIRECT CARE WORKER.—The term ‘direct care worker’ 

has the meaning given that term in the 2010 Standard Occupational Classifications of the Department of Labor for Home 

Health Aides [31–1011], Psychiatric Aides [31–1013], Nursing 

Assistants [31–1014], and Personal Care Aides [39–9021]. 

‘‘(17) FEDERALLY QUALIFIED HEALTH CENTER.—The term 

‘Federally qualified health center’ has the meaning given that 

term in section 1861(aa) of the Social Security Act (42 U.S.C. 

1395x(aa)). 

‘‘(18) FRONTIER HEALTH PROFESSIONAL SHORTAGE AREA.— 

The term ‘frontier health professional shortage area’ means an 

area— 

‘‘(A) with a population density less than 6 persons per 

square mile within the service area; and 
Sec. 5002 PPACA (Consolidated) 518 

‘‘(B) with respect to which the distance or time for the 

population to access care is excessive. 

‘‘(19) GRADUATE PSYCHOLOGY.—The term ‘graduate psychology’ means an accredited program in professional psychology. 

‘‘(20) HEALTH DISPARITY POPULATION.—The term ‘health 

disparity population’ has the meaning given such term in section 903(d)(1). 

‘‘(21) HEALTH LITERACY.—The term ‘health literacy’ means 

the degree to which an individual has the capacity to obtain, 

communicate, process, and understand health information and 

services in order to make appropriate health decisions. 

‘‘(22) MENTAL HEALTH SERVICE PROFESSIONAL.—The term 

‘mental health service professional’ means an individual with 

a graduate or postgraduate degree from an accredited institution of higher education in psychiatry, psychology, school psychology, behavioral pediatrics, psychiatric nursing, social work, 

school social work, substance abuse disorder prevention and 

treatment, marriage and family counseling, school counseling, 

or professional counseling. 

‘‘(23) ONE-STOP DELIVERY SYSTEM CENTER.—The term ‘onestop delivery system’ means a one-stop delivery system described in section 134(c) of the Workforce Investment Act of 

1998 (29 U.S.C. 2864(c)). 

‘‘(24) PARAPROFESSIONAL CHILD AND ADOLESCENT MENTAL

HEALTH WORKER.—The term ‘paraprofessional child and adolescent mental health worker’ means an individual who is not a 

mental or behavioral health service professional, but who 

works at the first stage of contact with children and families 

who are seeking mental or behavioral health services, including substance abuse prevention and treatment services. 

‘‘(25) RACIAL AND ETHNIC MINORITY GROUP; RACIAL AND

ETHNIC MINORITY POPULATION.—The terms ‘racial and ethnic 

minority group’ and ‘racial and ethnic minority population’ 

have the meaning given the term ‘racial and ethnic minority 

group’ in section 1707. 

‘‘(26) RURAL HEALTH CLINIC.—The term ‘rural health clinic’ 

has the meaning given that term in section 1861(aa) of the Social Security Act (42 U.S.C. 1395x(aa)).’’. 

(c) TITLE VIII OF THE PUBLIC HEALTH SERVICE ACT.—Section 

801 of the Public Health Service Act (42 U.S.C. 296) is amended— 

(1) in paragraph (2)— 

(A) by striking ‘‘means a’’ and inserting ‘‘means an accredited (as defined in paragraph 6)’’; and 

(B) by striking the period as inserting the following: 

‘‘where graduates are— 

‘‘(A) authorized to sit for the National Council Licensure EXamination-Registered Nurse (NCLEX–RN); or 

‘‘(B) licensed registered nurses who will receive a graduate or equivalent degree or training to become an advanced education nurse as defined by section 811(b).’’; and 

(2) by adding at the end the following: 

‘‘(16) ACCELERATED NURSING DEGREE PROGRAM.—The term 

‘accelerated nursing degree program’ means a program of edu-
519 Sec. 5101 PPACA (Consolidated) 

cation in professional nursing offered by an accredited school 

of nursing in which an individual holding a bachelors degree 

in another discipline receives a BSN or MSN degree in an accelerated time frame as determined by the accredited school of 

nursing. 

‘‘(17) BRIDGE OR DEGREE COMPLETION PROGRAM.—The term 

‘bridge or degree completion program’ means a program of education in professional nursing offered by an accredited school 

of nursing, as defined in paragraph (2), that leads to a baccalaureate degree in nursing. Such programs may include, Registered Nurse (RN) to Bachelor’s of Science of Nursing (BSN) 

programs, RN to MSN (Master of Science of Nursing) programs, or BSN to Doctoral programs.’’. 

Subtitle B—Innovations in the Health Care 

Workforce 

SEC. 5101. ø42 U.S.C. 294q¿ NATIONAL HEALTH CARE WORKFORCE COMMISSION. 

(a) PURPOSE.—It is the purpose of this section to establish a 

National Health Care Workforce Commission that— 

(1) serves as a national resource for Congress, the President, States, and localities; 

(2) communicates and coordinates with the Departments of 

Health and Human Services, Labor, Veterans Affairs, Homeland Security, and Education on related activities administered 

by one or more of such Departments; 

(3) develops and commissions evaluations of education and 

training activities to determine whether the demand for health 

care workers is being met; 

(4) identifies barriers to improved coordination at the Federal, State, and local levels and recommend ways to address 

such barriers; and 

(5) encourages innovations to address population needs, 

constant changes in technology, and other environmental factors. 

(b) ESTABLISHMENT.—There is hereby established the National 

Health Care Workforce Commission (in this section referred to as 

the ‘‘Commission’’). 

(c) MEMBERSHIP.— 

(1) NUMBER AND APPOINTMENT.—The Commission shall be 

composed of 15 members to be appointed by the Comptroller 

General, without regard to section 5 of the Federal Advisory 

Committee Act (5 U.S.C. App.). 

(2) QUALIFICATIONS.— 

(A) IN GENERAL.—The membership of the Commission 

shall include individuals— 

(i) with national recognition for their expertise in 

health care labor market analysis, including health 

care workforce analysis; health care finance and economics; health care facility management; health care 

plans and integrated delivery systems; health care 

workforce education and training; health care philan-
Sec. 5101 PPACA (Consolidated) 520 

thropy; providers of health care services; and other related fields; and 

(ii) who will provide a combination of professional 

perspectives, broad geographic representation, and a 

balance between urban, suburban, rural, and frontier 

representatives. 

(B) INCLUSION.— (i) IN GENERAL.—The membership of the Commission shall include no less than one representative of— 

(I) the health care workforce and health professionals; 

(II) employers, including representatives of 

small business and self-employed individuals; øAs 

revised by section 10501(a)(1)¿ 

(III) third-party payers; 

(IV) individuals skilled in the conduct and interpretation of health care services and health economics research; 

(V) representatives of consumers; 

(VI) labor unions; 

(VII) State or local workforce investment 

boards; and 

(VIII) educational institutions (which may include elementary and secondary institutions, institutions of higher education, including 2 and 4 year 

institutions, or registered apprenticeship programs). 

(ii) ADDITIONAL MEMBERS.—The remaining membership may include additional representatives from 

clause (i) and other individuals as determined appropriate by the Comptroller General of the United 

States. 

(C) MAJORITY NON-PROVIDERS.—Individuals who are 

directly involved in health professions education or practice shall not constitute a majority of the membership of 

the Commission. 

(D) ETHICAL DISCLOSURE.—The Comptroller General 

shall establish a system for public disclosure by members 

of the Commission of financial and other potential conflicts 

of interest relating to such members. Members of the Commission shall be treated as employees of Congress for purposes of applying title I of the Ethics in Government Act 

of 1978. Members of the Commission shall not be treated 

as special government employees under title 18, United 

States Code. 

(3) TERMS.— 

(A) IN GENERAL.—The terms of members of the Commission shall be for 3 years except that the Comptroller 

General shall designate staggered terms for the members 

first appointed. 

(B) VACANCIES.—Any member appointed to fill a vacancy occurring before the expiration of the term for which 

the member’s predecessor was appointed shall be appointed only for the remainder of that term. A member 
521 Sec. 5101 PPACA (Consolidated) 

may serve after the expiration of that member’s term until 

a successor has taken office. A vacancy in the Commission 

shall be filled in the manner in which the original appointment was made. 

(C) INITIAL APPOINTMENTS.—The Comptroller General 

shall make initial appointments of members to the Commission not later than September 30, 2010. 

(4) COMPENSATION.—While serving on the business of the 

Commission (including travel time), a member of the Commission shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule 

under section 5315 of tile 5, United States Code, and while so 

serving away from home and the member’s regular place of 

business, a member may be allowed travel expenses, as authorized by the Chairman of the Commission. Physicians serving 

as personnel of the Commission may be provided a physician 

comparability allowance by the Commission in the same manner as Government physicians may be provided such an allowance by an agency under section 5948 of title 5, United States 

Code, and for such purpose subsection (i) of such section shall 

apply to the Commission in the same manner as it applies to 

the Tennessee Valley Authority. For purposes of pay (other 

than pay of members of the Commission) and employment benefits, rights, and privileges, all personnel of the Commission 

shall be treated as if they were employees of the United States 

Senate. Personnel of the Commission shall not be treated as 

employees of the Government Accountability Office for any 

purpose. 

(5) CHAIRMAN, VICE CHAIRMAN.—The Comptroller General 

shall designate a member of the Commission, at the time of appointment of the member, as Chairman and a member as Vice 

Chairman for that term of appointment, except that in the case 

of vacancy of the chairmanship or vice chairmanship, the 

Comptroller General may designate another member for the 

remainder of that member’s term. 

(6) MEETINGS.—The Commission shall meet at the call of 

the chairman, but no less frequently than on a quarterly basis. 

(d) DUTIES.— 

(1) RECOGNITION, DISSEMINATION, AND COMMUNICATION.— 

The Commission shall— 

(A) recognize efforts of Federal, State, and local partnerships to develop and offer health care career pathways 

of proven effectiveness; 

(B) disseminate information on promising retention 

practices for health care professionals; and 

(C) communicate information on important policies 

and practices that affect the recruitment, education and 

training, and retention of the health care workforce. 

(2) REVIEW OF HEALTH CARE WORKFORCE AND ANNUAL REPORTS.—In order to develop a fiscally sustainable integrated 

workforce that supports a high-quality, readily accessible 

health care delivery system that meets the needs of patients 

and populations, the Commission, in consultation with relevant 

Federal, State, and local agencies, shall— 
Sec. 5101 PPACA (Consolidated) 522 

(A) review current and projected health care workforce 

supply and demand, including the topics described in paragraph (3); 

(B) make recommendations to Congress and the Administration concerning national health care workforce priorities, goals, and policies; 

(C) by not later than October 1 of each year (beginning 

with 2011), submit a report to Congress and the Administration containing the results of such reviews and recommendations concerning related policies; and 

(D) by not later than April 1 of each year (beginning 

with 2011), submit a report to Congress and the Administration containing a review of, and recommendations on, at 

a minimum one high priority area as described in paragraph (4). 

(3) SPECIFIC TOPICS TO BE REVIEWED.—The topics described 

in this paragraph include— 

(A) current health care workforce supply and distribution, including demographics, skill sets, and demands, with 

projected demands during the subsequent 10 and 25 year 

periods; 

(B) health care workforce education and training capacity, including the number of students who have completed education and training, including registered apprenticeships; the number of qualified faculty; the education 

and training infrastructure; and the education and training demands, with projected demands during the subsequent 10 and 25 year periods; 

(C) the education loan and grant programs in titles 

VII and VIII of the Public Health Service Act (42 U.S.C. 

292 et seq. and 296 et seq.), with recommendations on 

whether such programs should become part of the Higher 

Education Act of 1965 (20 U.S.C. 1001 et seq); 

(D) the implications of new and existing Federal policies which affect the health care workforce, including 

Medicare and Medicaid graduate medical education policies, titles VII and VIII of the Public Health Service Act 

(42 U.S.C. 292 et seq. and 296 et seq.), the National 

Health Service Corps (with recommendations for aligning 

such programs with national health workforce priorities 

and goals), and other health care workforce programs, including those supported through the Workforce Investment 

Act of 1998 (29 U.S.C. 2801 et seq.), the Carl D. Perkins 

Career and Technical Education Act of 2006 (20 U.S.C. 

2301 et seq.), the Higher Education Act of 1965 (20 U.S.C. 

1001 et seq.), and any other Federal health care workforce 

programs; 

(E) the health care workforce needs of special populations, such as minorities, rural populations, medically 

underserved populations, gender specific needs, individuals 

with disabilities, and geriatric and pediatric populations 

with recommendations for new and existing Federal policies to meet the needs of these special populations; and 
523 Sec. 5101 PPACA (Consolidated) 

(F) recommendations creating or revising national loan 

repayment programs and scholarship programs to require 

low-income, minority medical students to serve in their 

home communities, if designated as medical underserved 

community. 

(4) HIGH PRIORITY AREAS.— 

(A) IN GENERAL.—The initial high priority topics described in this paragraph include each of the following: 

(i) Integrated health care workforce planning that 

identifies health care professional skills needed and 

maximizes the skill sets of health care professionals 

across disciplines. 

(ii) An analysis of the nature, scopes of practice, 

and demands for health care workers in the enhanced 

information technology and management workplace. 

(iii) An analysis of how to align Medicare and 

Medicaid graduate medical education policies with national workforce goals. 

(iv) øAs added by section 10501(a)(3)¿ An analysis 

of, and recommendations for, eliminating the barriers 

to entering and staying in primary care, including provider compensation. 

(v) The education and training capacity, projected 

demands, and integration with the health care delivery system of each of the following: 

(I) Nursing workforce capacity at all levels. 

(II) Oral health care workforce capacity at all 

levels. 

(III) Mental and behavioral health care workforce capacity at all levels. 

(IV) Allied health and public health care 

workforce capacity at all levels. 

(V) Emergency medical service workforce capacity, including the retention and recruitment of 

the volunteer workforce, at all levels. 

(VI) The geographic distribution of health 

care providers as compared to the identified 

health care workforce needs of States and regions. 

(B) FUTURE DETERMINATIONS.—The Commission may 

require that additional topics be included under subparagraph (A). The appropriate committees of Congress may 

recommend to the Commission the inclusion of other topics 

for health care workforce development areas that require 

special attention. 

(5) GRANT PROGRAM.—The Commission shall— 

(A) review implementation progress reports on, and report to Congress about, the State Health Care Workforce 

Development Grant program established in section 5102; 

(B) in collaboration with the Department of Labor and 

in coordination with the Department of Education and 

other relevant Federal agencies, make recommendations to 

the fiscal and administrative agent under section 5102(b) 

for grant recipients under section 5102; 
Sec. 5101 PPACA (Consolidated) 524 

(C) assess the implementation of the grants under 

such section; and 

(D) collect performance and report information, including identified models and best practices, on grants from 

the fiscal and administrative agent under such section and 

distribute this information to Congress, relevant Federal 

agencies, and to the public. 

(6) STUDY.—The Commission shall study effective mechanisms for financing education and training for careers in 

health care, including public health and allied health. 

(7) RECOMMENDATIONS.—The Commission shall submit 

recommendations to Congress, the Department of Labor, and 

the Department of Health and Human Services about improving safety, health, and worker protections in the workplace for 

the health care workforce. 

(8) ASSESSMENT.—The Commission shall assess and receive reports from the National Center for Health Care Workforce Analysis established under section 761(b) of the Public 

Service Health Act (as amended by section 5103). 

(e) CONSULTATION WITH FEDERAL, STATE, AND LOCAL AGENCIES, CONGRESS, AND OTHER ORGANIZATIONS.— 

(1) IN GENERAL.—The Commission shall consult with Federal agencies (including the Departments of Health and 

Human Services, Labor, Education, Commerce, Agriculture, 

Defense, and Veterans Affairs and the Environmental Protection Agency), Congress, the Medicare Payment Advisory Commission, the Medicaid and CHIP Payment and Access Commission, and, to the extent practicable, with State and local agencies, Indian tribes, voluntary health care organizations, professional societies, and other relevant public-private health care 

partnerships. 

(2) OBTAINING OFFICIAL DATA.—The Commission, consistent with established privacy rules, may secure directly from 

any department or agency of the Executive Branch information 

necessary to enable the Commission to carry out this section. 

(3) DETAIL OF FEDERAL GOVERNMENT EMPLOYEES.—An employee of the Federal Government may be detailed to the Commission without reimbursement. The detail of such an employee shall be without interruption or loss of civil service status. 

(f) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS.—Subject 

to such review as the Comptroller General of the United States determines to be necessary to ensure the efficient administration of 

the Commission, the Commission may— 

(1) employ and fix the compensation of an executive director that shall not exceed the rate of basic pay payable for level 

V of the Executive Schedule and such other personnel as may 

be necessary to carry out its duties (without regard to the provisions of title 5, United States Code, governing appointments 

in the competitive service); 

(2) seek such assistance and support as may be required 

in the performance of its duties from appropriate Federal departments and agencies; 
525 Sec. 5101 PPACA (Consolidated) 

(3) enter into contracts or make other arrangements, as 

may be necessary for the conduct of the work of the Commission (without regard to section 3709 of the Revised Statutes 

(41 U.S.C. 5)); 

(4) make advance, progress, and other payments which relate to the work of the Commission; 

(5) provide transportation and subsistence for persons 

serving without compensation; and 

(6) prescribe such rules and regulations as the Commission 

determines to be necessary with respect to the internal organization and operation of the Commission. 

(g) POWERS.— (1) DATA COLLECTION.—In order to carry out its functions 

under this section, the Commission shall— 

(A) utilize existing information, both published and 

unpublished, where possible, collected and assessed either 

by its own staff or under other arrangements made in accordance with this section, including coordination with the 

Bureau of Labor Statistics; 

(B) carry out, or award grants or contracts for the carrying out of, original research and development, where existing information is inadequate, and 

(C) adopt procedures allowing interested parties to 

submit information for the Commission’s use in making reports and recommendations. 

(2) ACCESS OF THE GOVERNMENT ACCOUNTABILITY OFFICE

TO INFORMATION.—The Comptroller General of the United 

States shall have unrestricted access to all deliberations, 

records, and data of the Commission, immediately upon request. 

(3) PERIODIC AUDIT.—The Commission shall be subject to 

periodic audit by an independent public accountant under contract to the Commission. 

(h) AUTHORIZATION OF APPROPRIATIONS.— 

(1) REQUEST FOR APPROPRIATIONS.—The Commission shall 

submit requests for appropriations in the same manner as the 

Comptroller General of the United States submits requests for 

appropriations. Amounts so appropriated for the Commission 

shall be separate from amounts appropriated for the Comptroller General. 

(2) AUTHORIZATION.—There are authorized to be appropriated such sums as may be necessary to carry out this section. 

(3) GIFTS AND SERVICES.—The Commission may not accept 

gifts, bequeaths, or donations of property, but may accept and 

use donations of services for purposes of carrying out this section. 

(i) DEFINITIONS.—In this section: 

(1) HEALTH CARE WORKFORCE.—The term ‘‘health care 

workforce’’ includes all health care providers with direct patient care and support responsibilities, such as physicians, 

nurses, nurse practitioners, primary care providers, preventive 

medicine physicians, optometrists, ophthalmologists, physician 

assistants, pharmacists, dentists, dental hygienists, and other 
Sec. 5102 PPACA (Consolidated) 526 

oral healthcare professionals, allied health professionals, doctors of chiropractic, community health workers, health care 

paraprofessionals, direct care workers, psychologists and other 

behavioral and mental health professionals (including substance abuse prevention and treatment providers), social workers, physical and occupational therapists, certified nurse midwives, podiatrists, the EMS workforce (including professional 

and volunteer ambulance personnel and firefighters who perform emergency medical services), licensed complementary and 

alternative medicine providers, integrative health practitioners, public health professionals, and any other health professional that the Comptroller General of the United States determines appropriate. 

(2) HEALTH PROFESSIONALS.—The term ‘‘health professionals’’ includes— 

(A) dentists, dental hygienists, primary care providers, 

specialty physicians, nurses, nurse practitioners, physician 

assistants, psychologists and other behavioral and mental 

health professionals (including substance abuse prevention 

and treatment providers), social workers, physical and occupational therapists, øpossible intended addition by section 10501(a)(3)—which amended subsection (i)(2)(B): optometrists, ophthalmologists,¿ public health professionals, 

clinical pharmacists, allied health professionals, doctors of 

chiropractic, community health workers, school nurses, 

certified nurse midwives, podiatrists, licensed complementary and alternative medicine providers, the EMS workforce (including professional and volunteer ambulance personnel and firefighters who perform emergency medical 

services), and integrative health practitioners; 

(B) national representatives of health professionals; 

(C) representatives of schools of medicine, osteopathy, 

nursing, dentistry, optometry, pharmacy, chiropractic, allied health, educational programs for public health professionals, behavioral and mental health professionals (as so 

defined), social workers, pharmacists, physical and occupational therapists, øpossible intended addition by section 

10501(a)(3)—which amended subsection (i)(2)(B): optometrists, ophthalmologists,¿ oral health care industry dentistry and dental hygiene, and physician assistants; 

(D) representatives of public and private teaching hospitals, and ambulatory health facilities, including Federal 

medical facilities; and 

(E) any other health professional the Comptroller General of the United States determines appropriate. 

SEC. 5102. ø42 U.S.C. 294r¿ STATE HEALTH CARE WORKFORCE DEVELOPMENT GRANTS. 

(a) ESTABLISHMENT.—There is established a competitive health 

care workforce development grant program (referred to in this section as the ‘‘program’’) for the purpose of enabling State partnerships to complete comprehensive planning and to carry out activities leading to coherent and comprehensive health care workforce 

development strategies at the State and local levels. 
527 Sec. 5102 PPACA (Consolidated) 

(b) FISCAL AND ADMINISTRATIVE AGENT.—The Health Resources and Services Administration of the Department of Health 

and Human Services (referred to in this section as the ‘‘Administration’’) shall be the fiscal and administrative agent for the grants 

awarded under this section. The Administration is authorized to 

carry out the program, in consultation with the National Health 

Care Workforce Commission (referred to in this section as the 

‘‘Commission’’), which shall review reports on the development, implementation, and evaluation activities of the grant program, including— 

(1) administering the grants; 

(2) providing technical assistance to grantees; and 

(3) reporting performance information to the Commission. 

(c) PLANNING GRANTS.— 

(1) AMOUNT AND DURATION.—A planning grant shall be 

awarded under this subsection for a period of not more than 

one year and the maximum award may not be more than 

$150,000. 

(2) ELIGIBILITY.—To be eligible to receive a planning grant, 

an entity shall be an eligible partnership. An eligible partnership shall be a State workforce investment board, if it includes 

or modifies the members to include at least one representative 

from each of the following: health care employer, labor organization, a public 2-year institution of higher education, a public 

4-year institution of higher education, the recognized State federation of labor, the State public secondary education agency, 

the State P–16 or P–20 Council if such a council exists, and a 

philanthropic organization that is actively engaged in providing learning, mentoring, and work opportunities to recruit, 

educate, and train individuals for, and retain individuals in, 

careers in health care and related industries. 

(3) FISCAL AND ADMINISTRATIVE AGENT.—The Governor of 

the State receiving a planning grant has the authority to appoint a fiscal and an administrative agency for the partnership. 

(4) APPLICATION.—Each State partnership desiring a planning grant shall submit an application to the Administrator of 

the Administration at such time and in such manner, and accompanied by such information as the Administrator may reasonable require. Each application submitted for a planning 

grant shall describe the members of the State partnership, the 

activities for which assistance is sought, the proposed performance benchmarks to be used to measure progress under the 

planning grant, a budget for use of the funds to complete the 

required activities described in paragraph (5), and such additional assurance and information as the Administrator determines to be essential to ensure compliance with the grant program requirements. 

(5) REQUIRED ACTIVITIES.—A State partnership receiving a 

planning grant shall carry out the following: 

(A) Analyze State labor market information in order to 

create health care career pathways for students and 

adults, including dislocated workers. 
Sec. 5102 PPACA (Consolidated) 528 

(B) Identify current and projected high demand State 

or regional health care sectors for purposes of planning career pathways. 

(C) Identify existing Federal, State, and private resources to recruit, educate or train, and retain a skilled 

health care workforce and strengthen partnerships. 

(D) Describe the academic and health care industry 

skill standards for high school graduation, for entry into 

postsecondary education, and for various credentials and 

licensure. 

(E) Describe State secondary and postsecondary education and training policies, models, or practices for the 

health care sector, including career information and guidance counseling. 

(F) Identify Federal or State policies or rules to developing a coherent and comprehensive health care workforce 

development strategy and barriers and a plan to resolve 

these barriers. 

(G) Participate in the Administration’s evaluation and 

reporting activities. 

(6) PERFORMANCE AND EVALUATION.—Before the State 

partnership receives a planning grant, such partnership and 

the Administrator of the Administration shall jointly determine 

the performance benchmarks that will be established for the 

purposes of the planning grant. 

(7) MATCH.—Each State partnership receiving a planning 

grant shall provide an amount, in cash or in kind, that is not 

less that 15 percent of the amount of the grant, to carry out 

the activities supported by the grant. The matching requirement may be provided from funds available under other Federal, State, local or private sources to carry out the activities. 

(8) REPORT.— 

(A) REPORT TO ADMINISTRATION.—Not later than 1 

year after a State partnership receives a planning grant, 

the partnership shall submit a report to the Administration on the State’s performance of the activities under the 

grant, including the use of funds, including matching 

funds, to carry out required activities, and a description of 

the progress of the State workforce investment board in 

meeting the performance benchmarks. 

(B) REPORT TO CONGRESS.—The Administration shall 

submit a report to Congress analyzing the planning activities, performance, and fund utilization of each State grant 

recipient, including an identification of promising practices 

and a profile of the activities of each State grant recipient. 

(d) IMPLEMENTATION GRANTS.— 

(1) IN GENERAL.—The Administration shall— 

(A) competitively award implementation grants to 

State partnerships to enable such partnerships to implement activities that will result in a coherent and comprehensive plan for health workforce development that will 

address current and projected workforce demands within 

the State; and 
529 Sec. 5102 PPACA (Consolidated) 

(B) inform the Commission and Congress about the 

awards made. 

(2) DURATION.—An implementation grant shall be awarded 

for a period of no more than 2 years, except in those cases 

where the Administration determines that the grantee is high 

performing and the activities supported by the grant warrant 

up to 1 additional year of funding. 

(3) ELIGIBILITY.—To be eligible for an implementation 

grant, a State partnership shall have— 

(A) received a planning grant under subsection (c) and 

completed all requirements of such grant; or 

(B) completed a satisfactory application, including a 

plan to coordinate with required partners and complete the 

required activities during the 2 year period of the implementation grant. 

(4) FISCAL AND ADMINISTRATIVE AGENT.—A State partnership receiving an implementation grant shall appoint a fiscal 

and an administration agent for the implementation of such 

grant. 

(5) APPLICATION.—Each eligible State partnership desiring 

an implementation grant shall submit an application to the 

Administration at such time, in such manner, and accompanied by such information as the Administration may reasonably require. Each application submitted shall include— 

(A) a description of the members of the State partnership; 

(B) a description of how the State partnership completed the required activities under the planning grant, if 

applicable; 

(C) a description of the activities for which implementation grant funds are sought, including grants to regions 

by the State partnership to advance coherent and comprehensive regional health care workforce planning activities; 

(D) a description of how the State partnership will coordinate with required partners and complete the required 

partnership activities during the duration of an implementation grant; 

(E) a budget proposal of the cost of the activities supported by the implementation grant and a timeline for the 

provision of matching funds required; 

(F) proposed performance benchmarks to be used to 

assess and evaluate the progress of the partnership activities; 

(G) a description of how the State partnership will collect data to report progress in grant activities; and 

(H) such additional assurances as the Administration 

determines to be essential to ensure compliance with grant 

requirements. 

(6) REQUIRED ACTIVITIES.— 

(A) IN GENERAL.—A State partnership that receives an 

implementation grant may reserve not less than 60 percent of the grant funds to make grants to be competitively 

awarded by the State partnership, consistent with State 
Sec. 5102 PPACA (Consolidated) 530 

procurement rules, to encourage regional partnerships to 

address health care workforce development needs and to 

promote innovative health care workforce career pathway 

activities, including career counseling, learning, and employment. 

(B) ELIGIBLE PARTNERSHIP DUTIES.—An eligible State 

partnership receiving an implementation grant shall— 

(i) identify and convene regional leadership to discuss opportunities to engage in statewide health care 

workforce development planning, including the potential use of competitive grants to improve the development, distribution, and diversity of the regional health 

care workforce; the alignment of curricula for health 

care careers; and the access to quality career information and guidance and education and training opportunities; 

(ii) in consultation with key stakeholders and regional leaders, take appropriate steps to reduce Federal, State, or local barriers to a comprehensive and 

coherent strategy, including changes in State or local 

policies to foster coherent and comprehensive health 

care workforce development activities, including 

health care career pathways at the regional and State 

levels, career planning information, retraining for dislocated workers, and as appropriate, requests for Federal program or administrative waivers; 

(iii) develop, disseminate, and review with key 

stakeholders a preliminary statewide strategy that addresses short- and long-term health care workforce development supply versus demand; 

(iv) convene State partnership members on a regular basis, and at least on a semiannual basis; 

(v) assist leaders at the regional level to form 

partnerships, including technical assistance and capacity building activities; 

(vi) collect and assess data on and report on the 

performance benchmarks selected by the State partnership and the Administration for implementation activities carried out by regional and State partnerships; 

and 

(vii) participate in the Administration’s evaluation 

and reporting activities. 

(7) PERFORMANCE AND EVALUATION.—Before the State 

partnership receives an implementation grant, it and the Administrator shall jointly determine the performance benchmarks that shall be established for the purposes of the implementation grant. 

(8) MATCH.—Each State partnership receiving an implementation grant shall provide an amount, in cash or in kind 

that is not less than 25 percent of the amount of the grant, to 

carry out the activities supported by the grant. The matching 

funds may be provided from funds available from other Federal, State, local, or private sources to carry out such activities. 

(9) REPORTS.— 
531 Sec. 5103 PPACA (Consolidated) 

(A) REPORT TO ADMINISTRATION.—For each year of the 

implementation grant, the State partnership receiving the 

implementation grant shall submit a report to the Administration on the performance of the State of the grant activities, including a description of the use of the funds, including matched funds, to complete activities, and a description of the performance of the State partnership in 

meeting the performance benchmarks. 

(B) REPORT TO CONGRESS.—The Administration shall 

submit a report to Congress analyzing implementation activities, performance, and fund utilization of the State 

grantees, including an identification of promising practices 

and a profile of the activities of each State grantee. 

(e) AUTHORIZATION FOR APPROPRIATIONS.— 

(1) PLANNING GRANTS.—There are authorized to be appropriated to award planning grants under subsection (c) 

$8,000,000 for fiscal year 2010, and such sums as may be necessary for each subsequent fiscal year. 

(2) IMPLEMENTATION GRANTS.—There are authorized to be 

appropriated to award implementation grants under subsection 

(d), $150,000,000 for fiscal year 2010, and such sums as may 

be necessary for each subsequent fiscal year. 

SEC. 5103. HEALTH CARE WORKFORCE ASSESSMENT. 

(a) IN GENERAL.—Section 761 of the Public Health Service Act 

(42 U.S.C. 294m) is amended— 

(1) by redesignating subsection (c) as subsection (e); 

(2) by striking subsection (b) and inserting the following: 

‘‘(b) NATIONAL CENTER FOR HEALTH CARE WORKFORCE ANALYSIS.— 

‘‘(1) ESTABLISHMENT.—The Secretary shall establish the 

National Center for Health Workforce Analysis (referred to in 

this section as the ‘National Center’). 

‘‘(2) PURPOSES.—The National Center, in coordination to 

the extent practicable with the National Health Care Workforce Commission (established in section 5101 of the Patient 

Protection and Affordable Care Act), and relevant regional and 

State centers and agencies, shall— 

‘‘(A) provide for the development of information describing and analyzing the health care workforce and 

workforce related issues; 

‘‘(B) carry out the activities under section 792(a); 

‘‘(C) annually evaluate programs under this title; 

‘‘(D) develop and publish performance measures and 

benchmarks for programs under this title; and 

‘‘(E) establish, maintain, and publicize a national 

Internet registry of each grant awarded under this title 

and a database to collect data from longitudinal evaluations (as described in subsection (d)(2)) on performance 

measures (as developed under sections 749(d)(3), 757(d)(3), 

and 762(a)(3)). 

‘‘(3) COLLABORATION AND DATA SHARING.— 

‘‘(A) IN GENERAL.—The National Center shall collaborate with Federal agencies and relevant professional and 
Sec. 5103 PPACA (Consolidated) 532 

educational organizations or societies for the purpose of 

linking data regarding grants awarded under this title. 

‘‘(B) CONTRACTS FOR HEALTH WORKFORCE ANALYSIS.— 

For the purpose of carrying out the activities described in 

subparagraph (A), the National Center may enter into contracts with relevant professional and educational organizations or societies. 

‘‘(c) STATE AND REGIONAL CENTERS FOR HEALTH WORKFORCE

ANALYSIS.— 

‘‘(1) IN GENERAL.—The Secretary shall award grants to, or 

enter into contracts with, eligible entities for purposes of— 

‘‘(A) collecting, analyzing, and reporting data regarding programs under this title to the National Center and 

to the public; and 

‘‘(B) providing technical assistance to local and regional entities on the collection, analysis, and reporting of 

data. 

‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a grant or contract under this subsection, an entity shall— 

‘‘(A) be a State, a State workforce investment board, a 

public health or health professions school, an academic 

health center, or an appropriate public or private nonprofit 

entity; and 

‘‘(B) submit to the Secretary an application at such 

time, in such manner, and containing such information as 

the Secretary may require. 

‘‘(d) INCREASE IN GRANTS FOR LONGITUDINAL EVALUATIONS.— 

‘‘(1) IN GENERAL.—The Secretary shall increase the amount 

awarded to an eligible entity under this title for a longitudinal 

evaluation of individuals who have received education, training, or financial assistance from programs under this title. 

‘‘(2) CAPABILITY.—A longitudinal evaluation shall be capable of— 

‘‘(A) studying practice patterns; and 

‘‘(B) collecting and reporting data on performance 

measures developed under sections 749(d)(3), 757(d)(3), 

and 762(a)(3). 

‘‘(3) GUIDELINES.—A longitudinal evaluation shall comply 

with guidelines issued under sections 749(d)(4), 757(d)(4), and 

762(a)(4). 

‘‘(4) ELIGIBLE ENTITIES.—To be eligible to obtain an increase under this section, an entity shall be a recipient of a 

grant or contract under this title.’’; and 

(3) in subsection (e), as so redesignated— 

(A) by striking paragraph (1) and inserting the following: 

‘‘(1) IN GENERAL.— 

‘‘(A) NATIONAL CENTER.—To carry out subsection (b), 

there are authorized to be appropriated $7,500,000 for 

each of fiscal years 2010 through 2014. 

‘‘(B) STATE AND REGIONAL CENTERS.—To carry out subsection (c), there are authorized to be appropriated 

$4,500,000 for each of fiscal years 2010 through 2014. 
533 Sec. 5103 PPACA (Consolidated) 

‘‘(C) GRANTS FOR LONGITUDINAL EVALUATIONS.—To 

carry out subsection (d), there are authorized to be appropriated such sums as may be necessary for fiscal years 

2010 through 2014.’’; and 

(4) in paragraph (2), by striking ‘‘subsection (a)’’ and inserting ‘‘paragraph (1)’’. 

(b) TRANSFERS.—Not later than 180 days after the date of enactment of this Act, the responsibilities and resources of the National Center for Health Workforce Analysis, as in effect on the 

date before the date of enactment of this Act, shall be transferred 

to the National Center for Health Care Workforce Analysis established under section 761 of the Public Health Service Act, as 

amended by subsection (a). 

(c) USE OF LONGITUDINAL EVALUATIONS.—Section 791(a)(1) of 

the Public Health Service Act (42 U.S.C. 295j(a)(1)) is amended— 

(1) in subparagraph (A), by striking ‘‘or’’ at the end; 

(2) in subparagraph (B), by striking the period and inserting ‘‘; or’’; and 

(3) by adding at the end the following: 

‘‘(C) utilizes a longitudinal evaluation (as described in 

section 761(d)(2)) and reports data from such system to the 

national workforce database (as established under section 

761(b)(2)(E)).’’. 

(d) PERFORMANCE MEASURES; GUIDELINES FOR LONGITUDINAL

EVALUATIONS.— 

(1) ADVISORY COMMITTEE ON TRAINING IN PRIMARY CARE

MEDICINE AND DENTISTRY.—Section 748(d) of the Public Health 

Service Act is amended— 

(A) in paragraph (1), by striking ‘‘and’’ at the end; 

(B) in paragraph (2), by striking the period and inserting a semicolon; and 

(C) by adding at the end the following: 

‘‘(3) develop, publish, and implement performance measures for programs under this part; 

‘‘(4) develop and publish guidelines for longitudinal evaluations (as described in section 761(d)(2)) for programs under this 

part; and 

‘‘(5) recommend appropriation levels for programs under 

this part.’’. 

(2) ADVISORY COMMITTEE ON INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES.—Section 756(d) of the Public Health 

Service Act is amended— 

(A) in paragraph (1), by striking ‘‘and’’ at the end; 

(B) in paragraph (2), by striking the period and inserting a semicolon; and 

(C) by adding at the end the following: 

‘‘(3) develop, publish, and implement performance measures for programs under this part; 

‘‘(4) develop and publish guidelines for longitudinal evaluations (as described in section 761(d)(2)) for programs under this 

part; and 

‘‘(5) recommend appropriation levels for programs under 

this part.’’. 
Sec. 5104 PPACA (Consolidated) 534 

(3) ADVISORY COUNCIL ON GRADUATE MEDICAL EDU- CATION.—Section 762(a) of the Public Health Service Act (42 

U.S.C. 294o(a)) is amended— 

(A) in paragraph (1), by striking ‘‘and’’ at the end; 

(B) in paragraph (2), by striking the period and inserting a semicolon; and 

(C) by adding at the end the following: 

‘‘(3) develop, publish, and implement performance measures for programs under this title, except for programs under 

part C or D; 

‘‘(4) develop and publish guidelines for longitudinal evaluations (as described in section 761(d)(2)) for programs under this 

title, except for programs under part C or D; and 

‘‘(5) recommend appropriation levels for programs under 

this title, except for programs under part C or D.’’. 

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

øSection added by section 10501(b)¿ 

(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. 
535 Sec. 5202. PPACA (Consolidated) 

(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). 

Subtitle C—Increasing the Supply of the 

Health Care Workforce 

SEC. 5201. FEDERALLY SUPPORTED STUDENT LOAN FUNDS. 

(a) MEDICAL SCHOOLS AND PRIMARY HEALTH CARE.—Section 

723 of the Public Health Service Act (42 U.S.C. 292s) is amended— 

(1) in subsection (a)— 

(A) in paragraph (1), by striking subparagraph (B) and 

inserting the following: 

‘‘(B) to practice in such care for 10 years (including 

residency training in primary health care) or through the 

date on which the loan is repaid in full, whichever occurs 

first.’’; and 

(B) by striking paragraph (3) and inserting the following: 

‘‘(3) NONCOMPLIANCE BY STUDENT.—Each agreement entered into with a student pursuant to paragraph (1) shall provide that, if the student fails to comply with such agreement, 

the loan involved will begin to accrue interest at a rate of 2 

percent per year greater than the rate at which the student 

would pay if compliant in such year.’’; and 

(2) by adding at the end the following: 

‘‘(d) SENSE OF CONGRESS.—It is the sense of Congress that 

funds repaid under the loan program under this section should not 

be transferred to the Treasury of the United States or otherwise 

used for any other purpose other than to carry out this section.’’. 

(b) STUDENT LOAN GUIDELINES.—The Secretary of Health and 

Human Services shall not require parental financial information 

for an independent student to determine financial need under section 723 of the Public Health Service Act (42 U.S.C. 292s) and the 

determination of need for such information shall be at the discretion of applicable school loan officer. The Secretary shall amend 

guidelines issued by the Health Resources and Services Administration in accordance with the preceding sentence. 

SEC. 5202. NURSING STUDENT LOAN PROGRAM. 

(a) LOAN AGREEMENTS.—Section 836(a) of the Public Health 

Service Act (42 U.S.C. 297b(a)) is amended— 

(1) by striking ‘‘$2,500’’ and inserting ‘‘$3,300’’; 

(2) by striking ‘‘$4,000’’ and inserting ‘‘$5,200’’; and 

(3) by striking ‘‘$13,000’’ and all that follows through the 

period and inserting ‘‘$17,000 in the case of any student during 
Sec. 5203 PPACA (Consolidated) 536 

fiscal years 2010 and 2011. After fiscal year 2011, such 

amounts shall be adjusted to provide for a cost-of-attendance 

increase for the yearly loan rate and the aggregate of the 

loans.’’. 

(b) LOAN PROVISIONS.—Section 836(b) of the Public Health 

Service Act (42 U.S.C. 297b(b)) is amended— 

(1) in paragraph (1)(C), by striking ‘‘1986’’ and inserting 

‘‘2000’’; and 

(2) in paragraph (3), by striking ‘‘the date of enactment of 

the Nurse Training Amendments of 1979’’ and inserting ‘‘September 29, 1995’’. 

SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS. 

Part E of title VII of the Public Health Service Act (42 U.S.C. 

294n et seq.) is amended by adding at the end the following: 

‘‘Subpart 3—Recruitment and Retention Programs 

‘‘SEC. 775. ø42 U.S.C. 295f¿ INVESTMENT IN TOMORROW’S PEDIATRIC 

HEALTH CARE WORKFORCE. 

‘‘(a) ESTABLISHMENT.—The Secretary shall establish and carry 

out a pediatric specialty loan repayment program under which the 

eligible individual agrees to be employed full-time for a specified 

period (which shall not be less than 2 years) in providing pediatric 

medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care, including substance 

abuse prevention and treatment services. 

‘‘(b) PROGRAM ADMINISTRATION.—Through the program established under this section, the Secretary shall enter into contracts 

with qualified health professionals under which— 

‘‘(1) such qualified health professionals will agree to provide pediatric medical subspecialty, pediatric surgical specialty, 

or child and adolescent mental and behavioral health care in 

an area with a shortage of the specified pediatric subspecialty 

that has a sufficient pediatric population to support such pediatric subspecialty, as determined by the Secretary; and 

‘‘(2) the Secretary agrees to make payments on the principal and interest of undergraduate, graduate, or graduate 

medical education loans of professionals described in paragraph (1) of not more than $35,000 a year for each year of 

agreed upon service under such paragraph for a period of not 

more than 3 years during the qualified health professional’s— 

‘‘(A) participation in an accredited pediatric medical 

subspecialty, pediatric surgical specialty, or child and adolescent mental health subspecialty residency or fellowship; 

or 

‘‘(B) employment as a pediatric medical subspecialist, 

pediatric surgical specialist, or child and adolescent mental 

health professional serving an area or population described 

in such paragraph. 

‘‘(c) IN GENERAL.— 

‘‘(1) ELIGIBLE INDIVIDUALS.— 

‘‘(A) PEDIATRIC MEDICAL SPECIALISTS AND PEDIATRIC

SURGICAL SPECIALISTS.—For purposes of contracts with re-
537 Sec. 5203 PPACA (Consolidated) \775 PHSA 

spect to pediatric medical specialists and pediatric surgical 

specialists, the term ‘qualified health professional’ means 

a licensed physician who— 

‘‘(i) is entering or receiving training in an accredited pediatric medical subspecialty or pediatric surgical specialty residency or fellowship; or 

‘‘(ii) has completed (but not prior to the end of the 

calendar year in which this section is enacted) the 

training described in subparagraph (B). 

‘‘(B) CHILD AND ADOLESCENT MENTAL AND BEHAVIORAL

HEALTH.—For purposes of contracts with respect to child 

and adolescent mental and behavioral health care, the 

term ‘qualified health professional’ means a health care 

professional who— 

‘‘(i) has received specialized training or clinical experience in child and adolescent mental health in psychiatry, psychology, school psychology, behavioral pediatrics, psychiatric nursing, social work, school social 

work, substance abuse disorder prevention and treatment, marriage and family therapy, school counseling, 

or professional counseling; 

‘‘(ii) has a license or certification in a State to 

practice allopathic medicine, osteopathic medicine, 

psychology, school psychology, psychiatric nursing, social work, school social work, marriage and family 

therapy, school counseling, or professional counseling; 

or 

‘‘(iii) is a mental health service professional who 

completed (but not before the end of the calendar year 

in which this section is enacted) specialized training or 

clinical experience in child and adolescent mental 

health described in clause (i). 

‘‘(2) ADDITIONAL ELIGIBILITY REQUIREMENTS.—The Secretary may not enter into a contract under this subsection with 

an eligible individual unless— 

‘‘(A) the individual agrees to work in, or for a provider 

serving, a health professional shortage area or medically 

underserved area, or to serve a medically underserved population; 

‘‘(B) the individual is a United States citizen or a permanent legal United States resident; and 

‘‘(C) if the individual is enrolled in a graduate program, the program is accredited, and the individual has an 

acceptable level of academic standing (as determined by 

the Secretary). 

‘‘(d) PRIORITY.—In entering into contracts under this subsection, the Secretary shall give priority to applicants who— 

‘‘(1) are or will be working in a school or other pre-kindergarten, elementary, or secondary education setting; 

‘‘(2) have familiarity with evidence-based methods and cultural and linguistic competence health care services; and 

‘‘(3) demonstrate financial need. 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated $30,000,000 for each of fiscal years 2010 
Sec. 5204 PPACA (Consolidated) 538 

through 2014 to carry out subsection (c)(1)(A) and $20,000,000 for 

each of fiscal years 2010 through 2013 to carry out subsection 

(c)(1)(B).’’. 

SEC. 5204. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETENTION PROGRAMS. 

Part E of title VII of the Public Health Service Act (42 U.S.C. 

294n et seq.), as amended by section 5203, is further amended by 

adding at the end the following: 

‘‘SEC. 776. ø42 U.S.C. 295f–1¿ PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM. 

‘‘(a) ESTABLISHMENT.—The Secretary shall establish the Public 

Health Workforce Loan Repayment Program (referred to in this 

section as the ‘Program’) to assure an adequate supply of public 

health professionals to eliminate critical public health workforce 

shortages in Federal, State, local, and tribal public health agencies. 

‘‘(b) ELIGIBILITY.—To be eligible to participate in the Program, 

an individual shall— 

‘‘(1)(A) be accepted for enrollment, or be enrolled, as a student in an accredited academic educational institution in a 

State or territory in the final year of a course of study or program leading to a public health or health professions degree or 

certificate; and have accepted employment with a Federal, 

State, local, or tribal public health agency, or a related training 

fellowship, as recognized by the Secretary, to commence upon 

graduation; 

‘‘(B)(i) have graduated, during the preceding 10-year period, from an accredited educational institution in a State or 

territory and received a public health or health professions degree or certificate; and 

‘‘(ii) be employed by, or have accepted employment with, a 

Federal, State, local, or tribal public health agency or a related 

training fellowship, as recognized by the Secretary; 

‘‘(2) be a United States citizen; and 

‘‘(3)(A) submit an application to the Secretary to participate in the Program; 

‘‘(B) execute a written contract as required in subsection 

(c); and 

‘‘(4) not have received, for the same service, a reduction of 

loan obligations under section 455(m), 428J, 428K, 428L, or 

460 of the Higher Education Act of 1965. 

‘‘(c) CONTRACT.—The written contract (referred to in this section as the ‘written contract’) between the Secretary and an individual shall contain— 

‘‘(1) an agreement on the part of the Secretary that the 

Secretary will repay on behalf of the individual loans incurred 

by the individual in the pursuit of the relevant degree or certificate in accordance with the terms of the contract; 

‘‘(2) an agreement on the part of the individual that the individual will serve in the full-time employment of a Federal, 

State, local, or tribal public health agency or a related fellowship program in a position related to the course of study or 

program for which the contract was awarded for a period of 
539 Sec. 5204 PPACA (Consolidated) \776 PHSA 

time (referred to in this section as the ‘period of obligated service’) equal to the greater of— 

‘‘(A) 3 years; or 

‘‘(B) such longer period of time as determined appropriate by the Secretary and the individual; 

‘‘(3) an agreement, as appropriate, on the part of the individual to relocate to a priority service area (as determined by 

the Secretary) in exchange for an additional loan repayment 

incentive amount to be determined by the Secretary; 

‘‘(4) a provision that any financial obligation of the United 

States arising out of a contract entered into under this section 

and any obligation of the individual that is conditioned thereon, is contingent on funds being appropriated for loan repayments under this section; 

‘‘(5) a statement of the damages to which the United 

States is entitled, under this section for the individual’s breach 

of the contract; and 

‘‘(6) such other statements of the rights and liabilities of 

the Secretary and of the individual, not inconsistent with this 

section. 

‘‘(d) PAYMENTS.— 

‘‘(1) IN GENERAL.—A loan repayment provided for an individual under a written contract under the Program shall consist of payment, in accordance with paragraph (2), on behalf of 

the individual of the principal, interest, and related expenses 

on government and commercial loans received by the individual regarding the undergraduate or graduate education of 

the individual (or both), which loans were made for tuition expenses incurred by the individual. 

‘‘(2) PAYMENTS FOR YEARS SERVED.—For each year of obligated service that an individual contracts to serve under subsection (c) the Secretary may pay up to $35,000 on behalf of 

the individual for loans described in paragraph (1). With respect to participants under the Program whose total eligible 

loans are less than $105,000, the Secretary shall pay an 

amount that does not exceed 1⁄3 of the eligible loan balance for 

each year of obligated service of the individual. 

‘‘(3) TAX LIABILITY.—For the purpose of providing reimbursements for tax liability resulting from payments under 

paragraph (2) on behalf of an individual, the Secretary shall, 

in addition to such payments, make payments to the individual 

in an amount not to exceed 39 percent of the total amount of 

loan repayments made for the taxable year involved. 

‘‘(e) POSTPONING OBLIGATED SERVICE.—With respect to an individual receiving a degree or certificate from a health professions or 

other related school, the date of the initiation of the period of obligated service may be postponed as approved by the Secretary. 

‘‘(f) BREACH OF CONTRACT.—An individual who fails to comply 

with the contract entered into under subsection (c) shall be subject 

to the same financial penalties as provided for under section 338E 

for breaches of loan repayment contracts under section 338B. 

‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated to carry out this section $195,000,000 for fiscal 
Sec. 5205 PPACA (Consolidated) 540 

year 2010, and such sums as may be necessary for each of fiscal 

years 2011 through 2015.’’. 

SEC. 5205. ø20 U.S.C. 1078–11¿ ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION PROGRAMS. 

(a) PURPOSE.—The purpose of this section is to assure an adequate supply of allied health professionals to eliminate critical allied health workforce shortages in Federal, State, local, and tribal 

public health agencies or in settings where patients might require 

health care services, including acute care facilities, ambulatory 

care facilities, personal residences and other settings, as recognized 

by the Secretary of Health and Human Services by authorizing an 

Allied Health Loan Forgiveness Program. 

(b) ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION

PROGRAM.—Section 428K of the Higher Education Act of 1965 (20 

U.S.C. 1078–11) is amended— 

(1) in subsection (b), by adding at the end the following: 

‘‘(18) ALLIED HEALTH PROFESSIONALS.—The individual is 

employed full-time as an allied health professional— 

‘‘(A) in a Federal, State, local, or tribal public health 

agency; or 

‘‘(B) in a setting where patients might require health 

care services, including acute care facilities, ambulatory 

care facilities, personal residences and other settings located in health professional shortage areas, medically underserved areas, or medically underserved populations, as 

recognized by the Secretary of Health and Human Services.’’; and 

(2) in subsection (g)— 

(A) by redesignating paragraphs (1) through (9) as 

paragraphs (2) through (10), respectively; and 

(B) by inserting before paragraph (2) (as redesignated 

by subparagraph (A)) the following: 

‘‘(1) ALLIED HEALTH PROFESSIONAL.—The term ‘allied 

health professional’ means an allied health professional as defined in section 799B(5) of the Public Heath Service Act (42 

U.S.C. 295p(5)) who— 

‘‘(A) has graduated and received an allied health professions degree or certificate from an institution of higher 

education; and 

‘‘(B) is employed with a Federal, State, local or tribal 

public health agency, or in a setting where patients might 

require health care services, including acute care facilities, 

ambulatory care facilities, personal residences and other 

settings located in health professional shortage areas, 

medically underserved areas, or medically underserved 

populations, as recognized by the Secretary of Health and 

Human Services.’’. 

SEC. 5206. GRANTS FOR STATE AND LOCAL PROGRAMS. 

(a) IN GENERAL.—Section 765(d) of the Public Health Service 

Act (42 U.S.C. 295(d)) is amended— 

(1) in paragraph (7), by striking ‘‘; or’’ and inserting a 

semicolon; 

(2) by redesignating paragraph (8) as paragraph (9); and 
541 Sec. 5207 PPACA (Consolidated) 

(3) by inserting after paragraph (7) the following: 

‘‘(8) public health workforce loan repayment programs; or’’. 

(b) TRAINING FOR MID-CAREER PUBLIC HEALTH PROFESSIONALS.—Part E of title VII of the Public Health Service Act (42 

U.S.C. 294n et seq.), as amended by section 5204, is further 

amended by adding at the end the following: 

‘‘SEC. 777. ø42 U.S.C. 295f–2¿ TRAINING FOR MID-CAREER PUBLIC AND 

ALLIED HEALTH PROFESSIONALS. 

‘‘(a) IN GENERAL.—The Secretary may make grants to, or enter 

into contracts with, any eligible entity to award scholarships to eligible individuals to enroll in degree or professional training programs for the purpose of enabling mid-career professionals in the 

public health and allied health workforce to receive additional 

training in the field of public health and allied health. 

‘‘(b) ELIGIBILITY.— 

‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ indicates 

an accredited educational institution that offers a course of 

study, certificate program, or professional training program in 

public or allied health or a related discipline, as determined by 

the Secretary 

‘‘(2) ELIGIBLE INDIVIDUALS.—The term ‘eligible individuals’ 

includes those individuals employed in public and allied health 

positions at the Federal, State, tribal, or local level who are interested in retaining or upgrading their education. 

‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated to carry out this section, $60,000,000 for fiscal 

year 2010 and such sums as may be necessary for each of fiscal 

years 2011 through 2015. Fifty percent of appropriated funds shall 

be allotted to public health mid-career professionals and 50 percent 

shall be allotted to allied health mid-career professionals.’’. 

SEC. 5207. FUNDING FOR NATIONAL HEALTH SERVICE CORPS. 

Section 338H(a) of the Public Health Service Act (42 U.S.C. 

254q(a)) is amended to read as follows: 

‘‘(a) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 

carrying out this section, there is authorized to be appropriated, 

out of any funds in the Treasury not otherwise appropriated, the 

following: 

‘‘(1) For fiscal year 2010, $320,461,632. 

‘‘(2) For fiscal year 2011, $414,095,394. 

‘‘(3) For fiscal year 2012, $535,087,442. 

‘‘(4) For fiscal year 2013, $691,431,432. 

‘‘(5) For fiscal year 2014, $893,456,433. 

‘‘(6) For fiscal year 2015, $1,154,510,336. 

‘‘(7) For fiscal year 2016, and each subsequent fiscal year, 

the amount appropriated for the preceding fiscal year adjusted 

by the product of— 

‘‘(A) one plus the average percentage increase in the 

costs of health professions education during the prior fiscal 

year; and 

‘‘(B) one plus the average percentage change in the 

number of individuals residing in health professions shortage areas designated under section 333 during the prior 
Sec. 5208 PPACA (Consolidated) 542 

fiscal year, relative to the number of individuals residing 

in such areas during the previous fiscal year.’’. 

SEC. 5208. NURSE-MANAGED HEALTH CLINICS. 

(a) PURPOSE.—The purpose of this section is to fund the development and operation of nurse-managed health clinics. 

(b) GRANTS.—Subpart 1 of part D of title III of the Public 

Health Service Act (42 U.S.C. 254b et seq.) is amended by inserting 

after section 330A the following: 

‘‘SEC. 330A–1. ø42 U.S.C. 254c–1a¿ GRANTS TO NURSE–MANAGED 

HEALTH CLINICS. 

‘‘(a) DEFINITIONS.— 

‘‘(1) COMPREHENSIVE PRIMARY HEALTH CARE SERVICES.—In 

this section, the term ‘comprehensive primary health care services’ means the primary health services described in section 

330(b)(1). 

‘‘(2) NURSE-MANAGED HEALTH CLINIC.—The term ‘nursemanaged health clinic’ means a nurse-practice arrangement, 

managed by advanced practice nurses, that provides primary 

care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university 

or department of nursing, federally qualified health center, or 

independent nonprofit health or social services agency. 

‘‘(b) AUTHORITY TO AWARD GRANTS.—The Secretary shall 

award grants for the cost of the operation of nurse-managed health 

clinics that meet the requirements of this section. 

‘‘(c) APPLICATIONS.—To be eligible to receive a grant under this 

section, an entity shall— 

‘‘(1) be an NMHC; and 

‘‘(2) submit to the Secretary an application at such time, 

in such manner, and containing— 

‘‘(A) assurances that nurses are the major providers of 

services at the NMHC and that at least 1 advanced practice nurse holds an executive management position within 

the organizational structure of the NMHC; 

‘‘(B) an assurance that the NMHC will continue providing comprehensive primary health care services or 

wellness services without regard to income or insurance 

status of the patient for the duration of the grant period; 

and 

‘‘(C) an assurance that, not later than 90 days of receiving a grant under this section, the NMHC will establish a community advisory committee, for which a majority 

of the members shall be individuals who are served by the 

NMHC. 

‘‘(d) GRANT AMOUNT.—The amount of any grant made under 

this section for any fiscal year shall be determined by the Secretary, taking into account— 

‘‘(1) the financial need of the NMHC, considering State, 

local, and other operational funding provided to the NMHC; 

and 

‘‘(2) other factors, as the Secretary determines appropriate. 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—For the purposes of 

carrying out this section, there are authorized to be appropriated 
543 Sec. 5210 PPACA (Consolidated) \203 PHSA 

$50,000,000 for the fiscal year 2010 and such sums as may be necessary for each of the fiscal years 2011 through 2014.’’. 

SEC. 5209. ELIMINATION OF CAP ON COMMISSIONED CORPS. 

Section 202 of the Department of Health and Human Services 

Appropriations Act, 1993 (Public Law 102–394) is amended by 

striking ‘‘not to exceed 2,800’’. 

SEC. 5210. ESTABLISHING A READY RESERVE CORPS. 

Section 203 of the Public Health Service Act (42 U.S.C. 204) 

is amended to read as follows: 

‘‘SEC. 203. ø42 U.S.C. 204¿ COMMISSIONED CORPS AND READY RESERVE 

CORPS. 

‘‘(a) ESTABLISHMENT.— 

‘‘(1) IN GENERAL.—There shall be in the Service a commissioned Regular Corps and a Ready Reserve Corps for service 

in time of national emergency. 

‘‘(2) REQUIREMENT.—All commissioned officers shall be citizens of the United States and shall be appointed without regard to the civil-service laws and compensated without regard 

to the Classification Act of 1923, as amended. 

‘‘(3) APPOINTMENT.—Commissioned officers of the Ready 

Reserve Corps shall be appointed by the President and commissioned officers of the Regular Corps shall be appointed by 

the President with the advice and consent of the Senate. 

‘‘(4) ACTIVE DUTY.—Commissioned officers of the Ready Reserve Corps shall at all times be subject to call to active duty 

by the Surgeon General, including active duty for the purpose 

of training. 

‘‘(5) WARRANT OFFICERS.—Warrant officers may be appointed to the Service for the purpose of providing support to 

the health and delivery systems maintained by the Service and 

any warrant officer appointed to the Service shall be considered for purposes of this Act and title 37, United States Code, 

to be a commissioned officer within the Commissioned Corps of 

the Service. 

‘‘(b) ASSIMILATING RESERVE CORP OFFICERS INTO THE REGULAR

CORPS.—Effective on the date of enactment of the Patient Protection and Affordable Care Act, all individuals classified as officers 

in the Reserve Corps under this section (as such section existed on 

the day before the date of enactment of such Act) and serving on 

active duty shall be deemed to be commissioned officers of the Regular Corps. 

‘‘(c) PURPOSE AND USE OF READY RESEARCH.— 

‘‘(1) PURPOSE.—The purpose of the Ready Reserve Corps is 

to fulfill the need to have additional Commissioned Corps personnel available on short notice (similar to the uniformed service’s reserve program) to assist regular Commissioned Corps 

personnel to meet both routine public health and emergency 

response missions. 

‘‘(2) USES.—The Ready Reserve Corps shall— 

‘‘(A) participate in routine training to meet the general 

and specific needs of the Commissioned Corps; 
Sec. 5301 PPACA (Consolidated) 544 

‘‘(B) be available and ready for involuntary calls to active duty during national emergencies and public health 

crises, similar to the uniformed service reserve personnel; 

‘‘(C) be available for backfilling critical positions left 

vacant during deployment of active duty Commissioned 

Corps members, as well as for deployment to respond to 

public health emergencies, both foreign and domestic; and 

‘‘(D) be available for service assignment in isolated, 

hardship, and medically underserved communities (as defined in section 799B) to improve access to health services. 

‘‘(d) FUNDING.—For the purpose of carrying out the duties and 

responsibilities of the Commissioned Corps under this section, 

there are authorized to be appropriated $5,000,000 for each of fiscal years 2010 through 2014 for recruitment and training and 

$12,500,000 for each of fiscal years 2010 through 2014 for the 

Ready Reserve Corps.’’. 

Subtitle D—Enhancing Health Care 

Workforce Education and Training 

SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, GENERAL PEDIATRICS, AND PHYSICIAN 

ASSISTANTSHIP. 

Part C of title VII (42 U.S.C. 293k et seq.) is amended by striking section 747 and inserting the following: 

‘‘SEC. 747. ø42 U.S.C. 293k¿ PRIMARY CARE TRAINING AND ENHANCEMENT. 

‘‘(a) SUPPORT AND DEVELOPMENT OF PRIMARY CARE TRAINING

PROGRAMS.— 

‘‘(1) IN GENERAL.—The Secretary may make grants to, or 

enter into contracts with, an accredited public or nonprofit private hospital, school of medicine or osteopathic medicine, academically affiliated physician assistant training program, or a 

public or private nonprofit entity which the Secretary has determined is capable of carrying out such grant or contract— 

‘‘(A) to plan, develop, operate, or participate in an accredited professional training program, including an accredited residency or internship program in the field of 

family medicine, general internal medicine, or general pediatrics for medical students, interns, residents, or practicing physicians as defined by the Secretary; 

‘‘(B) to provide need-based financial assistance in the 

form of traineeships and fellowships to medical students, 

interns, residents, practicing physicians, or other medical 

personnel, who are participants in any such program, and 

who plan to specialize or work in the practice of the fields 

defined in subparagraph (A); 

‘‘(C) to plan, develop, and operate a program for the 

training of physicians who plan to teach in family medicine, general internal medicine, or general pediatrics training programs; 
545 Sec. 5301 PPACA (Consolidated) \747 PHSA 

‘‘(D) to plan, develop, and operate a program for the 

training of physicians teaching in community-based settings; 

‘‘(E) to provide financial assistance in the form of 

traineeships and fellowships to physicians who are participants in any such programs and who plan to teach or conduct research in a family medicine, general internal medicine, or general pediatrics training program; 

‘‘(F) to plan, develop, and operate a physician assistant 

education program, and for the training of individuals who 

will teach in programs to provide such training; 

‘‘(G) to plan, develop, and operate a demonstration 

program that provides training in new competencies, as 

recommended by the Advisory Committee on Training in 

Primary Care Medicine and Dentistry and the National 

Health Care Workforce Commission established in section 

5101 of the Patient Protection and Affordable Care Act, 

which may include— 

‘‘(i) providing training to primary care physicians 

relevant to providing care through patient-centered 

medical homes (as defined by the Secretary for purposes of this section); 

‘‘(ii) developing tools and curricula relevant to patient-centered medical homes; and 

‘‘(iii) providing continuing education to primary 

care physicians relevant to patient-centered medical 

homes; and 

‘‘(H) to plan, develop, and operate joint degree programs to provide interdisciplinary and interprofessional 

graduate training in public health and other health professions to provide training in environmental health, infectious disease control, disease prevention and health promotion, epidemiological studies and injury control. 

‘‘(2) DURATION OF AWARDS.—The period during which payments are made to an entity from an award of a grant or contract under this subsection shall be 5 years. 

‘‘(b) CAPACITY BUILDING IN PRIMARY CARE.— 

‘‘(1) IN GENERAL.—The Secretary may make grants to or 

enter into contracts with accredited schools of medicine or osteopathic medicine to establish, maintain, or improve— 

‘‘(A) academic units or programs that improve clinical 

teaching and research in fields defined in subsection 

(a)(1)(A); or 

‘‘(B) programs that integrate academic administrative 

units in fields defined in subsection (a)(1)(A) to enhance 

interdisciplinary recruitment, training, and faculty development. 

‘‘(2) PREFERENCE IN MAKING AWARDS UNDER THIS SUBSECTION.—In making awards of grants and contracts under 

paragraph (1), the Secretary shall give preference to any qualified applicant for such an award that agrees to expend the 

award for the purpose of— 

‘‘(A) establishing academic units or programs in fields 

defined in subsection (a)(1)(A); or 
Sec. 5301\747 PHSA PPACA (Consolidated) 546 

‘‘(B) substantially expanding such units or programs. 

‘‘(3) PRIORITIES IN MAKING AWARDS.—In awarding grants or 

contracts under paragraph (1), the Secretary shall give priority 

to qualified applicants that— 

‘‘(A) proposes a collaborative project between academic 

administrative units of primary care; 

‘‘(B) proposes innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, 

and interprofessional integrated models of health care that 

incorporate transitions in health care settings and integration physical and mental health provision; 

‘‘(C) have a record of training the greatest percentage 

of providers, or that have demonstrated significant improvements in the percentage of providers trained, who 

enter and remain in primary care practice; 

‘‘(D) have a record of training individuals who are 

from underrepresented minority groups or from a rural or 

disadvantaged background; 

‘‘(E) provide training in the care of vulnerable populations such as children, older adults, homeless individuals, victims of abuse or trauma, individuals with mental 

health or substance-related disorders, individuals with 

HIV/AIDS, and individuals with disabilities; 

‘‘(F) establish formal relationships and submit joint 

applications with federally qualified health centers, rural 

health clinics, area health education centers, or clinics located in underserved areas or that serve underserved populations; 

‘‘(G) teach trainees the skills to provide interprofessional, integrated care through collaboration among health 

professionals; 

‘‘(H) provide training in enhanced communication with 

patients, evidence-based practice, chronic disease management, preventive care, health information technology, or 

other competencies as recommended by the Advisory Committee on Training in Primary Care Medicine and Dentistry and the National Health Care Workforce Commission established in section 5101 of the Patient Protection 

and Affordable Care Act; or 

‘‘(I) provide training in cultural competency and health 

literacy. 

‘‘(4) DURATION OF AWARDS.—The period during which payments are made to an entity from an award of a grant or contract under this subsection shall be 5 years. 

‘‘(c) AUTHORIZATION OF APPROPRIATIONS.— 

‘‘(1) IN GENERAL.—For purposes of carrying out this section 

(other than subsection (b)(1)(B)), there are authorized to be appropriated $125,000,000 for fiscal year 2010, and such sums as 

may be necessary for each of fiscal years 2011 through 2014. 

‘‘(2) TRAINING PROGRAMS.—Fifteen percent of the amount 

appropriated pursuant to paragraph (1) in each such fiscal 

year shall be allocated to the physician assistant training pro-
547 Sec. 5302 PPACA (Consolidated) \747A PHSA 

grams described in subsection (a)(1)(F), which prepare students 

for practice in primary care. 

‘‘(3) INTEGRATING ACADEMIC ADMINISTRATIVE UNITS.—For 

purposes of carrying out subsection (b)(1)(B), there are authorized to be appropriated $750,000 for each of fiscal years 2010 

through 2014.’’. 

SEC. 5302. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS. 

Part C of title VII of the Public Health Service Act (42 U.S.C. 

293k et seq.) is amended by inserting after section 747, as amended 

by section 5301, the following: 

‘‘SEC. 747A. ø42 U.S.C. 293k–1¿ TRAINING OPPORTUNITIES FOR DIRECT 

CARE WORKERS. 

‘‘(a) IN GENERAL.—The Secretary shall award grants to eligible 

entities to enable such entities to provide new training opportunities for direct care workers who are employed in long-term care settings such as nursing homes (as defined in section 1908(e)(1) of the 

Social Security Act (42 U.S.C. 1396g(e)(1)), assisted living facilities 

and skilled nursing facilities, intermediate care facilities for individuals with mental retardation, home and community based settings, and any other setting the Secretary determines to be appropriate. 

‘‘(b) ELIGIBILITY.—To be eligible to receive a grant under this 

section, an entity shall— 

‘‘(1) be an institution of higher education (as defined in 

section 102 of the Higher Education Act of 1965 (20 U.S.C. 

1002)) that— 

‘‘(A) is accredited by a nationally recognized accrediting agency or association listed under section 101(c) of 

the Higher Education Act of 1965 (20 U.S.C. 1001(c)); and 

‘‘(B) has established a public-private educational partnership with a nursing home or skilled nursing facility, 

agency or entity providing home and community based 

services to individuals with disabilities, or other long-term 

care provider; and 

‘‘(2) submit to the Secretary an application at such time, 

in such manner, and containing such information as the Secretary may require. 

‘‘(c) USE OF FUNDS.—An eligible entity shall use amounts 

awarded under a grant under this section to provide assistance to 

eligible individuals to offset the cost of tuition and required fees for 

enrollment in academic programs provided by such entity. 

‘‘(d) ELIGIBLE INDIVIDUAL.— 

‘‘(1) ELIGIBILITY.—To be eligible for assistance under this 

section, an individual shall be enrolled in courses provided by 

a grantee under this subsection and maintain satisfactory academic progress in such courses. 

‘‘(2) CONDITION OF ASSISTANCE.—As a condition of receiving assistance under this section, an individual shall agree 

that, following completion of the assistance period, the individual will work in the field of geriatrics, disability services, 

long term services and supports, or chronic care management 

for a minimum of 2 years under guidelines set by the Secretary. 
Sec. 5303 PPACA (Consolidated) 548 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated to carry out this section, $10,000,000 for the period of fiscal years 2011 through 2013.’’. 

SEC. 5303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH 

DENTISTRY. 

Part C of Title VII of the Public Health Service Act (42 U.S.C. 

293k et seq.) is amended by— 

(1) redesignating section 748, as amended by section 5103 

of this Act, as section 749; and 

(2) inserting after section 747A, as added by section 5302, 

the following: 

‘‘SEC. 748. ø42 U.S.C. 293k–2¿ TRAINING IN GENERAL, PEDIATRIC, AND 

PUBLIC HEALTH DENTISTRY. 

‘‘(a) SUPPORT AND DEVELOPMENT OF DENTAL TRAINING PROGRAMS.— 

‘‘(1) IN GENERAL.—The Secretary may make grants to, or 

enter into contracts with, a school of dentistry, public or nonprofit private hospital, or a public or private nonprofit entity 

which the Secretary has determined is capable of carrying out 

such grant or contract— 

‘‘(A) to plan, develop, and operate, or participate in, an 

approved professional training program in the field of general dentistry, pediatric dentistry, or public health dentistry for dental students, residents, practicing dentists, 

dental hygienists, or other approved primary care dental 

trainees, that emphasizes training for general, pediatric, or 

public health dentistry; 

‘‘(B) to provide financial assistance to dental students, 

residents, practicing dentists, and dental hygiene students 

who are in need thereof, who are participants in any such 

program, and who plan to work in the practice of general, 

pediatric, public heath dentistry, or dental hygiene; 

‘‘(C) to plan, develop, and operate a program for the 

training of oral health care providers who plan to teach in 

general, pediatric, public health dentistry, or dental hygiene; 

‘‘(D) to provide financial assistance in the form of 

traineeships and fellowships to dentists who plan to teach 

or are teaching in general, pediatric, or public health dentistry; 

‘‘(E) to meet the costs of projects to establish, maintain, or improve dental faculty development programs in 

primary care (which may be departments, divisions or 

other units); 

‘‘(F) to meet the costs of projects to establish, maintain, or improve predoctoral and postdoctoral training in 

primary care programs; 

‘‘(G) to create a loan repayment program for faculty in 

dental programs; and 

‘‘(H) to provide technical assistance to pediatric training programs in developing and implementing instruction 

regarding the oral health status, dental care needs, and 
549 Sec. 5303 PPACA (Consolidated) \748 PHSA 

risk-based clinical disease management of all pediatric 

populations with an emphasis on underserved children. 

‘‘(2) FACULTY LOAN REPAYMENT.— ‘‘(A) IN GENERAL.—A grant or contract under subsection (a)(1)(G) may be awarded to a program of general, 

pediatric, or public health dentistry described in such subsection to plan, develop, and operate a loan repayment program under which— 

‘‘(i) individuals agree to serve full-time as faculty 

members; and 

‘‘(ii) the program of general, pediatric or public 

health dentistry agrees to pay the principal and interest on the outstanding student loans of the individuals. 

‘‘(B) MANNER OF PAYMENTS.—With respect to the payments described in subparagraph (A)(ii), upon completion 

by an individual of each of the first, second, third, fourth, 

and fifth years of service, the program shall pay an 

amount equal to 10, 15, 20, 25, and 30 percent, respectively, of the individual’s student loan balance as calculated based on principal and interest owed at the initiation of the agreement. 

‘‘(b) ELIGIBLE ENTITY.—For purposes of this subsection, entities 

eligible for such grants or contracts in general, pediatric, or public 

health dentistry shall include entities that have programs in dental 

or dental hygiene schools, or approved residency or advanced education programs in the practice of general, pediatric, or public 

health dentistry. Eligible entities may partner with schools of public health to permit the education of dental students, residents, and 

dental hygiene students for a master’s year in public health at a 

school of public health. 

‘‘(c) PRIORITIES IN MAKING AWARDS.—With respect to training 

provided for under this section, the Secretary shall give priority in 

awarding grants or contracts to the following: 

‘‘(1) Qualified applicants that propose collaborative projects 

between departments of primary care medicine and departments of general, pediatric, or public health dentistry. 

‘‘(2) Qualified applicants that have a record of training the 

greatest percentage of providers, or that have demonstrated 

significant improvements in the percentage of providers, who 

enter and remain in general, pediatric, or public health dentistry. 

‘‘(3) Qualified applicants that have a record of training individuals who are from a rural or disadvantaged background, 

or from underrepresented minorities. 

‘‘(4) Qualified applicants that establish formal relationships with Federally qualified health centers, rural health centers, or accredited teaching facilities and that conduct training 

of students, residents, fellows, or faculty at the center or facility. 

‘‘(5) Qualified applicants that conduct teaching programs 

targeting vulnerable populations such as older adults, homeless individuals, victims of abuse or trauma, individuals with 

mental health or substance-related disorders, individuals with 
Sec. 5304 PPACA (Consolidated) 550 

disabilities, and individuals with HIV/AIDS, and in the riskbased clinical disease management of all populations. 

‘‘(6) Qualified applicants that include educational activities 

in cultural competency and health literacy. 

‘‘(7) Qualified applicants that have a high rate for placing 

graduates in practice settings that serve underserved areas or 

health disparity populations, or who achieve a significant increase in the rate of placing graduates in such settings. 

‘‘(8) Qualified applicants that intend to establish a special 

populations oral health care education center or training program for the didactic and clinical education of dentists, dental 

health professionals, and dental hygienists who plan to teach 

oral health care for people with developmental disabilities, cognitive impairment, complex medical problems, significant physical limitations, and vulnerable elderly. 

‘‘(d) APPLICATION.—An eligible entity desiring a grant under 

this section shall submit to the Secretary an application at such 

time, in such manner, and containing such information as the Secretary may require. 

‘‘(e) DURATION OF AWARD.—The period during which payments 

are made to an entity from an award of a grant or contract under 

subsection (a) shall be 5 years. The provision of such payments 

shall be subject to annual approval by the Secretary and subject to 

the availability of appropriations for the fiscal year involved to 

make the payments. 

‘‘(f) AUTHORIZATIONS OF APPROPRIATIONS.—For the purpose of 

carrying out subsections (a) and (b), there is authorized to be appropriated $30,000,000 for fiscal year 2010 and such sums as may 

be necessary for each of fiscal years 2011 through 2015. 

‘‘(g) CARRYOVER FUNDS.—An entity that receives an award 

under this section may carry over funds from 1 fiscal year to another without obtaining approval from the Secretary. In no case 

may any funds be carried over pursuant to the preceding sentence 

for more than 3 years.’’. 

SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEMONSTRATION PROJECT. 

Subpart X of part D of title III of the Public Health Service Act 

(42 U.S.C. 256f et seq.) is amended by adding at the end the following: 

‘‘SEC. 340G–1. ø42 U.S.C. 256g–1¿ DEMONSTRATION PROGRAM. 

‘‘(a) IN GENERAL.— 

‘‘(1) AUTHORIZATION.—The Secretary is authorized to 

award grants to 15 eligible entities to enable such entities to 

establish a demonstration program to establish training programs to train, or to employ, alternative dental health care 

providers in order to increase access to dental health care services in rural and other underserved communities. 

‘‘(2) DEFINITION.—The term ‘alternative dental health care 

providers’ includes community dental health coordinators, advance practice dental hygienists, independent dental hygienists, supervised dental hygienists, primary care physicians, 

dental therapists, dental health aides, and any other health 

professional that the Secretary determines appropriate. 
551 Sec. 5304 PPACA (Consolidated) \340G–1 PHSA 

‘‘(b) TIMEFRAME.—The demonstration projects funded under 

this section shall begin not later than 2 years after the date of enactment of this section, and shall conclude not later than 7 years 

after such date of enactment. 

‘‘(c) ELIGIBLE ENTITIES.—To be eligible to receive a grant under 

subsection (a), an entity shall— 

‘‘(1) be— 

‘‘(A) an institution of higher education, including a 

community college; 

‘‘(B) a public-private partnership; 

‘‘(C) a federally qualified health center; 

‘‘(D) an Indian Health Service facility or a tribe or 

tribal organization (as such terms are defined in section 4 

of the Indian Self-Determination and Education Assistance 

Act); 

‘‘(E) a State or county public health clinic, a health facility operated by an Indian tribe or tribal organization, or 

urban Indian organization providing dental services; or 

‘‘(F) a public hospital or health system; 

‘‘(2) be within a program accredited by the Commission on 

Dental Accreditation or within a dental education program in 

an accredited institution; and 

‘‘(3) shall submit an application to the Secretary at such 

time, in such manner, and containing such information as the 

Secretary may require. 

‘‘(d) ADMINISTRATIVE PROVISIONS.— 

‘‘(1) AMOUNT OF GRANT.—Each grant under this section 

shall be in an amount that is not less than $4,000,000 for the 

5-year period during which the demonstration project being 

conducted. 

‘‘(2) DISBURSEMENT OF FUNDS.— 

‘‘(A) PRELIMINARY DISBURSEMENTS.—Beginning 1 year 

after the enactment of this section, the Secretary may disperse to any entity receiving a grant under this section not 

more than 20 percent of the total funding awarded to such 

entity under such grant, for the purpose of enabling the 

entity to plan the demonstration project to be conducted 

under such grant. 

‘‘(B) SUBSEQUENT DISBURSEMENTS.—The remaining 

amount of grant funds not dispersed under subparagraph 

(A) shall be dispersed such that not less than 15 percent 

of such remaining amount is dispersed each subsequent 

year. 

‘‘(e) COMPLIANCE WITH STATE REQUIREMENTS.—Each entity receiving a grant under this section shall certify that it is in compliance with all applicable State licensing requirements. 

‘‘(f) EVALUATION.—The Secretary shall contract with the Director of the Institute of Medicine to conduct a study of the demonstration programs conducted under this section that shall provide analysis, based upon quantitative and qualitative data, regarding access to dental health care in the United States. 

‘‘(g) CLARIFICATION REGARDING DENTAL HEALTH AIDE PROGRAM.—Nothing in this section shall prohibit a dental health aide 
Sec. 5305 PPACA (Consolidated) 552 

training program approved by the Indian Health Service from 

being eligible for a grant under this section. 

‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated such sums as may be necessary to carry out this 

section.’’. 

SEC. 5305. GERIATRIC EDUCATION AND TRAINING; CAREER AWARDS; 

COMPREHENSIVE GERIATRIC EDUCATION. 

(a) WORKFORCE DEVELOPMENT; CAREER AWARDS.—Section 753 

of the Public Health Service Act (42 U.S.C. 294c) is amended by 

adding at the end the following: 

‘‘(d) GERIATRIC WORKFORCE DEVELOPMENT.— ‘‘(1) IN GENERAL.—The Secretary shall award grants or 

contracts under this subsection to entities that operate a geriatric education center pursuant to subsection (a)(1). 

‘‘(2) APPLICATION.—To be eligible for an award under paragraph (1), an entity described in such paragraph shall submit 

to the Secretary an application at such time, in such manner, 

and containing such information as the Secretary may require. 

‘‘(3) USE OF FUNDS.—Amounts awarded under a grant or 

contract under paragraph (1) shall be used to— 

‘‘(A) carry out the fellowship program described in 

paragraph (4); and 

‘‘(B) carry out 1 of the 2 activities described in paragraph (5). 

‘‘(4) FELLOWSHIP PROGRAM.— ‘‘(A) IN GENERAL.—Pursuant to paragraph (3), a geriatric education center that receives an award under this 

subsection shall use such funds to offer short-term intensive courses (referred to in this subsection as a ‘fellowship’) 

that focus on geriatrics, chronic care management, and 

long-term care that provide supplemental training for faculty members in medical schools and other health professions schools with programs in psychology, pharmacy, 

nursing, social work, dentistry, public health, allied health, 

or other health disciplines, as approved by the Secretary. 

Such a fellowship shall be open to current faculty, and appropriately credentialed volunteer faculty and practitioners, who do not have formal training in geriatrics, to 

upgrade their knowledge and clinical skills for the care of 

older adults and adults with functional limitations and to 

enhance their interdisciplinary teaching skills. 

‘‘(B) LOCATION.—A fellowship shall be offered either at 

the geriatric education center that is sponsoring the 

course, in collaboration with other geriatric education centers, or at medical schools, schools of dentistry, schools of 

nursing, schools of pharmacy, schools of social work, graduate programs in psychology, or allied health and other 

health professions schools approved by the Secretary with 

which the geriatric education centers are affiliated. 

‘‘(C) CME CREDIT.—Participation in a fellowship under 

this paragraph shall be accepted with respect to complying 

with continuing health profession education requirements. 

As a condition of such acceptance, the recipient shall agree 

to subsequently provide a minimum of 18 hours of vol-
553 Sec. 5305 PPACA (Consolidated) 

untary instructional support through a geriatric education 

center that is providing clinical training to students or 

trainees in long-term care settings. 

‘‘(5) ADDITIONAL REQUIRED ACTIVITIES DESCRIBED.—Pursuant to paragraph (3), a geriatric education center that receives 

an award under this subsection shall use such funds to carry 

out 1 of the following 2 activities. 

‘‘(A) FAMILY CAREGIVER AND DIRECT CARE PROVIDER

TRAINING.—A geriatric education center that receives an 

award under this subsection shall offer at least 2 courses 

each year, at no charge or nominal cost, to family caregivers and direct care providers that are designed to provide practical training for supporting frail elders and individuals with disabilities. The Secretary shall require such 

Centers to work with appropriate community partners to 

develop training program content and to publicize the 

availability of training courses in their service areas. All 

family caregiver and direct care provider training programs shall include instruction on the management of psychological and behavioral aspects of dementia, communication techniques for working with individuals who have dementia, and the appropriate, safe, and effective use of 

medications for older adults. 

‘‘(B) INCORPORATION OF BEST PRACTICES.—A geriatric 

education center that receives an award under this subsection shall develop and include material on depression 

and other mental disorders common among older adults, 

medication safety issues for older adults, and management 

of the psychological and behavioral aspects of dementia 

and communication techniques with individuals who have 

dementia in all training courses, where appropriate. 

‘‘(6) TARGETS.—A geriatric education center that receives 

an award under this subsection shall meet targets approved by 

the Secretary for providing geriatric training to a certain number of faculty or practitioners during the term of the award, as 

well as other parameters established by the Secretary. 

‘‘(7) AMOUNT OF AWARD.—An award under this subsection 

shall be in an amount of $150,000. Not more than 24 geriatric 

education centers may receive an award under this subsection. 

‘‘(8) MAINTENANCE OF EFFORT.—A geriatric education center that receives an award under this subsection shall provide 

assurances to the Secretary that funds provided to the geriatric 

education center under this subsection will be used only to 

supplement, not to supplant, the amount of Federal, State, and 

local funds otherwise expended by the geriatric education center. 

‘‘(9) AUTHORIZATION OF APPROPRIATIONS.—In addition to 

any other funding available to carry out this section, there is 

authorized to be appropriated to carry out this subsection, 

$10,800,000 for the period of fiscal year 2011 through 2014. 

‘‘(e) GERIATRIC CAREER INCENTIVE AWARDS.— 

‘‘(1) IN GENERAL.—The Secretary shall award grants or 

contracts under this section to individuals described in paragraph (2) to foster greater interest among a variety of health 
Sec. 5305 PPACA (Consolidated) 554 

professionals in entering the field of geriatrics, long-term care, 

and chronic care management. 

‘‘(2) ELIGIBLE INDIVIDUALS.—To be eligible to received an 

award under paragraph (1), an individual shall— 

‘‘(A) be an advanced practice nurse, a clinical social 

worker, a pharmacist, or student of psychology who is pursuing a doctorate or other advanced degree in geriatrics or 

related fields in an accredited health professions school; 

and 

‘‘(B) submit to the Secretary an application at such 

time, in such manner, and containing such information as 

the Secretary may require. 

‘‘(3) CONDITION OF AWARD.—As a condition of receiving an 

award under this subsection, an individual shall agree that, 

following completion of the award period, the individual will 

teach or practice in the field of geriatrics, long-term care, or 

chronic care management for a minimum of 5 years under 

guidelines set by the Secretary. 

‘‘(4) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this subsection, 

$10,000,000 for the period of fiscal years 2011 through 2013.’’. 

(b) EXPANSION OF ELIGIBILITY FOR GERIATRIC ACADEMIC CAREER AWARDS; PAYMENT TO INSTITUTION.—Section 753(c) of the 

Public Health Service Act 294(c)) is amended— 

(1) by redesignating paragraphs (4) and (5) as paragraphs 

(5) and (6), respectively; 

(2) by striking paragraph (2) through paragraph (3) and inserting the following: 

‘‘(2) ELIGIBLE INDIVIDUALS.—To be eligible to receive an 

Award under paragraph (1), an individual shall— 

‘‘(A) be board certified or board eligible in internal 

medicine, family practice, psychiatry, or licensed dentistry, 

or have completed any required training in a discipline 

and employed in an accredited health professions school 

that is approved by the Secretary; 

‘‘(B) have completed an approved fellowship program 

in geriatrics or have completed specialty training in geriatrics as required by the discipline and any addition geriatrics training as required by the Secretary; and 

‘‘(C) have a junior (non-tenured) faculty appointment 

at an accredited (as determined by the Secretary) school of 

medicine, osteopathic medicine, nursing, social work, psychology, dentistry, pharmacy, or other allied health disciplines in an accredited health professions school that is 

approved by the Secretary. 

‘‘(3) LIMITATIONS.—No Award under paragraph (1) may be 

made to an eligible individual unless the individual— 

‘‘(A) has submitted to the Secretary an application, at 

such time, in such manner, and containing such information as the Secretary may require, and the Secretary has 

approved such application; 

‘‘(B) provides, in such form and manner as the Secretary may require, assurances that the individual will 
555 Sec. 5306 PPACA (Consolidated) 

meet the service requirement described in paragraph (6); 

and 

‘‘(C) provides, in such form and manner as the Secretary may require, assurances that the individual has a 

full-time faculty appointment in a health professions institution and documented commitment from such institution 

to spend 75 percent of the total time of such individual on 

teaching and developing skills in interdisciplinary education in geriatrics. 

‘‘(4) MAINTENANCE OF EFFORT.—An eligible individual that 

receives an Award under paragraph (1) shall provide assurances to the Secretary that funds provided to the eligible individual under this subsection will be used only to supplement, 

not to supplant, the amount of Federal, State, and local funds 

otherwise expended by the eligible individual.’’; and 

(3) in paragraph (5), as so designated— 

(A) in subparagraph (A)— 

(i) by inserting ‘‘for individuals who are physicians’’ after ‘‘this section’’; and 

(ii) by inserting after the period at the end the following: ‘‘The Secretary shall determine the amount of 

an Award under this section for individuals who are 

not physicians.’’; and 

(B) by adding at the end the following: 

‘‘(C) PAYMENT TO INSTITUTION.—The Secretary shall 

make payments to institutions which include schools of 

medicine, osteopathic medicine, nursing, social work, psychology, dentistry, and pharmacy, or other allied health 

discipline in an accredited health professions school that is 

approved by the Secretary.’’. 

(c) COMPREHENSIVE GERIATRIC EDUCATION.—Section 855 of the 

Public Health Service Act (42 U.S.C. 298) is amended— 

(1) in subsection (b)— 

(A) in paragraph (3), by striking ‘‘or’’ at the end; 

(B) in paragraph (4), by striking the period and inserting ‘‘; or’’; and 

(C) by adding at the end the following: 

‘‘(5) establish traineeships for individuals who are preparing for advanced education nursing degrees in geriatric 

nursing, long-term care, gero-psychiatric nursing or other nursing areas that specialize in the care of the elderly population.’’; 

and 

(2) in subsection (e), by striking ‘‘2003 through 2007’’ and 

inserting ‘‘2010 through 2014’’. 

SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND 

TRAINING GRANTS. 

(a) IN GENERAL.—Part D of title VII (42 U.S.C. 294 et seq.) is 

amended by— 

(1) striking section 757; 

(2) redesignating section 756 (as amended by section 5103) 

as section 757; and 

(3) inserting after section 755 the following: 
Sec. 5306\756 PHSA PPACA (Consolidated) 556 

‘‘SEC. 756. ø42 U.S.C. 294e–1¿ MENTAL AND BEHAVIORAL HEALTH EDUCATION AND TRAINING GRANTS. 

‘‘(a) GRANTS AUTHORIZED.—The Secretary may award grants to 

eligible institutions of higher education to support the recruitment 

of students for, and education and clinical experience of the students in— 

‘‘(1) baccalaureate, master’s, and doctoral degree programs 

of social work, as well as the development of faculty in social 

work; 

‘‘(2) accredited master’s, doctoral, internship, and post-doctoral residency programs of psychology for the development 

and implementation of interdisciplinary training of psychology 

graduate students for providing behavioral and mental health 

services, including substance abuse prevention and treatment 

services; 

‘‘(3) accredited institutions of higher education or accredited professional training programs that are establishing or expanding internships or other field placement programs in child 

and adolescent mental health in psychiatry, psychology, school 

psychology, behavioral pediatrics, psychiatric nursing, social 

work, school social work, substance abuse prevention and 

treatment, marriage and family therapy, school counseling, or 

professional counseling; and 

‘‘(4) State-licensed mental health nonprofit and for-profit 

organizations to enable such organizations to pay for programs 

for preservice or in-service training of paraprofessional child 

and adolescent mental health workers. 

‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eligible for a grant 

under this section, an institution shall demonstrate— 

‘‘(1) participation in the institutions’ programs of individuals and groups from different racial, ethnic, cultural, geographic, religious, linguistic, and class backgrounds, and different genders and sexual orientations; 

‘‘(2) knowledge and understanding of the concerns of the 

individuals and groups described in subsection (a); 

‘‘(3) any internship or other field placement program assisted under the grant will prioritize cultural and linguistic 

competency; 

‘‘(4) the institution will provide to the Secretary such data, 

assurances, and information as the Secretary may require; and 

‘‘(5) with respect to any violation of the agreement between 

the Secretary and the institution, the institution will pay such 

liquidated damages as prescribed by the Secretary by regulation. 

‘‘(c) INSTITUTIONAL REQUIREMENT.—For grants authorized 

under subsection (a)(1), at least 4 of the grant recipients shall be 

historically black colleges or universities or other minority-serving 

institutions. 

‘‘(d) PRIORITY.— 

‘‘(1) In selecting the grant recipients in social work under 

subsection (a)(1), the Secretary shall give priority to applicants 

that— 

‘‘(A) are accredited by the Council on Social Work Education; 
557 Sec. 5306 PPACA (Consolidated) 

‘‘(B) have a graduation rate of not less than 80 percent 

for social work students; and 

‘‘(C) exhibit an ability to recruit social workers from 

and place social workers in areas with a high need and 

high demand population. 

‘‘(2) In selecting the grant recipients in graduate psychology under subsection (a)(2), the Secretary shall give priority to institutions in which training focuses on the needs of 

vulnerable groups such as older adults and children, individuals with mental health or substance-related disorders, victims 

of abuse or trauma and of combat stress disorders such as 

posttraumatic stress disorder and traumatic brain injuries, 

homeless individuals, chronically ill persons, and their families. 

‘‘(3) In selecting the grant recipients in training programs 

in child and adolescent mental health under subsections (a)(3) 

and (a)(4), the Secretary shall give priority to applicants that— 

‘‘(A) have demonstrated the ability to collect data on 

the number of students trained in child and adolescent 

mental health and the populations served by such students 

after graduation or completion of preservice or in-service 

training; 

‘‘(B) have demonstrated familiarity with evidencebased methods in child and adolescent mental health services, including substance abuse prevention and treatment 

services; 

‘‘(C) have programs designed to increase the number of 

professionals and paraprofessionals serving high-priority 

populations and to applicants who come from high-priority 

communities and plan to serve medically underserved populations, in health professional shortage areas, or in medically underserved areas; 

‘‘(D) offer curriculum taught collaboratively with a 

family on the consumer and family lived experience or the 

importance of family-professional or family-paraprofessional partnerships; and 

‘‘(E) provide services through a community mental 

health program described in section 1913(b)(1). 

‘‘(e) AUTHORIZATION OF APPROPRIATION.—For the fiscal years 

2010 through 2013, there is authorized to be appropriated to carry 

out this section— 

‘‘(1) $8,000,000 for training in social work in subsection 

(a)(1); 

‘‘(2) $12,000,000 for training in graduate psychology in 

subsection (a)(2), of which not less than $10,000,000 shall be 

allocated for doctoral, postdoctoral, and internship level training; 

‘‘(3) $10,000,000 for training in professional child and adolescent mental health in subsection (a)(3); and 

‘‘(4) $5,000,000 for training in paraprofessional child and 

adolescent work in subsection (a)(4).’’. 

(b) CONFORMING AMENDMENTS.—Section 757(b)(2) of the Public 

Health Service Act, as redesignated by subsection (a), is amended 

by striking ‘‘sections 751(a)(1)(A), 751(a)(1)(B), 753(b), 754(3)(A), 
Sec. 5307 PPACA (Consolidated) 558 

and 755(b)’’ and inserting ‘‘sections 751(b)(1)(A), 753(b), and 

755(b)’’. 

SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND PUBLIC 

HEALTH AND INDIVIDUALS WITH DISABILITIES TRAINING. 

(a) TITLE VII.—Section 741 of the Public Health Service Act 

(42 U.S.C. 293e) is amended— 

(1) in subsection (a)— 

(A) by striking the subsection heading and inserting 

‘‘CULTURAL COMPETENCY, PREVENTION, AND PUBLIC

HEALTH AND INDIVIDUALS WITH DISABILITY GRANTS’’; and 

(B) in paragraph (1), by striking ‘‘for the purpose of’’ 

and all that follows through the period at the end and inserting ‘‘for the development, evaluation, and dissemination of research, demonstration projects, and model curricula for cultural competency, prevention, public health 

proficiency, reducing health disparities, and aptitude for 

working with individuals with disabilities training for use 

in health professions schools and continuing education programs, and for other purposes determined as appropriate 

by the Secretary.’’; and 

(2) by striking subsection (b) and inserting the following: 

‘‘(b) COLLABORATION.—In carrying out subsection (a), the Secretary shall collaborate with health professional societies, licensing 

and accreditation entities, health professions schools, and experts 

in minority health and cultural competency, prevention, and public 

health and disability groups, community-based organizations, and 

other organizations as determined appropriate by the Secretary. 

The Secretary shall coordinate with curricula and research and 

demonstration projects developed under section 807. 

‘‘(c) DISSEMINATION.— 

‘‘(1) IN GENERAL.—Model curricula developed under this 

section shall be disseminated through the Internet Clearinghouse under section 270 and such other means as determined 

appropriate by the Secretary. 

‘‘(2) EVALUATION.—The Secretary shall evaluate the adoption and the implementation of cultural competency, prevention, and public health, and working with individuals with a 

disability training curricula, and the facilitate inclusion of 

these competency measures in quality measurement systems 

as appropriate. 

‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated to carry out this section such sums as may be 

necessary for each of fiscal years 2010 through 2015.’’. 

(b) TITLE VIII.—Section 807 of the Public Health Service Act 

(42 U.S.C. 296e–1) is amended— 

(1) in subsection (a)— 

(A) by striking the subsection heading and inserting 

‘‘CULTURAL COMPETENCY, PREVENTION, AND PUBLIC

HEALTH AND INDIVIDUALS WITH DISABILITY GRANTS’’; and 

(B) by striking ‘‘for the purpose of’’ and all that follows 

through ‘‘health care.’’ and inserting ‘‘for the development, 

evaluation, and dissemination of research, demonstration 

projects, and model curricula for cultural competency, pre-
559 Sec. 5309 PPACA (Consolidated) 

vention, public health proficiency, reducing health disparities, and aptitude for working with individuals with disabilities training for use in health professions schools and 

continuing education programs, and for other purposes determined as appropriate by the Secretary.’’; and 

(2) by redesignating subsection (b) as subsection (d); 

(3) by inserting after subsection (a) the following: 

‘‘(b) COLLABORATION.—In carrying out subsection (a), the Secretary shall collaborate with the entities described in section 

741(b). The Secretary shall coordinate with curricula and research 

and demonstration projects developed under such section 741. 

‘‘(c) DISSEMINATION.—Model curricula developed under this section shall be disseminated and evaluated in the same manner as 

model curricula developed under section 741, as described in subsection (c) of such section.’’; and 

(4) in subsection (d), as so redesignated— 

(A) by striking ‘‘subsection (a)’’ and inserting ‘‘this section’’; and 

(B) by striking ‘‘2001 through 2004’’ and inserting 

‘‘2010 through 2015’’. 

SEC. 5308. ADVANCED NURSING EDUCATION GRANTS. 

Section 811 of the Public Health Service Act (42 U.S.C. 296j) 

is amended— 

(1) in subsection (c)— 

(A) in the subsection heading, by striking ‘‘AND NURSE

MIDWIFERY PROGRAMS’’; and 

(B) by striking ‘‘and nurse midwifery’’; 

(2) in subsection (f)— 

(A) by striking paragraph (2); and 

(B) by redesignating paragraph (3) as paragraph (2); 

and 

(3) by redesignating subsections (d), (e), and (f) as subsections (e), (f), and (g), respectively; and 

(4) by inserting after subsection (c), the following: 

‘‘(d) AUTHORIZED NURSE-MIDWIFERY PROGRAMS.—Midwifery 

programs that are eligible for support under this section are educational programs that— 

‘‘(1) have as their objective the education of midwives; and 

‘‘(2) are accredited by the American College of Nurse-Midwives Accreditation Commission for Midwifery Education.’’. 

SEC. 5309. NURSE EDUCATION, PRACTICE, AND RETENTION GRANTS. 

(a) IN GENERAL.—Section 831 of the Public Health Service Act 

(42 U.S.C. 296p) is amended— 

(1) in the section heading, by striking ‘‘RETENTION’’ and 

inserting ‘‘QUALITY’’; 

(2) in subsection (a)— 

(A) in paragraph (1), by adding ‘‘or’’ after the semicolon; 

(B) by striking paragraph (2); and 

(C) by redesignating paragraph (3) as paragraph (2); 

(3) in subsection (b)(3), by striking ‘‘managed care, quality 

improvement’’ and inserting ‘‘coordinated care’’; 
Sec. 5309\831A PHSA PPACA (Consolidated) 560 

(4) in subsection (g), by inserting ‘‘, as defined in section 

801(2),’’ after ‘‘school of nursing’’; and 

(5) in subsection (h), by striking ‘‘2003 through 2007’’ and 

inserting ‘‘2010 through 2014’’. 

(b) NURSE RETENTION GRANTS.—Title VIII of the Public Health 

Service Act is amended by inserting after section 831 (42 U.S.C. 

296b) the following: 

‘‘SEC. 831A. ø42 U.S.C. 296p–1¿ NURSE RETENTION GRANTS. 

‘‘(a) RETENTION PRIORITY AREAS.—The Secretary may award 

grants to, and enter into contracts with, eligible entities to enhance 

the nursing workforce by initiating and maintaining nurse retention programs pursuant to subsection (b) or (c). 

‘‘(b) GRANTS FOR CAREER LADDER PROGRAM.—The Secretary 

may award grants to, and enter into contracts with, eligible entities 

for programs— 

‘‘(1) to promote career advancement for individuals including licensed practical nurses, licensed vocational nurses, certified nurse assistants, home health aides, diploma degree or 

associate degree nurses, to become baccalaureate prepared registered nurses or advanced education nurses in order to meet 

the needs of the registered nurse workforce; 

‘‘(2) developing and implementing internships and residency programs in collaboration with an accredited school of 

nursing, as defined by section 801(2), to encourage mentoring 

and the development of specialties; or 

‘‘(3) to assist individuals in obtaining education and training required to enter the nursing profession and advance within such profession. 

‘‘(c) ENHANCING PATIENT CARE DELIVERY SYSTEMS.— 

‘‘(1) GRANTS.—The Secretary may award grants to eligible 

entities to improve the retention of nurses and enhance patient 

care that is directly related to nursing activities by enhancing 

collaboration and communication among nurses and other 

health care professionals, and by promoting nurse involvement 

in the organizational and clinical decision-making processes of 

a health care facility. 

‘‘(2) PRIORITY.—In making awards of grants under this 

subsection, the Secretary shall give preference to applicants 

that have not previously received an award under this subsection (or section 831(c) as such section existed on the day before the date of enactment of this section). 

‘‘(3) CONTINUATION OF AN AWARD.—The Secretary shall 

make continuation of any award under this subsection beyond 

the second year of such award contingent on the recipient of 

such award having demonstrated to the Secretary measurable 

and substantive improvement in nurse retention or patient 

care. 

‘‘(d) OTHER PRIORITY AREAS.—The Secretary may award grants 

to, or enter into contracts with, eligible entities to address other 

areas that are of high priority to nurse retention, as determined by 

the Secretary. 

‘‘(e) REPORT.—The Secretary shall submit to the Congress before the end of each fiscal year a report on the grants awarded and 
561 Sec. 5311 PPACA (Consolidated) 

the contracts entered into under this section. Each such report 

shall identify the overall number of such grants and contracts and 

provide an explanation of why each such grant or contract will 

meet the priority need of the nursing workforce. 

‘‘(f) ELIGIBLE ENTITY.—For purposes of this section, the term 

‘eligible entity’ includes an accredited school of nursing, as defined 

by section 801(2), a health care facility, or a partnership of such 

a school and facility. 

‘‘(g) 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 2010 through 2012.’’. 

SEC. 5310. LOAN REPAYMENT AND SCHOLARSHIP PROGRAM. 

(a) LOAN REPAYMENTS AND SCHOLARSHIPS.—Section 846(a)(3) 

of the Public Health Service Act (42 U.S.C. 297n(a)(3)) is amended 

by inserting before the semicolon the following: ‘‘, or in a accredited 

school of nursing, as defined by section 801(2), as nurse faculty’’. 

(b) TECHNICAL AND CONFORMING AMENDMENTS.—Title VIII (42 

U.S.C. 296 et seq.) is amended— 

(1) by redesignating section 810 (relating to prohibition 

against discrimination by schools on the basis of sex) as section 

809 and moving such section so that it follows section 808; 

(2) in sections 835, 836, 838, 840, and 842, by striking the 

term ‘‘this subpart’’ each place it appears and inserting ‘‘this 

part’’; 

(3) in section 836(h), by striking the last sentence; 

(4) in section 836, by redesignating subsection (l) as subsection (k); 

(5) in section 839, by striking ‘‘839’’ and all that follows 

through ‘‘(a)’’ and inserting ‘‘839. (a)’’; 

(6) in section 835(b), by striking ‘‘841’’ each place it appears and inserting ‘‘871’’; 

(7) by redesignating section 841 as section 871, moving 

part F to the end of the title, and redesignating such part as 

part I; 

(8) in part G— 

(A) by redesignating section 845 as section 851; and 

(B) by redesignating part G as part F; 

(9) in part H— 

(A) by redesignating sections 851 and 852 as sections 

861 and 862, respectively; and 

(B) by redesignating part H as part G; and 

(10) in part I— 

(A) by redesignating section 855, as amended by section 5305, as section 865; and 

(B) by redesignating part I as part H. 

SEC. 5311. NURSE FACULTY LOAN PROGRAM. 

(a) IN GENERAL.—Section 846A of the Public Health Service 

Act (42 U.S.C. 297n–1) is amended— 

(1) in subsection (a)— 

(A) in the subsection heading, by striking ‘‘ESTABLISHMENT’’ and inserting ‘‘SCHOOL OF NURSING STUDENT LOAN

FUND’’; and 
Sec. 5311\847 PHSA PPACA (Consolidated) 562 

(B) by inserting ‘‘accredited’’ after ‘‘agreement with 

any’’; 

(2) in subsection (c)— 

(A) in paragraph (2), by striking ‘‘$30,000’’ and all that follows through the semicolon and inserting ‘‘$35,500, during fiscal years 2010 and 2011 fiscal years (after fiscal 

year 2011, such amounts shall be adjusted to provide for 

a cost-of-attendance increase for the yearly loan rate and 

the aggregate loan;’’; and 

(B) in paragraph (3)(A), by inserting ‘‘an accredited’’ 

after ‘‘faculty member in’’; 

(3) in subsection (e), by striking ‘‘a school’’ and inserting 

‘‘an accredited school’’; and 

(4) in subsection (f), by striking ‘‘2003 through 2007’’ and 

inserting ‘‘2010 through 2014’’. 

(b) ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT.—Title 

VIII of the Public Health Service Act is amended by inserting after 

section 846A (42 U.S.C. 297n–1) the following: 

‘‘SEC. 847. ø42 U.S.C. 297o¿ ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Administrator of the Health Resources and Services Administration, may 

enter into an agreement with eligible individuals for the repayment 

of education loans, in accordance with this section, to increase the 

number of qualified nursing faculty. 

‘‘(b) AGREEMENTS.—Each agreement entered into under this 

subsection shall require that the eligible individual shall serve as 

a full-time member of the faculty of an accredited school of nursing, 

for a total period, in the aggregate, of at least 4 years during the 

6-year period beginning on the later of— 

‘‘(1) the date on which the individual receives a master’s 

or doctorate nursing degree from an accredited school of nursing; or 

‘‘(2) the date on which the individual enters into an agreement under this subsection. 

‘‘(c) AGREEMENT PROVISIONS.—Agreements entered into pursuant to subsection (b) shall be entered into on such terms and conditions as the Secretary may determine, except that— 

‘‘(1) not more than 10 months after the date on which the 

6-year period described under subsection (b) begins, but in no 

case before the individual starts as a full-time member of the 

faculty of an accredited school of nursing the Secretary shall 

begin making payments, for and on behalf of that individual, 

on the outstanding principal of, and interest on, any loan of 

that individual obtained to pay for such degree; 

‘‘(2) for an individual who has completed a master’s in 

nursing or equivalent degree in nursing— 

‘‘(A) payments may not exceed $10,000 per calendar 

year; and 

‘‘(B) total payments may not exceed $40,000 during 

the 2010 and 2011 fiscal years (after fiscal year 2011, such 

amounts shall be adjusted to provide for a cost-of-attendance increase for the yearly loan rate and the aggregate 

loan); and 
563 Sec. 5312 PPACA (Consolidated) 

‘‘(3) for an individual who has completed a doctorate or 

equivalent degree in nursing— 

‘‘(A) payments may not exceed $20,000 per calendar 

year; and 

‘‘(B) total payments may not exceed $80,000 during 

the 2010 and 2011 fiscal years (adjusted for subsequent 

fiscal years as provided for in the same manner as in paragraph (2)(B)). 

‘‘(d) BREACH OF AGREEMENT.— 

‘‘(1) IN GENERAL.—In the case of any agreement made 

under subsection (b), the individual is liable to the Federal 

Government for the total amount paid by the Secretary under 

such agreement, and for interest on such amount at the maximum legal prevailing rate, if the individual fails to meet the 

agreement terms required under such subsection. 

‘‘(2) WAIVER OR SUSPENSION OF LIABILITY.—In the case of 

an individual making an agreement for purposes of paragraph 

(1), the Secretary shall provide for the waiver or suspension of 

liability under such paragraph if compliance by the individual 

with the agreement involved is impossible or would involve extreme hardship to the individual or if enforcement of the agreement with respect to the individual would be unconscionable. 

‘‘(3) DATE CERTAIN FOR RECOVERY.—Subject to paragraph 

(2), any amount that the Federal Government is entitled to recover under paragraph (1) shall be paid to the United States 

not later than the expiration of the 3-year period beginning on 

the date the United States becomes so entitled. 

‘‘(4) AVAILABILITY.—Amounts recovered under paragraph 

(1) shall be available to the Secretary for making loan repayments under this section and shall remain available for such 

purpose until expended. 

‘‘(e) ELIGIBLE INDIVIDUAL DEFINED.—For purposes of this section, the term ‘eligible individual’ means an individual who— 

‘‘(1) is a United States citizen, national, or lawful permanent resident; 

‘‘(2) holds an unencumbered license as a registered nurse; 

and 

‘‘(3) has either already completed a master’s or doctorate 

nursing program at an accredited school of nursing or is currently enrolled on a full-time or part-time basis in such a program. 

‘‘(f) PRIORITY.—For the purposes of this section and section 

846A, funding priority will be awarded to School of Nursing Student Loans that support doctoral nursing students or Individual 

Student Loan Repayment that support doctoral nursing students. 

‘‘(g) 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 2010 through 2014.’’. 

SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR PARTS B 

THROUGH D OF TITLE VIII. 

Section 871 of the Public Health Service Act, as redesignated 

and moved by section 5310, is amended to read as follows: 
Sec. 5312\871 PHSA PPACA (Consolidated) 564 

‘‘SEC. 871. ø42 U.S.C. 298d¿ AUTHORIZATION OF APPROPRIATIONS. 

‘‘For the purpose of carrying out parts B, C, and D (subject to 

section 851(g)), there are authorized to be appropriated 

$338,000,000 for fiscal year 2010, and such sums as may be necessary for each of the fiscal years 2011 through 2016.’’. 

SEC. 5313. GRANTS TO PROMOTE THE COMMUNITY HEALTH WORKFORCE. 

(a) IN GENERAL.—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. 399V. ø42 U.S.C. 280g–11¿ GRANTS TO PROMOTE POSITIVE 

HEALTH BEHAVIORS AND OUTCOMES. 

‘‘(a) GRANTS AUTHORIZED.—The Director of the Centers for Disease Control and Prevention, in collaboration with the Secretary, 

shall award grants to eligible entities to promote positive health 

behaviors and outcomes for populations in medically underserved 

communities through the use of community health workers. 

‘‘(b) USE OF FUNDS.—Grants awarded under subsection (a) 

shall be used to support community health workers— 

‘‘(1) to educate, guide, and provide outreach in a community setting regarding health problems prevalent in medically 

underserved communities, particularly racial and ethnic minority populations; 

‘‘(2) to educate and provide guidance regarding effective 

strategies to promote positive health behaviors and discourage 

risky health behaviors; 

‘‘(3) to educate and provide outreach regarding enrollment 

in health insurance including the Children’s Health Insurance 

Program under title XXI of the Social Security Act, Medicare 

under title XVIII of such Act and Medicaid under title XIX of 

such Act; 

‘‘(4) to identify and refer underserved populations to appropriate healthcare agencies and community-based programs and 

organizations in order to increase access to quality healthcare 

services and to eliminate duplicative care; or øAs revised by 

section 10501(c)(1)¿ 

‘‘(5) to educate, guide, and provide home visitation services 

regarding maternal health and prenatal care. 

‘‘(c) APPLICATION.—Each eligible entity that desires to receive 

a grant under subsection (a) shall submit an application to the Secretary, at such time, in such manner, and accompanied by such information as the Secretary may require. 

‘‘(d) PRIORITY.—In awarding grants under subsection (a), the 

Secretary shall give priority to applicants that— 

‘‘(1) propose to target geographic areas— 

‘‘(A) with a high percentage of residents who are eligible for health insurance but are uninsured or underinsured; 

‘‘(B) with a high percentage of residents who suffer 

from chronic diseases; or 

‘‘(C) with a high infant mortality rate; 

‘‘(2) have experience in providing health or health-related 

social services to individuals who are underserved with respect 

to such services; and 
565 Sec. 5313 PPACA (Consolidated) \399V PHSA 

‘‘(3) have documented community activity and experience 

with community health workers. 

‘‘(e) COLLABORATION WITH ACADEMIC INSTITUTIONS AND THE

ONE-STOP DELIVERY SYSTEM.—The Secretary shall encourage community health worker programs receiving funds under this section 

to collaborate with academic institutions and one-stop delivery systems under section 134(c) of the Workforce Investment Act of 1998. 

Nothing in this section shall be construed to require such collaboration. 

‘‘(f) EVIDENCE-BASED INTERVENTIONS.—The Secretary shall encourage community health worker programs receiving funding 

under this section to implement a process or an outcome-based payment system that rewards community health workers for connecting underserved populations with the most appropriate services at the most appropriate time. Nothing in this section shall be 

construed to require such a payment. 

‘‘(g) QUALITY ASSURANCE AND COST EFFECTIVENESS.—The Secretary shall establish guidelines for assuring the quality of the 

training and supervision of community health workers under the 

programs funded under this section and for assuring the cost-effectiveness of such programs. 

‘‘(h) MONITORING.—The Secretary shall monitor community 

health worker programs identified in approved applications under 

this section and shall determine whether such programs are in 

compliance with the guidelines established under subsection (g). 

‘‘(i) TECHNICAL ASSISTANCE.—The Secretary may provide technical assistance to community health worker programs identified in 

approved applications under this section with respect to planning, 

developing, and operating programs under the grant. 

‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated, such sums as may be necessary to carry out 

this section for each of fiscal years 2010 through 2014. 

‘‘(k) DEFINITIONS.—In this section: 

‘‘(1) COMMUNITY HEALTH WORKER.—The term ‘community 

health worker’ means an individual who promotes health or 

nutrition within the community in which the individual resides—øAs revised by section 10501(c)(2)¿ 

‘‘(A) by serving as a liaison between communities and 

healthcare agencies; 

‘‘(B) by providing guidance and social assistance to 

community residents; 

‘‘(C) by enhancing community residents’ ability to effectively communicate with healthcare providers; 

‘‘(D) by providing culturally and linguistically appropriate health or nutrition education; 

‘‘(E) by advocating for individual and community 

health; 

‘‘(F) by providing referral and follow-up services or 

otherwise coordinating care; and 

‘‘(G) by proactively identifying and enrolling eligible 

individuals in Federal, State, local, private or nonprofit 

health and human services programs. 

‘‘(2) COMMUNITY SETTING.—The term ‘community setting’ 

means a home or a community organization located in the 
Sec. 5314 PPACA (Consolidated) 566 

neighborhood in which a participant in the program under this 

section resides. 

‘‘(3) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a 

public or nonprofit private entity (including a State or public 

subdivision of a State, a public health department, a free 

health clinic, a hospital, or a Federally-qualified health center 

(as defined in section 1861(aa) of the Social Security Act)), or 

a consortium of any such entities. 

‘‘(4) MEDICALLY UNDERSERVED COMMUNITY.—The term 

‘medically underserved community’ means a community identified by a State— 

‘‘(A) that has a substantial number of individuals who 

are members of a medically underserved population, as defined by section 330(b)(3); and 

‘‘(B) a significant portion of which is a health professional shortage area as designated under section 332.’’. 

SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH. 

Part E of title VII of the Public Health Service Act (42 U.S.C. 

294n et seq.), as amended by section 5206, is further amended by 

adding at the end the following: 

‘‘SEC. 778. ø42 U.S.C. 295f–3¿ FELLOWSHIP TRAINING IN APPLIED PUBLIC HEALTH EPIDEMIOLOGY, PUBLIC HEALTH LABORATORY SCIENCE, PUBLIC HEALTH INFORMATICS, AND EXPANSION OF THE EPIDEMIC INTELLIGENCE SERVICE. 

‘‘(a) IN GENERAL.—The Secretary may carry out activities to 

address documented workforce shortages in State and local health 

departments in the critical areas of applied public health epidemiology and public health laboratory science and informatics and may 

expand the Epidemic Intelligence Service. 

‘‘(b) SPECIFIC USES.—In carrying out subsection (a), the Secretary shall provide for the expansion of existing fellowship programs operated through the Centers for Disease Control and Prevention in a manner that is designed to alleviate shortages of the 

type described in subsection (a). 

‘‘(c) OTHER PROGRAMS.—The Secretary may provide for the expansion of other applied epidemiology training programs that meet 

objectives similar to the objectives of the programs described in 

subsection (b). 

‘‘(d) WORK OBLIGATION.—Participation in fellowship training 

programs under this section shall be deemed to be service for purposes of satisfying work obligations stipulated in contracts under 

section 338I(j). 

‘‘(e) GENERAL SUPPORT.—Amounts may be used from grants 

awarded under this section to expand the Public Health 

Informatics Fellowship Program at the Centers for Disease Control 

and Prevention to better support all public health systems at all 

levels of government. 

‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated to carry out this section $39,500,000 for each of 

fiscal years 2010 through 2013, of which— 

‘‘(1) $5,000,000 shall be made available in each such fiscal 

year for epidemiology fellowship training program activities 

under subsections (b) and (c); 
567 Sec. 5315 PPACA (Consolidated) \271 PHSA 

‘‘(2) $5,000,000 shall be made available in each such fiscal 

year for laboratory fellowship training programs under subsection (b); 

‘‘(3) $5,000,000 shall be made available in each such fiscal 

year for the Public Health Informatics Fellowship Program 

under subsection (e); and 

‘‘(4) $24,500,000 shall be made available for expanding the 

Epidemic Intelligence Service under subsection (a).’’. 

SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK. 

Title II of the Public Health Service Act (42 U.S.C. 202 et seq.) 

is amended by adding at the end the following: 

‘‘PART D—UNITED STATES PUBLIC HEALTH 

SCIENCES TRACK 

‘‘SEC. 271. ø42 U.S.C. 239l¿ ESTABLISHMENT. 

‘‘(a) UNITED STATES PUBLIC HEALTH SERVICES TRACK.— 

‘‘(1) IN GENERAL.—There is hereby authorized to be established a United States Public Health Sciences Track (referred 

to in this part as the ‘Track’), at sites to be selected by the Secretary, with authority to grant appropriate advanced degrees 

in a manner that uniquely emphasizes team-based service, 

public health, epidemiology, and emergency preparedness and 

response. It shall be so organized as to graduate not less 

than— 

‘‘(A) 150 medical students annually, 10 of whom shall 

be awarded studentships to the Uniformed Services University of Health Sciences; 

‘‘(B) 100 dental students annually; 

‘‘(C) 250 nursing students annually; 

‘‘(D) 100 public health students annually; 

‘‘(E) 100 behavioral and mental health professional 

students annually; 

‘‘(F) 100 physician assistant or nurse practitioner students annually; and 

‘‘(G) 50 pharmacy students annually. 

‘‘(2) LOCATIONS.—The Track shall be located at existing 

and accredited, affiliated health professions education training 

programs at academic health centers located in regions of the 

United States determined appropriate by the Surgeon General, 

in consultation with the National Health Care Workforce Commission established in section 5101 of the Patient Protection 

and Affordable Care Act. 

‘‘(b) NUMBER OF GRADUATES.—Except as provided in subsection 

(a), the number of persons to be graduated from the Track shall be 

prescribed by the Secretary. In so prescribing the number of persons to be graduated from the Track, the Secretary shall institute 

actions necessary to ensure the maximum number of first-year enrollments in the Track consistent with the academic capacity of the 

affiliated sites and the needs of the United States for medical, dental, and nursing personnel. 
Sec. 5315\272 PHSA PPACA (Consolidated) 568 

‘‘(c) DEVELOPMENT.—The development of the Track may be by 

such phases as the Secretary may prescribe subject to the requirements of subsection (a). 

‘‘(d) INTEGRATED LONGITUDINAL PLAN.—The Surgeon General 

shall develop an integrated longitudinal plan for health professions 

continuing education throughout the continuum of health-related 

education, training, and practice. Training under such plan shall 

emphasize patient-centered, interdisciplinary, and care coordination skills. Experience with deployment of emergency response 

teams shall be included during the clinical experiences. 

‘‘(e) FACULTY DEVELOPMENT.—The Surgeon General shall develop faculty development programs and curricula in decentralized 

venues of health care, to balance urban, tertiary, and inpatient 

venues. 

‘‘SEC. 272. ø42 U.S.C. 239l–1¿ ADMINISTRATION. 

‘‘(a) IN GENERAL.—The business of the Track shall be conducted by the Surgeon General with funds appropriated for and 

provided by the Department of Health and Human Services. The 

National Health Care Workforce Commission shall assist the Surgeon General in an advisory capacity. 

‘‘(b) FACULTY.— 

‘‘(1) IN GENERAL.—The Surgeon General, after considering 

the recommendations of the National Health Care Workforce 

Commission, shall obtain the services of such professors, instructors, and administrative and other employees as may be 

necessary to operate the Track, but utilize when possible, existing affiliated health professions training institutions. Members of the faculty and staff shall be employed under salary 

schedules and granted retirement and other related benefits 

prescribed by the Secretary so as to place the employees of the 

Track faculty on a comparable basis with the employees of 

fully accredited schools of the health professions within the 

United States. 

‘‘(2) TITLES.—The Surgeon General may confer academic 

titles, as appropriate, upon the members of the faculty. 

‘‘(3) NONAPPLICATION OF PROVISIONS.—The limitations in 

section 5373 of title 5, United States Code, shall not apply to 

the authority of the Surgeon General under paragraph (1) to 

prescribe salary schedules and other related benefits. 

‘‘(c) AGREEMENTS.—The Surgeon General may negotiate agreements with agencies of the Federal Government to utilize on a reimbursable basis appropriate existing Federal medical resources located in the United States (or locations selected in accordance with 

section 271(a)(2)). Under such agreements the facilities concerned 

will retain their identities and basic missions. The Surgeon General may negotiate affiliation agreements with accredited universities and health professions training institutions in the United 

States. Such agreements may include provisions for payments for 

educational services provided students participating in Department 

of Health and Human Services educational programs. 

‘‘(d) PROGRAMS.—The Surgeon General may establish the following educational programs for Track students: 
569 Sec. 5315 PPACA (Consolidated) \272 PHSA 

‘‘(1) Postdoctoral, postgraduate, and technological programs. 

‘‘(2) A cooperative program for medical, dental, physician 

assistant, pharmacy, behavioral and mental health, public 

health, and nursing students. 

‘‘(3) Other programs that the Surgeon General determines 

necessary in order to operate the Track in a cost-effective manner. 

‘‘(e) CONTINUING MEDICAL EDUCATION.—The Surgeon General 

shall establish programs in continuing medical education for members of the health professions to the end that high standards of 

health care may be maintained within the United States. 

‘‘(f) AUTHORITY OF THE SURGEON GENERAL.— 

‘‘(1) IN GENERAL.—The Surgeon General is authorized— 

‘‘(A) to enter into contracts with, accept grants from, 

and make grants to any nonprofit entity for the purpose of 

carrying out cooperative enterprises in medical, dental, 

physician assistant, pharmacy, behavioral and mental 

health, public health, and nursing research, consultation, 

and education; 

‘‘(B) to enter into contracts with entities under which 

the Surgeon General may furnish the services of such professional, technical, or clerical personnel as may be necessary to fulfill cooperative enterprises undertaken by the 

Track; 

‘‘(C) to accept, hold, administer, invest, and spend any 

gift, devise, or bequest of personal property made to the 

Track, including any gift, devise, or bequest for the support of an academic chair, teaching, research, or demonstration project; 

‘‘(D) to enter into agreements with entities that may 

be utilized by the Track for the purpose of enhancing the 

activities of the Track in education, research, and technological applications of knowledge; and 

‘‘(E) to accept the voluntary services of guest scholars 

and other persons. 

‘‘(2) LIMITATION.—The Surgeon General may not enter into 

any contract with an entity if the contract would obligate the 

Track to make outlays in advance of the enactment of budget 

authority for such outlays. 

‘‘(3) SCIENTISTS.—Scientists or other medical, dental, or 

nursing personnel utilized by the Track under an agreement 

described in paragraph (1) may be appointed to any position 

within the Track and may be permitted to perform such duties 

within the Track as the Surgeon General may approve. 

‘‘(4) VOLUNTEER SERVICES.—A person who provides voluntary services under the authority of subparagraph (E) of 

paragraph (1) shall be considered to be an employee of the Federal Government for the purposes of chapter 81 of title 5, relating to compensation for work-related injuries, and to be an employee of the Federal Government for the purposes of chapter 

171 of title 28, relating to tort claims. Such a person who is 

not otherwise employed by the Federal Government shall not 
Sec. 5315\273 PHSA PPACA (Consolidated) 570 

be considered to be a Federal employee for any other purpose 

by reason of the provision of such services. 

‘‘SEC. 273. ø42 U.S.C. 239l–2¿ STUDENTS; SELECTION; OBLIGATION. 

‘‘(a) STUDENT SELECTION.— 

‘‘(1) IN GENERAL.—Medical, dental, physician assistant, 

pharmacy, behavioral and mental health, public health, and 

nursing students at the Track shall be selected under procedures prescribed by the Surgeon General. In so prescribing, the 

Surgeon General shall consider the recommendations of the 

National Health Care Workforce Commission. 

‘‘(2) PRIORITY.—In developing admissions procedures under 

paragraph (1), the Surgeon General shall ensure that such procedures give priority to applicant medical, dental, physician assistant, pharmacy, behavioral and mental health, public 

health, and nursing students from rural communities and 

underrepresented minorities. 

‘‘(b) CONTRACT AND SERVICE OBLIGATION.— 

‘‘(1) CONTRACT.—Upon being admitted to the Track, a medical, dental, physician assistant, pharmacy, behavioral and 

mental health, public health, or nursing student shall enter 

into a written contract with the Surgeon General that shall 

contain— 

‘‘(A) an agreement under which— 

‘‘(i) subject to subparagraph (B), the Surgeon General agrees to provide the student with tuition (or tuition remission) and a student stipend (described in 

paragraph (2)) in each school year for a period of years 

(not to exceed 4 school years) determined by the student, during which period the student is enrolled in 

the Track at an affiliated or other participating health 

professions institution pursuant to an agreement between the Track and such institution; and 

‘‘(ii) subject to subparagraph (B), the student 

agrees— 

‘‘(I) to accept the provision of such tuition and 

student stipend to the student; 

‘‘(II) to maintain enrollment at the Track until 

the student completes the course of study involved; 

‘‘(III) while enrolled in such course of study, to 

maintain an acceptable level of academic standing 

(as determined by the Surgeon General); 

‘‘(IV) if pursuing a degree from a school of 

medicine or osteopathic medicine, dental, public 

health, or nursing school or a physician assistant, 

pharmacy, or behavioral and mental health professional program, to complete a residency or internship in a specialty that the Surgeon General 

determines is appropriate; and 

‘‘(V) to serve for a period of time (referred to 

in this part as the ‘period of obligated service’) 

within the Commissioned Corps of the Public 

Health Service equal to 2 years for each school 
571 Sec. 5315 PPACA (Consolidated) \273 PHSA 

year during which such individual was enrolled at 

the College, reduced as provided for in paragraph 

(3); 

‘‘(B) a provision that any financial obligation of the 

United States arising out of a contract entered into under 

this part and any obligation of the student which is conditioned thereon, is contingent upon funds being appropriated to carry out this part; 

‘‘(C) a statement of the damages to which the United 

States is entitled for the student’s breach of the contract; 

and 

‘‘(D) such other statements of the rights and liabilities 

of the Secretary and of the individual, not inconsistent 

with the provisions of this part. 

‘‘(2) TUITION AND STUDENT STIPEND.— ‘‘(A) TUITION REMISSION RATES.—The Surgeon General, 

based on the recommendations of the National Health 

Care Workforce Commission, shall establish Federal tuition remission rates to be used by the Track to provide reimbursement to affiliated and other participating health 

professions institutions for the cost of educational services 

provided by such institutions to Track students. The agreement entered into by such participating institutions under 

paragraph (1)(A)(i) shall contain an agreement to accept as 

payment in full the established remission rate under this 

subparagraph. 

‘‘(B) STIPEND.—The Surgeon General, based on the 

recommendations of the National Health Care Workforce 

Commission, shall establish and update Federal stipend 

rates for payment to students under this part. 

‘‘(3) REDUCTIONS IN THE PERIOD OF OBLIGATED SERVICE.— 

The period of obligated service under paragraph (1)(A)(ii)(V) 

shall be reduced— 

‘‘(A) in the case of a student who elects to participate 

in a high-needs speciality residency (as determined by the 

National Health Care Workforce Commission), by 3 

months for each year of such participation (not to exceed 

a total of 12 months); and 

‘‘(B) in the case of a student who, upon completion of 

their residency, elects to practice in a Federal medical facility (as defined in section 781(e)) that is located in a 

health professional shortage area (as defined in section 

332), by 3 months for year of full-time practice in such a 

facility (not to exceed a total of 12 months). 

‘‘(c) SECOND 2 YEARS OF SERVICE.—During the third and fourth 

years in which a medical, dental, physician assistant, pharmacy, 

behavioral and mental health, public health, or nursing student is 

enrolled in the Track, training should be designed to prioritize clinical rotations in Federal medical facilities in health professional 

shortage areas, and emphasize a balance of hospital and community-based experiences, and training within interdisciplinary 

teams. 

‘‘(d) DENTIST, PHYSICIAN ASSISTANT, PHARMACIST, BEHAVIORAL

AND MENTAL HEALTH PROFESSIONAL, PUBLIC HEALTH PROFES-
Sec. 5315\274 PHSA PPACA (Consolidated) 572 

SIONAL, AND NURSE TRAINING.—The Surgeon General shall establish provisions applicable with respect to dental, physician assistant, pharmacy, behavioral and mental health, public health, and 

nursing students that are comparable to those for medical students 

under this section, including service obligations, tuition support, 

and stipend support. The Surgeon General shall give priority to 

health professions training institutions that train medical, dental, 

physician assistant, pharmacy, behavioral and mental health, public health, and nursing students for some significant period of time 

together, but at a minimum have a discrete and shared core curriculum. 

‘‘(e) ELITE FEDERAL DISASTER TEAMS.—The Surgeon General, 

in consultation with the Secretary, the Director of the Centers for 

Disease Control and Prevention, and other appropriate military 

and Federal government agencies, shall develop criteria for the appointment of highly qualified Track faculty, medical, dental, physician assistant, pharmacy, behavioral and mental health, public 

health, and nursing students, and graduates to elite Federal disaster preparedness teams to train and to respond to public health 

emergencies, natural disasters, bioterrorism events, and other 

emergencies. 

‘‘(f) STUDENT DROPPED FROM TRACK IN AFFILIATE SCHOOL.—A 

medical, dental, physician assistant, pharmacy, behavioral and 

mental health, public health, or nursing student who, under regulations prescribed by the Surgeon General, is dropped from the 

Track in an affiliated school for deficiency in conduct or studies, or 

for other reasons, shall be liable to the United States for all tuition 

and stipend support provided to the student. 

‘‘SEC. 274. ø42 U.S.C. 239l–3¿ FUNDING. 

‘‘Beginning with fiscal year 2010, the Secretary shall transfer 

from the Public Health and Social Services Emergency Fund such 

sums as may be necessary to carry out this part.’’. 

SEC. 5316. ø42 U.S.C. 296j–1¿ DEMONSTRATION GRANTS FOR FAMILY 

NURSE PRACTITIONER TRAINING PROGRAMS. 

øSection added by section 10501(e)¿ 

(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 
573 Sec. 5316 PPACA (Consolidated) 

(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 Serv-
Sec. 5401 PPACA (Consolidated) 574 

ice 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. 

Subtitle E—Supporting the Existing Health 

Care Workforce 

SEC. 5401. CENTERS OF EXCELLENCE. 

Section 736 of the Public Health Service Act (42 U.S.C. 293) 

is amended by striking subsection (h) and inserting the following: 

‘‘(h) FORMULA FOR ALLOCATIONS.— 

‘‘(1) ALLOCATIONS.—Based on the amount appropriated 

under subsection (i) for a fiscal year, the following subparagraphs shall apply as appropriate: 

‘‘(A) IN GENERAL.—If the amounts appropriated under 

subsection (i) for a fiscal year are $24,000,000 or less— 

‘‘(i) the Secretary shall make available 

$12,000,000 for grants under subsection (a) to health 

professions schools that meet the conditions described 

in subsection (c)(2)(A); and 

‘‘(ii) and available after grants are made with 

funds under clause (i), the Secretary shall make available— 

‘‘(I) 60 percent of such amount for grants 

under subsection (a) to health professions schools 

that meet the conditions described in paragraph 

(3) or (4) of subsection (c) (including meeting the 

conditions under subsection (e)); and 

‘‘(II) 40 percent of such amount for grants 

under subsection (a) to health professions schools 

that meet the conditions described in subsection 

(c)(5). 

‘‘(B) FUNDING IN EXCESS OF $24,000,000.—If amounts appropriated under subsection (i) for a fiscal year exceed 

$24,000,000 but are less than $30,000,000— 

‘‘(i) 80 percent of such excess amounts shall be 

made available for grants under subsection (a) to 

health professions schools that meet the requirements 

described in paragraph (3) or (4) of subsection (c) (in-
575 Sec. 5401 PPACA (Consolidated) 

cluding meeting conditions pursuant to subsection (e)); 

and 

‘‘(ii) 20 percent of such excess amount shall be 

made available for grants under subsection (a) to 

health professions schools that meet the conditions described in subsection (c)(5). 

‘‘(C) FUNDING IN EXCESS OF $30,000,000.—If amounts appropriated under subsection (i) for a fiscal year exceed 

$30,000,000 but are less than $40,000,000, the Secretary 

shall make available— 

‘‘(i) not less than $12,000,000 for grants under 

subsection (a) to health professions schools that meet 

the conditions described in subsection (c)(2)(A); ‘‘(ii) not less than $12,000,000 for grants under 

subsection (a) to health professions schools that meet 

the conditions described in paragraph (3) or (4) of subsection (c) (including meeting conditions pursuant to 

subsection (e)); ‘‘(iii) not less than $6,000,000 for grants under 

subsection (a) to health professions schools that meet 

the conditions described in subsection (c)(5); and 

‘‘(iv) after grants are made with funds under 

clauses (i) through (iii), any remaining excess amount 

for grants under subsection (a) to health professions 

schools that meet the conditions described in paragraph (2)(A), (3), (4), or (5) of subsection (c). 

‘‘(D) FUNDING IN EXCESS OF $40,000,000.—If amounts 

appropriated under subsection (i) for a fiscal year are 

$40,000,000 or more, the Secretary shall make available— 

‘‘(i) not less than $16,000,000 for grants under 

subsection (a) to health professions schools that meet 

the conditions described in subsection (c)(2)(A); 

‘‘(ii) not less than $16,000,000 for grants under 

subsection (a) to health professions schools that meet 

the conditions described in paragraph (3) or (4) of subsection (c) (including meeting conditions pursuant to 

subsection (e)); 

‘‘(iii) not less than $8,000,000 for grants under 

subsection (a) to health professions schools that meet 

the conditions described in subsection (c)(5); and 

‘‘(iv) after grants are made with funds under 

clauses (i) through (iii), any remaining funds for 

grants under subsection (a) to health professions 

schools that meet the conditions described in paragraph (2)(A), (3), (4), or (5) of subsection (c). 

‘‘(2) NO LIMITATION.—Nothing in this subsection shall be 

construed as limiting the centers of excellence referred to in 

this section to the designated amount, or to preclude such entities from competing for grants under this section. 

‘‘(3) MAINTENANCE OF EFFORT.— 

‘‘(A) IN GENERAL.—With respect to activities for which 

a grant made under this part are authorized to be expended, the Secretary may not make such a grant to a center of excellence for any fiscal year unless the center 
Sec. 5402 PPACA (Consolidated) 576 

agrees 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 center for the fiscal year preceding the fiscal year for which the school receives such a grant. 

‘‘(B) USE OF FEDERAL FUNDS.—With respect to any 

Federal amounts received by a center of excellence and 

available for carrying out activities for which a grant 

under this part is authorized to be expended, the center 

shall, before expending the grant, expend the Federal 

amounts obtained from sources other than the grant, unless given prior approval from the Secretary. 

‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated to carry out this section— ‘‘(1) $50,000,000 for each of the fiscal years 2010 through 

2015; and 

‘‘(2) and such sums as are necessary for each subsequent 

fiscal year.’’. 

SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR DIVERSITY. 

(a) LOAN REPAYMENTS AND FELLOWSHIPS REGARDING FACULTY

POSITIONS.—Section 738(a)(1) of the Public Health Service Act (42 

U.S.C. 293b(a)(1)) is amended by striking ‘‘$20,000 of the principal 

and interest of the educational loans of such individuals.’’ and inserting ‘‘$30,000 of the principal and interest of the educational 

loans of such individuals.’’. 

(b) SCHOLARSHIPS FOR DISADVANTAGED STUDENTS.—Section 

740(a) of such Act (42 U.S.C. 293d(a)) is amended by striking 

‘‘$37,000,000’’ and all that follows through ‘‘2002’’ and inserting 

‘‘$51,000,000 for fiscal year 2010, and such sums as may be necessary for each of the fiscal years 2011 through 2014’’. 

(c) REAUTHORIZATION FOR LOAN REPAYMENTS AND FELLOW- SHIPS REGARDING FACULTY POSITIONS.—Section 740(b) of such Act 

(42 U.S.C. 293d(b)) is amended by striking ‘‘appropriated’’ and all 

that follows through the period at the end and inserting ‘‘appropriated, $5,000,000 for each of the fiscal years 2010 through 2014.’’. 

(d) REAUTHORIZATION FOR EDUCATIONAL ASSISTANCE IN THE

HEALTH PROFESSIONS REGARDING INDIVIDUALS FROM A DISADVAN- TAGED BACKGROUND.—Section 740(c) of such Act (42 U.S.C. 

293d(c)) is amended by striking the first sentence and inserting the 

following: ‘‘For the purpose of grants and contracts under section 

739(a)(1), there is authorized to be appropriated $60,000,000 for fiscal year 2010 and such sums as may be necessary for each of the 

fiscal years 2011 through 2014.’’ 

SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES. 

(a) AREA HEALTH EDUCATION CENTERS.—Section 751 of the 

Public Health Service Act (42 U.S.C. 294a) is amended to read as 

follows: 

‘‘SEC. 751. ø42 U.S.C. 294a¿ AREA HEALTH EDUCATION CENTERS. 

‘‘(a) ESTABLISHMENT OF AWARDS.—The Secretary shall make 

the following 2 types of awards in accordance with this section: 

‘‘(1) INFRASTRUCTURE DEVELOPMENT AWARD.—The Secretary shall make awards to eligible entities to enable such entities to initiate health care workforce educational programs or 
577 Sec. 5403 PPACA (Consolidated) \751 PHSA 

to continue to carry out comparable programs that are operating at the time the award is made by planning, developing, 

operating, and evaluating an area health education center program. 

‘‘(2) POINT OF SERVICE MAINTENANCE AND ENHANCEMENT

AWARD.—The Secretary shall make awards to eligible entities 

to maintain and improve the effectiveness and capabilities of 

an existing area health education center program, and make 

other modifications to the program that are appropriate due to 

changes in demographics, needs of the populations served, or 

other similar issues affecting the area health education center 

program. For the purposes of this section, the term ‘Program’ 

refers to the area health education center program. 

‘‘(b) ELIGIBLE ENTITIES; APPLICATION.— ‘‘(1) ELIGIBLE ENTITIES.— ‘‘(A) INFRASTRUCTURE DEVELOPMENT.—For purposes of 

subsection (a)(1), the term ‘eligible entity’ means a school 

of medicine or osteopathic medicine, an incorporated consortium of such schools, or the parent institutions of such 

a school. With respect to a State in which no area health 

education center program is in operation, the Secretary 

may award a grant or contract under subsection (a)(1) to 

a school of nursing. 

‘‘(B) POINT OF SERVICE MAINTENANCE AND ENHANCE- MENT.—For purposes of subsection (a)(2), the term ‘eligible 

entity’ means an entity that has received funds under this 

section, is operating an area health education center program, including an area health education center or centers, and has a center or centers that are no longer eligible 

to receive financial assistance under subsection (a)(1). 

‘‘(2) APPLICATION.—An eligible entity desiring to receive an 

award under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. 

‘‘(c) USE OF FUNDS.— 

‘‘(1) REQUIRED ACTIVITIES.—An eligible entity shall use 

amounts awarded under a grant under subsection (a)(1) or 

(a)(2) to carry out the following activities: 

‘‘(A) Develop and implement strategies, in coordination 

with the applicable one-stop delivery system under section 

134(c) of the Workforce Investment Act of 1998, to recruit 

individuals from underrepresented minority populations or 

from disadvantaged or rural backgrounds into health professions, and support such individuals in attaining such 

careers. 

‘‘(B) Develop and implement strategies to foster and 

provide community-based training and education to individuals seeking careers in health professions within underserved areas for the purpose of developing and maintaining a diverse health care workforce that is prepared to deliver high-quality care, with an emphasis on primary care, 

in underserved areas or for health disparity populations, 

in collaboration with other Federal and State health care 

workforce development programs, the State workforce 
Sec. 5403\751 PHSA PPACA (Consolidated) 578 

agency, and local workforce investment boards, and in 

health care safety net sites. 

‘‘(C) Prepare individuals to more effectively provide 

health services to underserved areas and health disparity 

populations through field placements or preceptorships in 

conjunction with community-based organizations, accredited primary care residency training programs, Federally 

qualified health centers, rural health clinics, public health 

departments, or other appropriate facilities. 

‘‘(D) Conduct and participate in interdisciplinary training that involves physicians, physician assistants, nurse 

practitioners, nurse midwives, dentists, psychologists, 

pharmacists, optometrists, community health workers, 

public and allied health professionals, or other health professionals, as practicable. 

‘‘(E) Deliver or facilitate continuing education and information dissemination programs for health care professionals, with an emphasis on individuals providing care in 

underserved areas and for health disparity populations. 

‘‘(F) Propose and implement effective program and outcomes measurement and evaluation strategies. 

‘‘(G) Establish a youth public health program to expose 

and recruit high school students into health careers, with 

a focus on careers in public health. 

‘‘(2) INNOVATIVE OPPORTUNITIES.—An eligible entity may 

use amounts awarded under a grant under subsection (a)(1) or 

subsection (a)(2) to carry out any of the following activities: 

‘‘(A) Develop and implement innovative curricula in 

collaboration with community-based accredited primary 

care residency training programs, Federally qualified 

health centers, rural health clinics, behavioral and mental 

health facilities, public health departments, or other appropriate facilities, with the goal of increasing the number 

of primary care physicians and other primary care providers prepared to serve in underserved areas and health 

disparity populations. 

‘‘(B) Coordinate community-based participatory research with academic health centers, and facilitate rapid 

flow and dissemination of evidence-based health care information, research results, and best practices to improve 

quality, efficiency, and effectiveness of health care and 

health care systems within community settings. 

‘‘(C) Develop and implement other strategies to address identified workforce needs and increase and enhance 

the health care workforce in the area served by the area 

health education center program. 

‘‘(d) REQUIREMENTS.— 

‘‘(1) AREA HEALTH EDUCATION CENTER PROGRAM.—In carrying out this section, the Secretary shall ensure the following: 

‘‘(A) An entity that receives an award under this section shall conduct at least 10 percent of clinical education 

required for medical students in community settings that 

are removed from the primary teaching facility of the contracting institution for grantees that operate a school of 
579 Sec. 5403 PPACA (Consolidated) \751 PHSA 

medicine or osteopathic medicine. In States in which an 

entity that receives an award under this section is a nursing school or its parent institution, the Secretary shall alternatively ensure that— 

‘‘(i) the nursing school conducts at least 10 percent 

of clinical education required for nursing students in 

community settings that are remote from the primary 

teaching facility of the school; and 

‘‘(ii) the entity receiving the award maintains a 

written agreement with a school of medicine or osteopathic medicine to place students from that school in 

training sites in the area health education center program area. 

‘‘(B) An entity receiving funds under subsection (a)(2) 

does not distribute such funding to a center that is eligible 

to receive funding under subsection (a)(1). 

‘‘(2) AREA HEALTH EDUCATION CENTER.—The Secretary 

shall ensure that each area health education center program 

includes at least 1 area health education center, and that each 

such center— 

‘‘(A) is a public or private organization whose structure, governance, and operation is independent from the 

awardee and the parent institution of the awardee; 

‘‘(B) is not a school of medicine or osteopathic medicine, the parent institution of such a school, or a branch 

campus or other subunit of a school of medicine or osteopathic medicine or its parent institution, or a consortium 

of such entities; 

‘‘(C) designates an underserved area or population to 

be served by the center which is in a location removed 

from the main location of the teaching facilities of the 

schools participating in the program with such center and 

does not duplicate, in whole or in part, the geographic area 

or population served by any other center; 

‘‘(D) fosters networking and collaboration among communities and between academic health centers and community-based centers; 

‘‘(E) serves communities with a demonstrated need of 

health professionals in partnership with academic medical 

centers; 

‘‘(F) addresses the health care workforce needs of the 

communities served in coordination with the public workforce investment system; and 

‘‘(G) has a community-based governing or advisory 

board that reflects the diversity of the communities involved. 

‘‘(e) MATCHING FUNDS.—With respect to the costs of operating 

a program through a grant under this section, to be eligible for financial assistance under this section, an entity shall make available (directly or through contributions from State, county or municipal governments, or the private sector) recurring non-Federal contributions in cash or in kind, toward such costs in an amount that 

is equal to not less than 50 percent of such costs. At least 25 percent of the total required non-Federal contributions shall be in 
Sec. 5403\751 PHSA PPACA (Consolidated) 580 

cash. An entity may apply to the Secretary for a waiver of not more 

than 75 percent of the matching fund amount required by the entity for each of the first 3 years the entity is funded through a grant 

under subsection (a)(1). 

‘‘(f) LIMITATION.—Not less than 75 percent of the total amount 

provided to an area health education center program under subsection (a)(1) or (a)(2) shall be allocated to the area health education centers participating in the program under this section. To 

provide needed flexibility to newly funded area health education 

center programs, the Secretary may waive the requirement in the 

sentence for the first 2 years of a new area health education center 

program funded under subsection (a)(1). 

‘‘(g) AWARD.—An award to an entity under this section shall be 

not less than $250,000 annually per area health education center 

included in the program involved. If amounts appropriated to carry 

out this section are not sufficient to comply with the preceding sentence, the Secretary may reduce the per center amount provided for 

in such sentence as necessary, provided the distribution established 

in subsection (j)(2) is maintained. 

‘‘(h) PROJECT TERMS.— 

‘‘(1) IN GENERAL.—Except as provided in paragraph (2), the 

period during which payments may be made under an award 

under subsection (a)(1) may not exceed— 

‘‘(A) in the case of a program, 12 years; or 

‘‘(B) in the case of a center within a program, 6 years. 

‘‘(2) EXCEPTION.—The periods described in paragraph (1) 

shall not apply to programs receiving point of service maintenance and enhancement awards under subsection (a)(2) to 

maintain existing centers and activities. 

‘‘(i) INAPPLICABILITY OF PROVISION.—Notwithstanding any 

other provision of this title, section 791(a) shall not apply to an 

area health education center funded under this section. 

‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— 

‘‘(1) IN GENERAL.—There is authorized to be appropriated 

to carry out this section $125,000,000 for each of the fiscal 

years 2010 through 2014. 

‘‘(2) REQUIREMENTS.—Of the amounts appropriated for a 

fiscal year under paragraph (1)— 

‘‘(A) not more than 35 percent shall be used for awards 

under subsection (a)(1); 

‘‘(B) not less than 60 percent shall be used for awards 

under subsection (a)(2); 

‘‘(C) not more than 1 percent shall be used for grants 

and contracts to implement outcomes evaluation for the 

area health education centers; and 

‘‘(D) not more than 4 percent shall be used for grants 

and contracts to provide technical assistance to entities receiving awards under this section. 

‘‘(3) CARRYOVER FUNDS.—An entity that receives an award 

under this section may carry over funds from 1 fiscal year to 

another without obtaining approval from the Secretary. In no 

case may any funds be carried over pursuant to the preceding 

sentence for more than 3 years. 
581 Sec. 5404 PPACA (Consolidated) 

‘‘(k) SENSE OF CONGRESS.—It is the sense of the Congress that 

every State have an area health education center program in effect 

under this section.’’. 

(b) CONTINUING EDUCATIONAL SUPPORT FOR HEALTH PROFESSIONALS SERVING IN UNDERSERVED COMMUNITIES.—Part D of title 

VII of the Public Health Service Act (42 U.S.C. 294 et seq.) is 

amended by striking section 752 and inserting the following: 

‘‘SEC. 752. ø42 U.S.C. 294b¿ CONTINUING EDUCATIONAL SUPPORT FOR 

HEALTH PROFESSIONALS SERVING IN UNDERSERVED 

COMMUNITIES. 

‘‘(a) IN GENERAL.—The Secretary shall make grants to, and 

enter into contracts with, eligible entities to improve health care, 

increase retention, increase representation of minority faculty 

members, enhance the practice environment, and provide information dissemination and educational support to reduce professional 

isolation through the timely dissemination of research findings 

using relevant resources. 

‘‘(b) ELIGIBLE ENTITIES.—For purposes of this section, the term 

‘eligible entity’ means an entity described in section 799(b). 

‘‘(c) APPLICATION.—An eligible entity desiring to receive an 

award under this section shall submit to the Secretary an application at such time, in such manner, and containing such information 

as the Secretary may require. 

‘‘(d) USE OF FUNDS.—An eligible entity shall use amounts 

awarded under a grant or contract under this section to provide innovative supportive activities to enhance education through distance learning, continuing educational activities, collaborative conferences, and electronic and telelearning activities, with priority for 

primary care. 

‘‘(e) AUTHORIZATION.—There is authorized to be appropriated to 

carry out this section $5,000,000 for each of the fiscal years 2010 

through 2014, and such sums as may be necessary for each subsequent fiscal year.’’. 

SEC. 5404. WORKFORCE DIVERSITY GRANTS. 

Section 821 of the Public Health Service Act (42 U.S.C. 296m) 

is amended— 

(1) in subsection (a)— 

(A) by striking ‘‘The Secretary may’’ and inserting the 

following: 

‘‘(1) AUTHORITY.—The Secretary may’’; 

(B) by striking ‘‘pre-entry preparation, and retention 

activities’’ and inserting the following: ‘‘stipends for diploma or associate degree nurses to enter a bridge or degree completion program, student scholarships or stipends 

for accelerated nursing degree programs, pre-entry preparation, advanced education preparation, and retention activities’’; and 

(2) in subsection (b)— 

(A) by striking ‘‘First’’ and all that follows through ‘‘including the’’ and inserting ‘‘National Advisory Council on 

Nurse Education and Practice and consult with nursing associations including the National Coalition of Ethnic Minority Nurse Associations,’’; and 
Sec. 5405 PPACA (Consolidated) 582 

(B) by inserting before the period the following: ‘‘, and 

other organizations determined appropriate by the Secretary’’. 

SEC. 5405. PRIMARY CARE EXTENSION PROGRAM. 

Part P of title III of the Public Health Service Act (42 U.S.C. 

280g et seq.), as amended by section 5313, is further amended by 

adding at the end the following: øAs redesignated by section 

10501(f)¿ 

‘‘SEC. 399V–1. ø42 U.S.C. 280g–12¿ PRIMARY CARE EXTENSION PROGRAM. 

‘‘(a) ESTABLISHMENT, PURPOSE AND DEFINITION.— 

‘‘(1) IN GENERAL.—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall 

establish a Primary Care Extension Program. 

‘‘(2) PURPOSE.—The Primary Care Extension Program 

shall provide support and assistance to primary care providers 

to educate providers about preventive medicine, health promotion, chronic disease management, mental and behavioral 

health services (including substance abuse prevention and 

treatment services), and evidence-based and evidence-informed 

therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors (referred to in this section as ‘Health Extension Agents’). 

‘‘(3) DEFINITIONS.—In this section: 

‘‘(A) HEALTH EXTENSION AGENT.—The term ‘Health Extension Agent’ means any local, community-based health 

worker who facilitates and provides assistance to primary 

care practices by implementing quality improvement or 

system redesign, incorporating the principles of the patient-centered medical home to provide high-quality, effective, efficient, and safe primary care and to provide guidance to patients in culturally and linguistically appropriate 

ways, and linking practices to diverse health system resources. 

‘‘(B) PRIMARY CARE PROVIDER.—The term ‘primary care 

provider’ means a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services for men, women, and children of all ages, developing 

a sustained partnership with patients, and practicing in 

the context of family and community, as recognized by a 

State licensing or regulatory authority, unless otherwise 

specified in this section. 

‘‘(b) GRANTS TO ESTABLISH STATE HUBS AND LOCAL PRIMARY

CARE EXTENSION AGENCIES.— 

‘‘(1) GRANTS.—The Secretary shall award competitive 

grants to States for the establishment of State- or multistatelevel primary care Primary Care Extension Program State 

Hubs (referred to in this section as ‘Hubs’). 

‘‘(2) COMPOSITION OF HUBS.—A Hub established by a State 

pursuant to paragraph (1)— 
583 Sec. 5405 PPACA (Consolidated) \399V–1 PHSA 

‘‘(A) øAs revised by section 10501(f)(2)¿ shall consist of, 

at a minimum, the State health department, the entity responsible for administering the State Medicaid program (if 

other than the State health department), the State-level 

entity administering the Medicare program, and the departments that train providers in primary care in 1 or 

more health professions schools in the State; and 

‘‘(B) may include entities such as hospital associations, 

primary care practice-based research networks, health professional societies, State primary care associations, State 

licensing boards, organizations with a contract with the 

Secretary under section 1153 of the Social Security Act, 

consumer groups, and other appropriate entities. 

‘‘(c) STATE AND LOCAL ACTIVITIES.— 

‘‘(1) HUB ACTIVITIES.—Hubs established under a grant 

under subsection (b) shall— 

‘‘(A) submit to the Secretary a plan to coordinate functions with quality improvement organizations and area 

health education centers if such entities are members of 

the Hub not described in subsection (b)(2)(A); 

‘‘(B) contract with a county- or local-level entity that 

shall serve as the Primary Care Extension Agency to administer the services described in paragraph (2); 

‘‘(C) organize and administer grant funds to county- or 

local-level Primary Care Extension Agencies that serve a 

catchment area, as determined by the State; and 

‘‘(D) organize State-wide or multistate networks of 

local-level Primary Care Extension Agencies to share and 

disseminate information and practices. 

‘‘(2) LOCAL PRIMARY CARE EXTENSION AGENCY ACTIVITIES.— 

‘‘(A) REQUIRED ACTIVITIES.—Primary Care Extension 

Agencies established by a Hub under paragraph (1) shall— 

‘‘(i) assist primary care providers to implement a 

patient-centered medical home to improve the accessibility, quality, and efficiency of primary care services, 

including health homes; 

‘‘(ii) develop and support primary care learning 

communities to enhance the dissemination of research 

findings for evidence-based practice, assess implementation of practice improvement, share best practices, 

and involve community clinicians in the generation of 

new knowledge and identification of important questions for research; 

‘‘(iii) participate in a national network of Primary 

Care Extension Hubs and propose how the Primary 

Care Extension Agency will share and disseminate lessons learned and best practices; and 

‘‘(iv) develop a plan for financial sustainability involving State, local, and private contributions, to provide for the reduction in Federal funds that is expected after an initial 6-year period of program establishment, infrastructure development, and planning. 
Sec. 5405\399V–1 PHSA PPACA (Consolidated) 584 

‘‘(B) DISCRETIONARY ACTIVITIES.—Primary Care Extension Agencies established by a Hub under paragraph (1) 

may— 

‘‘(i) provide technical assistance, training, and organizational support for community health teams established under section 3602 of the Patient Protection 

and Affordable Care Act; 

‘‘(ii) collect data and provision of primary care provider feedback from standardized measurements of 

processes and outcomes to aid in continuous performance improvement; 

‘‘(iii) collaborate with local health departments, 

community health centers, tribes and tribal entities, 

and other community agencies to identify community 

health priorities and local health workforce needs, and 

participate in community-based efforts to address the 

social and primary determinants of health, strengthen 

the local primary care workforce, and eliminate health 

disparities; 

‘‘(iv) develop measures to monitor the impact of 

the proposed program on the health of practice enrollees and of the wider community served; and 

‘‘(v) participate in other activities, as determined 

appropriate by the Secretary. 

‘‘(d) FEDERAL PROGRAM ADMINISTRATION.— ‘‘(1) GRANTS; TYPES.—Grants awarded under subsection (b) 

shall be— 

‘‘(A) program grants, that are awarded to State or 

multistate entities that submit fully-developed plans for 

the implementation of a Hub, for a period of 6 years; or 

‘‘(B) planning grants, that are awarded to State or 

multistate entities with the goal of developing a plan for 

a Hub, for a period of 2 years. 

‘‘(2) APPLICATIONS.—To be eligible for a grant under subsection (b), a State or multistate entity shall submit to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require. 

‘‘(3) EVALUATION.—A State that receives a grant under 

subsection (b) shall be evaluated at the end of the grant period 

by an evaluation panel appointed by the Secretary. 

‘‘(4) CONTINUING SUPPORT.—After the sixth year in which 

assistance is provided to a State under a grant awarded under 

subsection (b), the State may receive additional support under 

this section if the State program has received satisfactory evaluations with respect to program performance and the merits of 

the State sustainability plan, as determined by the Secretary. 

‘‘(5) LIMITATION.—A State shall not use in excess of 10 percent of the amount received under a grant to carry out administrative activities under this section. Funds awarded pursuant 

to this section shall not be used for funding direct patient care. 

‘‘(e) REQUIREMENTS ON THE SECRETARY.—In carrying out this 

section, the Secretary shall consult with the heads of other Federal 

agencies with demonstrated experience and expertise in health care 

and preventive medicine, such as the Centers for Disease Control 
585 Sec. 5501 PPACA (Consolidated) 

and Prevention, the Substance Abuse and Mental Health Administration, the Health Resources and Services Administration, the National Institutes of Health, the Office of the National Coordinator 

for Health Information Technology, the Indian Health Service, the 

Agricultural Cooperative Extension Service of the Department of 

Agriculture, and other entities, as the Secretary determines appropriate. 

‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—To awards grants as 

provided in subsection (d), there are authorized to be appropriated 

$120,000,000 for each of fiscal years 2011 and 2012, and such sums 

as may be necessary to carry out this section for each of fiscal 

years 2013 through 2014.’’. 

Subtitle F—Strengthening Primary Care 

and Other Workforce Improvements 

SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERVICES AND 

GENERAL SURGERY SERVICES. 

(a) INCENTIVE PAYMENT PROGRAM FOR PRIMARY CARE SERV- ICES.— (1) IN GENERAL.—Section 1833 of the Social Security Act 

(42 U.S.C. 1395l) is amended by adding at the end the following new subsection: 

‘‘(x) INCENTIVE PAYMENTS FOR PRIMARY CARE SERVICES.— ‘‘(1) IN GENERAL.—In the case of primary care services furnished on or after January 1, 2011, and before January 1, 

2016, by a primary care practitioner, in addition to the amount 

of payment that would otherwise be made for such services 

under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment 

amount for the service under this part. 

‘‘(2) DEFINITIONS.—In this subsection: 

‘‘(A) PRIMARY CARE PRACTITIONER.—The term ‘primary 

care practitioner’ means an individual— 

‘‘(i) who— 

‘‘(I) is a physician (as described in section 

1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or 

‘‘(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are 

defined in section 1861(aa)(5)); and 

‘‘(ii) for whom primary care services accounted for 

at least 60 percent of the allowed charges under this 

part for such physician or practitioner in a prior period as determined appropriate by the Secretary. 

‘‘(B) PRIMARY CARE SERVICES.—The term ‘primary care 

services’ means services identified, as of January 1, 2009, 

by the following HCPCS codes (and as subsequently modified by the Secretary): 

‘‘(i) 99201 through 99215. 

‘‘(ii) 99304 through 99340. 

‘‘(iii) 99341 through 99350. 
Sec. 5501 PPACA (Consolidated) 586 

‘‘(3) COORDINATION WITH OTHER PAYMENTS.—The amount 

of the additional payment for a service under this subsection 

and subsection (m) shall be determined without regard to any 

additional payment for the service under subsection (m) and 

this subsection, respectively. 

‘‘(4) LIMITATION ON REVIEW.—There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the identification of primary care practitioners 

under this subsection.’’. 

(2) CONFORMING AMENDMENT.—Section 1834(g)(2)(B) of the 

Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by 

adding at the end the following sentence: ‘‘Section 1833(x) shall 

not be taken into account in determining the amounts that 

would otherwise be paid pursuant to the preceding sentence.’’. 

(b) INCENTIVE PAYMENT PROGRAM FOR MAJOR SURGICAL PRO- CEDURES FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.— (1) IN GENERAL.—Section 1833 of the Social Security Act 

(42 U.S.C. 1395l), as amended by subsection (a)(1), is amended 

by adding at the end the following new subsection: 

‘‘(y) INCENTIVE PAYMENTS FOR MAJOR SURGICAL PROCEDURES

FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.— ‘‘(1) IN GENERAL.—In the case of major surgical procedures 

furnished on or after January 1, 2011, and before January 1, 

2016, by a general surgeon in an area that is designated 

(under section 332(a)(1)(A) of the Public Health Service Act) as 

a health professional shortage area as identified by the Secretary prior to the beginning of the year involved, in addition 

to the amount of payment that would otherwise be made for 

such services under this part, there also shall be paid (on a 

monthly or quarterly basis) an amount equal to 10 percent of 

the payment amount for the service under this part. 

‘‘(2) DEFINITIONS.—In this subsection: 

‘‘(A) GENERAL SURGEON.—In this subsection, the term 

‘general surgeon’ means a physician (as described in section 1861(r)(1)) who has designated CMS specialty code 

02–General Surgery as their primary specialty code in the 

physician’s enrollment under section 1866(j). 

‘‘(B) MAJOR SURGICAL PROCEDURES.—The term ‘major 

surgical procedures’ means physicians’ services which are 

surgical procedures for which a 10-day or 90-day global period is used for payment under the fee schedule under section 1848(b). 

‘‘(3) COORDINATION WITH OTHER PAYMENTS.—The amount 

of the additional payment for a service under this subsection 

and subsection (m) shall be determined without regard to any 

additional payment for the service under subsection (m) and 

this subsection, respectively. 

‘‘(4) APPLICATION.—The provisions of paragraph (2) and (4) 

of subsection (m) shall apply to the determination of additional 

payments under this subsection in the same manner as such 

provisions apply to the determination of additional payments 

under subsection (m).’’. 

(2) CONFORMING AMENDMENT.—Section 1834(g)(2)(B) of the 

Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended by 
587 Sec. 5503 PPACA (Consolidated) 

subsection (a)(2), is amended by striking ‘‘Section 1833(x)’’ and 

inserting ‘‘Subsections (x) and (y) of section 1833’’ in the last 

sentence. 

øSubsection (c) repealed by section 10501(h)¿ 

SEC. 5502. øMEDICARE FEDERALLY QUALIFIED HEALTH CENTER IMPROVEMENTS¿øREPEALED¿. 

øSection repealed by section 10501(i)(1); subsequent sections not 

redesignated.¿ 

SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS. 

(a) IN GENERAL.—Section 1886(h) of the Social Security Act (42 

U.S.C. 1395ww(h)) is amended— 

(1) in paragraph (4)(F)(i), by striking ‘‘paragraph (7)’’ and 

inserting ‘‘paragraphs (7) and (8)’’; 

(2) in paragraph (4)(H)(i), by striking ‘‘paragraph (7)’’ and 

inserting ‘‘paragraphs (7) and (8)’’; 

(3) in paragraph (7)(E), by inserting ‘‘or paragraph (8)’’ before the period at the end; and 

(4) by adding at the end the following new paragraph: 

‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.— 

‘‘(A) REDUCTIONS IN LIMIT BASED ON UNUSED POSITIONS.— ‘‘(i) IN GENERAL.—Except as provided in clause (ii), 

if a hospital’s reference resident level (as defined in 

subparagraph (H)(i)) is less than the otherwise applicable resident limit (as defined in subparagraph 

(H)(iii)), effective for portions of cost reporting periods 

occurring on or after July 1, 2011, the otherwise applicable resident limit shall be reduced by 65 percent of 

the difference between such otherwise applicable resident limit and such reference resident level. 

‘‘(ii) EXCEPTIONS.—This subparagraph shall not 

apply to— 

‘‘(I) a hospital located in a rural area (as defined in subsection (d)(2)(D)(ii)) with fewer than 

250 acute care inpatient beds; 

‘‘(II) a hospital that was part of a qualifying 

entity which had a voluntary residency reduction 

plan approved under paragraph (6)(B) or under 

the authority of section 402 of Public Law 90–248, 

if the hospital demonstrates to the Secretary that 

it has a specified plan in place for filling the unused positions by not later than 2 years after the 

date of enactment of this paragraph; or 

‘‘(III) a hospital described in paragraph 

(4)(H)(v). 

‘‘(B) DISTRIBUTION.— 

‘‘(i) IN GENERAL.—The Secretary shall increase the 

otherwise applicable resident limit for each qualifying 

hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring 

on or after July 1, 2011. The aggregate number of increases in the otherwise applicable resident limit 
Sec. 5503 PPACA (Consolidated) 588 

under this subparagraph shall be equal to the aggregate reduction in such limits attributable to subparagraph (A) (as estimated by the Secretary). 

‘‘(ii) REQUIREMENTS.—Subject to clause (iii), a hospital that receives an increase in the otherwise applicable resident limit under this subparagraph shall ensure, during the 5-year period beginning on the date 

of such increase, that— 

‘‘(I) the number of full-time equivalent primary care residents, as defined in paragraph 

(5)(H) (as determined by the Secretary), excluding 

any additional positions under subclause (II), is 

not less than the average number of full-time 

equivalent primary care residents (as so determined) during the 3 most recent cost reporting periods ending prior to the date of enactment of this 

paragraph; and 

‘‘(II) not less than 75 percent of the positions 

attributable to such increase are in a primary care 

or general surgery residency (as determined by 

the Secretary). 

The Secretary may determine whether a hospital has 

met the requirements under this clause during such 5- 

year period in such manner and at such time as the 

Secretary determines appropriate, including at the end 

of such 5-year period. 

‘‘(iii) REDISTRIBUTION OF POSITIONS IF HOSPITAL NO

LONGER MEETS CERTAIN REQUIREMENTS.—In the case 

where the Secretary determines that a hospital described in clause (ii) does not meet either of the requirements under subclause (I) or (II) of such clause, 

the Secretary shall— 

‘‘(I) reduce the otherwise applicable resident 

limit of the hospital by the amount by which such 

limit was increased under this paragraph; and 

‘‘(II) provide for the distribution of positions 

attributable to such reduction in accordance with 

the requirements of this paragraph. 

‘‘(C) CONSIDERATIONS IN REDISTRIBUTION.—In determining for which hospitals the increase in the otherwise 

applicable resident limit is provided under subparagraph 

(B), the Secretary shall take into account— 

‘‘(i) the demonstration likelihood of the hospital 

filling the positions made available under this paragraph within the first 3 cost reporting periods beginning on or after July 1, 2011, as determined by the 

Secretary; and 

‘‘(ii) whether the hospital has an accredited rural 

training track (as described in paragraph (4)(H)(iv)). 

‘‘(D) PRIORITY FOR CERTAIN AREAS.—In determining for 

which hospitals the increase in the otherwise applicable 

resident limit is provided under subparagraph (B), subject 

to subparagraph (E), the Secretary shall distribute the increase to hospitals based on the following factors: 
589 Sec. 5503 PPACA (Consolidated) 

‘‘(i) Whether the hospital is located in a State with 

a resident-to-population ratio in the lowest quartile (as 

determined by the Secretary). 

‘‘(ii) Whether the hospital is located in a State, a 

territory of the United States, or the District of Columbia that is among the top 10 States, territories, or 

Districts in terms of the ratio of— 

‘‘(I) the total population of the State, territory, 

or District living in an area designated (under 

such section 332(a)(1)(A)) as a health professional 

shortage area (as of the date of enactment of this 

paragraph); to 

‘‘(II) the total population of the State, territory, or District (as determined by the Secretary 

based on the most recent available population 

data published by the Bureau of the Census). 

‘‘(iii) Whether the hospital is located in a rural 

area (as defined in subsection (d)(2)(D)(ii)). 

‘‘(E) RESERVATION OF POSITIONS FOR CERTAIN HOS- PITALS.— ‘‘(i) IN GENERAL.—Subject to clause (ii), the Secretary shall reserve the positions available for distribution under this paragraph as follows: 

‘‘(I) 70 percent of such positions for distribution to hospitals described in clause (i) of subparagraph (D). 

‘‘(II) 30 percent of such positions for distribution to hospitals described in clause (ii) and (iii) of 

such subparagraph. 

‘‘(ii) EXCEPTION IF POSITIONS NOT REDISTRIBUTED

BY JULY 1, 2011.—In the case where the Secretary does 

not distribute positions to hospitals in accordance with 

clause (i) by July 1, 2011, the Secretary shall distribute such positions to other hospitals in accordance 

with the considerations described in subparagraph (C) 

and the priority described in subparagraph (D). 

‘‘(F) LIMITATION.—A hospital may not receive more 

than 75 full-time equivalent additional residency positions 

under this paragraph. 

‘‘(G) APPLICATION OF PER RESIDENT AMOUNTS FOR PRIMARY CARE AND NONPRIMARY CARE.—With respect to additional residency positions in a hospital attributable to the 

increase provided under this paragraph, the approved FTE 

per resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital. 

‘‘(H) DEFINITIONS.—In this paragraph: 

‘‘(i) REFERENCE RESIDENT LEVEL.—The term ‘reference resident level’ means, with respect to a hospital, the highest resident level for any of the 3 most 

recent cost reporting periods (ending before the date of 

the enactment of this paragraph) of the hospital for 

which a cost report has been settled (or, if not, sub-
Sec. 5504 PPACA (Consolidated) 590 

mitted (subject to audit)), as determined by the Secretary. 

‘‘(ii) RESIDENT LEVEL.—The term ‘resident level’ 

has the meaning given such term in paragraph 

(7)(C)(i). 

‘‘(iii) OTHERWISE APPLICABLE RESIDENT LIMIT.— 

The term ‘otherwise applicable resident limit’ means, 

with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph 

(4) on the resident level for the hospital determined 

without regard to this paragraph but taking into account paragraph (7)(A).’’. 

(b) IME.— 

(1) IN GENERAL.—Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, is amended— 

(A) by striking ‘‘subsection (h)(7)’’ and inserting ‘‘subsections (h)(7) and (h)(8)’’; and 

(B) by striking ‘‘it applies’’ and inserting ‘‘they apply’’. 

(2) CONFORMING AMENDMENT.—Section 1886(d)(5)(B) of the 

Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 

adding at the end the following clause: 

‘‘(x) For discharges occurring on or after July 1, 2011, insofar as an additional payment amount under this subparagraph 

is attributable to resident positions distributed to a hospital 

under subsection (h)(8)(B), the indirect teaching adjustment 

factor shall be computed in the same manner as provided 

under clause (ii) with respect to such resident positions.’’. 

(c) CONFORMING AMENDMENT.—Section 422(b)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 (Public Law 108–173) is amended by striking ‘‘section 

1886(h)(7)’’ and all that follows and inserting ‘‘paragraphs (7) and 

(8) of subsection (h) of section 1886 of the Social Security Act’’. 

SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER SETTINGS. 

(a) GME.—Section 1886(h)(4)(E) of the Social Security Act (42 

U.S.C. 1395ww(h)(4)(E)) is amended— 

(1) by striking ‘‘shall be counted and that all the time’’ and 

inserting ‘‘shall be counted and that— 

‘‘(i) effective for cost reporting periods beginning 

before July 1, 2010, all the time;’’; 

(2) in clause (i), as inserted by paragraph (1), by striking 

the period at the end and inserting ‘‘; and’’; 

(3) by inserting after clause (i), as so inserted, the following new clause: 

‘‘(ii) effective for cost reporting periods beginning 

on or after July 1, 2010, all the time so spent by a 

resident shall be counted towards the determination of 

full-time equivalency, without regard to the setting in 

which the activities are performed, if a hospital incurs 

the costs of the stipends and fringe benefits of the 

resident during the time the resident spends in that 

setting. If more than one hospital incurs these costs, 

either directly or through a third party, such hospitals 
591 Sec. 5505 PPACA (Consolidated) 

shall count a proportional share of the time, as determined by written agreement between the hospitals, 

that a resident spends training in that setting.’’; and 

(4) by adding at the end the following flush sentence: 

‘‘Any hospital claiming under this subparagraph for time 

spent in a nonprovider setting shall maintain and make 

available to the Secretary records regarding the amount of 

such time and such amount in comparison with amounts 

of such time in such base year as the Secretary shall specify.’’. 

(b) IME.—Section 1886(d)(5)(B)(iv) of the Social Security Act 

(42 U.S.C. 1395ww(d)(5)) is amended— 

(1) by striking ‘‘(iv) Effective for discharges occurring on or 

after October 1, 1997’’ and inserting ‘‘(iv)(I) Effective for discharges occurring on or after October 1, 1997, and before July 

1, 2010’’; and 

(2) by inserting after clause (I), as inserted by paragraph 

(1), the following new subparagraph: 

‘‘(II) Effective for discharges occurring on or after July 1, 

2010, all the time spent by an intern or resident in patient 

care activities in a nonprovider setting shall be counted towards the determination of full-time equivalency if a hospital 

incurs the costs of the stipends and fringe benefits of the intern or resident during the time the intern or resident spends 

in that setting. If more than one hospital incurs these costs, either directly or through a third party, such hospitals shall 

count a proportional share of the time, as determined by written agreement between the hospitals, that a resident spends 

training in that setting.’’. 

(c) APPLICATION.—The amendments made by this section shall 

not be applied in a manner that requires reopening of any settled 

hospital cost reports as to which there is not a jurisdictionally 

proper appeal pending as of the date of the enactment of this Act 

on the issue of payment for indirect costs of medical education 

under section 1886(d)(5)(B) of the Social Security Act (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)). 

SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND 

SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES. 

(a) GME.—Section 1886(h) of the Social Security Act (42 U.S.C. 

1395ww(h)), as amended by section 5504, is amended— 

(1) in paragraph (4)— 

(A) in subparagraph (E), by striking ‘‘Such rules’’ and 

inserting ‘‘Subject to subparagraphs (J) and (K), such 

rules’’; and 

(B) by adding at the end the following new subparagraphs: 

‘‘(J) TREATMENT OF CERTAIN NONPROVIDER AND DIDACTIC ACTIVITIES.—Such rules shall provide that all time 

spent by an intern or resident in an approved medical residency training program in a nonprovider setting that is 

primarily engaged in furnishing patient care (as defined in 

paragraph (5)(K)) in non-patient care activities, such as didactic conferences and seminars, but not including re-
Sec. 5505 PPACA (Consolidated) 592 

search not associated with the treatment or diagnosis of a 

particular patient, as such time and activities are defined 

by the Secretary, shall be counted toward the determination of full-time equivalency. 

‘‘(K) TREATMENT OF CERTAIN OTHER ACTIVITIES.—In 

determining the hospital’s number of full-time equivalent 

residents for purposes of this subsection, all the time that 

is spent by an intern or resident in an approved medical 

residency training program on vacation, sick leave, or 

other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the 

normal duration of the program shall be counted toward 

the determination of full-time equivalency.’’; and 

(2) in paragraph (5), by adding at the end the following 

new subparagraph: 

‘‘(K) NONPROVIDER SETTING THAT IS PRIMARILY EN- GAGED IN FURNISHING PATIENT CARE.—The term ‘nonprovider setting that is primarily engaged in furnishing patient care’ means a nonprovider setting in which the primary activity is the care and treatment of patients, as defined by the Secretary.’’. 

(b) IME DETERMINATIONS.—Section 1886(d)(5)(B) of such Act 

(42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the 

following new clause: 

‘‘(x)(I) The provisions of subparagraph (K) of subsection (h)(4) shall apply under this subparagraph in 

the same manner as they apply under such subsection. 

‘‘(II) In determining the hospital’s number of fulltime equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in 

an approved medical residency training program in 

non-patient care activities, such as didactic conferences and seminars, as such time and activities are 

defined by the Secretary, that occurs in the hospital 

shall be counted toward the determination of full-time 

equivalency if the hospital— 

‘‘(aa) is recognized as a subsection (d) hospital; 

‘‘(bb) is recognized as a subsection (d) Puerto 

Rico hospital; 

‘‘(cc) is reimbursed under a reimbursement 

system authorized under section 1814(b)(3); or 

‘‘(dd) is a provider-based hospital outpatient 

department. 

‘‘(III) In determining the hospital’s number of fulltime equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in 

an approved medical residency training program in research activities that are not associated with the treatment or diagnosis of a particular patient, as such time 

and activities are defined by the Secretary, shall not 

be counted toward the determination of full-time 

equivalency.’’. 
593 Sec. 5506 PPACA (Consolidated) 

(c) EFFECTIVE DATES.— 

(1) IN GENERAL.—Except as otherwise provided, the Secretary of Health and Human Services shall implement the 

amendments made by this section in a manner so as to apply 

to cost reporting periods beginning on or after January 1, 1983. 

(2) GME.—Section 1886(h)(4)(J) of the Social Security Act, 

as added by subsection (a)(1)(B), shall apply to cost reporting 

periods beginning on or after July 1, 2009. 

(3) IME.—Section 1886(d)(5)(B)(x)(III) of the Social Security Act, as added by subsection (b), shall apply to cost reporting periods beginning on or after October 1, 2001. Such section, 

as so added, shall not give rise to any inference as to how the 

law in effect prior to such date should be interpreted. 

(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)). øAs added by section 

10501(j)¿ 

SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM 

CLOSED HOSPITALS. 

(a) GME.—Section 1886(h)(4)(H) of the Social Security Act (42 

U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end 

the following new clause: 

‘‘(vi) REDISTRIBUTION OF RESIDENCY SLOTS AFTER A

HOSPITAL CLOSES.— 

‘‘(I) IN GENERAL.—Subject to the succeeding 

provisions of this clause, the Secretary shall, by 

regulation, establish a process under which, in the 

case where a hospital (other than a hospital described in clause (v)) with an approved medical 

residency program closes on or after a date that is 

2 years before the date of enactment of this 

clause, the Secretary shall increase the otherwise 

applicable resident limit under this paragraph for 

other hospitals in accordance with this clause. 

‘‘(II) PRIORITY FOR HOSPITALS IN CERTAIN

AREAS.—Subject to the succeeding provisions of 

this clause, in determining for which hospitals the 

increase in the otherwise applicable resident limit 

is provided under such process, the Secretary 

shall distribute the increase to hospitals in the following priority order (with preference given within each category to hospitals that are members of 

the same affiliated group (as defined by the Secretary under clause (ii)) as the closed hospital): 

‘‘(aa) First, to hospitals located in the 

same core-based statistical area as, or a corebased statistical area contiguous to, the hospital that closed. 
Sec. 5506 PPACA (Consolidated) 594 

‘‘(bb) Second, to hospitals located in the 

same State as the hospital that closed. 

‘‘(cc) Third, to hospitals located in the 

same region of the country as the hospital 

that closed. 

‘‘(dd) Fourth, only if the Secretary is not 

able to distribute the increase to hospitals described in item (cc), to qualifying hospitals in 

accordance with the provisions of paragraph 

(8). 

‘‘(III) REQUIREMENT HOSPITAL LIKELY TO FILL

POSITION WITHIN CERTAIN TIME PERIOD.—The Secretary may only increase the otherwise applicable 

resident limit of a hospital under such process if 

the Secretary determines the hospital has demonstrated a likelihood of filling the positions made 

available under this clause within 3 years. 

‘‘(IV) LIMITATION.—The aggregate number of 

increases in the otherwise applicable resident limits for hospitals under this clause shall be equal 

to the number of resident positions in the approved medical residency programs that closed on 

or after the date described in subclause (I). 

‘‘(V) ADMINISTRATION.—Chapter 35 of title 44, 

United States Code, shall not apply to the implementation of this clause.’’. 

(b) IME.—Section 1886(d)(5)(B)(v) of the Social Security Act 

(42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended 

by section 5503, is amended by striking ‘‘subsections (h)(7) and 

(h)(8)’’ and inserting ‘‘subsections (h)(4)(H)(vi), (h)(7), and (h)(8)’’. 

(c) APPLICATION.—The amendments made by this section shall 

not be applied in a manner that requires reopening of any settled 

hospital cost reports as to which there is not a jurisdictionally 

proper appeal pending as of the date of the enactment of this Act 

on the issue of payment for indirect costs of medical education 

under section 1886(d)(5)(B) of the Social Security Act (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. Section 1395ww(h)). 

(d) EFFECT ON TEMPORARY FTE CAP ADJUSTMENTS.—The Secretary of Health and Human Services shall give consideration to 

the effect of the amendments made by this section on any temporary adjustment to a hospital’s FTE cap under section 413.79(h) 

of title 42, Code of Federal Regulations (as in effect on the date of 

enactment of this Act) in order to ensure that there is no duplication of FTE slots. Such amendments shall not affect the application 

of section 1886(h)(4)(H)(v) of the Social Security Act (42 U.S.C. 

1395ww(h)(4)(H)(v)). 

(e) CONFORMING AMENDMENT.—Section 1886(h)(7)(E) of the Social Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended by section 5503(a), is amended by striking ‘‘paragraph or paragraph (8)’’ 

and inserting ‘‘this paragraph, paragraph (8), or paragraph 

(4)(H)(vi)’’. 
595 Sec. 5507 PPACA (Consolidated) \2008 SSA 

SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFESSIONS WORKFORCE NEEDS; EXTENSION OF FAMILYTO-FAMILY HEALTH INFORMATION CENTERS. 

(a) AUTHORITY TO CONDUCT DEMONSTRATION PROJECTS.—Title 

XX of the Social Security Act (42 U.S.C. 1397 et seq.) is amended 

by adding at the end the following: 

‘‘SEC. 2008. ø42 U.S.C. 1397g¿ DEMONSTRATION PROJECTS TO ADDRESS 

HEALTH PROFESSIONS WORKFORCE NEEDS. 

‘‘(a) DEMONSTRATION PROJECTS TO PROVIDE LOW-INCOME INDIVIDUALS WITH OPPORTUNITIES FOR EDUCATION, TRAINING, AND CAREER ADVANCEMENT TO ADDRESS HEALTH PROFESSIONS WORKFORCE NEEDS.— 

‘‘(1) AUTHORITY TO AWARD GRANTS.—The Secretary, in consultation with the Secretary of Labor, shall award grants to eligible entities to conduct demonstration projects that are designed to provide eligible individuals with the opportunity to 

obtain education and training for occupations in the health 

care field that pay well and are expected to either experience 

labor shortages or be in high demand. 

‘‘(2) REQUIREMENTS.— ‘‘(A) AID AND SUPPORTIVE SERVICES.— ‘‘(i) IN GENERAL.—A demonstration project conducted by an eligible entity awarded a grant under 

this section shall, if appropriate, provide eligible individuals participating in the project with financial aid, 

child care, case management, and other supportive 

services. 

‘‘(ii) TREATMENT.—Any aid, services, or incentives 

provided to an eligible beneficiary participating in a 

demonstration project under this section shall not be 

considered income, and shall not be taken into account 

for purposes of determining the individual’s eligibility 

for, or amount of, benefits under any means-tested 

program. 

‘‘(B) CONSULTATION AND COORDINATION.—An eligible 

entity applying for a grant to carry out a demonstration 

project under this section shall demonstrate in the application that the entity has consulted with the State agency 

responsible for administering the State TANF program, 

the local workforce investment board in the area in which 

the project is to be conducted (unless the applicant is such 

board), the State workforce investment board established 

under section 111 of the Workforce Investment Act of 

1998, and the State Apprenticeship Agency recognized 

under the Act of August 16, 1937 (commonly known as the 

‘National Apprenticeship Act’) (or if no agency has been 

recognized in the State, the Office of Apprenticeship of the 

Department of Labor) and that the project will be carried 

out in coordination with such entities. 

‘‘(C) ASSURANCE OF OPPORTUNITIES FOR INDIAN POPULATIONS.—The Secretary shall award at least 3 grants 

under this subsection to an eligible entity that is an Indian 

tribe, tribal organization, or Tribal College or University. 

‘‘(3) REPORTS AND EVALUATION.— 
Sec. 5507\2008 SSA PPACA (Consolidated) 596 

‘‘(A) ELIGIBLE ENTITIES.—An eligible entity awarded a 

grant to conduct a demonstration project under this subsection shall submit interim reports to the Secretary on 

the activities carried out under the project and a final report on such activities upon the conclusion of the entities’ 

participation in the project. Such reports shall include assessments of the effectiveness of such activities with respect to improving outcomes for the eligible individuals 

participating in the project and with respect to addressing 

health professions workforce needs in the areas in which 

the project is conducted. 

‘‘(B) EVALUATION.—The Secretary shall, by grant, contract, or interagency agreement, evaluate the demonstration projects conducted under this subsection. Such evaluation shall include identification of successful activities for 

creating opportunities for developing and sustaining, particularly with respect to low-income individuals and other 

entry-level workers, a health professions workforce that 

has accessible entry points, that meets high standards for 

education, training, certification, and professional development, and that provides increased wages and affordable 

benefits, including health care coverage, that are responsive to the workforce’s needs. 

‘‘(C) REPORT TO CONGRESS.—The Secretary shall submit interim reports and, based on the evaluation conducted under subparagraph (B), a final report to Congress 

on the demonstration projects conducted under this subsection. 

‘‘(4) DEFINITIONS.—In this subsection: 

‘‘(A) ELIGIBLE ENTITY.—The term ‘eligible entity’ 

means a State, an Indian tribe or tribal organization, an 

institution of higher education, a local workforce investment board established under section 117 of the Workforce 

Investment Act of 1998, a sponsor of an apprenticeship 

program registered under the National Apprenticeship Act 

or a community-based organization. 

‘‘(B) ELIGIBLE INDIVIDUAL.— 

‘‘(i) IN GENERAL.—The term ‘eligible individual’ 

means a individual receiving assistance under the 

State TANF program. 

‘‘(ii) OTHER LOW-INCOME INDIVIDUALS.—Such term 

may include other low-income individuals described by 

the eligible entity in its application for a grant under 

this section. 

‘‘(C) INDIAN TRIBE; TRIBAL ORGANIZATION.—The terms 

‘Indian tribe’ and ‘tribal organization’ have the meaning 

given such terms in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b). 

‘‘(D) INSTITUTION OF HIGHER EDUCATION.—The term 

‘institution of higher education’ has the meaning given 

that term in section 101 of the Higher Education Act of 

1965 (20 U.S.C. 1001). 

‘‘(E) STATE.—The term ‘State’ means each of the 50 

States, the District of Columbia, the Commonwealth of 
597 Sec. 5507 PPACA (Consolidated) \2008 SSA 

Puerto Rico, the United States Virgin Islands, Guam, and 

American Samoa. 

‘‘(F) STATE TANF PROGRAM.—The term ‘State TANF 

program’ means the temporary assistance for needy families program funded under part A of title IV. 

‘‘(G) TRIBAL COLLEGE OR UNIVERSITY.—The term ‘Tribal College or University’ has the meaning given that term 

in section 316(b) of the Higher Education Act of 1965 (20 

U.S.C. 1059c(b)). 

‘‘(b) DEMONSTRATION PROJECT TO DEVELOP TRAINING AND CER- TIFICATION PROGRAMS FOR PERSONAL OR HOME CARE AIDES.— ‘‘(1) AUTHORITY TO AWARD GRANTS.—Not later than 18 

months after the date of enactment of this section, the Secretary shall award grants to eligible entities that are States to 

conduct demonstration projects for purposes of developing core 

training competencies and certification programs for personal 

or home care aides. The Secretary shall— 

‘‘(A) evaluate the efficacy of the core training competencies described in paragraph (3)(A) for newly hired 

personal or home care aides and the methods used by 

States to implement such core training competencies in accordance with the issues specified in paragraph (3)(B); and 

‘‘(B) ensure that the number of hours of training provided by States under the demonstration project with respect to such core training competencies are not less than 

the number of hours of training required under any applicable State or Federal law or regulation. 

‘‘(2) DURATION.—A demonstration project shall be conducted under this subsection for not less than 3 years. 

‘‘(3) CORE TRAINING COMPETENCIES FOR PERSONAL OR HOME

CARE AIDES.— 

‘‘(A) IN GENERAL.—The core training competencies for 

personal or home care aides described in this subparagraph include competencies with respect to the following 

areas: 

‘‘(i) The role of the personal or home care aide (including differences between a personal or home care 

aide employed by an agency and a personal or home 

care aide employed directly by the health care consumer or an independent provider). 

‘‘(ii) Consumer rights, ethics, and confidentiality 

(including the role of proxy decision-makers in the 

case where a health care consumer has impaired decision-making capacity). 

‘‘(iii) Communication, cultural and linguistic competence and sensitivity, problem solving, behavior 

management, and relationship skills. 

‘‘(iv) Personal care skills. 

‘‘(v) Health care support. 

‘‘(vi) Nutritional support. 

‘‘(vii) Infection control. 

‘‘(viii) Safety and emergency training. 

‘‘(ix) Training specific to an individual consumer’s 

needs (including older individuals, younger individuals 
Sec. 5507\2008 SSA PPACA (Consolidated) 598 

with disabilities, individuals with developmental disabilities, individuals with dementia, and individuals 

with mental and behavioral health needs). 

‘‘(x) Self-Care. 

‘‘(B) IMPLEMENTATION.—The implementation issues 

specified in this subparagraph include the following: 

‘‘(i) The length of the training. 

‘‘(ii) The appropriate trainer to student ratio. 

‘‘(iii) The amount of instruction time spent in the 

classroom as compared to on-site in the home or a facility. 

‘‘(iv) Trainer qualifications. 

‘‘(v) Content for a ‘hands-on’ and written certification exam. 

‘‘(vi) Continuing education requirements. 

‘‘(4) APPLICATION AND SELECTION CRITERIA.— 

‘‘(A) IN GENERAL.— 

‘‘(i) NUMBER OF STATES.—The Secretary shall 

enter into agreements with not more than 6 States to 

conduct demonstration projects under this subsection. 

‘‘(ii) REQUIREMENTS FOR STATES.—An agreement 

entered into under clause (i) shall require that a participating State— 

‘‘(I) implement the core training competencies 

described in paragraph (3)(A); and 

‘‘(II) develop written materials and protocols 

for such core training competencies, including the 

development of a certification test for personal or 

home care aides who have completed such training competencies. 

‘‘(iii) CONSULTATION AND COLLABORATION WITH

COMMUNITY AND VOCATIONAL COLLEGES.—The Secretary shall encourage participating States to consult 

with community and vocational colleges regarding the 

development of curricula to implement the project 

with respect to activities, as applicable, which may include consideration of such colleges as partners in 

such implementation. 

‘‘(B) APPLICATION AND ELIGIBILITY.—A State seeking to 

participate in the project shall— 

‘‘(i) submit an application to the Secretary containing such information and at such time as the Secretary may specify; 

‘‘(ii) meet the selection criteria established under 

subparagraph (C); and 

‘‘(iii) meet such additional criteria as the Secretary may specify. 

‘‘(C) SELECTION CRITERIA.—In selecting States to participate in the program, the Secretary shall establish criteria to ensure (if applicable with respect to the activities 

involved)— 

‘‘(i) geographic and demographic diversity; 
599 Sec. 5507 PPACA (Consolidated) \2008 SSA 

‘‘(ii) that participating States offer medical assistance for personal care services under the State Medicaid plan; 

‘‘(iii) that the existing training standards for personal or home care aides in each participating State— 

‘‘(I) are different from such standards in the 

other participating States; and 

‘‘(II) are different from the core training competencies described in paragraph (3)(A); 

‘‘(iv) that participating States do not reduce the 

number of hours of training required under applicable 

State law or regulation after being selected to participate in the project; and 

‘‘(v) that participating States recruit a minimum 

number of eligible health and long-term care providers 

to participate in the project. 

‘‘(D) TECHNICAL ASSISTANCE.—The Secretary shall provide technical assistance to States in developing written 

materials and protocols for such core training competencies. 

‘‘(5) EVALUATION AND REPORT.— ‘‘(A) EVALUATION.—The Secretary shall develop an experimental or control group testing protocol in consultation 

with an independent evaluation contractor selected by the 

Secretary. Such contractor shall evaluate— 

‘‘(i) the impact of core training competencies described in paragraph (3)(A), including curricula developed to implement such core training competencies, 

for personal or home care aides within each participating State on job satisfaction, mastery of job skills, 

beneficiary and family caregiver satisfaction with services, and additional measures determined by the Secretary in consultation with the expert panel; 

‘‘(ii) the impact of providing such core training 

competencies on the existing training infrastructure 

and resources of States; and 

‘‘(iii) whether a minimum number of hours of initial training should be required for personal or home 

care aides and, if so, what minimum number of hours 

should be required. 

‘‘(B) REPORTS.— 

‘‘(i) REPORT ON INITIAL IMPLEMENTATION.—Not 

later than 2 years after the date of enactment of this 

section, the Secretary shall submit to Congress a report on the initial implementation of activities conducted under the demonstration project, including any 

available results of the evaluation conducted under 

subparagraph (A) with respect to such activities, together with such recommendations for legislation or 

administrative action as the Secretary determines appropriate. 

‘‘(ii) FINAL REPORT.—Not later than 1 year after 

the completion of the demonstration project, the Secretary shall submit to Congress a report containing 
Sec. 5507 PPACA (Consolidated) 600 

the results of the evaluation conducted under subparagraph (A), together with such recommendations for 

legislation or administrative action as the Secretary 

determines appropriate. 

‘‘(6) DEFINITIONS.—In this subsection: 

‘‘(A) ELIGIBLE HEALTH AND LONG-TERM CARE PRO- VIDER.—The term ‘eligible health and long-term care provider’ means a personal or home care agency (including 

personal or home care public authorities), a nursing home, 

a home health agency (as defined in section 1861(o)), or 

any other health care provider the Secretary determines 

appropriate which— 

‘‘(i) is licensed or authorized to provide services in 

a participating State; and 

‘‘(ii) receives payment for services under title XIX. 

‘‘(B) PERSONAL CARE SERVICES.—The term ‘personal 

care services’ has the meaning given such term for purposes of title XIX. 

‘‘(C) PERSONAL OR HOME CARE AIDE.—The term ‘personal or home care aide’ means an individual who helps individuals who are elderly, disabled, ill, or mentally disabled (including an individual with Alzheimer’s disease or 

other dementia) to live in their own home or a residential 

care facility (such as a nursing home, assisted living facility, or any other facility the Secretary determines appropriate) by providing routine personal care services and 

other appropriate services to the individual. 

‘‘(D) STATE.—The term ‘State’ has the meaning given 

that term for purposes of title XIX. 

‘‘(c) FUNDING.— 

‘‘(1) IN GENERAL.—Subject to paragraph (2), out of any 

funds in the Treasury not otherwise appropriated, there are 

appropriated to the Secretary to carry out subsections (a) and 

(b), $85,000,000 for each of fiscal years 2010 through 2014. 

‘‘(2) TRAINING AND CERTIFICATION PROGRAMS FOR PERSONAL

AND HOME CARE AIDES.—With respect to the demonstration 

projects under subsection (b), the Secretary shall use 

$5,000,000 of the amount appropriated under paragraph (1) for 

each of fiscal years 2010 through 2012 to carry out such 

projects. No funds appropriated under paragraph (1) shall be 

used to carry out demonstration projects under subsection (b) 

after fiscal year 2012. 

‘‘(d) NONAPPLICATION.— 

‘‘(1) IN GENERAL.—Except as provided in paragraph (2), the 

preceding sections of this title shall not apply to grant awarded 

under this section. 

‘‘(2) LIMITATIONS ON USE OF GRANTS.—Section 2005(a) 

(other than paragraph (6)) 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.’’. 

(b) EXTENSION OF FAMILY-TO-FAMILY HEALTH INFORMATION

CENTERS.—Section 501(c)(1)(A)(iii) of the Social Security Act (42 

U.S.C. 701(c)(1)(A)(iii)) is amended by striking ‘‘fiscal year 2009’’ 

and inserting ‘‘each of fiscal years 2009 through 2012’’. 
601 Sec. 5508 PPACA (Consolidated) \749A PHSA 

SEC. 5508. INCREASING TEACHING CAPACITY. 

(a) TEACHING HEALTH CENTERS TRAINING AND ENHANCE- MENT.—Part C of title VII of the Public Health Service Act (42 

U.S.C. 293k et. seq.), as amended by section 5303, is further 

amended by inserting after section 749 the following: 

‘‘SEC. 749A. ø42 U.S.C. 293l–1¿ TEACHING HEALTH CENTERS DEVELOPMENT GRANTS. 

‘‘(a) PROGRAM AUTHORIZED.—The Secretary may award grants 

under this section to teaching health centers for the purpose of establishing new accredited or expanded primary care residency programs. 

‘‘(b) AMOUNT AND DURATION.—Grants awarded under this section shall be for a term of not more than 3 years and the maximum 

award may not be more than $500,000. 

‘‘(c) USE OF FUNDS.—Amounts provided under a grant under 

this section shall be used to cover the costs of— 

‘‘(1) establishing or expanding a primary care residency 

training program described in subsection (a), including costs 

associated with— 

‘‘(A) curriculum development; 

‘‘(B) recruitment, training and retention of residents 

and faculty: 

‘‘(C) accreditation by the Accreditation Council for 

Graduate Medical Education (ACGME), the American Dental Association (ADA), or the American Osteopathic Association (AOA); and 

‘‘(D) faculty salaries during the development phase; 

and 

‘‘(2) technical assistance provided by an eligible entity. 

‘‘(d) APPLICATION.—A teaching health center seeking a grant 

under this section shall submit an application to the Secretary at 

such time, in such manner, and containing such information as the 

Secretary may require. 

‘‘(e) PREFERENCE FOR CERTAIN APPLICATIONS.—In selecting recipients for grants under this section, the Secretary shall give preference to any such application that documents an existing affiliation agreement with an area health education center program as 

defined in sections 751 and 799B. 

‘‘(f) DEFINITIONS.—In this section: 

‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means an 

organization capable of providing technical assistance including an area health education center program as defined in sections 751 and 799B. 

‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.—The term ‘primary care residency program’ means an approved graduate 

medical residency training program (as defined in section 

340H) in family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, 

general dentistry, pediatric dentistry, and geriatrics. 

‘‘(3) TEACHING HEALTH CENTER.— 

‘‘(A) IN GENERAL.—The term ‘teaching health center’ 

means an entity that— 

‘‘(i) is a community based, ambulatory patient care 

center; and 
Sec. 5508 PPACA (Consolidated) 602 

‘‘(ii) operates a primary care residency program. 

‘‘(B) INCLUSION OF CERTAIN ENTITIES.—Such term includes the following: 

‘‘(i) A Federally qualified health center (as defined 

in section 1905(l)(2)(B), of the Social Security Act). 

‘‘(ii) A community mental health center (as defined in section 1861(ff)(3)(B) of the Social Security 

Act). 

‘‘(iii) A rural health clinic, as defined in section 

1861(aa) of the Social Security Act. 

‘‘(iv) A health center operated by the Indian 

Health Service, an Indian tribe or tribal organization, 

or an urban Indian organization (as defined in section 

4 of the Indian Health Care Improvement Act). 

‘‘(v) An entity receiving funds under title X of the 

Public Health Service Act. 

‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 

to be appropriated, $25,000,000 for fiscal year 2010, $50,000,000 

for fiscal year 2011, $50,000,000 for fiscal year 2012, and such 

sums as may be necessary for each fiscal year thereafter to carry 

out this section. Not to exceed $5,000,000 annually may be used for 

technical assistance program grants.’’. 

(b) NATIONAL HEALTH SERVICE CORPS TEACHING CAPACITY.— 

Section 338C(a) of the Public Health Service Act (42 U.S.C. 

254m(a)) is amended to read as follows: 

‘‘(a) SERVICE IN FULL-TIME CLINICAL PRACTICE.—Except as provided in section 338D, each individual who has entered into a written contract with the Secretary under section 338A or 338B shall 

provide service in the full-time clinical practice of such individual’s 

profession as a member of the Corps for the period of obligated 

service provided in such contract. The Secretary may treat teaching 

as clinical practice for up to 20 percent of such period of obligated 

service. 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. øAs 

revised by section 10501(n)(5)¿’’. 

(c) PAYMENTS TO QUALIFIED TEACHING HEALTH CENTERS.— 

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—Support of Graduate Medical 

Education in Qualified Teaching Health Centers 

‘‘SEC. 340H. ø42 U.S.C. 256h¿ PROGRAM OF PAYMENTS TO TEACHING 

HEALTH CENTERS THAT OPERATE GRADUATE MEDICAL 

EDUCATION PROGRAMS. 

‘‘(a) PAYMENTS.—Subject to subsection (h)(2), the Secretary 

shall make payments under this section for direct expenses and for 

indirect expenses to qualified teaching health centers that are listed as sponsoring institutions by the relevant accrediting body for 
603 Sec. 5508 PPACA (Consolidated) \340H PHSA 

expansion of existing or establishment of new approved graduate 

medical residency training programs. 

‘‘(b) AMOUNT OF PAYMENTS.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the amounts 

payable under this section to qualified teaching health centers 

for an approved graduate medical residency training program 

for a fiscal year are each of the following amounts: 

‘‘(A) DIRECT EXPENSE AMOUNT.—The amount determined under subsection (c) for direct expenses associated 

with sponsoring approved graduate medical residency 

training programs. 

‘‘(B) INDIRECT EXPENSE AMOUNT.—The amount determined under subsection (d) for indirect expenses associated with the additional costs relating to teaching residents in such programs. 

‘‘(2) CAPPED AMOUNT.— ‘‘(A) IN GENERAL.—The total of the payments made to 

qualified teaching health centers under paragraph (1)(A) 

or paragraph (1)(B) in a fiscal year shall not exceed the 

amount of funds appropriated under subsection (g) for 

such payments for that fiscal year. 

‘‘(B) LIMITATION.—The Secretary shall limit the funding of full-time equivalent residents in order to ensure the 

direct and indirect payments as determined under subsection (c) and (d) do not exceed the total amount of funds 

appropriated in a fiscal year under subsection (g). 

‘‘(c) AMOUNT OF PAYMENT FOR DIRECT GRADUATE MEDICAL

EDUCATION.— ‘‘(1) IN GENERAL.—The amount determined under this subsection for payments to qualified teaching health centers for direct graduate expenses relating to approved graduate medical 

residency training programs for a fiscal year is equal to the 

product of— 

‘‘(A) the updated national per resident amount for direct graduate medical education, as determined under 

paragraph (2); and 

‘‘(B) the average number of full-time equivalent residents in the teaching health center’s graduate approved 

medical residency training programs as determined under 

section 1886(h)(4) of the Social Security Act (without regard to the limitation under subparagraph (F) of such section) during the fiscal year. 

‘‘(2) UPDATED NATIONAL PER RESIDENT AMOUNT FOR DIRECT

GRADUATE MEDICAL EDUCATION.—The updated per resident 

amount for direct graduate medical education for a qualified 

teaching health center for a fiscal year is an amount determined as follows: 

‘‘(A) DETERMINATION OF QUALIFIED TEACHING HEALTH

CENTER PER RESIDENT AMOUNT.—The Secretary shall compute for each individual qualified teaching health center a 

per resident amount— 

‘‘(i) by dividing the national average per resident 

amount computed under section 340E(c)(2)(D) into a 

wage-related portion and a non-wage related portion 
Sec. 5508\340H PHSA PPACA (Consolidated) 604 

by applying the proportion determined under subparagraph (B); 

‘‘(ii) by multiplying the wage-related portion by 

the factor applied under section 1886(d)(3)(E) of the 

Social Security Act (but without application of section 

4410 of the Balanced Budget Act of 1997 (42 U.S.C. 

1395ww note)) during the preceding fiscal year for the 

teaching health center’s area; and 

‘‘(iii) by adding the non-wage-related portion to 

the amount computed under clause (ii). 

‘‘(B) UPDATING RATE.—The Secretary shall update 

such per resident amount for each such qualified teaching 

health center as determined appropriate by the Secretary. 

‘‘(d) AMOUNT OF PAYMENT FOR INDIRECT MEDICAL EDUCATION.— 

‘‘(1) IN GENERAL.—The amount determined under this subsection for payments to qualified teaching health centers for indirect expenses associated with the additional costs of teaching 

residents for a fiscal year is equal to an amount determined 

appropriate by the Secretary. 

‘‘(2) FACTORS.—In determining the amount under paragraph (1), the Secretary shall— 

‘‘(A) evaluate indirect training costs relative to supporting a primary care residency program in qualified 

teaching health centers; and 

‘‘(B) based on this evaluation, assure that the aggregate of the payments for indirect expenses under this section and the payments for direct graduate medical education as determined under subsection (c) in a fiscal year 

do not exceed the amount appropriated for such expenses 

as determined in subsection (g). 

‘‘(3) INTERIM PAYMENT.—Before the Secretary makes a payment under this subsection pursuant to a determination of indirect expenses under paragraph (1), the Secretary may provide to qualified teaching health centers a payment, in addition to any payment made under subsection (c), for expected 

indirect expenses associated with the additional costs of teaching residents for a fiscal year, based on an estimate by the Secretary. 

‘‘(e) CLARIFICATION REGARDING RELATIONSHIP TO OTHER PAYMENTS FOR GRADUATE MEDICAL EDUCATION.—Payments under this 

section— 

‘‘(1) shall be in addition to any payments— 

‘‘(A) for the indirect costs of medical education under 

section 1886(d)(5)(B) of the Social Security Act; 

‘‘(B) for direct graduate medical education costs under 

section 1886(h) of such Act; and 

‘‘(C) for direct costs of medical education under section 

1886(k) of such Act; 

‘‘(2) shall not be taken into account in applying the limitation on the number of total full-time equivalent residents 

under subparagraphs (F) and (G) of section 1886(h)(4) of such 

Act and clauses (v), (vi)(I), and (vi)(II) of section 1886(d)(5)(B) 
605 Sec. 5508 PPACA (Consolidated) \340H PHSA 

of such Act for the portion of time that a resident rotates to 

a hospital; and 

‘‘(3) shall not include the time in which a resident is counted toward full-time equivalency by a hospital under paragraph 

(2) or under section 1886(d)(5)(B)(iv) of the Social Security Act, 

section 1886(h)(4)(E) of such Act, or section 340E of this Act. 

‘‘(f) RECONCILIATION.—The Secretary shall determine any 

changes to the number of residents reported by a hospital in the 

application of the hospital for the current fiscal year to determine 

the final amount payable to the hospital for the current fiscal year 

for both direct expense and indirect expense amounts. Based on 

such determination, the Secretary shall recoup any overpayments 

made to pay any balance due to the extent possible. The final 

amount so determined shall be considered a final intermediary determination for the purposes of section 1878 of the Social Security 

Act and shall be subject to administrative and judicial review 

under that section in the same manner as the amount of payment 

under section 1186(d) of such Act is subject to review under such 

section. 

‘‘(g) FUNDING.—To carry out this section, there are appropriated such sums as may be necessary, not to exceed 

$230,000,000, for the period of fiscal years 2011 through 2015. 

‘‘(h) ANNUAL REPORTING REQUIRED.— 

‘‘(1) ANNUAL REPORT.—The report required under this 

paragraph for a qualified teaching health center for a fiscal 

year is a report that includes (in a form and manner specified 

by the Secretary) the following information for the residency 

academic year completed immediately prior to such fiscal year: 

‘‘(A) The types of primary care resident approved 

training programs that the qualified teaching health center provided for residents. 

‘‘(B) The number of approved training positions for 

residents described in paragraph (4). 

‘‘(C) The number of residents described in paragraph 

(4) who completed their residency training at the end of 

such residency academic year and care for vulnerable populations living in underserved areas. 

‘‘(D) Other information as deemed appropriate by the 

Secretary. 

‘‘(2) AUDIT AUTHORITY; LIMITATION ON PAYMENT.— 

‘‘(A) AUDIT AUTHORITY.—The Secretary may audit a 

qualified teaching health center to ensure the accuracy 

and completeness of the information submitted in a report 

under paragraph (1). 

‘‘(B) LIMITATION ON PAYMENT.—A teaching health center may only receive payment in a cost reporting period for 

a number of such resident positions that is greater than 

the base level of primary care resident positions, as determined by the Secretary. For purposes of this subparagraph, the ‘base level of primary care residents’ for a 

teaching health center is the level of such residents as of 

a base period. 

‘‘(3) REDUCTION IN PAYMENT FOR FAILURE TO REPORT.— 
Sec. 5509 PPACA (Consolidated) 606 

‘‘(A) IN GENERAL.—The amount payable under this section to a qualified teaching health center for a fiscal year 

shall be reduced by at least 25 percent if the Secretary determines that— 

‘‘(i) the qualified teaching health center has failed 

to provide the Secretary, as an addendum to the qualified teaching health center’s application under this 

section for such fiscal year, the report required under 

paragraph (1) for the previous fiscal year; or 

‘‘(ii) such report fails to provide complete and accurate information required under any subparagraph 

of such paragraph. 

‘‘(B) NOTICE AND OPPORTUNITY TO PROVIDE ACCURATE

AND MISSING INFORMATION.—Before imposing a reduction 

under subparagraph (A) on the basis of a qualified teaching health center’s failure to provide complete and accurate information described in subparagraph (A)(ii), the 

Secretary shall provide notice to the teaching health center 

of such failure and the Secretary’s intention to impose 

such reduction and shall provide the teaching health center with the opportunity to provide the required information within the period of 30 days beginning on the date of 

such notice. If the teaching health center provides such information within such period, no reduction shall be made 

under subparagraph (A) on the basis of the previous failure to provide such information. 

‘‘(4) RESIDENTS.—The residents described in this paragraph are those who are in part-time or full-time equivalent 

resident training positions at a qualified teaching health center 

in any approved graduate medical residency training program. 

‘‘(i) REGULATIONS.—The Secretary shall promulgate regulations 

to carry out this section. 

‘‘(j) DEFINITIONS.—In this section: 

‘‘(1) APPROVED GRADUATE MEDICAL RESIDENCY TRAINING

PROGRAM.—The term ‘approved graduate medical residency 

training program’ means a residency or other postgraduate 

medical training program— 

‘‘(A) participation in which may be counted toward certification in a specialty or subspecialty and includes formal 

postgraduate training programs in geriatric medicine approved by the Secretary; and 

‘‘(B) that meets criteria for accreditation (as established by the Accreditation Council for Graduate Medical 

Education, the American Osteopathic Association, or the 

American Dental Association). 

‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.—The term ‘primary care residency program’ has the meaning given that term 

in section 749A. 

‘‘(3) QUALIFIED TEACHING HEALTH CENTER.—The term 

‘qualified teaching health center’ has the meaning given the 

term ‘teaching health center’ in section 749A.’’. 

SEC. 5509. ø42 U.S.C. 1395ww note¿ GRADUATE NURSE EDUCATION DEMONSTRATION. 

(a) IN GENERAL.— 
607 Sec. 5509 PPACA (Consolidated) 

(1) ESTABLISHMENT.— 

(A) IN GENERAL.—The Secretary shall establish a 

graduate nurse education demonstration under title XVIII 

of the Social Security Act (42 U.S.C. 1395 et seq.) under 

which an eligible hospital may receive payment for the 

hospital’s reasonable costs (described in paragraph (2)) for 

the provision of qualified clinical training to advance practice nurses. 

(B) NUMBER.—The demonstration shall include up to 

5 eligible hospitals. 

(C) WRITTEN AGREEMENTS.—Eligible hospitals selected 

to participate in the demonstration shall enter into written 

agreements pursuant to subsection (b) in order to reimburse the eligible partners of the hospital the share of the 

costs attributable to each partner. 

(2) COSTS DESCRIBED.— 

(A) IN GENERAL.—Subject to subparagraph (B) and 

subsection (d), the costs described in this paragraph are 

the reasonable costs (as described in section 1861(v) of the 

Social Security Act (42 U.S.C. 1395x(v))) of each eligible 

hospital for the clinical training costs (as determined by 

the Secretary) that are attributable to providing advanced 

practice registered nurses with qualified training. 

(B) LIMITATION.—With respect to a year, the amount 

reimbursed under subparagraph (A) may not exceed the 

amount of costs described in subparagraph (A) that are attributable to an increase in the number of advanced practice registered nurses enrolled in a program that provides 

qualified training during the year and for which the hospital is being reimbursed under the demonstration, as 

compared to the average number of advanced practice registered nurses who graduated in each year during the period beginning on January 1, 2006, and ending on December 31, 2010 (as determined by the Secretary) from the 

graduate nursing education program operated by the applicable school of nursing that is an eligible partner of the 

hospital for purposes of the demonstration. 

(3) WAIVER AUTHORITY.—The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act as 

may be necessary to carry out the demonstration. 

(4) ADMINISTRATION.—Chapter 35 of title 44, United States 

Code, shall not apply to the implementation of this section. 

(b) WRITTEN AGREEMENTS WITH ELIGIBLE PARTNERS.—No payment shall be made under this section to an eligible hospital unless 

such hospital has in effect a written agreement with the eligible 

partners of the hospital. Such written agreement shall describe, at 

a minimum— 

(1) the obligations of the eligible partners with respect to 

the provision of qualified training; and 

(2) the obligation of the eligible hospital to reimburse such 

eligible partners applicable (in a timely manner) for the costs 

of such qualified training attributable to partner. 
Sec. 5509 PPACA (Consolidated) 608 

(c) EVALUATION.—Not later than October 17, 2017, the Secretary shall submit to Congress a report on the demonstration. 

Such report shall include an analysis of the following: 

(1) The growth in the number of advanced practice registered nurses with respect to a specific base year as a result 

of the demonstration. 

(2) The growth for each of the specialties described in subparagraphs (A) through (D) of subsection (e)(1). 

(3) The costs to the Medicare program under title XVIII of 

the Social Security Act as a result of the demonstration. 

(4) Other items the Secretary determines appropriate and 

relevant. 

(d) FUNDING.— 

(1) IN GENERAL.—There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $50,000,000 for each of fiscal years 2012 through 2015 

to carry out this section, including the design, implementation, 

monitoring, and evaluation of the demonstration. 

(2) PRORATION.—If the aggregate payments to eligible hospitals under the demonstration exceed $50,000,000 for a fiscal 

year described in paragraph (1), the Secretary shall prorate the 

payment amounts to each eligible hospital in order to ensure 

that the aggregate payments do not exceed such amount. 

(3) WITHOUT FISCAL YEAR LIMITATION.—Amounts appropriated under this subsection shall remain available without 

fiscal year limitation. 

(e) DEFINITIONS.—In this section: 

(1) ADVANCED PRACTICE REGISTERED NURSE.—The term 

‘‘advanced practice registered nurse’’ includes the following: 

(A) A clinical nurse specialist (as defined in subsection 

(aa)(5) of section 1861 of the Social Security Act (42 U.S.C. 

1395x)). 

(B) A nurse practitioner (as defined in such subsection). 

(C) A certified registered nurse anesthetist (as defined 

in subsection (bb)(2) of such section). 

(D) A certified nurse-midwife (as defined in subsection 

(gg)(2) of such section). 

(2) APPLICABLE NON-HOSPITAL COMMUNITY-BASED CARE

SETTING.—The term ‘‘applicable non-hospital community-based 

care setting’’ means a non-hospital community-based care setting which has entered into a written agreement (as described 

in subsection (b)) with the eligible hospital participating in the 

demonstration. Such settings include Federally qualified health 

centers, rural health clinics, and other non-hospital settings as 

determined appropriate by the Secretary. 

(3) APPLICABLE SCHOOL OF NURSING.—The term ‘‘applicable 

school of nursing’’ means an accredited school of nursing (as 

defined in section 801 of the Public Health Service Act) which 

has entered into a written agreement (as described in subsection (b)) with the eligible hospital participating in the demonstration. 
609 Sec. 5601 PPACA (Consolidated) 

(4) DEMONSTRATION.—The term ‘‘demonstration’’ means 

the graduate nurse education demonstration established under 

subsection (a). 

(5) ELIGIBLE HOSPITAL.—The term ‘‘eligible hospital’’ 

means a hospital (as defined in subsection (e) of section 1861 

of the Social Security Act (42 U.S.C. 1395x)) or a critical access 

hospital (as defined in subsection (mm)(1) of such section) that 

has a written agreement in place with— 

(A) 1 or more applicable schools of nursing; and 

(B) 2 or more applicable non-hospital communitybased care settings. 

(6) ELIGIBLE PARTNERS.—The term ‘‘eligible partners’’ includes the following: 

(A) An applicable non-hospital community-based care 

setting. 

(B) An applicable school of nursing. 

(7) QUALIFIED TRAINING.— 

(A) IN GENERAL.—The term ‘‘qualified training’’ means 

training— 

(i) that provides an advanced practice registered 

nurse with the clinical skills necessary to provide primary care, preventive care, transitional care, chronic 

care management, and other services appropriate 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; and 

(ii) subject to subparagraph (B), at least half of 

which is provided in a non-hospital community-based 

care setting. 

(B) WAIVER OF REQUIREMENT HALF OF TRAINING BE

PROVIDED IN NON-HOSPITAL COMMUNITY-BASED CARE SET- TING IN CERTAIN AREAS.—The Secretary may waive the requirement under subparagraph (A)(ii) with respect to eligible hospitals located in rural or medically underserved 

areas. 

(8) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health and Human Services. 

Subtitle G—Improving Access to Health 

Care Services 

SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH CENTERS 

(FQHCS). 

(a) IN GENERAL.—Section 330(r) of the Public Health Service 

Act (42 U.S.C. 254b(r)) is amended by striking paragraph (1) and 

inserting the following: 

‘‘(1) GENERAL AMOUNTS FOR GRANTS.—For the purpose of 

carrying out this section, in addition to the amounts authorized 

to be appropriated under subsection (d), there is authorized to 

be appropriated the following: 

‘‘(A) For fiscal year 2010, $2,988,821,592. 

‘‘(B) For fiscal year 2011, $3,862,107,440. 

‘‘(C) For fiscal year 2012, $4,990,553,440. 
Sec. 5602 PPACA (Consolidated) 610 

‘‘(D) For fiscal year 2013, $6,448,713,307. 

‘‘(E) For fiscal year 2014, $7,332,924,155. 

‘‘(F) For fiscal year 2015, $8,332,924,155. 

‘‘(G) For fiscal year 2016, and each subsequent fiscal 

year, the amount appropriated for the preceding fiscal year 

adjusted by the product of— 

‘‘(i) one plus the average percentage increase in 

costs incurred per patient served; and 

‘‘(ii) one plus the average percentage increase in 

the total number of patients served.’’. 

(b) RULE OF CONSTRUCTION.—Section 330(r) of the Public 

Health Service Act (42 U.S.C. 254b(r)) is amended by adding at the 

end the following: 

‘‘(4) RULE OF CONSTRUCTION WITH RESPECT TO RURAL

HEALTH CLINICS.— 

‘‘(A) IN GENERAL.—Nothing in this section shall be construed to prevent a community health center from contracting with a Federally certified rural health clinic (as 

defined in section 1861(aa)(2) of the Social Security Act), 

a low-volume hospital (as defined for purposes of section 

1886 of such Act), a critical access hospital, a sole community hospital (as defined for purposes of section 

1886(d)(5)(D)(iii) of such Act), or a medicare-dependent 

share hospital (as defined for purposes of section 

1886(d)(5)(G)(iv) of such Act) for the delivery of primary 

health care services that are available at the clinic or hospital to individuals who would otherwise be eligible for 

free or reduced cost care if that individual were able to obtain that care at the community health center. Such services may be limited in scope to those primary health care 

services available in that clinic or hospitals. 

‘‘(B) ASSURANCES.—In order for a clinic or hospital to 

receive funds under this section through a contract with a 

community health center under subparagraph (A), such 

clinic or hospital shall establish policies to ensure— 

‘‘(i) nondiscrimination based on the ability of a patient to pay; and 

‘‘(ii) the establishment of a sliding fee scale for 

low-income patients.’’. 

SEC. 5602. NEGOTIATED RULEMAKING FOR DEVELOPMENT OF METHODOLOGY AND CRITERIA FOR DESIGNATING MEDICALLY 

UNDERSERVED POPULATIONS AND HEALTH PROFESSIONS SHORTAGE AREAS. 

(a) ESTABLISHMENT.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services (in this section referred to as the ‘‘Secretary’’) shall establish, through a negotiated rulemaking process under subchapter 3 of chapter 5 of title 5, United States Code, a comprehensive methodology and criteria for designation of— 

(A) medically underserved populations in accordance 

with section 330(b)(3) of the Public Health Service Act (42 

U.S.C. 254b(b)(3)); 

(B) health professions shortage areas under section 

332 of the Public Health Service Act (42 U.S.C. 254e). 
611 Sec. 5602 PPACA (Consolidated) 

(2) FACTORS TO CONSIDER.—In establishing the methodology and criteria under paragraph (1), the Secretary— 

(A) shall consult with relevant stakeholders who will 

be significantly affected by a rule (such as national, State 

and regional organizations representing affected entities), 

State health offices, community organizations, health centers and other affected entities, and other interested parties; and 

(B) shall take into account— 

(i) the timely availability and appropriateness of 

data used to determine a designation to potential applicants for such designations; 

(ii) the impact of the methodology and criteria on 

communities of various types and on health centers 

and other safety net providers; 

(iii) the degree of ease or difficulty that will face 

potential applicants for such designations in securing 

the necessary data; and 

(iv) the extent to which the methodology accurately measures various barriers that confront individuals and population groups in seeking health care 

services. 

(b) PUBLICATION OF NOTICE.—In carrying out the rulemaking 

process under this subsection, the Secretary shall publish the notice provided for under section 564(a) of title 5, United States Code, 

by not later than 45 days after the date of the enactment of this 

Act. 

(c) TARGET DATE FOR PUBLICATION OF RULE.—As part of the 

notice under subsection (b), and for purposes of this subsection, the 

‘‘target date for publication’’, as referred to in section 564(a)(5) of 

title 5, United Sates Code, shall be July 1, 2010. 

(d) APPOINTMENT OF NEGOTIATED RULEMAKING COMMITTEE

AND FACILITATOR.—The Secretary shall provide for— 

(1) the appointment of a negotiated rulemaking committee 

under section 565(a) of title 5, United States Code, by not later 

than 30 days after the end of the comment period provided for 

under section 564(c) of such title; and 

(2) the nomination of a facilitator under section 566(c) of 

such title 5 by not later than 10 days after the date of appointment of the committee. 

(e) PRELIMINARY COMMITTEE REPORT.—The negotiated rulemaking committee appointed under subsection (d) shall report to 

the Secretary, by not later than April 1, 2010, regarding the committee’s progress on achieving a consensus with regard to the rulemaking proceeding and whether such consensus is likely to occur 

before one month before the target date for publication of the rule. 

If the committee reports that the committee has failed to make significant progress toward such consensus or is unlikely to reach 

such consensus by the target date, the Secretary may terminate 

such process and provide for the publication of a rule under this 

section through such other methods as the Secretary may provide. 

(f) FINAL COMMITTEE REPORT.—If the committee is not terminated under subsection (e), the rulemaking committee shall submit 
Sec. 5603 PPACA (Consolidated) 612 

a report containing a proposed rule by not later than one month 

before the target publication date. 

(g) INTERIM FINAL EFFECT.—The Secretary shall publish a rule 

under this section in the Federal Register by not later than the target publication date. Such rule shall be effective and final immediately on an interim basis, but is subject to change and revision 

after public notice and opportunity for a period (of not less than 90 

days) for public comment. In connection with such rule, the Secretary shall specify the process for the timely review and approval 

of applications for such designations pursuant to such rules and 

consistent with this section. 

(h) PUBLICATION OF RULE AFTER PUBLIC COMMENT.—The Secretary shall provide for consideration of such comments and republication of such rule by not later than 1 year after the target publication date. 

SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMERGENCY MEDICAL SERVICES FOR CHILDREN PROGRAM. 

Section 1910 of the Public Health Service Act (42 U.S.C. 300w– 

9) is amended— 

(1) in subsection (a), by striking ‘‘3-year period (with an optional 4th year’’ and inserting ‘‘4-year period (with an optional 

5th year’’; and 

(2) in subsection (d)— 

(A) by striking ‘‘and such sums’’ and inserting ‘‘such 

sums’’; and 

(B) by inserting before the period the following: ‘‘, 

$25,000,000 for fiscal year 2010, $26,250,000 for fiscal year 

2011, $27,562,500 for fiscal year 2012, $28,940,625 for fiscal year 2013, and $30,387,656 for fiscal year 2014’’. 

SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN COMMUNITY-BASED MENTAL HEALTH SETTINGS. 

Subpart 3 of part B of title V of the Public Health Service Act 

(42 U.S.C. 290bb–31 et seq.) is amended by adding at the end the 

following: 

‘‘SEC. 520K. ø42 U.S.C. 290bb–42¿ AWARDS FOR CO-LOCATING PRIMARY 

AND SPECIALTY CARE IN COMMUNITY-BASED MENTAL 

HEALTH SETTINGS. 

‘‘(a) DEFINITIONS.—In this section: 

‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a 

qualified community mental health program defined under section 1913(b)(1). 

‘‘(2) SPECIAL POPULATIONS.—The term ‘special populations’ 

means adults with mental illnesses who have co-occurring primary care conditions and chronic diseases. 

‘‘(b) PROGRAM AUTHORIZED.—The Secretary, acting through the 

Administrator shall award grants and cooperative agreements to 

eligible entities to establish demonstration projects for the provision of coordinated and integrated services to special populations 

through the co-location of primary and specialty care services in 

community-based mental and behavioral health settings. 

‘‘(c) APPLICATION.—To be eligible to receive a grant or cooperative agreement under this section, an eligible entity shall submit 

an application to the Administrator at such time, in such manner, 
613 Sec. 5605 PPACA (Consolidated) 

and accompanied by such information as the Administrator may require, including a description of partnerships, or other arrangements with local primary care providers, including community 

health centers, to provide services to special populations. 

‘‘(d) USE OF FUNDS.— 

‘‘(1) IN GENERAL.—For the benefit of special populations, 

an eligible entity shall use funds awarded under this section 

for— 

‘‘(A) the provision, by qualified primary care professionals, of on site primary care services; 

‘‘(B) reasonable costs associated with medically necessary referrals to qualified specialty care professionals, 

other coordinators of care or, if permitted by the terms of 

the grant or cooperative agreement, by qualified specialty 

care professionals on a reasonable cost basis on site at the 

eligible entity; 

‘‘(C) information technology required to accommodate 

the clinical needs of primary and specialty care professionals; or 

‘‘(D) facility modifications needed to bring primary and 

specialty care professionals on site at the eligible entity. 

‘‘(2) LIMITATION.—Not to exceed 15 percent of grant or cooperative agreement funds may be used for activities described 

in subparagraphs (C) and (D) of paragraph (1). 

‘‘(e) EVALUATION.—Not later than 90 days after a grant or cooperative agreement awarded under this section expires, an eligible 

entity shall submit to the Secretary the results of an evaluation to 

be conducted by the entity concerning the effectiveness of the activities carried out under the grant or agreement. 

‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated to carry out this section, $50,000,000 for fiscal 

year 2010 and such sums as may be necessary for each of fiscal 

years 2011 through 2014.’’. 

SEC. 5605. ø36 U.S.C. 150303 note¿ KEY NATIONAL INDICATORS. 

(a) DEFINITIONS.—In this section: 

(1) ACADEMY.—The term ‘‘Academy’’ means the National 

Academy of Sciences. 

(2) COMMISSION.—The term ‘‘Commission’’ means the Commission on Key National Indicators established under subsection (b). 

(3) INSTITUTE.—The term ‘‘Institute’’ means a Key National Indicators Institute as designated under subsection 

(c)(3). 

(b) COMMISSION ON KEY NATIONAL INDICATORS.— 

(1) ESTABLISHMENT.—There is established a ‘‘Commission 

on Key National Indicators’’. 

(2) MEMBERSHIP.— 

(A) NUMBER AND APPOINTMENT.—The Commission 

shall be composed of 8 members, to be appointed equally 

by the majority and minority leaders of the Senate and the 

Speaker and minority leader of the House of Representatives. 
Sec. 5605 PPACA (Consolidated) 614 

(B) PROHIBITED APPOINTMENTS.—Members of the Commission shall not include Members of Congress or other 

elected Federal, State, or local government officials. 

(C) QUALIFICATIONS.—In making appointments under 

subparagraph (A), the majority and minority leaders of the 

Senate and the Speaker and minority leader of the House 

of Representatives shall appoint individuals who have 

shown a dedication to improving civic dialogue and decision-making through the wide use of scientific evidence 

and factual information. 

(D) PERIOD OF APPOINTMENT.—Each member of the 

Commission shall be appointed for a 2-year term, except 

that 1 initial appointment shall be for 3 years. Any vacancies shall not affect the power and duties of the Commission but shall be filled in the same manner as the original 

appointment and shall last only for the remainder of that 

term. 

(E) DATE.—Members of the Commission shall be appointed by not later than 30 days after the date of enactment of this Act. 

(F) INITIAL ORGANIZING PERIOD.—–Not later than 60 

days after the date of enactment of this Act, the Commission shall develop and implement a schedule for completion of the review and reports required under subsection 

(d). 

(G) CO-CHAIRPERSONS.—The Commission shall select 2 

Co-Chairpersons from among its members. 

(c) DUTIES OF THE COMMISSION.— (1) IN GENERAL.—The Commission shall— 

(A) conduct comprehensive oversight of a newly established key national indicators system consistent with the 

purpose described in this subsection; 

(B) make recommendations on how to improve the key 

national indicators system; 

(C) coordinate with Federal Government users and information providers to assure access to relevant and quality data; and 

(D) enter into contracts with the Academy. 

(2) REPORTS.— 

(A) ANNUAL REPORT TO CONGRESS.—Not later than 1 

year after the selection of the 2 Co-Chairpersons of the 

Commission, and each subsequent year thereafter, the 

Commission shall prepare and submit to the appropriate 

Committees of Congress and the President a report that 

contains a detailed statement of the recommendations, 

findings, and conclusions of the Commission on the activities of the Academy and a designated Institute related to 

the establishment of a Key National Indicator System. 

(B) ANNUAL REPORT TO THE ACADEMY.— 

(i) IN GENERAL.—Not later than 6 months after 

the selection of the 2 Co-Chairpersons of the Commission, and each subsequent year thereafter, the Commission shall prepare and submit to the Academy and 

a designated Institute a report making recommenda-
615 Sec. 5605 PPACA (Consolidated) 

tions concerning potential issue areas and key indicators to be included in the Key National Indicators. 

(ii) LIMITATION.—The Commission shall not have 

the authority to direct the Academy or, if established, 

the Institute, to adopt, modify, or delete any key indicators. 

(3) CONTRACT WITH THE NATIONAL ACADEMY OF

SCIENCES.— 

(A) IN GENERAL.—–As soon as practicable after the selection of the 2 Co-Chairpersons of the Commission, the 

Co-Chairpersons shall enter into an arrangement with the 

National Academy of Sciences under which the Academy 

shall— 

(i) review available public and private sector research on the selection of a set of key national indicators; 

(ii) determine how best to establish a key national 

indicator system for the United States, by either creating its own institutional capability or designating an 

independent private nonprofit organization as an Institute to implement a key national indicator system; 

(iii) if the Academy designates an independent Institute under clause (ii), provide scientific and technical advice to the Institute and create an appropriate 

governance mechanism that balances Academy involvement and the independence of the Institute; and 

(iv) provide an annual report to the Commission 

addressing scientific and technical issues related to 

the key national indicator system and, if established, 

the Institute, and governance of the Institute’s budget 

and operations. 

(B) PARTICIPATION.—In executing the arrangement 

under subparagraph (A), the National Academy of Sciences 

shall convene a multi-sector, multi-disciplinary process to 

define major scientific and technical issues associated with 

developing, maintaining, and evolving a Key National Indicator System and, if an Institute is established, to provide 

it with scientific and technical advice. 

(C) ESTABLISHMENT OF A KEY NATIONAL INDICATOR

SYSTEM.— 

(i) IN GENERAL.—In executing the arrangement 

under subparagraph (A), the National Academy of 

Sciences shall enable the establishment of a key national indicator system by— 

(I) creating its own institutional capability; or 

(II) partnering with an independent private 

nonprofit organization as an Institute to implement a key national indicator system. 

(ii) INSTITUTE.—If the Academy designates an Institute under clause (i)(II), such Institute shall be a 

non-profit entity (as defined for purposes of section 

501(c)(3) of the Internal Revenue Code of 1986) with 

an educational mission, a governance structure that 

emphasizes independence, and characteristics that 
Sec. 5605 PPACA (Consolidated) 616 

make such entity appropriate for establishing a key 

national indicator system. 

(iii) RESPONSIBILITIES.—Either the Academy or 

the Institute designated under clause (i)(II) shall be 

responsible for the following: 

(I) Identifying and selecting issue areas to be 

represented by the key national indicators. 

(II) Identifying and selecting the measures 

used for key national indicators within the issue 

areas under subclause (I). 

(III) Identifying and selecting data to populate 

the key national indicators described under subclause (II). 

(IV) Designing, publishing, and maintaining a 

public website that contains a freely accessible 

database allowing public access to the key national indicators. 

(V) Developing a quality assurance framework 

to ensure rigorous and independent processes and 

the selection of quality data. 

(VI) Developing a budget for the construction 

and management of a sustainable, adaptable, and 

evolving key national indicator system that reflects all Commission funding of Academy and, if 

an Institute is established, Institute activities. 

(VII) Reporting annually to the Commission 

regarding its selection of issue areas, key indicators, data, and progress toward establishing a 

web-accessible database. 

(VIII) Responding directly to the Commission 

in response to any Commission recommendations 

and to the Academy regarding any inquiries by 

the Academy. 

(iv) GOVERNANCE.—Upon the establishment of a 

key national indicator system, the Academy shall create an appropriate governance mechanism that incorporates advisory and control functions. If an Institute 

is designated under clause (i)(II), the governance 

mechanism shall balance appropriate Academy involvement and the independence of the Institute. 

(v) MODIFICATION AND CHANGES.—The Academy 

shall retain the sole discretion, at any time, to alter its 

approach to the establishment of a key national indicator system or, if an Institute is designated under 

clause (i)(II), to alter any aspect of its relationship 

with the Institute or to designate a different non-profit 

entity to serve as the Institute. 

(vi) CONSTRUCTION.—Nothing in this section shall 

be construed to limit the ability of the Academy or the 

Institute designated under clause (i)(II) to receive private funding for activities related to the establishment 

of a key national indicator system. 

(D) ANNUAL REPORT.—As part of the arrangement 

under subparagraph (A), the National Academy of Sciences 
617 Sec. 5606 PPACA (Consolidated) 

shall, not later than 270 days after the date of enactment 

of this Act, and annually thereafter, submit to the CoChairpersons of the Commission a report that contains the 

findings and recommendations of the Academy. 

(d) GOVERNMENT ACCOUNTABILITY OFFICE STUDY AND REPORT.— 

(1) GAO STUDY.—The Comptroller General of the United 

States shall conduct a study of previous work conducted by all 

public agencies, private organizations, or foreign countries with 

respect to best practices for a key national indicator system. 

The study shall be submitted to the appropriate authorizing 

committees of Congress. 

(2) GAO FINANCIAL AUDIT.—If an Institute is established 

under this section, the Comptroller General shall conduct an 

annual audit of the financial statements of the Institute, in accordance with generally accepted government auditing standards and submit a report on such audit to the Commission and 

the appropriate authorizing committees of Congress. 

(3) GAO PROGRAMMATIC REVIEW.—The Comptroller General of the United States shall conduct programmatic assessments of the Institute established under this section as determined necessary by the Comptroller General and report the 

findings to the Commission and to the appropriate authorizing 

committees of Congress. 

(e) AUTHORIZATION OF APPROPRIATIONS.— 

(1) IN GENERAL.—There are authorized to be appropriated 

to carry out the purposes of this section, $10,000,000 for fiscal 

year 2010, and $7,500,000 for each of fiscal year 2011 through 

2018. 

(2) AVAILABILITY.—Amounts appropriated under paragraph 

(1) shall remain available until expended. 

SEC. 5606. ø42 U.S.C. 254b–1¿ STATE GRANTS TO HEALTH CARE PROVIDERS WHO PROVIDE SERVICES TO A HIGH PERCENTAGE OF MEDICALLY UNDERSERVED POPULATIONS OR 

OTHER SPECIAL POPULATIONS. 

øSection added by section 10501(k)¿ 

(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). 
Sec. 5701 PPACA (Consolidated) 618 

Subtitle H—General Provisions 

SEC. 5701. REPORTS. 

(a) REPORTS BY SECRETARY OF HEALTH AND HUMAN SERVICES.—On an annual basis, the Secretary of Health and Human 

Services shall submit to the appropriate Committees of Congress a 

report on the activities carried out under the amendments made by 

this title, and the effectiveness of such activities. 

(b) REPORTS BY RECIPIENTS OF FUNDS.—The Secretary of 

Health and Human Services may require, as a condition of receiving funds under the amendments made by this title, that the entity 

receiving such award submit to such Secretary such reports as the 

such Secretary may require on activities carried out with such 

award, and the effectiveness of such activities. 

øMiscellaneous additional amendments made to the Public 

Health Service Act by section 10501(d), (g), (l), (m), & (n); by section 

10502; and by section 10503¿ 
619 Sec. 6001 PPACA (Consolidated) 

TITLE VI—TRANSPARENCY AND 

PROGRAM INTEGRITY 

Subtitle A—Physician Ownership and 

Other Transparency 

SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS. 

(a) IN GENERAL.—Section 1877 of the Social Security Act (42 

U.S.C. 1395nn) is amended— 

(1) in subsection (d)(2)— 

(A) in subparagraph (A), by striking ‘‘and’’ at the end; 

(B) in subparagraph (B), by striking the period at the 

end and inserting ‘‘; and’’; and 

(C) by adding at the end the following new subparagraph: 

‘‘(C) in the case where the entity is a hospital, the hospital meets the requirements of paragraph (3)(D).’’; 

(2) in subsection (d)(3)— 

(A) in subparagraph (B), by striking ‘‘and’’ at the end; 

(B) in subparagraph (C), by striking the period at the 

end and inserting ‘‘; and’’; and 

(C) by adding at the end the following new subparagraph: 

‘‘(D) the hospital meets the requirements described in 

subsection (i)(1) not later than 18 months after the date of 

the enactment of this subparagraph.’’; 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 December 31, 2010; and øsection 10601(a)(1) amended this 

clause by striking ‘February 1’ and inserting ‘August 1’; 

section 1106(1) of HCERA further amended this clause 

by striking ‘August 1, 2010’ and inserting ‘December 

31, 2010’; shown to reflect probable intent¿ 

‘‘(ii) a provider agreement under section 1866 in 

effect on such date. 

‘‘(B) LIMITATION ON EXPANSION OF FACILITY CAPAC- ITY.—Except as provided in paragraph (3), the number of 

operating rooms, procedure rooms, and beds for which the 

hospital is licensed at any time on or after the date of the 

enactment of this subsection is no greater than the number of operating rooms, procedure rooms, and beds for 

which the hospital is licensed as of such date. 

‘‘(C) PREVENTING CONFLICTS OF INTEREST.— 
Sec. 6001 PPACA (Consolidated) 620 

‘‘(i) The hospital submits to the Secretary an annual report containing a detailed description of— 

‘‘(I) the identity of each physician owner or 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 interests either directly or 

indirectly on the physician owner or investor making 

or influencing referrals to the hospital or otherwise 

generating business for the hospital. 

‘‘(iv) The hospital discloses the fact that the hospital is partially owned or invested in by physicians— 

‘‘(I) on any public website for the hospital; and 

‘‘(II) in any public advertising for the hospital. 

‘‘(D) ENSURING BONA FIDE INVESTMENT.— 

‘‘(i) 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. 

‘‘(ii) 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. 

‘‘(iii) The hospital (or any owner or investor in the 

hospital) does not directly or indirectly provide loans 

or financing for any investment in the hospital by a 

physician owner or investor. 

‘‘(iv) The hospital (or any owner or investor 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. 

‘‘(v) Ownership or investment returns are distributed to each owner or investor in the hospital in an 

amount that is directly proportional to the ownership 
621 Sec. 6001 PPACA (Consolidated) 

or investment interest of such owner or investor in the 

hospital. 

‘‘(vi) Physician owners and investors do not receive, directly or indirectly, any guaranteed receipt of 

or right to purchase other business interests related to 

the hospital, including the purchase or lease of any 

property under the control of other owners or investors 

in the hospital or located near the premises of the hospital. 

‘‘(vii) The hospital does not offer a physician 

owner or investor the opportunity to purchase or lease 

any property under the control of the hospital or any 

other owner or investor in the hospital on more favorable terms than the terms offered to an individual who 

is not a physician owner or investor. 

‘‘(E) PATIENT SAFETY.— ‘‘(i) Insofar as the hospital 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— 

‘‘(I) the hospital discloses such fact to a patient; and 

‘‘(II) following such disclosure, the hospital receives from the patient a signed acknowledgment 

that the patient understands such fact. 

‘‘(ii) 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. 

‘‘(F) LIMITATION ON APPLICATION TO CERTAIN CONVERTED FACILITIES.—The hospital was not converted from 

an ambulatory surgical center to a hospital on or after the 

date of enactment of this subsection. 

‘‘(2) PUBLICATION OF INFORMATION REPORTED.—The Secretary shall publish, and update on an annual basis, the information submitted by hospitals under paragraph (1)(C)(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 a hospital 

that is an applicable hospital (as defined in subparagraph (E)) or is a high Medicaid facility described in 

subparagraph (F) may apply for an exception from the 

requirement under paragraph (1)(B). øAs revised by 

section 1106(2)(A) of HCERA¿ 

‘‘(ii) OPPORTUNITY FOR COMMUNITY INPUT.—The 

process under clause (i) shall provide individuals and 

entities in the community in which the applicable hos-
Sec. 6001 PPACA (Consolidated) 622 

pital 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 

February 1, 2012. øAs revised by section 

10601(a)(2)(A)¿ 

‘‘(iv) REGULATIONS.—Not later than January 1, 

2012, the Secretary shall promulgate regulations to 

carry out the process under clause (i). øAs revised by 

section 10601(a)(2)(B)¿ 

‘‘(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 for which the applicable hospital is licensed 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 for which the hospital is licensed 

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 for which 

an applicable hospital is licensed under clause (i) to 

the extent such increase would result in the number 

of operating rooms, procedure rooms, and beds for 

which the applicable hospital is licensed 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 for which the applicable hospital is licensed as of the date of enactment 

of this subsection (or, in the case of a hospital that did 

not have a provider agreement in effect as of such date 

but does have such an agreement in effect on December 31, 2010, the effective date of such provider agreement). øAs revised by section 1106(2)(B) of HCERA¿ 

‘‘(D) INCREASE LIMITED TO FACILITIES ON THE MAIN

CAMPUS OF THE HOSPITAL.—Any increase in the number of 

operating rooms, procedure rooms, and beds for which an 

applicable hospital is licensed pursuant to this paragraph 

may only occur in facilities on the main campus of the applicable hospital. 
623 Sec. 6001 PPACA (Consolidated) 

‘‘(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; 

‘‘(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) HIGH MEDICAID FACILITY DESCRIBED.—øAs added 

by section 1106(2)(D) of HCERA¿ A high Medicaid facility 

described in this subparagraph is a hospital that— 

‘‘(i) is not the sole hospital in a county; 

‘‘(ii) with respect to each of the 3 most recent 

years for which data are available, has an annual percent of total inpatient admissions that represent inpatient admissions under title XIX that is estimated to 

be greater than such percent with respect to such admissions for any other hospital located in the county 

in which the hospital is located; and 

‘‘(iii) meets the conditions described in subparagraph (E)(iii). 

‘‘(G) 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). 

‘‘(H) 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. 

‘‘(I) 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). 
Sec. 6002 PPACA (Consolidated) 624 

‘‘(4) COLLECTION OF OWNERSHIP AND INVESTMENT INFORMATION.—For purposes of subparagraphs (A)(i) and (D)(i) 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) 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 subsection 

(i)(1) 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 May 1, 2012, the 

Secretary of Health and Human Services shall conduct audits 

to determine if hospitals violate the requirements referred to 

in paragraph (1). øAs revised by section 10601(b)¿ 

SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN 

OWNERSHIP OR INVESTMENT INTERESTS. 

Part A of 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. ø42 U.S.C. 1320a–7h¿ TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN OWNERSHIP OR INVESTMENT INTERESTS. 

‘‘(a) TRANSPARENCY REPORTS.— 

‘‘(1) PAYMENTS OR OTHER TRANSFERS OF VALUE.— 

‘‘(A) IN GENERAL.—On March 31, 2013, and on the 

90th day of each calendar year beginning thereafter, any 

applicable manufacturer that provides a payment or other 

transfer of value to a covered recipient (or to an entity or 

individual at the request of or designated on behalf of a 

covered recipient), shall submit to the Secretary, in such 

electronic form as the Secretary shall require, the following information with respect to the preceding calendar 

year: 

‘‘(i) The name of the covered recipient. 

‘‘(ii) The business address of the covered recipient 

and, in the case of a covered recipient who is a physician, the specialty and National Provider Identifier of 

the covered recipient. 

‘‘(iii) The amount of the payment or other transfer 

of value. 

‘‘(iv) The dates on which the payment or other 

transfer of value was provided to the covered recipient. 
625 Sec. 6002 PPACA (Consolidated) \1128G SSA 

‘‘(v) A description of the form of the payment or 

other transfer of value, indicated (as appropriate for 

all that apply) as— 

‘‘(I) cash or a cash equivalent; 

‘‘(II) in-kind items or services; 

‘‘(III) stock, a stock option, or any other ownership interest, dividend, profit, or other return on 

investment; or 

‘‘(IV) any other form of payment or other 

transfer of value (as defined by the Secretary). 

‘‘(vi) A description of the nature of the payment or 

other transfer of value, indicated (as appropriate for 

all that apply) as— 

‘‘(I) consulting fees; 

‘‘(II) compensation for services other than consulting; 

‘‘(III) honoraria; 

‘‘(IV) gift; 

‘‘(V) entertainment; 

‘‘(VI) food; 

‘‘(VII) travel (including the specified destinations); 

‘‘(VIII) education; 

‘‘(IX) research; 

‘‘(X) charitable contribution; 

‘‘(XI) royalty or license; 

‘‘(XII) current or prospective ownership or investment interest; 

‘‘(XIII) direct compensation for serving as faculty or as a speaker for a medical education program; 

‘‘(XIV) grant; or 

‘‘(XV) any other nature of the payment or 

other transfer of value (as defined by the Secretary). 

‘‘(vii) If the payment or other transfer of value is 

related to marketing, education, or research specific to 

a covered drug, device, biological, or medical supply, 

the name of that covered drug, device, biological, or 

medical supply. 

‘‘(viii) Any other categories of information regarding the payment or other transfer of value the Secretary determines appropriate. 

‘‘(B) SPECIAL RULE FOR CERTAIN PAYMENTS OR OTHER

TRANSFERS OF VALUE.—In the case where an applicable 

manufacturer provides a payment or other transfer of 

value to an entity or individual at the request of or designated on behalf of a covered recipient, the applicable 

manufacturer shall disclose that payment or other transfer 

of value under the name of the covered recipient. 

‘‘(2) PHYSICIAN OWNERSHIP.—In addition to the requirement under paragraph (1)(A), on March 31, 2013, and on the 

90th day of each calendar year beginning thereafter, any applicable manufacturer or applicable group purchasing organiza-
Sec. 6002\1128G SSA PPACA (Consolidated) 626 

tion shall submit to the Secretary, in such electronic form as 

the Secretary shall require, the following information regarding any ownership or investment interest (other than an ownership or investment interest in a publicly traded security and 

mutual fund, as described in section 1877(c)) held by a physician (or an immediate family member of such physician (as defined for purposes of section 1877(a))) in the applicable manufacturer or applicable group purchasing organization during 

the preceding year: 

‘‘(A) The dollar amount invested by each physician 

holding such an ownership or investment interest. 

‘‘(B) The value and terms of each such ownership or 

investment interest. 

‘‘(C) Any payment or other transfer of value provided 

to a physician holding such an ownership or investment interest (or to an entity or individual at the request of or 

designated on behalf of a physician holding such an ownership or investment interest), including the information described in clauses (i) through (viii) of paragraph (1)(A), except that in applying such clauses, ‘physician’ shall be substituted for ‘covered recipient’ each place it appears. 

‘‘(D) Any other information regarding the ownership or 

investment interest the Secretary determines appropriate. 

‘‘(b) PENALTIES FOR NONCOMPLIANCE.— ‘‘(1) FAILURE TO REPORT.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B) except 

as provided in paragraph (2), any applicable manufacturer 

or applicable group purchasing organization that fails to 

submit information required under subsection (a) in a 

timely manner in accordance with rules or regulations promulgated to carry out such subsection, shall be subject to 

a civil money penalty of not less than $1,000, but not more 

than $10,000, for each payment or other transfer of value 

or ownership or investment interest not reported as required under such subsection. Such penalty shall be imposed and collected in the same manner as civil money 

penalties under subsection (a) of section 1128A are imposed and collected under that section. 

‘‘(B) LIMITATION.—The total amount of civil money 

penalties imposed under subparagraph (A) with respect to 

each annual submission of information under subsection 

(a) by an applicable manufacturer or applicable group purchasing organization shall not exceed $150,000. 

‘‘(2) KNOWING FAILURE TO REPORT.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), any 

applicable manufacturer or applicable group purchasing 

organization that knowingly fails to submit information required under subsection (a) in a timely manner in accordance with rules or regulations promulgated to carry out 

such subsection, shall be subject to a civil money penalty 

of not less than $10,000, but not more than $100,000, for 

each payment or other transfer of value or ownership or 

investment interest not reported as required under such 

subsection. Such penalty shall be imposed and collected in 
627 Sec. 6002 PPACA (Consolidated) \1128G SSA 

the same manner as civil money penalties under subsection (a) of section 1128A are imposed and collected 

under that section. 

‘‘(B) LIMITATION.—The total amount of civil money 

penalties imposed under subparagraph (A) with respect to 

each annual submission of information under subsection 

(a) by an applicable manufacturer or applicable group purchasing organization shall not exceed $1,000,000. 

‘‘(3) USE OF FUNDS.—Funds collected by the Secretary as 

a result of the imposition of a civil money penalty under this 

subsection shall be used to carry out this section. 

‘‘(c) PROCEDURES FOR SUBMISSION OF INFORMATION AND PUBLIC

AVAILABILITY.— ‘‘(1) IN GENERAL.— ‘‘(A) ESTABLISHMENT.—Not later than October 1, 2011, 

the Secretary shall establish procedures— 

‘‘(i) for applicable manufacturers and applicable 

group purchasing organizations to submit information 

to the Secretary under subsection (a); and 

‘‘(ii) for the Secretary to make such information 

submitted available to the public. 

‘‘(B) DEFINITION OF TERMS.—The procedures established under subparagraph (A) shall provide for the definition of terms (other than those terms defined in subsection 

(e)), as appropriate, for purposes of this section. 

‘‘(C) PUBLIC AVAILABILITY.—Except as provided in subparagraph (E), the procedures established under subparagraph (A)(ii) shall ensure that, not later than September 

30, 2013, and on June 30 of each calendar year beginning 

thereafter, the information submitted under subsection (a) 

with respect to the preceding calendar year is made available through an Internet website that— 

‘‘(i) is searchable and is in a format that is clear 

and understandable; 

‘‘(ii) contains information that is presented by the 

name of the applicable manufacturer or applicable 

group purchasing organization, the name of the covered recipient, the business address of the covered recipient, the specialty of the covered recipient, the 

value of the payment or other transfer of value, the 

date on which the payment or other transfer of value 

was provided to the covered recipient, the form of the 

payment or other transfer of value, indicated (as appropriate) under subsection (a)(1)(A)(v), the nature of 

the payment or other transfer of value, indicated (as 

appropriate) under subsection (a)(1)(A)(vi), and the 

name of the covered drug, device, biological, or medical 

supply, as applicable; 

‘‘(iii) contains information that is able to be easily 

aggregated and downloaded; 

‘‘(iv) contains a description of any enforcement actions taken to carry out this section, including any 

penalties imposed under subsection (b), during the 

preceding year; 
Sec. 6002\1128G SSA PPACA (Consolidated) 628 

‘‘(v) contains background information on industryphysician relationships; 

‘‘(vi) in the case of information submitted with respect to a payment or other transfer of value described 

in subparagraph (E)(i), lists such information separately from the other information submitted under 

subsection (a) and designates such separately listed 

information as funding for clinical research; 

‘‘(vii) contains any other information the Secretary 

determines would be helpful to the average consumer; 

‘‘(viii) does not contain the National Provider Identifier of the covered recipient, and 

‘‘(ix) subject to subparagraph (D), provides the applicable manufacturer, applicable group purchasing organization, or covered recipient an opportunity to review and submit corrections to the information submitted with respect to the applicable manufacturer, 

applicable group purchasing organization, or covered 

recipient, respectively, for a period of not less than 45 

days prior to such information being made available to 

the public. 

‘‘(D) CLARIFICATION OF TIME PERIOD FOR REVIEW AND

CORRECTIONS.—In no case may the 45-day period for review and submission of corrections to information under 

subparagraph (C)(ix) prevent such information from being 

made available to the public in accordance with the dates 

described in the matter preceding clause (i) in subparagraph (C). 

‘‘(E) DELAYED PUBLICATION FOR PAYMENTS MADE PURSUANT TO PRODUCT RESEARCH OR DEVELOPMENT AGREEMENTS AND CLINICAL INVESTIGATIONS.— 

‘‘(i) IN GENERAL.—In the case of information submitted under subsection (a) with respect to a payment 

or other transfer of value made to a covered recipient 

by an applicable manufacturer pursuant to a product 

research or development agreement for services furnished in connection with research on a potential new 

medical technology or a new application of an existing 

medical technology or the development of a new drug, 

device, biological, or medical supply, or by an applicable manufacturer in connection with a clinical investigation regarding a new drug, device, biological, or 

medical supply, the procedures established under subparagraph (A)(ii) shall provide that such information 

is made available to the public on the first date described in the matter preceding clause (i) in subparagraph (C) after the earlier of the following: 

‘‘(I) The date of the approval or clearance of 

the covered drug, device, biological, or medical 

supply by the Food and Drug Administration. 

‘‘(II) Four calendar years after the date such 

payment or other transfer of value was made. 

‘‘(ii) CONFIDENTIALITY OF INFORMATION PRIOR TO

PUBLICATION.—Information described in clause (i) 
629 Sec. 6002 PPACA (Consolidated) \1128G SSA 

shall be considered confidential and shall not be subject to disclosure under section 552 of title 5, United 

States Code, or any other similar Federal, State, or 

local law, until on or after the date on which the information is made available to the public under such 

clause. 

‘‘(2) CONSULTATION.—In establishing the procedures under 

paragraph (1), the Secretary shall consult with the Inspector 

General of the Department of Health and Human Services, affected industry, consumers, consumer advocates, and other interested parties in order to ensure that the information made 

available to the public under such paragraph is presented in 

the appropriate overall context. 

‘‘(d) ANNUAL REPORTS AND RELATION TO STATE LAWS.— ‘‘(1) ANNUAL REPORT TO CONGRESS.—Not later than April 

1 of each year beginning with 2013, the Secretary shall submit 

to Congress a report that includes the following: 

‘‘(A) The information submitted under subsection (a) 

during the preceding year, aggregated for each applicable 

manufacturer and applicable group purchasing organization that submitted such information during such year (except, in the case of information submitted with respect to 

a payment or other transfer of value described in subsection (c)(1)(E)(i), such information shall be included in 

the first report submitted to Congress after the date on 

which such information is made available to the public 

under such subsection). 

‘‘(B) A description of any enforcement actions taken to 

carry out this section, including any penalties imposed 

under subsection (b), during the preceding year. 

‘‘(2) ANNUAL REPORTS TO STATES.—Not later than September 30, 2013 and on June 30 of each calendar year thereafter, the Secretary shall submit to States a report that includes a summary of the information submitted under subsection (a) during the preceding year with respect to covered 

recipients in the State (except, in the case of information submitted with respect to a payment or other transfer of value described in subsection (c)(1)(E)(i), such information shall be included in the first report submitted to States after the date on 

which such information is made available to the public under 

such subsection). 

‘‘(3) RELATION TO STATE LAWS.— 

‘‘(A) IN GENERAL.—In the case of a payment or other 

transfer of value provided by an applicable manufacturer 

that is received by a covered recipient (as defined in subsection (e)) on or after January 1, 2012, subject to subparagraph (B), the provisions of this section shall preempt any 

statute or regulation of a State or of a political subdivision 

of a State that requires an applicable manufacturer (as so 

defined) to disclose or report, in any format, the type of information (as described in subsection (a)) regarding such 

payment or other transfer of value. 

‘‘(B) NO PREEMPTION OF ADDITIONAL REQUIREMENTS.— 

Subparagraph (A) shall not preempt any statute or regula-
Sec. 6002\1128G SSA PPACA (Consolidated) 630 

tion of a State or of a political subdivision of a State that 

requires the disclosure or reporting of information— 

‘‘(i) not of the type required to be disclosed or reported under this section; 

‘‘(ii) described in subsection (e)(10)(B), except in 

the case of information described in clause (i) of such 

subsection; 

‘‘(iii) by any person or entity other than an applicable manufacturer (as so defined) or a covered recipient (as defined in subsection (e)); or 

‘‘(iv) to a Federal, State, or local governmental 

agency for public health surveillance, investigation, or 

other public health purposes or health oversight purposes. 

‘‘(C) Nothing in subparagraph (A) shall be construed to 

limit the discovery or admissibility of information described in such subparagraph in a criminal, civil, or administrative proceeding. 

‘‘(4) CONSULTATION.—The Secretary shall consult with the 

Inspector General of the Department of Health and Human 

Services on the implementation of this section. 

‘‘(e) DEFINITIONS.—In this section: 

‘‘(1) APPLICABLE GROUP PURCHASING ORGANIZATION.—The 

term ‘applicable group purchasing organization’ means a group 

purchasing organization (as defined by the Secretary) that purchases, arranges for, or negotiates the purchase of a covered 

drug, device, biological, or medical supply which is operating in 

the United States, or in a territory, possession, or commonwealth of the United States. 

‘‘(2) APPLICABLE MANUFACTURER.—The term ‘applicable 

manufacturer’ means a manufacturer of a covered drug, device, 

biological, or medical supply which is operating in the United 

States, or in a territory, possession, or commonwealth of the 

United States. 

‘‘(3) CLINICAL INVESTIGATION.—The term ‘clinical investigation’ means any experiment involving 1 or more human subjects, or materials derived from human subjects, in which a 

drug or device is administered, dispensed, or used. 

‘‘(4) COVERED DEVICE.—The term ‘covered device’ means 

any device for which payment is available under title XVIII or 

a State plan under title XIX or XXI (or a waiver of such a 

plan). 

‘‘(5) COVERED DRUG, DEVICE, BIOLOGICAL, OR MEDICAL SUPPLY.—The term ‘covered drug, device, biological, or medical 

supply’ means any drug, biological product, device, or medical 

supply for which payment is available under title XVIII or a 

State plan under title XIX or XXI (or a waiver of such a plan). 

‘‘(6) COVERED RECIPIENT.— 

‘‘(A) IN GENERAL.—Except as provided in subparagraph (B), the term ‘covered recipient’ means the following: 

‘‘(i) A physician. 

‘‘(ii) A teaching hospital. 

‘‘(B) EXCLUSION.—Such term does not include a physician who is an employee of the applicable manufacturer 
631 Sec. 6002 PPACA (Consolidated) \1128G SSA 

that is required to submit information under subsection 

(a). 

‘‘(7) EMPLOYEE.—The term ‘employee’ has the meaning 

given such term in section 1877(h)(2). 

‘‘(8) KNOWINGLY.—The term ‘knowingly’ has the meaning 

given such term in section 3729(b) of title 31, United States 

Code. 

‘‘(9) MANUFACTURER OF A COVERED DRUG, DEVICE, BIOLOGI- CAL, OR MEDICAL SUPPLY.—The term ‘manufacturer of a covered drug, device, biological, or medical supply’ means any entity which is engaged in the production, preparation, propagation, compounding, or conversion of a covered drug, device, biological, or medical supply (or any entity under common ownership with such entity which provides assistance or support to 

such entity with respect to the production, preparation, propagation, compounding, conversion, marketing, promotion, sale, 

or distribution of a covered drug, device, biological, or medical 

supply). 

‘‘(10) PAYMENT OR OTHER TRANSFER OF VALUE.— ‘‘(A) IN GENERAL.—The term ‘payment or other transfer of value’ means a transfer of anything of value. Such 

term does not include a transfer of anything of value that 

is made indirectly to a covered recipient through a third 

party in connection with an activity or service in the case 

where the applicable manufacturer is unaware of the identity of the covered recipient. 

‘‘(B) EXCLUSIONS.—An applicable manufacturer shall 

not be required to submit information under subsection (a) 

with respect to the following: 

‘‘(i) A transfer of anything the value of which is 

less than $10, unless the aggregate amount transferred to, requested by, or designated on behalf of the 

covered recipient by the applicable manufacturer during the calendar year exceeds $100. For calendar years 

after 2012, the dollar amounts specified in the preceding sentence shall be increased by the same percentage as the percentage increase in the consumer 

price index for all urban consumers (all items; U.S. 

city average) for the 12-month period ending with 

June of the previous year. 

‘‘(ii) Product samples that are not intended to be 

sold and are intended for patient use. 

‘‘(iii) Educational materials that directly benefit 

patients or are intended for patient use. 

‘‘(iv) The loan of a covered device for a short-term 

trial period, not to exceed 90 days, to permit evaluation of the covered device by the covered recipient. 

‘‘(v) Items or services provided under a contractual 

warranty, including the replacement of a covered device, where the terms of the warranty are set forth in 

the purchase or lease agreement for the covered device. 

‘‘(vi) A transfer of anything of value to a covered 

recipient when the covered recipient is a patient and 
Sec. 6003 PPACA (Consolidated) 632 

not acting in the professional capacity of a covered recipient. 

‘‘(vii) Discounts (including rebates). 

‘‘(viii) In-kind items used for the provision of charity care. 

‘‘(ix) A dividend or other profit distribution from, 

or ownership or investment interest in, a publicly 

traded security and mutual fund (as described in section 1877(c)). 

‘‘(x) In the case of an applicable manufacturer who 

offers a self-insured plan, payments for the provision 

of health care to employees under the plan. 

‘‘(xi) In the case of a covered recipient who is a licensed non-medical professional, a transfer of anything of value to the covered recipient if the transfer 

is payment solely for the non-medical professional 

services of such licensed non-medical professional. 

‘‘(xii) In the case of a covered recipient who is a 

physician, a transfer of anything of value to the covered recipient if the transfer is payment solely for the 

services of the covered recipient with respect to a civil 

or criminal action or an administrative proceeding. 

‘‘(11) PHYSICIAN.—The term ‘physician’ has the meaning 

given that term in section 1861(r).’’. 

SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE ANCILLARY 

SERVICES EXCEPTION TO THE PROHIBITION ON PHYSICIAN SELF-REFERRAL FOR CERTAIN IMAGING SERVICES. 

(a) IN GENERAL.—Section 1877(b)(2) of the Social Security Act 

(42 U.S.C. 1395nn(b)(2)) is amended by adding at the end the following new sentence: ‘‘Such requirements shall, with respect to 

magnetic resonance imaging, computed tomography, positron emission tomography, and any other designated health services specified under subsection (h)(6)(D) that the Secretary determines appropriate, include a requirement that the referring physician inform the individual in writing at the time of the referral that the 

individual may obtain the services for which the individual is being 

referred from a person other than a person described in subparagraph (A)(i) and provide such individual with a written list of suppliers (as defined in section 1861(d)) who furnish such services in 

the area in which such individual resides.’’. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall apply to services furnished on or after January 1, 2010. 

SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY. 

Part A of title XI of the Social Security Act (42 U.S.C. 1301 et 

seq.), as amended by section 6002, is amended by inserting after 

section 1128G the following new section: 

‘‘SEC. 1128H. ø42 U.S.C. 1320a–7i¿ REPORTING OF INFORMATION RELATING TO DRUG SAMPLES. 

‘‘(a) IN GENERAL.—Not later than April 1 of each year (beginning with 2012), each manufacturer and authorized distributor of 

record of an applicable drug shall submit to the Secretary (in a 

form and manner specified by the Secretary) the following information with respect to the preceding year: 
633 Sec. 6005 PPACA (Consolidated) \1150A SSA 

‘‘(1) In the case of a manufacturer or authorized distributor 

of record which makes distributions by mail or common carrier 

under subsection (d)(2) of section 503 of the Federal Food, 

Drug, and Cosmetic Act (21 U.S.C. 353), the identity and quantity of drug samples requested and the identity and quantity 

of drug samples distributed under such subsection during that 

year, aggregated by— 

‘‘(A) the name, address, professional designation, and 

signature of the practitioner making the request under 

subparagraph (A)(i) of such subsection, or of any individual 

who makes or signs for the request on behalf of the practitioner; and 

‘‘(B) any other category of information determined appropriate by the Secretary. 

‘‘(2) In the case of a manufacturer or authorized distributor 

of record which makes distributions by means other than mail 

or common carrier under subsection (d)(3) of such section 503, 

the identity and quantity of drug samples requested and the 

identity and quantity of drug samples distributed under such 

subsection during that year, aggregated by— 

‘‘(A) the name, address, professional designation, and 

signature of the practitioner making the request under 

subparagraph (A)(i) of such subsection, or of any individual 

who makes or signs for the request on behalf of the practitioner; and 

‘‘(B) any other category of information determined appropriate by the Secretary. 

‘‘(b) DEFINITIONS.—In this section: 

‘‘(1) APPLICABLE DRUG.—The term ‘applicable drug’ means 

a drug— 

‘‘(A) which is subject to subsection (b) of such section 

503; and 

‘‘(B) for which payment is available under title XVIII 

or a State plan under title XIX or XXI (or a waiver of such 

a plan). 

‘‘(2) AUTHORIZED DISTRIBUTOR OF RECORD.—The term ‘authorized distributor of record’ has the meaning given that term 

in subsection (e)(3)(A) of such section. 

‘‘(3) MANUFACTURER.—The term ‘manufacturer’ has the 

meaning given that term for purposes of subsection (d) of such 

section.’’. 

SEC. 6005. PHARMACY BENEFIT MANAGERS TRANSPARENCY REQUIREMENTS. 

Part A of title XI of the Social Security Act (42 U.S.C. 1301 et 

seq.) is amended by inserting after section 1150 the following new 

section: 

‘‘SEC. 1150A. ø42 U.S.C. 1320b–23¿ PHARMACY BENEFIT MANAGERS 

TRANSPARENCY REQUIREMENTS. 

‘‘(a) PROVISION OF INFORMATION.—A health benefits plan or 

any entity that provides pharmacy benefits management services 

on behalf of a health benefits plan (in this section referred to as 

a ‘PBM’) that manages prescription drug coverage under a contract 

with— 
Sec. 6005\1150A SSA PPACA (Consolidated) 634 

‘‘(1) a PDP sponsor of a prescription drug plan or an MA 

organization offering an MA–PD plan under part D of title 

XVIII; or 

‘‘(2) a qualified health benefits plan offered through an exchange established by a State under section 1311 of the Patient Protection and Affordable Care Act, 

shall provide the information described in subsection (b) to the Secretary and, in the case of a PBM, to the plan with which the PBM 

is under contract with, at such times, and in such form and manner, as the Secretary shall specify. 

‘‘(b) INFORMATION DESCRIBED.—The information described in 

this subsection is the following with respect to services provided by 

a health benefits plan or PBM for a contract year: 

‘‘(1) The percentage of all prescriptions that were provided 

through retail pharmacies compared to mail order pharmacies, 

and the percentage of prescriptions for which a generic drug 

was available and dispensed (generic dispensing rate), by pharmacy type (which includes an independent pharmacy, chain 

pharmacy, supermarket pharmacy, or mass merchandiser 

pharmacy that is licensed as a pharmacy by the State and that 

dispenses medication to the general public), that is paid by the 

health benefits plan or PBM under the contract. 

‘‘(2) The aggregate amount, and the type of rebates, discounts, or price concessions (excluding bona fide service fees, 

which include but are not limited to distribution service fees, 

inventory management fees, product stocking allowances, and 

fees associated with administrative services agreements and 

patient care programs (such as medication compliance programs and patient education programs)) that the PBM negotiates that are attributable to patient utilization under the 

plan, and the aggregate amount of the rebates, discounts, or 

price concessions that are passed through to the plan sponsor, 

and the total number of prescriptions that were dispensed. 

‘‘(3) The aggregate amount of the difference between the 

amount the health benefits plan pays the PBM and the 

amount that the PBM pays retail pharmacies, and mail order 

pharmacies, and the total number of prescriptions that were 

dispensed. 

‘‘(c) CONFIDENTIALITY.—Information disclosed by a health benefits plan or PBM under this section is confidential and shall not be 

disclosed by the Secretary or by a plan receiving the information, 

except that the Secretary may disclose the information in a form 

which does not disclose the identity of a specific PBM, plan, or 

prices charged for drugs, for the following purposes: 

‘‘(1) As the Secretary determines to be necessary to carry 

out this section or part D of title XVIII. 

‘‘(2) To permit the Comptroller General to review the information provided. 

‘‘(3) To permit the Director of the Congressional Budget 

Office to review the information provided. 

‘‘(4) To States to carry out section 1311 of the Patient Protection and Affordable Care Act. 

‘‘(d) PENALTIES.—The provisions of subsection (b)(3)(C) of section 1927 shall apply to a health benefits plan or PBM that fails 
635 Sec. 6101 PPACA (Consolidated) 

to provide information required under subsection (a) on a timely 

basis or that knowingly provides false information in the same 

manner as such provisions apply to a manufacturer with an agreement under that section.’’. 

Subtitle B—Nursing Home Transparency 

and Improvement 

PART 1—IMPROVING TRANSPARENCY OF 

INFORMATION 

SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL 

DISCLOSABLE PARTIES INFORMATION. 

(a) IN GENERAL.—Section 1124 of the Social Security Act (42 

U.S.C. 1320a–3) is amended by adding at the end the following 

new subsection: 

‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL

DISCLOSABLE PARTIES INFORMATION.— ‘‘(1) DISCLOSURE.—A facility shall have the information described in paragraph (2) available— 

‘‘(A) during the period beginning on the date of the enactment of this subsection and ending on the date such information is made available to the public under section 

6101(b) of the Patient Protection and Affordable Care Act 

for submission to the Secretary, the Inspector General of 

the Department of Health and Human Services, the State 

in which the facility is located, and the State long-term 

care ombudsman in the case where the Secretary, the Inspector General, the State, or the State long-term care ombudsman requests such information; and 

‘‘(B) beginning on the effective date of the final regulations promulgated under paragraph (3)(A), for reporting 

such information in accordance with such final regulations. 

Nothing in subparagraph (A) shall be construed as authorizing 

a facility to dispose of or delete information described in such 

subparagraph after the effective date of the final regulations 

promulgated under paragraph (3)(A). 

‘‘(2) INFORMATION DESCRIBED.— 

‘‘(A) IN GENERAL.—The following information is described in this paragraph: 

‘‘(i) The information described in subsections (a) 

and (b), subject to subparagraph (C). 

‘‘(ii) The identity of and information on— 

‘‘(I) each member of the governing body of the 

facility, including the name, title, and period of 

service of each such member; 

‘‘(II) each person or entity who is an officer, 

director, member, partner, trustee, or managing 

employee of the facility, including the name, title, 

and period of service of each such person or entity; 

and 

‘‘(III) each person or entity who is an additional disclosable party of the facility. 
Sec. 6101 PPACA (Consolidated) 636 

‘‘(iii) The organizational structure of each additional disclosable party of the facility and a description 

of the relationship of each such additional disclosable 

party to the facility and to one another. 

‘‘(B) SPECIAL RULE WHERE INFORMATION IS ALREADY

REPORTED OR SUBMITTED.—To the extent that information 

reported by a facility to the Internal Revenue Service on 

Form 990, information submitted by a facility to the Securities and Exchange Commission, or information otherwise 

submitted to the Secretary or any other Federal agency 

contains the information described in clauses (i), (ii), or 

(iii) of subparagraph (A), the facility may provide such 

Form or such information submitted to meet the requirements of paragraph (1). 

‘‘(C) SPECIAL RULE.—In applying subparagraph (A)(i)— 

‘‘(i) with respect to subsections (a) and (b), ‘ownership or control interest’ shall include direct or indirect 

interests, including such interests in intermediate entities; and 

‘‘(ii) subsection (a)(3)(A)(ii) shall include the owner 

of a whole or part interest in any mortgage, deed of 

trust, note, or other obligation secured, in whole or in 

part, by the entity or any of the property or assets 

thereof, if the interest is equal to or exceeds 5 percent 

of the total property or assets of the entirety. 

‘‘(3) REPORTING.— ‘‘(A) IN GENERAL.—Not later than the date that is 2 

years after the date of the enactment of this subsection, 

the Secretary shall promulgate final regulations requiring, 

effective on the date that is 90 days after the date on 

which such final regulations are published in the Federal 

Register, a facility to report the information described in 

paragraph (2) to the Secretary in a standardized format, 

and such other regulations as are necessary to carry out 

this subsection. Such final regulations shall ensure that 

the facility certifies, as a condition of participation and 

payment under the program under title XVIII or XIX, that 

the information reported by the facility in accordance with 

such final regulations is, to the best of the facility’s knowledge, accurate and current. 

‘‘(B) GUIDANCE.—The Secretary shall provide guidance 

and technical assistance to States on how to adopt the 

standardized format under subparagraph (A). 

‘‘(4) NO EFFECT ON EXISTING REPORTING REQUIREMENTS.— 

Nothing in this subsection shall reduce, diminish, or alter any 

reporting requirement for a facility that is in effect as of the 

date of the enactment of this subsection. 

‘‘(5) DEFINITIONS.—In this subsection: 

‘‘(A) ADDITIONAL DISCLOSABLE PARTY.—The term ‘additional disclosable party’ means, with respect to a facility, 

any person or entity who— 

‘‘(i) exercises operational, financial, or managerial 

control over the facility or a part thereof, or provides 

policies or procedures for any of the operations of the 
637 Sec. 6101 PPACA (Consolidated) 

facility, or provides financial or cash management 

services to the facility; 

‘‘(ii) leases or subleases real property to the facility, or owns a whole or part interest equal to or exceeding 5 percent of the total value of such real property; or 

‘‘(iii) provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility. 

‘‘(B) FACILITY.—The term ‘facility’ means a disclosing 

entity which is— 

‘‘(i) a skilled nursing facility (as defined in section 

1819(a)); or 

‘‘(ii) a nursing facility (as defined in section 

1919(a)). 

‘‘(C) MANAGING EMPLOYEE.—The term ‘managing employee’ means, with respect to a facility, an individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly 

manages, advises, or supervises any element of the practices, finances, or operations of the facility. 

‘‘(D) ORGANIZATIONAL STRUCTURE.—The term ‘organizational structure’ means, in the case of— 

‘‘(i) a corporation, the officers, directors, and 

shareholders of the corporation who have an ownership interest in the corporation which is equal to or 

exceeds 5 percent; 

‘‘(ii) a limited liability company, the members and 

managers of the limited liability company (including, 

as applicable, what percentage each member and manager has of the ownership interest in the limited liability company); 

‘‘(iii) a general partnership, the partners of the 

general partnership; 

‘‘(iv) a limited partnership, the general partners 

and any limited partners of the limited partnership 

who have an ownership interest in the limited partnership which is equal to or exceeds 10 percent; 

‘‘(v) a trust, the trustees of the trust; 

‘‘(vi) an individual, contact information for the individual; and 

‘‘(vii) any other person or entity, such information 

as the Secretary determines appropriate.’’. 

(b) PUBLIC AVAILABILITY OF INFORMATION.—Not later than the 

date that is 1 year after the date on which the final regulations 

promulgated under section 1124(c)(3)(A) of the Social Security Act, 

as added by subsection (a), are published in the Federal Register, 

the Secretary of Health and Human Services shall make the information reported in accordance with such final regulations available 

to the public in accordance with procedures established by the Secretary. 

(c) CONFORMING AMENDMENTS.— 

(1) IN GENERAL.— 
Sec. 6102 PPACA (Consolidated) 638 

(A) SKILLED NURSING FACILITIES.—Section 1819(d)(1) 

of the Social Security Act (42 U.S.C. 1395i–3(d)(1)) is 

amended by striking subparagraph (B) and redesignating 

subparagraph (C) as subparagraph (B). 

(B) NURSING FACILITIES.—Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)) is amended by 

striking subparagraph (B) and redesignating subparagraph 

(C) as subparagraph (B). 

(2) EFFECTIVE DATE.—The amendments made by paragraph (1) shall take effect on the date on which the Secretary 

makes the information described in subsection (b)(1) available 

to the public under such subsection. 

SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING 

FACILITIES AND NURSING FACILITIES. 

Part A of title XI of the Social Security Act (42 U.S.C. 1301 et 

seq.), as amended by sections 6002 and 6004, is amended by inserting after section 1128H the following new section: 

‘‘SEC. 1128I. ø42 U.S.C. 1320a–7j¿ ACCOUNTABILITY REQUIREMENTS FOR 

FACILITIES. 

‘‘(a) DEFINITION OF FACILITY.—In this section, the term ‘facility’ 

means— 

‘‘(1) a skilled nursing facility (as defined in section 

1819(a)); or 

‘‘(2) a nursing facility (as defined in section 1919(a)). 

‘‘(b) EFFECTIVE COMPLIANCE AND ETHICS PROGRAMS.— 

‘‘(1) REQUIREMENT.—On or after the date that is 36 

months after the date of the enactment of this section, a facility shall, with respect to the entity that operates the facility 

(in this subparagraph referred to as the ‘operating organization’ or ‘organization’), have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under this Act and in 

promoting quality of care consistent with regulations developed 

under paragraph (2). 

‘‘(2) DEVELOPMENT OF REGULATIONS.— 

‘‘(A) IN GENERAL.—Not later than the date that is 2 

years after such date of the enactment, the Secretary, 

working jointly with the Inspector General of the Department of Health and Human Services, shall promulgate regulations for an effective compliance and ethics program for 

operating organizations, which may include a model compliance program. 

‘‘(B) DESIGN OF REGULATIONS.—Such regulations with 

respect to specific elements or formality of a program 

shall, in the case of an organization that operates 5 or 

more facilities, vary with the size of the organization, such 

that larger organizations should have a more formal program and include established written policies defining the 

standards and procedures to be followed by its employees. 

Such requirements may specifically apply to the corporate 

level management of multi unit nursing home chains. 

‘‘(C) EVALUATION.—Not later than 3 years after the 

date of the promulgation of regulations under this para-
639 Sec. 6102 PPACA (Consolidated) \1128I SSA 

graph, the Secretary shall complete an evaluation of the 

compliance and ethics programs required to be established 

under this subsection. Such evaluation shall determine if 

such programs led to changes in deficiency citations, 

changes in quality performance, or changes in other 

metrics of patient quality of care. The Secretary shall submit to Congress a report on such evaluation and shall include in such report such recommendations regarding 

changes in the requirements for such programs as the Secretary determines appropriate. 

‘‘(3) REQUIREMENTS FOR COMPLIANCE AND ETHICS PROGRAMS.—In this subsection, the term ‘compliance and ethics 

program’ means, with respect to a facility, a program of the operating organization that— 

‘‘(A) has been reasonably designed, implemented, and 

enforced so that it generally will be effective in preventing 

and detecting criminal, civil, and administrative violations 

under this Act and in promoting quality of care; and 

‘‘(B) includes at least the required components specified in paragraph (4). 

‘‘(4) REQUIRED COMPONENTS OF PROGRAM.—The required 

components of a compliance and ethics program of an operating organization are the following: 

‘‘(A) The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative 

violations under this Act. 

‘‘(B) Specific individuals within high-level personnel of 

the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority to assure such compliance. 

‘‘(C) The organization must have used due care not to 

delegate substantial discretionary authority to individuals 

whom the organization knew, or should have known 

through the exercise of due diligence, had a propensity to 

engage in criminal, civil, and administrative violations 

under this Act. 

‘‘(D) The organization must have taken steps to communicate effectively its standards and procedures to all 

employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required. 

‘‘(E) The organization must have taken reasonable 

steps to achieve compliance with its standards, such as by 

utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and 

by having in place and publicizing a reporting system 

whereby employees and other agents could report violations by others within the organization without fear of retribution. 
Sec. 6103 PPACA (Consolidated) 640 

‘‘(F) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. 

‘‘(G) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including any necessary modification to its program 

to prevent and detect criminal, civil, and administrative 

violations under this Act. 

‘‘(H) The organization must periodically undertake reassessment of its compliance program to identify changes 

necessary to reflect changes within the organization and 

its facilities. 

‘‘(c) QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT

PROGRAM.— 

‘‘(1) IN GENERAL.—Not later than December 31, 2011, the 

Secretary shall establish and implement a quality assurance 

and performance improvement program (in this subparagraph 

referred to as the ‘QAPI program’) for facilities, including multi 

unit chains of facilities. Under the QAPI program, the Secretary shall establish standards relating to quality assurance 

and performance improvement with respect to facilities and 

provide technical assistance to facilities on the development of 

best practices in order to meet such standards. Not later than 

1 year after the date on which the regulations are promulgated 

under paragraph (2), a facility must submit to the Secretary a 

plan for the facility to meet such standards and implement 

such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under sections 1819(b)(1)(B) and 

1919(b)(1)(B), as applicable. 

‘‘(2) REGULATIONS.—The Secretary shall promulgate regulations to carry out this subsection.’’. 

SEC. 6103. NURSING HOME COMPARE MEDICARE WEBSITE. 

(a) SKILLED NURSING FACILITIES.— 

(1) IN GENERAL.—Section 1819 of the Social Security Act 

(42 U.S.C. 1395i–3) is amended— 

(A) by redesignating subsection (i) as subsection (j); 

and 

(B) by inserting after subsection (h) the following new 

subsection: 

‘‘(i) NURSING HOME COMPARE WEBSITE.— 

‘‘(1) INCLUSION OF ADDITIONAL INFORMATION.— 

‘‘(A) IN GENERAL.—The Secretary shall ensure that the 

Department of Health and Human Services includes, as 

part of the information provided for comparison of nursing 

homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to 

as the ‘Nursing Home Compare’ Medicare website) (or a 

successor website), the following information in a manner 

that is prominent, updated on a timely basis, easily acces-
641 Sec. 6103 PPACA (Consolidated) 

sible, readily understandable to consumers of long-term 

care services, and searchable: 

‘‘(i) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted 

under section 1128I(g), including information on staffing turnover and tenure, in a format that is clearly 

understandable to consumers of long-term care services and allows such consumers to compare differences 

in staffing between facilities and State and national 

averages for the facilities. Such format shall include— 

‘‘(I) concise explanations of how to interpret 

the data (such as a plain English explanation of 

data reflecting ‘nursing home staff hours per resident day’); 

‘‘(II) differences in types of staff (such as 

training associated with different categories of 

staff); 

‘‘(III) the relationship between nurse staffing 

levels and quality of care; and 

‘‘(IV) an explanation that appropriate staffing 

levels vary based on patient case mix. 

‘‘(ii) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or 

a successor form) on such websites, information to 

guide consumers in how to interpret and understand 

such reports, and the facility plan of correction or 

other response to such report. Any such links shall be 

posted on a timely basis. 

‘‘(iii) The standardized complaint form developed 

under section 1128I(f), including explanatory material 

on what complaint forms are, how they are used, and 

how to file a complaint with the State survey and certification program and the State long-term care ombudsman program. 

‘‘(iv) Summary information on the number, type, 

severity, and outcome of substantiated complaints. 

‘‘(v) The number of adjudicated instances of criminal violations by a facility or the employees of a facility— 

‘‘(I) that were committed inside the facility; 

‘‘(II) with respect to such instances of violations or crimes committed inside of the facility 

that were the violations or crimes of abuse, neglect, and exploitation, criminal sexual abuse, or 

other violations or crimes that resulted in serious 

bodily injury; and 

‘‘(III) the number of civil monetary penalties 

levied against the facility, employees, contractors, 

and other agents. 

‘‘(B) DEADLINE FOR PROVISION OF INFORMATION.— 

‘‘(i) IN GENERAL.—Except as provided in clause (ii), 

the Secretary shall ensure that the information de-
Sec. 6103 PPACA (Consolidated) 642 

scribed in subparagraph (A) is included on such 

website (or a successor website) not later than 1 year 

after the date of the enactment of this subsection. 

‘‘(ii) EXCEPTION.—The Secretary shall ensure that 

the information described in subparagraph (A)(i) is included on such website (or a successor website) not 

later than the date on which the requirements under 

section 1128I(g) are implemented. 

‘‘(2) REVIEW AND MODIFICATION OF WEBSITE.— ‘‘(A) IN GENERAL.—The Secretary shall establish a 

process— 

‘‘(i) to review the accuracy, clarity of presentation, 

timeliness, and comprehensiveness of information reported on such website as of the day before the date 

of the enactment of this subsection; and 

‘‘(ii) not later than 1 year after the date of the enactment of this subsection, to modify or revamp such 

website in accordance with the review conducted 

under clause (i). 

‘‘(B) CONSULTATION.—In conducting the review under 

subparagraph (A)(i), the Secretary shall consult with— 

‘‘(i) State long-term care ombudsman programs; 

‘‘(ii) consumer advocacy groups; 

‘‘(iii) provider stakeholder groups; and 

‘‘(iv) any other representatives of programs or 

groups the Secretary determines appropriate.’’. 

(2) TIMELINESS OF SUBMISSION OF SURVEY AND CERTIFI- CATION INFORMATION.— (A) IN GENERAL.—Section 1819(g)(5) of the Social Security Act (42 U.S.C. 1395i–3(g)(5)) is amended by adding at 

the end the following new subparagraph: 

‘‘(E) SUBMISSION OF SURVEY AND CERTIFICATION INFORMATION TO THE SECRETARY.—In order to improve the timeliness of information made available to the public under 

subparagraph (A) and provided on the Nursing Home 

Compare Medicare website under subsection (i), each State 

shall submit information respecting any survey or certification made respecting a skilled nursing facility (including 

any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends 

such information to the facility. The Secretary shall use 

the information submitted under the preceding sentence to 

update the information provided on the Nursing Home 

Compare Medicare website as expeditiously as practicable 

but not less frequently than quarterly.’’. 

(B) EFFECTIVE DATE.—The amendment made by this 

paragraph shall take effect 1 year after the date of the enactment of this Act. 

(3) SPECIAL FOCUS FACILITY PROGRAM.—Section 1819(f) of 

the Social Security Act (42 U.S.C. 1395i–3(f)) is amended by 

adding at the end the following new paragraph: 

‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 

‘‘(A) IN GENERAL.—The Secretary shall conduct a special focus facility program for enforcement of requirements 
643 Sec. 6103 PPACA (Consolidated) 

for skilled nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirement of this Act. 

‘‘(B) PERIODIC SURVEYS.—Under such program the Secretary shall conduct surveys of each facility in the program 

not less than once every 6 months.’’. 

(b) NURSING FACILITIES.— 

(1) IN GENERAL.—Section 1919 of the Social Security Act 

(42 U.S.C. 1396r) is amended— 

(A) by redesignating subsection (i) as subsection (j); 

and 

(B) by inserting after subsection (h) the following new 

subsection: 

‘‘(i) NURSING HOME COMPARE WEBSITE.— 

‘‘(1) INCLUSION OF ADDITIONAL INFORMATION.— 

‘‘(A) IN GENERAL.—The Secretary shall ensure that the 

Department of Health and Human Services includes, as 

part of the information provided for comparison of nursing 

homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to 

as the ‘Nursing Home Compare’ Medicare website) (or a 

successor website), the following information in a manner 

that is prominent, updated on a timely basis, easily accessible, readily understandable to consumers of long-term 

care services, and searchable: 

‘‘(i) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted 

under section 1128I(g), including information on staffing turnover and tenure, in a format that is clearly 

understandable to consumers of long-term care services and allows such consumers to compare differences 

in staffing between facilities and State and national 

averages for the facilities. Such format shall include— 

‘‘(I) concise explanations of how to interpret 

the data (such as plain English explanation of 

data reflecting ‘nursing home staff hours per resident day’); 

‘‘(II) differences in types of staff (such as 

training associated with different categories of 

staff); 

‘‘(III) the relationship between nurse staffing 

levels and quality of care; and 

‘‘(IV) an explanation that appropriate staffing 

levels vary based on patient case mix. 

‘‘(ii) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or 

a successor form) on such websites, information to 

guide consumers in how to interpret and understand 

such reports, and the facility plan of correction or 

other response to such report. Any such links shall be 

posted on a timely basis. 
Sec. 6103 PPACA (Consolidated) 644 

‘‘(iii) The standardized complaint form developed 

under section 1128I(f), including explanatory material 

on what complaint forms are, how they are used, and 

how to file a complaint with the State survey and certification program and the State long-term care ombudsman program. 

‘‘(iv) Summary information on the number, type, 

severity, and outcome of substantiated complaints. 

‘‘(v) The number of adjudicated instances of criminal violations by a facility or the employees of a facility— 

‘‘(I) that were committed inside of the facility; 

and 

‘‘(II) with respect to such instances of violations or crimes committed outside of the facility, 

that were violations or crimes that resulted in the 

serious bodily injury of an elder. 

‘‘(B) DEADLINE FOR PROVISION OF INFORMATION.— 

‘‘(i) IN GENERAL.—Except as provided in clause (ii), 

the Secretary shall ensure that the information described in subparagraph (A) is included on such 

website (or a successor website) not later than 1 year 

after the date of the enactment of this subsection. 

‘‘(ii) EXCEPTION.—The Secretary shall ensure that 

the information described in subparagraph (A)(i) is included on such website (or a successor website) not 

later than the date on which the requirements under 

section 1128I(g) are implemented. 

‘‘(2) REVIEW AND MODIFICATION OF WEBSITE.— 

‘‘(A) IN GENERAL.—The Secretary shall establish a 

process— 

‘‘(i) to review the accuracy, clarity of presentation, 

timeliness, and comprehensiveness of information reported on such website as of the day before the date 

of the enactment of this subsection; and 

‘‘(ii) not later than 1 year after the date of the enactment of this subsection, to modify or revamp such 

website in accordance with the review conducted 

under clause (i). 

‘‘(B) CONSULTATION.—In conducting the review under 

subparagraph (A)(i), the Secretary shall consult with— 

‘‘(i) State long-term care ombudsman programs; 

‘‘(ii) consumer advocacy groups; 

‘‘(iii) provider stakeholder groups; 

‘‘(iv) skilled nursing facility employees and their 

representatives; and 

‘‘(v) any other representatives of programs or 

groups the Secretary determines appropriate.’’. 

(2) TIMELINESS OF SUBMISSION OF SURVEY AND CERTIFICATION INFORMATION.— 

(A) IN GENERAL.—Section 1919(g)(5) of the Social Security Act (42 U.S.C. 1396r(g)(5)) is amended by adding at 

the end the following new subparagraph: 
645 Sec. 6103 PPACA (Consolidated) 

‘‘(E) SUBMISSION OF SURVEY AND CERTIFICATION INFOR- MATION TO THE SECRETARY.—In order to improve the timeliness of information made available to the public under 

subparagraph (A) and provided on the Nursing Home 

Compare Medicare website under subsection (i), each State 

shall submit information respecting any survey or certification made respecting a nursing facility (including any 

enforcement actions taken by the State) to the Secretary 

not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update 

the information provided on the Nursing Home Compare 

Medicare website as expeditiously as practicable but not 

less frequently than quarterly.’’. 

(B) EFFECTIVE DATE.—The amendment made by this 

paragraph shall take effect 1 year after the date of the enactment of this Act. 

(3) SPECIAL FOCUS FACILITY PROGRAM.—Section 1919(f) of 

the Social Security Act (42 U.S.C. 1396r(f)) is amended by adding at the end of the following new paragraph: 

‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— ‘‘(A) IN GENERAL.—The Secretary shall conduct a special focus facility program for enforcement of requirements 

for nursing facilities that the Secretary has identified as 

having substantially failed to meet applicable requirements of this Act. 

‘‘(B) PERIODIC SURVEYS.—Under such program the Secretary shall conduct surveys of each facility in the program 

not less often than once every 6 months.’’. 

(c) AVAILABILITY OF REPORTS ON SURVEYS, CERTIFICATIONS, 

AND COMPLAINT INVESTIGATIONS.— 

(1) SKILLED NURSING FACILITIES.—Section 1819(d)(1) of the 

Social Security Act (42 U.S.C. 1395i–3(d)(1)), as amended by 

section 6101, is amended by adding at the end the following 

new subparagraph: 

‘‘(C) AVAILABILITY OF SURVEY, CERTIFICATION, AND

COMPLAINT INVESTIGATION REPORTS.—A skilled nursing facility must— 

‘‘(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available 

for any individual to review upon request; and 

‘‘(ii) post notice of the availability of such reports 

in areas of the facility that are prominent and accessible to the public. 

The facility shall not make available under clause (i) identifying information about complainants or residents.’’. 

(2) NURSING FACILITIES.—Section 1919(d)(1) of the Social 

Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 

6101, is amended by adding at the end the following new subparagraph: 

‘‘(V) AVAILABILITY OF SURVEY, CERTIFICATION, AND

COMPLAINT INVESTIGATION REPORTS.—A nursing facility 

must— 
Sec. 6103 PPACA (Consolidated) 646 

‘‘(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available 

for any individual to review upon request; and 

‘‘(ii) post notice of the availability of such reports 

in areas of the facility that are prominent and accessible to the public. 

The facility shall not make available under clause (i) identifying information about complainants or residents.’’. 

(3) EFFECTIVE DATE.—The amendments made by this subsection shall take effect 1 year after the date of the enactment 

of this Act. 

(d) GUIDANCE TO STATES ON FORM 2567 STATE INSPECTION RE- PORTS AND COMPLAINT INVESTIGATION REPORTS.— (1) GUIDANCE.—The Secretary of Health and Human Services (in this subtitle referred to as the ‘‘Secretary’’) shall provide guidance to States on how States can establish electronic 

links to Form 2567 State inspection reports (or a successor 

form), complaint investigation reports, and a facility’s plan of 

correction or other response to such Form 2567 State inspection reports (or a successor form) on the Internet website of the 

State that provides information on skilled nursing facilities 

and nursing facilities and the Secretary shall, if possible, include such information on Nursing Home Compare. 

(2) REQUIREMENT.—Section 1902(a)(9) of the Social Security Act (42 U.S.C. 1396a(a)(9)) is amended— 

(A) by striking ‘‘and’’ at the end of subparagraph (B); 

(B) by striking the semicolon at the end of subparagraph (C) and inserting ‘‘, and’’; and 

(C) by adding at the end the following new subparagraph: 

‘‘(D) that the State maintain a consumer-oriented 

website providing useful information to consumers regarding all skilled nursing facilities and all nursing facilities in 

the State, including for each facility, Form 2567 State inspection reports (or a successor form), complaint investigation reports, the facility’s plan of correction, and such 

other information that the State or the Secretary considers 

useful in assisting the public to assess the quality of long 

term care options and the quality of care provided by individual facilities;’’. 

(3) DEFINITIONS.—In this subsection: 

(A) NURSING FACILITY.—The term ‘‘nursing facility’’ 

has the meaning given such term in section 1919(a) of the 

Social Security Act (42 U.S.C. 1396r(a)). 

(B) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health and Human Services. 

(C) SKILLED NURSING FACILITY.—The term ‘‘skilled 

nursing facility’’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395i– 

3(a)). 

(e) DEVELOPMENT OF CONSUMER RIGHTS INFORMATION PAGE ON

NURSING HOME COMPARE WEBSITE.—Not later than 1 year after 

the date of enactment of this Act, the Secretary shall ensure that 
647 Sec. 6104 PPACA (Consolidated) 

the Department of Health and Human Services, as part of the information provided for comparison of nursing facilities on the Nursing Home Compare Medicare website develops and includes a consumer rights information page that contains links to descriptions 

of, and information with respect to, the following: 

(1) The documentation on nursing facilities that is available to the public. 

(2) General information and tips on choosing a nursing facility that meets the needs of the individual. 

(3) General information on consumer rights with respect to 

nursing facilities. 

(4) The nursing facility survey process (on a national and 

State-specific basis). 

(5) On a State-specific basis, the services available through 

the State long-term care ombudsman for such State. 

SEC. 6104. REPORTING OF EXPENDITURES. 

Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is 

amended by adding at the end the following new subsection: 

‘‘(f) REPORTING OF DIRECT CARE EXPENDITURES.— 

‘‘(1) IN GENERAL.—For cost reports submitted under this 

title for cost reporting periods beginning on or after the date 

that is 2 years after the date of the enactment of this subsection, skilled nursing facilities shall separately report expenditures for wages and benefits for direct care staff (breaking out (at a minimum) registered nurses, licensed professional 

nurses, certified nurse assistants, and other medical and therapy staff). 

‘‘(2) MODIFICATION OF FORM.—The Secretary, in consultation with private sector accountants experienced with Medicare 

and Medicaid nursing facility home cost reports, shall redesign 

such reports to meet the requirement of paragraph (1) not later 

than 1 year after the date of the enactment of this subsection. 

‘‘(3) CATEGORIZATION BY FUNCTIONAL ACCOUNTS.—Not later 

than 30 months after the date of the enactment of this subsection, the Secretary, working in consultation with the Medicare Payment Advisory Commission, the Medicaid and CHIP 

Payment and Access Commission, the Inspector General of the 

Department of Health and Human Services, and other expert 

parties the Secretary determines appropriate, shall take the 

expenditures listed on cost reports, as modified under paragraph (1), submitted by skilled nursing facilities and categorize 

such expenditures, regardless of any source of payment for 

such expenditures, for each skilled nursing facility into the following functional accounts on an annual basis: 

‘‘(A) Spending on direct care services (including nursing, therapy, and medical services). 

‘‘(B) Spending on indirect care (including housekeeping 

and dietary services). 

‘‘(C) Capital assets (including building and land costs). 

‘‘(D) Administrative services costs. 

‘‘(4) AVAILABILITY OF INFORMATION SUBMITTED.—The Secretary shall establish procedures to make information on expenditures submitted under this subsection readily available to 
Sec. 6105 PPACA (Consolidated) 648 

interested parties upon request, subject to such requirements 

as the Secretary may specify under the procedures established 

under this paragraph.’’. 

SEC. 6105. STANDARDIZED COMPLAINT FORM. 

(a) IN GENERAL.—Section 1128I of the Social Security Act, as 

added and amended by this Act, is amended by adding at the end 

the following new subsection: 

‘‘(f) STANDARDIZED COMPLAINT FORM.— ‘‘(1) DEVELOPMENT BY THE SECRETARY.—The Secretary 

shall develop a standardized complaint form for use by a resident (or a person acting on the resident’s behalf) in filing a 

complaint with a State survey and certification agency and a 

State long-term care ombudsman program with respect to a facility. 

‘‘(2) COMPLAINT FORMS AND RESOLUTION PROCESSES.— 

‘‘(A) COMPLAINT FORMS.—The State must make the 

standardized complaint form developed under paragraph 

(1) available upon request to— 

‘‘(i) a resident of a facility; and 

‘‘(ii) any person acting on the resident’s behalf. 

‘‘(B) COMPLAINT RESOLUTION PROCESS.—The State 

must establish a complaint resolution process in order to 

ensure that the legal representative of a resident of a facility or other responsible party is not denied access to such 

resident or otherwise retaliated against if they have complained about the quality of care provided by the facility 

or other issues relating to the facility. Such complaint resolution process shall include— 

‘‘(i) procedures to assure accurate tracking of complaints received, including notification to the complainant that a complaint has been received; 

‘‘(ii) procedures to determine the likely severity of 

a complaint and for the investigation of the complaint; 

and 

‘‘(iii) deadlines for responding to a complaint and 

for notifying the complainant of the outcome of the investigation. 

‘‘(3) RULE OF CONSTRUCTION.—Nothing in this subsection 

shall be construed as preventing a resident of a facility (or a 

person acting on the resident’s behalf) from submitting a complaint in a manner or format other than by using the standardized complaint form developed under paragraph (1) (including 

submitting a complaint orally).’’. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall take effect 1 year after the date of the enactment of this Act. 

SEC. 6106. ENSURING STAFFING ACCOUNTABILITY. 

Section 1128I of the Social Security Act, as added and amended by this Act, is amended by adding at the end the following new 

subsection: 

‘‘(g) SUBMISSION OF STAFFING INFORMATION BASED ON PAYROLL

DATA IN A UNIFORM FORMAT.—Beginning not later than 2 years 

after the date of the enactment of this subsection, and after consulting with State long-term care ombudsman programs, consumer 
649 Sec. 6111 PPACA (Consolidated) 

advocacy groups, provider stakeholder groups, employees and their 

representatives, and other parties the Secretary deems appropriate, 

the Secretary shall require a facility to electronically submit to the 

Secretary direct care staffing information (including information 

with respect to agency and contract staff) based on payroll and 

other verifiable and auditable data in a uniform format (according 

to specifications established by the Secretary in consultation with 

such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence— 

‘‘(1) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified 

nursing assistant, therapist, or other medical personnel); 

‘‘(2) include resident census data and information on resident case mix; 

‘‘(3) include a regular reporting schedule; and 

‘‘(4) include information on employee turnover and tenure 

and on the hours of care provided by each category of certified 

employees referenced in paragraph (1) per resident per day. 

Nothing in this subsection shall be construed as preventing the 

Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subsection 

with respect to agency and contract staff shall be kept separate 

from information on employee staffing.’’. 

SEC. 6107. GAO STUDY AND REPORT ON FIVE-STAR QUALITY RATING 

SYSTEM. 

(a) STUDY.—The Comptroller General of the United States (in 

this section referred to as the ‘‘Comptroller General’’) shall conduct 

a study on the Five-Star Quality Rating System for nursing homes 

of the Centers for Medicare & Medicaid Services. Such study shall 

include an analysis of— 

(1) how such system is being implemented; 

(2) any problems associated with such system or its implementation; and 

(3) how such system could be improved. 

(b) REPORT.—Not later than 2 years 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. 

PART 2—TARGETING ENFORCEMENT 

SEC. 6111. CIVIL MONEY PENALTIES. 

(a) SKILLED NURSING FACILITIES.— 

(1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of the Social Security Act (42 U.S.C. 1395i–3(h)(2)(B)(ii)) is amended— 

(A) by striking ‘‘PENALTIES.—The Secretary’’ and inserting ‘‘PENALTIES.— 
Sec. 6111 PPACA (Consolidated) 650 

‘‘(I) IN GENERAL.—Subject to subclause (II), 

the Secretary’’; and 

(B) by adding at the end the following new subclauses: 

‘‘(II) REDUCTION OF CIVIL MONEY PENALTIES IN

CERTAIN CIRCUMSTANCES.—Subject to subclause 

(III), in the case where a facility self-reports and 

promptly corrects a deficiency for which a penalty 

was imposed under this clause not later than 10 

calendar days after the date of such imposition, 

the Secretary may reduce the amount of the penalty imposed by not more than 50 percent. 

‘‘(III) PROHIBITIONS ON REDUCTION FOR CERTAIN DEFICIENCIES.— 

‘‘(aa) REPEAT DEFICIENCIES.—The Secretary may not reduce the amount of a penalty under subclause (II) if the Secretary had 

reduced a penalty imposed on the facility in 

the preceding year under such subclause with 

respect to a repeat deficiency. 

‘‘(bb) CERTAIN OTHER DEFICIENCIES.—The 

Secretary may not reduce the amount of a 

penalty under subclause (II) if the penalty is 

imposed on the facility for a deficiency that is 

found to result in a pattern of harm or widespread harm, immediately jeopardizes the 

health or safety of a resident or residents of 

the facility, or results in the death of a resident of the facility. 

‘‘(IV) COLLECTION OF CIVIL MONEY PENALTIES.—In the case of a civil money penalty imposed under this clause, the Secretary shall issue 

regulations that— 

‘‘(aa) subject to item (cc), not later than 

30 days after the imposition of the penalty, 

provide for the facility to have the opportunity 

to participate in an independent informal dispute resolution process which generates a 

written record prior to the collection of such 

penalty; 

‘‘(bb) in the case where the penalty is imposed for each day of noncompliance, provide 

that a penalty may not be imposed for any 

day during the period beginning on the initial 

day of the imposition of the penalty and ending on the day on which the informal dispute 

resolution process under item (aa) is completed; 

‘‘(cc) may provide for the collection of such 

civil money penalty and the placement of such 

amounts collected in an escrow account under 

the direction of the Secretary on the earlier of 

the date on which the informal dispute resolution process under item (aa) is completed or 
651 Sec. 6111 PPACA (Consolidated) 

the date that is 90 days after the date of the 

imposition of the penalty; 

‘‘(dd) may provide that such amounts collected are kept in such account pending the 

resolution of any subsequent appeals; 

‘‘(ee) in the case where the facility successfully appeals the penalty, may provide for 

the return of such amounts collected (plus interest) to the facility; and 

‘‘(ff) in the case where all such appeals 

are unsuccessful, may provide that some portion of such amounts collected may be used to 

support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or 

involuntarily) or is decertified (including offsetting costs of relocating residents to home 

and community-based settings or another facility), projects that support resident and family councils and other consumer involvement 

in assuring quality care in facilities, and facility improvement initiatives approved by the 

Secretary (including joint training of facility 

staff and surveyors, technical assistance for 

facilities implementing quality assurance programs, the appointment of temporary management firms, and other activities approved 

by the Secretary).’’. 

(2) CONFORMING AMENDMENT.—The second sentence of section 1819(h)(5) of the Social Security Act (42 U.S.C. 1395i– 

3(h)(5)) is amended by inserting ‘‘(ii)(IV),’’ after ‘‘(i),’’. 

(b) NURSING FACILITIES.— 

(1) IN GENERAL.—Section 1919(h)(3)(C)(ii) of the Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended— 

(A) by striking ‘‘PENALTIES.—The Secretary’’ and inserting ‘‘PENALTIES.— 

‘‘(I) IN GENERAL.—Subject to subclause (II), 

the Secretary’’; and 

(B) by adding at the end the following new subclauses: 

‘‘(II) REDUCTION OF CIVIL MONEY PENALTIES IN

CERTAIN CIRCUMSTANCES.—Subject to subclause 

(III), in the case where a facility self-reports and 

promptly corrects a deficiency for which a penalty 

was imposed under this clause not later than 10 

calendar days after the date of such imposition, 

the Secretary may reduce the amount of the penalty imposed by not more than 50 percent. 

‘‘(III) PROHIBITIONS ON REDUCTION FOR CERTAIN DEFICIENCIES.— 

‘‘(aa) REPEAT DEFICIENCIES.—The Secretary may not reduce the amount of a penalty under subclause (II) if the Secretary had 

reduced a penalty imposed on the facility in 
Sec. 6111 PPACA (Consolidated) 652 

the preceding year under such subclause with 

respect to a repeat deficiency. 

‘‘(bb) CERTAIN OTHER DEFICIENCIES.—The 

Secretary may not reduce the amount of a 

penalty under subclause (II) if the penalty is 

imposed on the facility for a deficiency that is 

found to result in a pattern of harm or widespread harm, immediately jeopardizes the 

health or safety of a resident or residents of 

the facility, or results in the death of a resident of the facility. 

‘‘(IV) COLLECTION OF CIVIL MONEY PEN- ALTIES.—In the case of a civil money penalty imposed under this clause, the Secretary shall issue 

regulations that— 

‘‘(aa) subject to item (cc), not later than 

30 days after the imposition of the penalty, 

provide for the facility to have the opportunity 

to participate in an independent informal dispute resolution process which generates a 

written record prior to the collection of such 

penalty; 

‘‘(bb) in the case where the penalty is imposed for each day of noncompliance, provide 

that a penalty may not be imposed for any 

day during the period beginning on the initial 

day of the imposition of the penalty and ending on the day on which the informal dispute 

resolution process under item (aa) is completed; 

‘‘(cc) may provide for the collection of such 

civil money penalty and the placement of such 

amounts collected in an escrow account under 

the direction of the Secretary on the earlier of 

the date on which the informal dispute resolution process under item (aa) is completed or 

the date that is 90 days after the date of the 

imposition of the penalty; 

‘‘(dd) may provide that such amounts collected are kept in such account pending the 

resolution of any subsequent appeals; 

‘‘(ee) in the case where the facility successfully appeals the penalty, may provide for 

the return of such amounts collected (plus interest) to the facility; and 

‘‘(ff) in the case where all such appeals 

are unsuccessful, may provide that some portion of such amounts collected may be used to 

support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or 

involuntarily) or is decertified (including offsetting costs of relocating residents to home 

and community-based settings or another fa-
653 Sec. 6112 PPACA (Consolidated) 

cility), projects that support resident and family councils and other consumer involvement 

in assuring quality care in facilities, and facility improvement initiatives approved by the 

Secretary (including joint training of facility 

staff and surveyors, technical assistance for 

facilities implementing quality assurance programs, the appointment of temporary management firms, and other activities approved 

by the Secretary).’’. 

(2) CONFORMING AMENDMENT.—Section 1919(h)(5)(8) of the 

Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by inserting ‘‘(ii)(IV),’’ after ‘‘(i),’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall take effect 1 year after the date of the enactment of this Act. 

SEC. 6112. ø42 U.S.C. 1320a–7j note¿ NATIONAL INDEPENDENT MONITOR 

DEMONSTRATION PROJECT. 

(a) ESTABLISHMENT.— 

(1) IN GENERAL.—The Secretary, in consultation with the 

Inspector General of the Department of Health and Human 

Services, shall conduct a demonstration project to develop, test, 

and implement an independent monitor program to oversee 

interstate and large intrastate chains of skilled nursing facilities and nursing facilities. 

(2) SELECTION.—The Secretary shall select chains of 

skilled nursing facilities and nursing facilities described in 

paragraph (1) to participate in the demonstration project under 

this section from among those chains that submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. 

(3) DURATION.—The Secretary shall conduct the demonstration project under this section for a 2-year period. 

(4) IMPLEMENTATION.—The Secretary shall implement the 

demonstration project under this section not later than 1 year 

after the date of the enactment of this Act. 

(b) REQUIREMENTS.—The Secretary shall evaluate chains selected to participate in the demonstration project under this section 

based on criteria selected by the Secretary, including where evidence suggests that a number of the facilities of the chain are experiencing serious safety and quality of care problems. Such criteria 

may include the evaluation of a chain that includes a number of 

facilities participating in the ‘‘Special Focus Facility’’ program (or 

a successor program) or multiple facilities with a record of repeated 

serious safety and quality of care deficiencies. 

(c) RESPONSIBILITIES.—An independent monitor that enters 

into a contract with the Secretary to participate in the conduct of 

the demonstration project under this section shall— 

(1) conduct periodic reviews and prepare root-cause quality 

and deficiency analyses of a chain to assess if facilities of the 

chain are in compliance with State and Federal laws and regulations applicable to the facilities; 

(2) conduct sustained oversight of the efforts of the chain, 

whether publicly or privately held, to achieve compliance by fa-
Sec. 6112 PPACA (Consolidated) 654 

cilities of the chain with State and Federal laws and regulations applicable to the facilities; 

(3) analyze the management structure, distribution of expenditures, and nurse staffing levels of facilities of the chain 

in relation to resident census, staff turnover rates, and tenure; 

(4) report findings and recommendations with respect to 

such reviews, analyses, and oversight to the chain and facilities of the chain, to the Secretary, and to relevant States; and 

(5) publish the results of such reviews, analyses, and oversight. 

(d) IMPLEMENTATION OF RECOMMENDATIONS.— (1) RECEIPT OF FINDING BY CHAIN.—Not later than 10 days 

after receipt of a finding of an independent monitor under subsection (c)(4), a chain participating in the demonstration 

project shall submit to the independent monitor a report— 

(A) outlining corrective actions the chain will take to 

implement the recommendations in such report; or 

(B) indicating that the chain will not implement such 

recommendations, and why it will not do so. 

(2) RECEIPT OF REPORT BY INDEPENDENT MONITOR.—Not 

later than 10 days after receipt of a report submitted by a 

chain under paragraph (1), an independent monitor shall finalize its recommendations and submit a report to the chain and 

facilities of the chain, the Secretary, and the State or States, 

as appropriate, containing such final recommendations. 

(e) COST OF APPOINTMENT.—A chain shall be responsible for a 

portion of the costs associated with the appointment of independent 

monitors under the demonstration project under this section. The 

chain shall pay such portion to the Secretary (in an amount and 

in accordance with procedures established by the Secretary). 

(f) WAIVER AUTHORITY.—The Secretary may waive such requirements of titles XVIII and XIX of the Social Security Act (42 

U.S.C. 1395 et seq.; 1396 et seq.) as may be necessary for the purpose of carrying out the demonstration project under this section. 

(g) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated such sums as may be necessary to carry out this 

section. 

(h) DEFINITIONS.—In this section: 

(1) ADDITIONAL DISCLOSABLE PARTY.—The term ‘‘additional 

disclosable party’’ has the meaning given such term in section 

1124(c)(5)(A) of the Social Security Act, as added by section 

4201(a). 

(2) FACILITY.—The term ‘‘facility’’ means a skilled nursing 

facility or a nursing facility. 

(3) NURSING FACILITY.—The term ‘‘nursing facility’’ has the 

meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). 

(4) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health and Human Services, acting through the Assistant Secretary for Planning and Evaluation. 

(5) SKILLED NURSING FACILITY.—The term ‘‘skilled nursing 

facility’’ has the meaning given such term in section 1819(a) of 

the Social Security Act (42 U.S.C. 1395(a)). 

(i) EVALUATION AND REPORT.— 
655 Sec. 6113 PPACA (Consolidated) 

(1) EVALUATION.—The Secretary, in consultation with the 

Inspector General of the Department of Health and Human 

Services, shall evaluate the demonstration project conducted 

under this section. 

(2) REPORT.—Not later than 180 days after the completion 

of the demonstration project under this section, the Secretary 

shall submit to Congress a report containing the results of the 

evaluation conducted under paragraph (1), together with recommendations— 

(A) as to whether the independent monitor program 

should be established on a permanent basis; 

(B) if the Secretary recommends that such program be 

so established, on appropriate procedures and mechanisms 

for such establishment; and 

(C) for such legislation and administrative action as 

the Secretary determines appropriate. 

SEC. 6113. NOTIFICATION OF FACILITY CLOSURE. 

(a) IN GENERAL.—Section 1128I of the Social Security Act, as 

added and amended by this Act, is amended by adding at the end 

the following new subsection: 

‘‘(h) NOTIFICATION OF FACILITY CLOSURE.— 

‘‘(1) IN GENERAL.—Any individual who is the administrator 

of a facility must— 

‘‘(A) submit to the Secretary, the State long-term care 

ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, 

written notification of an impending closure— 

‘‘(i) subject to clause (ii), not later than the date 

that is 60 days prior to the date of such closure; and 

‘‘(ii) in the case of a facility where the Secretary 

terminates the facility’s participation under this title, 

not later than the date that the Secretary determines 

appropriate; 

‘‘(B) ensure that the facility does not admit any new 

residents on or after the date on which such written notification is submitted; and 

‘‘(C) include in the notice a plan for the transfer and 

adequate relocation of the residents of the facility by a 

specified date prior to closure that has been approved by 

the State, including assurances that the residents will be 

transferred to the most appropriate facility or other setting 

in terms of quality, services, and location, taking into consideration the needs, choice, and best interests of each 

resident. 

‘‘(2) RELOCATION.— 

‘‘(A) IN GENERAL.—The State shall ensure that, before 

a facility closes, all residents of the facility have been successfully relocated to another facility or an alternative 

home and community-based setting. 

‘‘(B) CONTINUATION OF PAYMENTS UNTIL RESIDENTS RELOCATED.—The Secretary may, as the Secretary determines appropriate, continue to make payments under this 

title with respect to residents of a facility that has sub-
Sec. 6114 PPACA (Consolidated) 656 

mitted a notification under paragraph (1) during the period beginning on the date such notification is submitted 

and ending on the date on which the resident is successfully relocated. 

‘‘(3) SANCTIONS.—Any individual who is the administrator 

of a facility that fails to comply with the requirements of paragraph (1)— 

‘‘(A) shall be subject to a civil monetary penalty of up 

to $100,000; 

‘‘(B) may be subject to exclusion from participation in 

any Federal health care program (as defined in section 

1128B(f)); and 

‘‘(C) shall be subject to any other penalties that may 

be prescribed by law. 

‘‘(4) PROCEDURE.—The provisions of section 1128A (other 

than subsections (a) and (b) and the second sentence of subsection (f)) shall apply to a civil money penalty or exclusion 

under paragraph (3) in the same manner as such provisions 

apply to a penalty or proceeding under section 1128A(a).’’. 

(b) CONFORMING AMENDMENTS.—Section 1819(h)(4) of the Social Security Act (42 U.S.C. 1395i–3(h)(4)) is amended— 

(1) in the first sentence, by striking ‘‘the Secretary shall 

terminate’’ and inserting ‘‘the Secretary, subject to section 

1128I(h), shall terminate’’; and 

(2) in the second sentence, by striking ‘‘subsection (c)(2)’’ 

and inserting ‘‘subsection (c)(2) and section 1128I(h)’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall take effect 1 year after the date of the enactment of this Act. 

SEC. 6114. ø42 U.S.C. 1395i–3 note¿ NATIONAL DEMONSTRATION 

PROJECTS ON CULTURE CHANGE AND USE OF INFORMATION TECHNOLOGY IN NURSING HOMES. 

(a) IN GENERAL.—The Secretary shall conduct 2 demonstration 

projects, 1 for the development of best practices in skilled nursing 

facilities and nursing facilities that are involved in the culture 

change movement (including the development of resources for facilities to find and access funding in order to undertake culture 

change) and 1 for the development of best practices in skilled nursing facilities and nursing facilities for the use of information technology to improve resident care. 

(b) CONDUCT OF DEMONSTRATION PROJECTS.— 

(1) GRANT AWARD.—Under each demonstration project conducted under this section, the Secretary shall award 1 or more 

grants to facility-based settings for the development of best 

practices described in subsection (a) with respect to the demonstration project involved. Such award shall be made on a 

competitive basis and may be allocated in 1 lump-sum payment. 

(2) CONSIDERATION OF SPECIAL NEEDS OF RESIDENTS.— 

Each demonstration project conducted under this section shall 

take into consideration the special needs of residents of skilled 

nursing facilities and nursing facilities who have cognitive impairment, including dementia. 

(c) DURATION AND IMPLEMENTATION.— 
657 Sec. 6121 PPACA (Consolidated) 

(1) DURATION.—The demonstration projects shall each be 

conducted for a period not to exceed 3 years. 

(2) IMPLEMENTATION.—The demonstration projects shall 

each be implemented not later than 1 year after the date of the 

enactment of this Act. 

(d) DEFINITIONS.—In this section: 

(1) NURSING FACILITY.—The term ‘‘nursing facility’’ has the 

meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). 

(2) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health and Human Services. 

(3) SKILLED NURSING FACILITY.—The term ‘‘skilled nursing 

facility’’ has the meaning given such term in section 1819(a) of 

the Social Security Act (42 U.S.C. 1395(a)). 

(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated such sums as may be necessary to carry out this 

section. 

(f) REPORT.—Not later than 9 months after the completion of 

the demonstration project, the Secretary shall submit to Congress 

a report on such project, together with recommendations for such 

legislation and administrative action as the Secretary determines 

appropriate. 

PART 3—IMPROVING STAFF TRAINING 

SEC. 6121. DEMENTIA AND ABUSE PREVENTION TRAINING. 

(a) SKILLED NURSING FACILITIES.— (1) IN GENERAL.—Section 1819(f)(2)(A)(i)(I) of the Social 

Security Act (42 U.S.C. 1395i–3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(including, in the case of initial training and, if the 

Secretary determines appropriate, in the case of ongoing training, dementia management training, and patient abuse prevention training’’ before ‘‘, (II)’’. 

(2) CLARIFICATION OF DEFINITION OF NURSE AIDE.—Section 

1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i– 

3(b)(5)(F)) is amended by adding at the end the following flush 

sentence: 

‘‘Such term includes an individual who provides such services through an agency or under a contract with the facility.’’. 

(b) NURSING FACILITIES.— (1) IN GENERAL.—Section 1919(f)(2)(A)(i)(I) of the Social 

Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by inserting ‘‘(including, in the case of initial training and, if the 

Secretary determines appropriate, in the case of ongoing training, dementia management training, and patient abuse prevention training’’ before ‘‘, (II)’’. 

(2) CLARIFICATION OF DEFINITION OF NURSE AIDE.—Section 

1919(b)(5)(F) of the Social Security Act (42 U.S.C. 

1396r(b)(5)(F)) is amended by adding at the end the following 

flush sentence: 

‘‘Such term includes an individual who provides such services through an agency or under a contract with the facility.’’. 
Sec. 6201 PPACA (Consolidated) 658 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall take effect 1 year after the date of the enactment of this Act. 

Subtitle C—Nationwide Program for National and State Background Checks on 

Direct Patient Access Employees of 

Long-term Care Facilities and Providers 

SEC. 6201. ø42 U.S.C. 1320a–7l¿ NATIONWIDE PROGRAM FOR NATIONAL 

AND STATE BACKGROUND CHECKS ON DIRECT PATIENT 

ACCESS EMPLOYEES OF LONG-TERM CARE FACILITIES 

AND PROVIDERS. 

(a) IN GENERAL.—The Secretary of Health and Human Services (in this section referred to as the ‘‘Secretary’’), shall establish 

a program to identify efficient, effective, and economical procedures 

for long term care facilities or providers to conduct background 

checks on prospective direct patient access employees on a nationwide basis (in this subsection, such program shall be referred to as 

the ‘‘nationwide program’’). Except for the following modifications, 

the Secretary shall carry out the nationwide program under similar 

terms and conditions as the pilot program under section 307 of the 

Medicare Prescription Drug, Improvement, and Modernization Act 

of 2003 (Public Law 108–173; 117 Stat. 2257), including the prohibition on hiring abusive workers and the authorization of the imposition of penalties by a participating State under subsection 

(b)(3)(A) and (b)(6), respectively, of such section 307: 

(1) AGREEMENTS.— 

(A) NEWLY PARTICIPATING STATES.—The Secretary 

shall enter into agreements with each State— 

(i) that the Secretary has not entered into an 

agreement with under subsection (c)(1) of such section 

307; 

(ii) that agrees to conduct background checks 

under the nationwide program on a Statewide basis; 

and 

(iii) that submits an application to the Secretary 

containing such information and at such time as the 

Secretary may specify. 

(B) CERTAIN PREVIOUSLY PARTICIPATING STATES.—The 

Secretary shall enter into agreements with each State— 

(i) that the Secretary has entered into an agreement with under such subsection (c)(1), but only in the 

case where such agreement did not require the State 

to conduct background checks under the program established under subsection (a) of such section 307 on 

a Statewide basis; 

(ii) that agrees to conduct background checks 

under the nationwide program on a Statewide basis; 

and 

(iii) that submits an application to the Secretary 

containing such information and at such time as the 

Secretary may specify. 
659 Sec. 6201 PPACA (Consolidated) 

(2) NONAPPLICATION OF SELECTION CRITERIA.—The selection criteria required under subsection (c)(3)(B) of such section 

307 shall not apply. 

(3) REQUIRED FINGERPRINT CHECK AS PART OF CRIMINAL

HISTORY BACKGROUND CHECK.—The procedures established 

under subsection (b)(1) of such section 307 shall— 

(A) require that the long-term care facility or provider 

(or the designated agent of the long-term care facility or 

provider) obtain State and national criminal history background checks on the prospective employee through such 

means as the Secretary determines appropriate, efficient, 

and effective that utilize a search of State-based abuse and 

neglect registries and databases, including the abuse and 

neglect registries of another State in the case where a prospective employee previously resided in that State, State 

criminal history records, the records of any proceedings in 

the State that may contain disqualifying information about 

prospective employees (such as proceedings conducted by 

State professional licensing and disciplinary boards and 

State Medicaid Fraud Control Units), and Federal criminal 

history records, including a fingerprint check using the Integrated Automated Fingerprint Identification System of 

the Federal Bureau of Investigation; 

(B) require States to describe and test methods that 

reduce duplicative fingerprinting, including providing for 

the development of ‘‘rap back’’ capability by the State such 

that, if a direct patient access employee of a long-term care 

facility or provider is convicted of a crime following the initial criminal history background check conducted with respect to such employee, and the employee’s fingerprints 

match the prints on file with the State law enforcement 

department, the department will immediately inform the 

State and the State will immediately inform the long-term 

care facility or provider which employs the direct patient 

access employee of such conviction; and 

(C) require that criminal history background checks 

conducted under the nationwide program remain valid for 

a period of time specified by the Secretary. 

(4) STATE REQUIREMENTS.—An agreement entered into 

under paragraph (1) shall require that a participating State— 

(A) be responsible for monitoring compliance with the 

requirements of the nationwide program; 

(B) have procedures in place to— 

(i) conduct screening and criminal history background checks under the nationwide program in accordance with the requirements of this section; 

(ii) monitor compliance by long-term care facilities 

and providers with the procedures and requirements 

of the nationwide program; 

(iii) as appropriate, provide for a provisional period of employment by a long-term care facility or provider of a direct patient access employee, not to exceed 

60 days, pending completion of the required criminal 

history background check and, in the case where the 
Sec. 6201 PPACA (Consolidated) 660 

employee has appealed the results of such background 

check, pending completion of the appeals process, during which the employee shall be subject to direct onsite supervision (in accordance with procedures established by the State to ensure that a long-term care facility or provider furnishes such direct on-site supervision); 

(iv) provide an independent process by which a 

provisional employee or an employee may appeal or 

dispute the accuracy of the information obtained in a 

background check performed under the nationwide 

program, including the specification of criteria for appeals for direct patient access employees found to have 

disqualifying information which shall include consideration of the passage of time, extenuating circumstances, demonstration of rehabilitation, and relevancy of the particular disqualifying information with 

respect to the current employment of the individual; 

(v) provide for the designation of a single State 

agency as responsible for— 

(I) overseeing the coordination of any State 

and national criminal history background checks 

requested by a long-term care facility or provider 

(or the designated agent of the long-term care facility or provider) utilizing a search of State and 

Federal criminal history records, including a fingerprint check of such records; 

(II) overseeing the design of appropriate privacy and security safeguards for use in the review 

of the results of any State or national criminal 

history background checks conducted regarding a 

prospective direct patient access employee to determine whether the employee has any conviction 

for a relevant crime; 

(III) immediately reporting to the long-term 

care facility or provider that requested the criminal history background check the results of such 

review; and 

(IV) in the case of an employee with a conviction for a relevant crime that is subject to reporting under section 1128E of the Social Security Act 

(42 U.S.C. 1320a–7e), reporting the existence of 

such conviction to the database established under 

that section; 

(vi) determine which individuals are direct patient 

access employees (as defined in paragraph (6)(B)) for 

purposes of the nationwide program; 

(vii) as appropriate, specify offenses, including 

convictions for violent crimes, for purposes of the nationwide program; and 

(viii) describe and test methods that reduce duplicative fingerprinting, including providing for the development of ‘‘rap back’’ capability such that, if a direct patient access employee of a long-term care facil-
661 Sec. 6201 PPACA (Consolidated) 

ity or provider is convicted of a crime following the initial criminal history background check conducted with 

respect to such employee, and the employee’s fingerprints match the prints on file with the State law enforcement department— 

(I) the department will immediately inform 

the State agency designated under clause (v) and 

such agency will immediately inform the facility 

or provider which employs the direct patient access employee of such conviction; and 

(II) the State will provide, or will require the 

facility to provide, to the employee a copy of the 

results of the criminal history background check 

conducted with respect to the employee at no 

charge in the case where the individual requests 

such a copy. 

(5) PAYMENTS.— 

(A) NEWLY PARTICIPATING STATES.— 

(i) IN GENERAL.—As part of the application submitted by a State under paragraph (1)(A)(iii), the 

State shall guarantee, with respect to the costs to be 

incurred by the State in carrying out the nationwide 

program, that the State will make available (directly 

or through donations from public or private entities) a 

particular amount of non-Federal contributions, as a 

condition of receiving the Federal match under clause 

(ii). 

(ii) FEDERAL MATCH.—The payment amount to 

each State that the Secretary enters into an agreement with under paragraph (1)(A) shall be 3 times the 

amount that the State guarantees to make available 

under clause (i), except that in no case may the payment amount exceed $3,000,000. 

(B) PREVIOUSLY PARTICIPATING STATES.— 

(i) IN GENERAL.—As part of the application submitted by a State under paragraph (1)(B)(iii), the 

State shall guarantee, with respect to the costs to be 

incurred by the State in carrying out the nationwide 

program, that the State will make available (directly 

or through donations from public or private entities) a 

particular amount of non-Federal contributions, as a 

condition of receiving the Federal match under clause 

(ii). 

(ii) FEDERAL MATCH.—The payment amount to 

each State that the Secretary enters into an agreement with under paragraph (1)(B) shall be 3 times the 

amount that the State guarantees to make available 

under clause (i), except that in no case may the payment amount exceed $1,500,000. 

(6) DEFINITIONS.—Under the nationwide program: 

(A) CONVICTION FOR A RELEVANT CRIME.—The term 

‘‘conviction for a relevant crime’’ means any Federal or 

State criminal conviction for— 
Sec. 6201 PPACA (Consolidated) 662 

(i) any offense described in section 1128(a) of the 

Social Security Act (42 U.S.C. 1320a–7); or 

(ii) such other types of offenses as a participating 

State may specify for purposes of conducting the program in such State. 

(B) DISQUALIFYING INFORMATION.—The term ‘‘disqualifying information’’ means a conviction for a relevant crime 

or a finding of patient or resident abuse. 

(C) FINDING OF PATIENT OR RESIDENT ABUSE.—The 

term ‘‘finding of patient or resident abuse’’ means any substantiated finding by a State agency under section 

1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act (42 

U.S.C. 1395i–3(g)(1)(C), 1396r(g)(1)(C)) or a Federal agency 

that a direct patient access employee has committed— 

(i) an act of patient or resident abuse or neglect 

or a misappropriation of patient or resident property; 

or 

(ii) such other types of acts as a participating 

State may specify for purposes of conducting the program in such State. 

(D) DIRECT PATIENT ACCESS EMPLOYEE.—The term ‘‘direct patient access employee’’ means any individual who 

has access to a patient or resident of a long-term care facility or provider through employment or through a contract 

with such facility or provider and has duties that involve 

(or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State 

for purposes of the nationwide program. Such term does 

not include a volunteer unless the volunteer has duties 

that are equivalent to the duties of a direct patient access 

employee and those duties involve (or may involve) one-onone contact with a patient or resident of the long-term care 

facility or provider. 

(E) LONG-TERM CARE FACILITY OR PROVIDER.—The 

term ‘‘long-term care facility or provider’’ means the following facilities or providers which receive payment for 

services under title XVIII or XIX of the Social Security 

Act: 

(i) A skilled nursing facility (as defined in section 

1819(a) of the Social Security Act (42 U.S.C. 1395i– 

3(a))). 

(ii) A nursing facility (as defined in section 

1919(a) of such Act (42 U.S.C. 1396r(a))). 

(iii) A home health agency. 

(iv) A provider of hospice care (as defined in section 1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))). 

(v) A long-term care hospital (as described in section 1886(d)(1)(B)(iv) of such Act (42 U.S.C. 

1395ww(d)(1)(B)(iv))). 

(vi) A provider of personal care services. 

(vii) A provider of adult day care. 

(viii) A residential care provider that arranges for, 

or directly provides, long-term care services, including 
663 Sec. 6201 PPACA (Consolidated) 

an assisted living facility that provides a level of care 

established by the Secretary. 

(ix) An intermediate care facility for the mentally 

retarded (as defined in section 1905(d) of such Act (42 

U.S.C. 1396d(d))). 

(x) Any other facility or provider of long-term care 

services under such titles as the participating State 

determines appropriate. 

(7) EVALUATION AND REPORT.— (A) EVALUATION.— (i) IN GENERAL.—The Inspector General of the Department of Health and Human Services shall conduct 

an evaluation of the nationwide program. 

(ii) INCLUSION OF SPECIFIC TOPICS.—The evaluation conducted under clause (i) shall include the following: 

(I) A review of the various procedures implemented by participating States for long-term care 

facilities or providers, including staffing agencies, 

to conduct background checks of direct patient access employees under the nationwide program and 

identification of the most appropriate, efficient, 

and effective procedures for conducting such background checks. 

(II) An assessment of the costs of conducting 

such background checks (including start up and 

administrative costs). 

(III) A determination of the extent to which 

conducting such background checks leads to any 

unintended consequences, including a reduction in 

the available workforce for long-term care facilities or providers. 

(IV) An assessment of the impact of the nationwide program on reducing the number of incidents of neglect, abuse, and misappropriation of 

resident property to the extent practicable. 

(V) An evaluation of other aspects of the nationwide program, as determined appropriate by 

the Secretary. 

(B) REPORT.—Not later than 180 days after the completion of the nationwide program, the Inspector General 

of the Department of Health and Human Services shall 

submit a report to Congress containing the results of the 

evaluation conducted under subparagraph (A). 

(b) FUNDING.— 

(1) NOTIFICATION.—The Secretary of Health and Human 

Services shall notify the Secretary of the Treasury of the 

amount necessary to carry out the nationwide program under 

this section for the period of fiscal years 2010 through 2012, 

except that in no case shall such amount exceed $160,000,000. 

(2) TRANSFER OF FUNDS.— 

(A) IN GENERAL.—Out of any funds in the Treasury 

not otherwise appropriated, the Secretary of the Treasury 

shall provide for the transfer to the Secretary of Health 
Sec. 6301 PPACA (Consolidated) 664 

and Human Services of the amount specified as necessary 

to carry out the nationwide program under paragraph (1). 

Such amount shall remain available until expended. 

(B) RESERVATION OF FUNDS FOR CONDUCT OF EVALUATION.—The Secretary may reserve not more than 

$3,000,000 of the amount transferred under subparagraph 

(A) to provide for the conduct of the evaluation under subsection (a)(7)(A). 

Subtitle D—Patient-Centered Outcomes 

Research 

SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH. 

(a) IN GENERAL.—Title XI of the Social Security Act (42 U.S.C. 

1301 et seq.) is amended by adding at the end the following new 

part: 

‘‘PART D—COMPARATIVE CLINICAL EFFECTIVENESS RESEARCH

‘‘COMPARATIVE CLINICAL EFFECTIVENESS RESEARCH

‘‘SEC. 1181. ø42 U.S.C. 1320e¿ (a) DEFINITIONS.—In this section: 

‘‘(1) BOARD.—The term ‘Board’ means the Board of Governors established under subsection (f). 

‘‘(2) COMPARATIVE CLINICAL EFFECTIVENESS RESEARCH; RESEARCH.— 

‘‘(A) IN GENERAL.—The terms ‘comparative clinical effectiveness research’ and ‘research’ mean research evaluating and comparing health outcomes and the clinical effectiveness, risks, and benefits of 2 or more medical treatments, services, and items described in subparagraph (B). 

‘‘(B) MEDICAL TREATMENTS, SERVICES, AND ITEMS DESCRIBED.—The medical treatments, services, and items described in this subparagraph are health care interventions, 

protocols for treatment, care management, and delivery, 

procedures, medical devices, diagnostic tools, pharmaceuticals (including drugs and biologicals), integrative 

health practices, and any other strategies or items being 

used in the treatment, management, and diagnosis of, or 

prevention of illness or injury in, individuals. 

‘‘(3) CONFLICT OF INTEREST.—The term ‘conflict of interest’ 

means an association, including a financial or personal association, that have the potential to bias or have the appearance of 

biasing an individual’s decisions in matters related to the Institute or the conduct of activities under this section. 

‘‘(4) REAL CONFLICT OF INTEREST.—The term ‘real conflict 

of interest’ means any instance where a member of the Board, 

the methodology committee established under subsection (d)(6), 

or an advisory panel appointed under subsection (d)(4), or a 

close relative of such member, has received or could receive either of the following: 
665 Sec. 6301 PPACA (Consolidated) \1181 SSA 

‘‘(A) A direct financial benefit of any amount deriving 

from the result or findings of a study conducted under this 

section. 

‘‘(B) A financial benefit from individuals or companies 

that own or manufacture medical treatments, services, or 

items to be studied under this section that in the aggregate exceeds $10,000 per year. For purposes of the preceding sentence, a financial benefit includes honoraria, 

fees, stock, or other financial benefit and the current value 

of the member or close relative’s already existing stock 

holdings, in addition to any direct financial benefit deriving from the results or findings of a study conducted under 

this section. 

‘‘(b) PATIENT-CENTERED OUTCOMES RESEARCH INSTITUTE.— ‘‘(1) ESTABLISHMENT.—There is authorized to be established a nonprofit corporation, to be known as the ‘PatientCentered Outcomes Research Institute’ (referred to in this section as the ‘Institute’) which is neither an agency nor establishment of the United States Government. 

‘‘(2) APPLICATION OF PROVISIONS.—The Institute shall be 

subject to the provisions of this section, and, to the extent consistent with this section, to the District of Columbia Nonprofit 

Corporation Act. 

‘‘(3) FUNDING OF COMPARATIVE CLINICAL EFFECTIVENESS

RESEARCH.—For fiscal year 2010 and each subsequent fiscal 

year, amounts in the Patient-Centered Outcomes Research 

Trust Fund (referred to in this section as the ‘PCORTF’) under 

section 9511 of the Internal Revenue Code of 1986 shall be 

available, without further appropriation, to the Institute to 

carry out this section. 

‘‘(c) PURPOSE.—The purpose of the Institute is to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of 

evidence concerning the manner in which diseases, disorders, and 

other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis that considers variations in patient 

subpopulations, and the dissemination of research findings with respect to the relative health outcomes, clinical effectiveness, and appropriateness of the medical treatments, services, and items described in subsection (a)(2)(B). 

‘‘(d) DUTIES.— 

‘‘(1) IDENTIFYING RESEARCH PRIORITIES AND ESTABLISHING

RESEARCH PROJECT AGENDA.— 

‘‘(A) IDENTIFYING RESEARCH PRIORITIES.—The Institute 

shall identify national priorities for research, taking into 

account factors of disease incidence, prevalence, and burden in the United States (with emphasis on chronic conditions), gaps in evidence in terms of clinical outcomes, practice variations and health disparities in terms of delivery 

and outcomes of care, the potential for new evidence to improve patient health, well-being, and the quality of care, 

the effect on national expenditures associated with a 

health care treatment, strategy, or health conditions, as 
Sec. 6301\1181 SSA PPACA (Consolidated) 666 

well as patient needs, outcomes, and preferences, the relevance to patients and clinicians in making informed 

health decisions, and priorities in the National Strategy 

for quality care established under section 399H of the Public Health Service Act that are consistent with this section. 

‘‘(B) ESTABLISHING RESEARCH PROJECT AGENDA.—The 

Institute shall establish and update a research project 

agenda for research to address the priorities identified 

under subparagraph (A), taking into consideration the 

types of research that might address each priority and the 

relative value (determined based on the cost of conducting 

research compared to the potential usefulness of the information produced by research) associated with the different 

types of research, and such other factors as the Institute 

determines appropriate. 

‘‘(2) CARRYING OUT RESEARCH PROJECT AGENDA.— 

‘‘(A) RESEARCH.—The Institute shall carry out the research project agenda established under paragraph (1)(B) 

in accordance with the methodological standards adopted 

under paragraph (9) using methods, including the following: 

‘‘(i) Systematic reviews and assessments of existing and future research and evidence including original research conducted subsequent to the date of the 

enactment of this section. 

‘‘(ii) Primary research, such as randomized clinical 

trials, molecularly informed trials, and observational 

studies. 

‘‘(iii) Any other methodologies recommended by 

the methodology committee established under paragraph (6) that are adopted by the Board under paragraph (9). 

‘‘(B) CONTRACTS FOR THE MANAGEMENT OF FUNDING

AND CONDUCT OF RESEARCH.— 

‘‘(i) CONTRACTS.— 

‘‘(I) IN GENERAL.—In accordance with the research project agenda established under paragraph (1)(B), the Institute shall enter into contracts for the management of funding and conduct 

of research in accordance with the following: 

‘‘(aa) Appropriate agencies and instrumentalities of the Federal Government. 

‘‘(bb) Appropriate academic research, private sector research, or study-conducting entities. 

‘‘(II) PREFERENCE.—In entering into contracts 

under subclause (I), the Institute shall give preference to the Agency for Healthcare Research and 

Quality and the National Institutes of Health, but 

only if the research to be conducted or managed 

under such contract is authorized by the governing statutes of such Agency or Institutes. 
667 Sec. 6301 PPACA (Consolidated) \1181 SSA 

‘‘(ii) CONDITIONS FOR CONTRACTS.—A contract entered into under this subparagraph shall require that 

the agency, instrumentality, or other entity— 

‘‘(I) abide by the transparency and conflicts of 

interest requirements under subsection (h) that 

apply to the Institute with respect to the research 

managed or conducted under such contract; 

‘‘(II) comply with the methodological standards adopted under paragraph (9) with respect to 

such research; 

‘‘(III) consult with the expert advisory panels 

for clinical trials and rare disease appointed under 

clauses (ii) and (iii), respectively, of paragraph 

(4)(A); 

‘‘(IV) subject to clause (iv), permit a researcher who conducts original research, as described in subparagraph (A)(ii), under the contract 

for the agency, instrumentality, or other entity to 

have such research published in a peer-reviewed 

journal or other publication, 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; øAs revised by section 

10602(1)(A)(i) and (ii)¿ 

‘‘(V) have appropriate processes in place to 

manage data privacy and meet ethical standards 

for the research; 

‘‘(VI) comply with the requirements of the Institute for making the information available to the 

public under paragraph (8); and 

‘‘(VII) comply with other terms and conditions 

determined necessary by the Institute to carry out 

the research agenda adopted under paragraph (2). 

‘‘(iii) COVERAGE OF COPAYMENTS OR COINSURANCE.—A contract entered into under this subparagraph may allow for the coverage of copayments or coinsurance, or allow for other appropriate measures, to 

the extent that such coverage or other measures are 

necessary to preserve the validity of a research 

project, such as in the case where the research project 

must be blinded. 

‘‘(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. øReplaced by 

section 10602(1)(B)¿ 

‘‘(C) REVIEW AND UPDATE OF EVIDENCE.—The Institute 

shall review and update evidence on a periodic basis as appropriate. 

‘‘(D) TAKING INTO ACCOUNT POTENTIAL DIFFERENCES.— 

Research shall be designed, as appropriate, to take into account the potential for differences in the effectiveness of 
Sec. 6301\1181 SSA PPACA (Consolidated) 668 

health care treatments, services, and items as used with 

various subpopulations, such as racial and ethnic minorities, women, age, and groups of individuals with different 

comorbidities, genetic and molecular sub-types, or quality 

of life preferences and include members of such subpopulations as subjects in the research as feasible and appropriate. 

‘‘(E) DIFFERENCES IN TREATMENT MODALITIES.—Research shall be designed, as appropriate, to take into account different characteristics of treatment modalities that 

may affect research outcomes, such as the phase of the 

treatment modality in the innovation cycle and the impact 

of the skill of the operator of the treatment modality. 

‘‘(3) DATA COLLECTION.— ‘‘(A) IN GENERAL.—The Secretary shall, with appropriate safeguards for privacy, make available to the Institute such data collected by the Centers for Medicare & 

Medicaid Services under the programs under titles XVIII, 

XIX, and XXI, as well as provide access to the data networks developed under section 937(f) of the Public Health 

Service Act, as the Institute and its contractors may require to carry out this section. The Institute may also request and obtain data from Federal, State, or private entities, including data from clinical databases and registries. 

‘‘(B) USE OF DATA.—The Institute shall only use data 

provided to the Institute under subparagraph (A) in accordance with laws and regulations governing the release 

and use of such data, including applicable confidentiality 

and privacy standards. 

‘‘(4) APPOINTING EXPERT ADVISORY PANELS.— 

‘‘(A) APPOINTMENT.— 

‘‘(i) IN GENERAL.—The Institute may appoint permanent or ad hoc expert advisory panels as determined appropriate to assist in identifying research priorities and establishing the research project agenda 

under paragraph (1) and for other purposes. 

‘‘(ii) EXPERT ADVISORY PANELS FOR CLINICAL

TRIALS.—The Institute shall appoint expert advisory 

panels in carrying out randomized clinical trials under 

the research project agenda under paragraph (2)(A)(ii). 

Such expert advisory panels shall advise the Institute 

and the agency, instrumentality, or entity conducting 

the research on the research question involved and the 

research design or protocol, including important patient subgroups and other parameters of the research. 

Such panels shall be available as a resource for technical questions that may arise during the conduct of 

such research. 

‘‘(iii) EXPERT ADVISORY PANEL FOR RARE DISEASE.— 

In the case of a research study for rare disease, the Institute shall appoint an expert advisory panel for purposes of assisting in the design of the research study 

and determining the relative value and feasibility of 

conducting the research study. 
669 Sec. 6301 PPACA (Consolidated) \1181 SSA 

‘‘(B) COMPOSITION.—An expert advisory panel appointed under subparagraph (A) shall include representatives of practicing and research clinicians, patients, and 

experts in scientific and health services research, health 

services delivery, and evidence-based medicine who have 

experience in the relevant topic, and as appropriate, experts in integrative health and primary prevention strategies. The Institute may include a technical expert of each 

manufacturer or each medical technology that is included 

under the relevant topic, project, or category for which the 

panel is established. 

‘‘(5) SUPPORTING PATIENT AND CONSUMER REPRESENTA- TIVES.—The Institute shall provide support and resources to 

help patient and consumer representatives effectively participate on the Board and expert advisory panels appointed by the 

Institute under paragraph (4). 

‘‘(6) ESTABLISHING METHODOLOGY COMMITTEE.— ‘‘(A) IN GENERAL.—The Institute shall establish a 

standing methodology committee to carry out the functions 

described in subparagraph (C). 

‘‘(B) APPOINTMENT AND COMPOSITION.—The methodology committee established under subparagraph (A) shall 

be composed of not more than 15 members appointed by 

the Comptroller General of the United States. Members 

appointed to the methodology committee shall be experts 

in their scientific field, such as health services research, 

clinical research, comparative clinical effectiveness research, biostatistics, genomics, and research methodologies. Stakeholders with such expertise may be appointed to 

the methodology committee. In addition to the members 

appointed under the first sentence, the Directors of the 

National Institutes of Health and the Agency for 

Healthcare Research and Quality (or their designees) shall 

each be included as members of the methodology committee. 

‘‘(C) FUNCTIONS.—Subject to subparagraph (D), the 

methodology committee shall work to develop and improve 

the science and methods of comparative clinical effectiveness research by, not later than 18 months after the establishment of the Institute, directly or through subcontract, 

developing and periodically updating the following: 

‘‘(i) Methodological standards for research. Such 

methodological standards shall provide specific criteria 

for internal validity, generalizability, feasibility, and 

timeliness of research and for health outcomes measures, risk adjustment, and other relevant aspects of 

research and assessment with respect to the design of 

research. Any methodological standards developed and 

updated under this subclause shall be scientifically 

based and include methods by which new information, 

data, or advances in technology are considered and incorporated into ongoing research projects by the Institute, as appropriate. The process for developing and 

updating such standards shall include input from rel-
Sec. 6301\1181 SSA PPACA (Consolidated) 670 

evant experts, stakeholders, and decisionmakers, and 

shall provide opportunities for public comment. Such 

standards shall also include methods by which patient 

subpopulations can be accounted for and evaluated in 

different types of research. As appropriate, such standards shall build on existing work on methodological 

standards for defined categories of health interventions and for each of the major categories of comparative clinical effectiveness research methods (determined as of the date of enactment of the Patient Protection and Affordable Care Act). 

‘‘(ii) A translation table that is designed to provide 

guidance and act as a reference for the Board to determine research methods that are most likely to address 

each specific research question. 

‘‘(D) CONSULTATION AND CONDUCT OF EXAMINATIONS.— The methodology committee may consult and contract with 

the Institute of Medicine of the National Academies and 

academic, nonprofit, or other private and governmental entities with relevant expertise to carry out activities described in subparagraph (C) and may consult with relevant 

stakeholders to carry out such activities. 

‘‘(E) REPORTS.—The methodology committee shall submit reports to the Board on the committee’s performance 

of the functions described in subparagraph (C). Reports 

shall contain recommendations for the Institute to adopt 

methodological standards developed and updated by the 

methodology committee as well as other actions deemed 

necessary to comply with such methodological standards. 

‘‘(7) PROVIDING FOR A PEER-REVIEW PROCESS FOR PRIMARY

RESEARCH.— 

‘‘(A) IN GENERAL.—The Institute shall ensure that 

there is a process for peer review of primary research described in subparagraph (A)(ii) of paragraph (2) that is 

conducted under such paragraph. Under such process— 

‘‘(i) evidence from such primary research shall be 

reviewed to assess scientific integrity and adherence to 

methodological standards adopted under paragraph 

(9); and 

‘‘(ii) a list of the names of individuals contributing 

to any peer-review process during the preceding year 

or years shall be made public and included in annual 

reports in accordance with paragraph (10)(D). 

‘‘(B) COMPOSITION.—Such peer-review process shall be 

designed in a manner so as to avoid bias and conflicts of 

interest on the part of the reviewers and shall be composed 

of experts in the scientific field relevant to the research 

under review. 

‘‘(C) USE OF EXISTING PROCESSES.— 

‘‘(i) PROCESSES OF ANOTHER ENTITY.—In the case 

where the Institute enters into a contract or other 

agreement with another entity for the conduct or management of research under this section, the Institute 

may utilize the peer-review process of such entity if 
671 Sec. 6301 PPACA (Consolidated) \1181 SSA 

such process meets the requirements under subparagraphs (A) and (B). 

‘‘(ii) PROCESSES OF APPROPRIATE MEDICAL JOUR- NALS.—The Institute may utilize the peer-review process of appropriate medical journals if such process 

meets the requirements under subparagraphs (A) and 

(B). 

‘‘(8) RELEASE OF RESEARCH FINDINGS.— ‘‘(A) IN GENERAL.—The Institute shall, not later than 

90 days after the conduct or receipt of research findings 

under this part, make such research findings available to 

clinicians, patients, and the general public. The Institute 

shall ensure that the research findings— 

‘‘(i) convey the findings of research in a manner 

that is comprehensible and useful to patients and providers in making health care decisions; 

‘‘(ii) fully convey findings and discuss considerations specific to certain subpopulations, risk factors, 

and comorbidities, as appropriate; 

‘‘(iii) include limitations of the research and what 

further research may be needed as appropriate; 

‘‘(iv) do not include practice guidelines, coverage 

recommendations, payment, or policy recommendations; and øAs revised by section 10602(2)¿ 

‘‘(v) not include any data which would violate the 

privacy of research participants or any confidentiality 

agreements made with respect to the use of data 

under this section. 

‘‘(B) DEFINITION OF RESEARCH FINDINGS.—In this paragraph, the term ‘research findings’ means the results of a 

study or assessment. 

‘‘(9) ADOPTION.—Subject to subsection (h)(1), the Institute 

shall adopt the national priorities identified under paragraph 

(1)(A), the research project agenda established under paragraph (1)(B), the methodological standards developed and updated by the methodology committee under paragraph (6)(C)(i), 

and any peer-review process provided under paragraph (7) by 

majority vote. In the case where the Institute does not adopt 

such processes in accordance with the preceding sentence, the 

processes shall be referred to the appropriate staff or entity 

within the Institute (or, in the case of the methodological 

standards, the methodology committee) for further review. 

‘‘(10) ANNUAL REPORTS.—The Institute shall submit an annual report to Congress and the President, and shall make the 

annual report available to the public. Such report shall contain— 

‘‘(A) a description of the activities conducted under 

this section, research priorities identified under paragraph 

(1)(A) and methodological standards developed and updated by the methodology committee under paragraph 

(6)(C)(i) that are adopted under paragraph (9) during the 

preceding year; 

‘‘(B) the research project agenda and budget of the Institute for the following year; 
Sec. 6301\1181 SSA PPACA (Consolidated) 672 

‘‘(C) any administrative activities conducted by the Institute during the preceding year; 

‘‘(D) the names of individuals contributing to any peerreview process under paragraph (7), without identifying 

them with a particular research project; and 

‘‘(E) any other relevant information (including information on the membership of the Board, expert advisory 

panels, methodology committee, and the executive staff of 

the Institute, any conflicts of interest with respect to these 

individuals, and any bylaws adopted by the Board during 

the preceding year). 

‘‘(e) ADMINISTRATION.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the Board 

shall carry out the duties of the Institute. 

‘‘(2) NONDELEGABLE DUTIES.—The activities described in 

subsections (d)(1) and (d)(9) are nondelegable. 

‘‘(f) BOARD OF GOVERNORS.— ‘‘(1) IN GENERAL.—The Institute shall have a Board of Governors, which shall consist of the following members: 

‘‘(A) The Director of Agency for Healthcare Research 

and Quality (or the Director’s designee). 

‘‘(B) The Director of the National Institutes of Health 

(or the Director’s designee). 

‘‘(C) Seventeen members appointed, not later than 6 

months after the date of enactment of this section, by the 

Comptroller General of the United States as follows: 

‘‘(i) 3 members representing patients and health 

care consumers. 

‘‘(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. øReplaced by section 

10602(3)¿ 

‘‘(iii) 3 members representing private payers, of 

whom at least 1 member shall represent health insurance issuers and at least 1 member shall represent 

employers who self-insure employee benefits. 

‘‘(iv) 3 members representing pharmaceutical, device, and diagnostic manufacturers or developers. 

‘‘(v) 1 member representing quality improvement 

or independent health service researchers. 

‘‘(vi) 2 members representing the Federal Government or the States, including at least 1 member representing a Federal health program or agency. 

‘‘(2) QUALIFICATIONS.—The Board shall represent a broad 

range of perspectives and collectively have scientific expertise 

in clinical health sciences research, including epidemiology, decisions sciences, health economics, and statistics. In appointing 

the Board, the Comptroller General of the United States shall 

consider and disclose any conflicts of interest in accordance 

with subsection (h)(4)(B). Members of the Board shall be 

recused from relevant Institute activities in the case where the 

member (or an immediate family member of such member) has 
673 Sec. 6301 PPACA (Consolidated) \1181 SSA 

a real conflict of interest directly related to the research project 

or the matter that could affect or be affected by such participation. 

‘‘(3) TERMS; VACANCIES.—A member of the Board shall be 

appointed for a term of 6 years, except with respect to the 

members first appointed, whose terms of appointment shall be 

staggered evenly over 2-year increments. No individual shall 

be appointed to the Board for more than 2 terms. Vacancies 

shall be filled in the same manner as the original appointment 

was made. 

‘‘(4) CHAIRPERSON AND VICE-CHAIRPERSON.—The Comptroller General of the United States shall designate a Chairperson and Vice Chairperson of the Board from among the 

members of the Board. Such members shall serve as Chairperson or Vice Chairperson for a period of 3 years. 

‘‘(5) COMPENSATION.—Each member of the Board who is 

not an officer or employee of the Federal Government shall be 

entitled to compensation (equivalent to the rate provided for 

level IV of the Executive Schedule under section 5315 of title 

5, United States Code) and expenses incurred while performing 

the duties of the Board. An officer or employee of the Federal 

government who is a member of the Board shall be exempt 

from compensation. 

‘‘(6) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS.— 

The Board may employ and fix the compensation of an Executive Director and such other personnel as may be necessary to 

carry out the duties of the Institute and may seek such assistance and support of, or contract with, experts and consultants 

that may be necessary for the performance of the duties of the 

Institute. 

‘‘(7) MEETINGS AND HEARINGS.—The Board shall meet and 

hold hearings at the call of the Chairperson or a majority of 

its members. Meetings not solely concerning matters of personnel shall be advertised at least 7 days in advance and open 

to the public. A majority of the Board members shall constitute 

a quorum, but a lesser number of members may meet and hold 

hearings. 

‘‘(g) FINANCIAL AND GOVERNMENTAL OVERSIGHT.— 

‘‘(1) CONTRACT FOR AUDIT.—The Institute shall provide for 

the conduct of financial audits of the Institute on an annual 

basis by a private entity with expertise in conducting financial 

audits. 

‘‘(2) REVIEW AND ANNUAL REPORTS.— 

‘‘(A) REVIEW.—The Comptroller General of the United 

States shall review the following: 

‘‘(i) Not less frequently than on an annual basis, 

the financial audits conducted under paragraph (1). 

‘‘(ii) Not less frequently than every 5 years, the 

processes established by the Institute, including the 

research priorities and the conduct of research 

projects, in order to determine whether information 

produced by such research projects is objective and 

credible, is produced in a manner consistent with the 
Sec. 6301\1181 SSA PPACA (Consolidated) 674 

requirements under this section, and is developed 

through a transparent process. 

‘‘(iii) Not less frequently than every 5 years, the 

dissemination and training activities and data networks established under section 937 of the Public 

Health Service Act, including the methods and products used to disseminate research, the types of training conducted and supported, and the types and functions of the data networks established, in order to determine whether the activities and data are produced 

in a manner consistent with the requirements under 

such section. 

‘‘(iv) Not less frequently than every 5 years, the 

overall effectiveness of activities conducted under this 

section and the dissemination, training, and capacity 

building activities conducted under section 937 of the 

Public Health Service Act. Such review shall include 

an analysis of the extent to which research findings 

are used by health care decision-makers, the effect of 

the dissemination of such findings on reducing practice variation and disparities in health care, and the 

effect of the research conducted and disseminated on 

innovation and the health care economy of the United 

States. 

‘‘(v) Not later than 8 years after the date of enactment of this section, the adequacy and use of the funding for the Institute and the activities conducted under 

section 937 of the Public Health Service Act, including 

a determination as to whether, based on the utilization of research findings by public and private payers, 

funding sources for the Patient-Centered Outcomes 

Research Trust Fund under section 9511 of the Internal Revenue Code of 1986 are appropriate and whether such sources of funding should be continued or adjusted. 

‘‘(B) ANNUAL REPORTS.—Not later than April 1 of each 

year, the Comptroller General of the United States shall 

submit to Congress a report containing the results of the 

review conducted under subparagraph (A) with respect to 

the preceding year (or years, if applicable), together with 

recommendations for such legislation and administrative 

action as the Comptroller General determines appropriate. 

‘‘(h) ENSURING TRANSPARENCY, CREDIBILITY, AND ACCESS.—The 

Institute shall establish procedures to ensure that the following requirements for ensuring transparency, credibility, and access are 

met: 

‘‘(1) PUBLIC COMMENT PERIODS.—The Institute shall provide for a public comment period of not less than 45 days and 

not more than 60 days prior to the adoption under subsection 

(d)(9) of the national priorities identified under subsection 

(d)(1)(A), the research project agenda established under subsection (d)(1)(B), the methodological standards developed and 

updated by the methodology committee under subsection 

(d)(6)(C)(i), and the peer-review process provided under para-
675 Sec. 6301 PPACA (Consolidated) \1181 SSA 

graph (7), and after the release of draft findings with respect 

to systematic reviews of existing research and evidence. 

‘‘(2) ADDITIONAL FORUMS.—The Institute shall support forums to increase public awareness and obtain and incorporate 

public input and feedback through media (such as an Internet 

website) on research priorities, research findings, and other duties, activities, or processes the Institute determines appropriate. 

‘‘(3) PUBLIC AVAILABILITY.—The Institute shall make available to the public and disclose through the official public Internet website of the Institute the following: 

‘‘(A) Information contained in research findings as 

specified in subsection (d)(9). 

‘‘(B) The process and methods for the conduct of research, including the identity of the entity and the investigators conducing such research and any conflicts of interests of such parties, any direct or indirect links the entity 

has to industry, and research protocols, including measures taken, methods of research and analysis, research results, and such other information the Institute determines 

appropriate) concurrent with the release of research findings. 

‘‘(C) Notice of public comment periods under paragraph (1), including deadlines for public comments. 

‘‘(D) Subsequent comments received during each of the 

public comment periods. 

‘‘(E) In accordance with applicable laws and processes 

and as the Institute determines appropriate, proceedings 

of the Institute. 

‘‘(4) DISCLOSURE OF CONFLICTS OF INTEREST.— 

‘‘(A) IN GENERAL.—A conflict of interest shall be disclosed in the following manner: 

‘‘(i) By the Institute in appointing members to an 

expert advisory panel under subsection (d)(4), in selecting individuals to contribute to any peer-review 

process under subsection (d)(7), and for employment as 

executive staff of the Institute. 

‘‘(ii) By the Comptroller General in appointing 

members of the methodology committee under subsection (d)(6); 

‘‘(iii) By the Institute in the annual report under 

subsection (d)(10), except that, in the case of individuals contributing to any such peer review process, 

such description shall be in a manner such that those 

individuals cannot be identified with a particular research project. 

‘‘(B) MANNER OF DISCLOSURE.—Conflicts of interest 

shall be disclosed as described in subparagraph (A) as soon 

as practicable on the Internet web site of the Institute and 

of the Government Accountability Office. The information 

disclosed under the preceding sentence shall include the 

type, nature, and magnitude of the interests of the individual involved, except to the extent that the individual 

recuses himself or herself from participating in the consid-
Sec. 6301 PPACA (Consolidated) 676 

eration of or any other activity with respect to the study 

as to which the potential conflict exists. 

‘‘(i) RULES.—The Institute, its Board or staff, shall be prohibited from accepting gifts, bequeaths, or donations of services or 

property. In addition, the Institute shall be prohibited from establishing a corporation or generating revenues from activities other 

than as provided under this section. 

‘‘(j) RULES OF CONSTRUCTION.— ‘‘(1) COVERAGE.—Nothing in this section shall be construed— 

‘‘(A) to permit the Institute to mandate coverage, reimbursement, or other policies for any public or private 

payer; or 

‘‘(B) as preventing the Secretary from covering the 

routine costs of clinical care received by an individual entitled to, or enrolled for, benefits under title XVIII, XIX, or 

XXI in the case where such individual is participating in 

a clinical trial and such costs would otherwise be covered 

under such title with respect to the beneficiary.’’. 

(b) DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH.— Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.), 

as amended by section 3606, is further amended by inserting after 

section 936 the following: 

‘‘SEC. 937. ø42 U.S.C. 299b–37¿ DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH. 

‘‘(a) IN GENERAL.— ‘‘(1) DISSEMINATION.—The Office of Communication and 

Knowledge Transfer (referred to in this section as the ‘Office’) 

at the Agency for Healthcare Research and Quality (or any 

other relevant office designated by Agency for Healthcare Research and Quality), in consultation with the National Institutes of Health, shall broadly disseminate the research findings that are published by the Patient Centered Outcomes Research Institute established under section 1181(b) of the Social 

Security Act (referred to in this section as the ‘Institute’) and 

other government-funded research relevant to comparative 

clinical effectiveness research. The Office shall create informational tools that organize and disseminate research findings for 

physicians, health care providers, patients, payers, and policy 

makers. The Office shall also develop a publicly available resource database that collects and contains government-funded 

evidence and research from public, private, not-for profit, and 

academic sources. 

‘‘(2) REQUIREMENTS.—The Office shall provide for the dissemination of the Institute’s research findings and government-funded research relevant to comparative clinical effectiveness research to physicians, health care providers, patients, 

vendors of health information technology focused on clinical decision support, appropriate professional associations, and Federal and private health plans. Materials, forums, and media 

used to disseminate the findings, informational tools, and resource databases shall— 

‘‘(A) include a description of considerations for specific 

subpopulations, the research methodology, and the limita-
677 Sec. 6301 PPACA (Consolidated) \1182 SSA 

tions of the research, and the names of the entities, agencies, instrumentalities, and individuals who conducted any 

research which was published by the Institute; and 

‘‘(B) not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment. 

‘‘(b) INCORPORATION OF RESEARCH FINDINGS.—The Office, in 

consultation with relevant medical and clinical associations, shall 

assist users of health information technology focused on clinical decision support to promote the timely incorporation of research findings disseminated under subsection (a) into clinical practices and 

to promote the ease of use of such incorporation. 

‘‘(c) FEEDBACK.—The Office shall establish a process to receive 

feedback from physicians, health care providers, patients, and vendors of health information technology focused on clinical decision 

support, appropriate professional associations, and Federal and private health plans about the value of the information disseminated 

and the assistance provided under this section. 

‘‘(d) RULE OF CONSTRUCTION.—Nothing in this section shall 

preclude the Institute from making its research findings publicly 

available as required under section 1181(d)(8) of the Social Security 

Act. 

‘‘(e) TRAINING OF RESEARCHERS.—The Agency for Health Care 

Research and Quality, in consultation with the National Institutes 

of Health, shall build capacity for comparative clinical effectiveness 

research by establishing a grant program that provides for the 

training of researchers in the methods used to conduct such research, including systematic reviews of existing research and primary research such as clinical trials. At a minimum, such training 

shall be in methods that meet the methodological standards adopted under section 1181(d)(9) of the Social Security Act. 

‘‘(f) BUILDING DATA FOR RESEARCH.—The Secretary shall provide for the coordination of relevant Federal health programs to 

build data capacity for comparative clinical effectiveness research, 

including the development and use of clinical registries and health 

outcomes research data networks, in order to develop and maintain 

a comprehensive, interoperable data network to collect, link, and 

analyze data on outcomes and effectiveness from multiple sources, 

including electronic health records. 

‘‘(g) AUTHORITY TO CONTRACT WITH THE INSTITUTE.—Agencies 

and instrumentalities of the Federal Government may enter into 

agreements with the Institute, and accept and retain funds, for the 

conduct and support of research described in this part, provided 

that the research to be conducted or supported under such agreements is authorized under the governing statutes of such agencies 

and instrumentalities.’’. 

(c) IN GENERAL.—Part D of title XI of the Social Security Act, 

as added by subsection (a), is amended by adding at the end the 

following new section: 

‘‘LIMITATIONS ON CERTAIN USES OF COMPARATIVE CLINICAL

EFFECTIVENESS RESEARCH

‘‘SEC. 1182. ø42 U.S.C. 1320e–1¿ (a) The Secretary may only 

use evidence and findings from research conducted under section 

1181 to make a determination regarding coverage under title XVIII 
Sec. 6301\1182 SSA PPACA (Consolidated) 678 

if such use is through an iterative and transparent process which 

includes public comment and considers the effect on subpopulations. 

‘‘(b) Nothing in section 1181 shall be construed as— 

‘‘(1) superceding or modifying the coverage of items or 

services under title XVIII that the Secretary determines are 

reasonable and necessary under section 1862(l)(1); or 

‘‘(2) authorizing the Secretary to deny coverage of items or 

services under such title solely on the basis of comparative 

clinical effectiveness research. 

‘‘(c)(1) The Secretary shall not use evidence or findings from 

comparative clinical effectiveness research conducted under section 

1181 in determining coverage, reimbursement, or incentive programs under title XVIII in a manner that treats extending the life 

of an elderly, disabled, or terminally ill individual as of lower value 

than extending the life of an individual who is younger, nondisabled, or not terminally ill. 

‘‘(2) Paragraph (1) shall not be construed as preventing the 

Secretary from using evidence or findings from such comparative 

clinical effectiveness research in determining coverage, reimbursement, or incentive programs under title XVIII based upon a comparison of the difference in the effectiveness of alternative treatments in extending an individual’s life due to the individual’s age, 

disability, or terminal illness. 

‘‘(d)(1) The Secretary shall not use evidence or findings from 

comparative clinical effectiveness research conducted under section 

1181 in determining coverage, reimbursement, or incentive programs under title XVIII in a manner that precludes, or with the 

intent to discourage, an individual from choosing a health care 

treatment based on how the individual values the tradeoff between 

extending the length of their life and the risk of disability. 

‘‘(2)(A) Paragraph (1) shall not be construed to— 

‘‘(i) limit the application of differential copayments under 

title XVIII based on factors such as cost or type of service; or 

‘‘(ii) prevent the Secretary from using evidence or findings 

from such comparative clinical effectiveness research in determining coverage, reimbursement, or incentive programs under 

such title based upon a comparison of the difference in the effectiveness of alternative health care treatments in extending 

an individual’s life due to that individual’s age, disability, or 

terminal illness. 

‘‘(3) Nothing in the provisions of, or amendments made by the 

Patient Protection and Affordable Care Act, shall be construed to 

limit comparative clinical effectiveness research or any other research, evaluation, or dissemination of information concerning the 

likelihood that a health care treatment will result in disability. 

‘‘(e) The Patient-Centered Outcomes Research Institute established under section 1181(b)(1) shall not develop or employ a dollars-per-quality adjusted life year (or similar measure that discounts the value of a life because of an individual’s disability) as 

a threshold to establish what type of health care is cost effective 

or recommended. The Secretary shall not utilize such an adjusted 

life year (or such a similar measure) as a threshold to determine 
679 Sec. 6301 PPACA (Consolidated) \9511 IRC 

coverage, reimbursement, or incentive programs under title 

XVIII.’’. 

(d) IN GENERAL.—Part D of title XI of the Social Security Act, 

as added by subsection (a) and amended by subsection (c), is 

amended by adding at the end the following new section: 

‘‘TRUST FUND TRANSFERS TO PATIENT-CENTERED OUTCOMES

RESEARCH TRUST FUND

‘‘SEC. 1183. ø42 U.S.C. 1320e–2¿ (a) IN GENERAL.—The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in proportion (as estimated by the Secretary) to the total expenditures 

during such fiscal year that are made under title XVIII from the 

respective trust fund, to the Patient-Centered Outcomes Research 

Trust Fund (referred to in this section as the ‘PCORTF’) under section 9511 of the Internal Revenue Code of 1986, of the following: 

‘‘(1) For fiscal year 2013, an amount equal to $1 multiplied 

by the average number of individuals entitled to benefits under 

part A, or enrolled under part B, of title XVIII during such fiscal year. 

‘‘(2) For each of fiscal years 2014, 2015, 2016, 2017, 2018, 

and 2019, an amount equal to $2 multiplied by the average 

number of individuals entitled to benefits under part A, or enrolled under part B, of title XVIII during such fiscal year. 

‘‘(b) ADJUSTMENTS FOR INCREASES IN HEALTH CARE SPENDING.—In the case of any fiscal year beginning after September 30, 

2014, the dollar amount in effect under subsection (a)(2) for such 

fiscal year shall be equal to the sum of such dollar amount for the 

previous fiscal year (determined after the application of this subsection), plus an amount equal to the product of— 

‘‘(1) such dollar amount for the previous fiscal year, multiplied by 

‘‘(2) the percentage increase in the projected per capita 

amount of National Health Expenditures, as most recently 

published by the Secretary before the beginning of the fiscal 

year.’’. 

(e) PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND; FINANCING FOR TRUST FUND.— 

(1) ESTABLISHMENT OF TRUST FUND.— 

(A) IN GENERAL.—Subchapter A of chapter 98 of the 

Internal Revenue Code of 1986 (relating to establishment 

of trust funds) is amended by adding at the end the following new section: 

‘‘SEC. 9511. PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND. 

‘‘(a) CREATION OF TRUST FUND.—There is established in the 

Treasury of the United States a trust fund to be known as the ‘Patient-Centered Outcomes Research Trust Fund’ (hereafter in this 

section referred to as the ‘PCORTF’), consisting of such amounts as 

may be appropriated or credited to such Trust Fund as provided in 

this section and section 9602(b). 

‘‘(b) TRANSFERS TO FUND.— 
Sec. 6301\9511 IRC PPACA (Consolidated) 680 

‘‘(1) APPROPRIATION.—There are hereby appropriated to the 

Trust Fund the following: ‘‘(A) For fiscal year 2010, $10,000,000. 

‘‘(B) For fiscal year 2011, $50,000,000. 

‘‘(C) For fiscal year 2012, $150,000,000. 

‘‘(D) For fiscal year 2013— 

‘‘(i) an amount equivalent to the net revenues received in the Treasury from the fees imposed under 

subchapter B of chapter 34 (relating to fees on health 

insurance and self-insured plans) for such fiscal year; 

and 

‘‘(ii) $150,000,000. 

‘‘(E) For each of fiscal years 2014, 2015, 2016, 2017, 

2018, and 2019— 

‘‘(i) an amount equivalent to the net revenues received in the Treasury from the fees imposed under 

subchapter B of chapter 34 (relating to fees on health 

insurance and self-insured plans) for such fiscal year; 

and 

‘‘(ii) $150,000,000. 

The amounts appropriated under subparagraphs (A), (B), 

(C), (D)(ii), and (E)(ii) shall be transferred from the general 

fund of the Treasury, from funds not otherwise appropriated. 

‘‘(2) TRUST FUND TRANSFERS.—In addition to the amounts 

appropriated under paragraph (1), there shall be credited to 

the PCORTF the amounts transferred under section 1183 of 

the Social Security Act. 

‘‘(3) LIMITATION ON TRANSFERS TO PCORTF.—No amount 

may be appropriated or transferred to the PCORTF on and 

after the date of any expenditure from the PCORTF which is 

not an expenditure permitted under this section. The determination of whether an expenditure is so permitted shall be 

made without regard to— 

‘‘(A) any provision of law which is not contained or referenced in this chapter or in a revenue Act, and 

‘‘(B) whether such provision of law is a subsequently 

enacted provision or directly or indirectly seeks to waive 

the application of this paragraph. 

‘‘(c) TRUSTEE.—The Secretary of the Treasury shall be a trustee 

of the PCORTF. 

‘‘(d) EXPENDITURES FROM FUND.— 

‘‘(1) AMOUNTS AVAILABLE TO THE PATIENT-CENTERED OUTCOMES RESEARCH INSTITUTE.—Subject to paragraph (2), 

amounts in the PCORTF are available, without further appropriation, to the Patient-Centered Outcomes Research Institute 

established under section 1181(b) of the Social Security Act for 

carrying out part D of title XI of the Social Security Act (as in 

effect on the date of enactment of such Act). 

‘‘(2) TRANSFER OF FUNDS.— 

‘‘(A) IN GENERAL.—The trustee of the PCORTF shall 

provide for the transfer from the PCORTF of 20 percent of 

the amounts appropriated or credited to the PCORTF for 

each of fiscal years 2011 through 2019 to the Secretary of 
681 Sec. 6301 PPACA (Consolidated) \4375 IRC 

Health and Human Services to carry out section 937 of the 

Public Health Service Act. 

‘‘(B) AVAILABILITY.—Amounts transferred under subparagraph (A) shall remain available until expended. 

‘‘(C) REQUIREMENTS.—Of the amounts transferred 

under subparagraph (A) with respect to a fiscal year, the 

Secretary of Health and Human Services shall distribute— 

‘‘(i) 80 percent to the Office of Communication and 

Knowledge Transfer of the Agency for Healthcare Research and Quality (or any other relevant office designated by Agency for Healthcare Research and Quality) to carry out the activities described in section 937 

of the Public Health Service Act; and 

‘‘(ii) 20 percent to the Secretary to carry out the 

activities described in such section 937. 

‘‘(e) NET REVENUES.—For purposes of this section, the term 

‘net revenues’ means the amount estimated by the Secretary of the 

Treasury based on the excess of— 

‘‘(1) the fees received in the Treasury under subchapter B 

of chapter 34, over 

‘‘(2) the decrease in the tax imposed by chapter 1 resulting 

from the fees imposed by such subchapter. 

‘‘(f) TERMINATION.—No amounts shall be available for expenditure from the PCORTF after September 30, 2019, and any amounts 

in such Trust Fund after such date shall be transferred to the general fund of the Treasury.’’. 

(B) CLERICAL AMENDMENT.—The table of sections for 

subchapter A of chapter 98 of such Code is amended by 

adding at the end the following new item: 

‘‘Sec. 9511. Patient-centered outcomes research trust fund.’’. 

(2) FINANCING FOR FUND FROM FEES ON INSURED AND SELF- INSURED HEALTH PLANS.— (A) GENERAL RULE.—Chapter 34 of the Internal Revenue Code of 1986 is amended by adding at the end the 

following new subchapter: 

‘‘Subchapter B—Insured and Self-Insured Health Plans 

‘‘Sec. 4375. Health insurance. 

‘‘Sec. 4376. Self-insured health plans. 

‘‘Sec. 4377. Definitions and special rules. 

‘‘SEC. 4375. HEALTH INSURANCE. 

‘‘(a) IMPOSITION OF FEE.—There is hereby imposed on each 

specified health insurance policy for each policy year ending after 

September 30, 2012, a fee equal to the product of $2 ($1 in the case 

of policy years ending during fiscal year 2013) multiplied by the average number of lives covered under the policy. 

‘‘(b) LIABILITY FOR FEE.—The fee imposed by subsection (a) 

shall be paid by the issuer of the policy. 

‘‘(c) SPECIFIED HEALTH INSURANCE POLICY.—For purposes of 

this section: 

‘‘(1) IN GENERAL.—Except as otherwise provided in this 

section, the term ‘specified health insurance policy’ means any 

accident or health insurance policy (including a policy under a 
Sec. 6301\4376 IRC PPACA (Consolidated) 682 

group health plan) issued with respect to individuals residing 

in the United States. 

‘‘(2) EXEMPTION FOR CERTAIN POLICIES.—The term ‘specified health insurance policy’ does not include any insurance if 

substantially all of its coverage is of excepted benefits described in section 9832(c). 

‘‘(3) TREATMENT OF PREPAID HEALTH COVERAGE ARRANGEMENTS.— 

‘‘(A) IN GENERAL.—In the case of any arrangement described in subparagraph (B), such arrangement shall be 

treated as a specified health insurance policy, and the person referred to in such subparagraph shall be treated as 

the issuer. 

‘‘(B) DESCRIPTION OF ARRANGEMENTS.—An arrangement is described in this subparagraph if under such arrangement fixed payments or premiums are received as 

consideration for any person’s agreement to provide or arrange for the provision of accident or health coverage to 

residents of the United States, regardless of how such coverage is provided or arranged to be provided. 

‘‘(d) ADJUSTMENTS FOR INCREASES IN HEALTH CARE SPENDING.—In the case of any policy year ending in any fiscal year beginning after September 30, 2014, the dollar amount in effect under 

subsection (a) for such policy year shall be equal to the sum of such 

dollar amount for policy years ending in the previous fiscal year 

(determined after the application of this subsection), plus an 

amount equal to the product of— 

‘‘(1) such dollar amount for policy years ending in the previous fiscal year, multiplied by 

‘‘(2) the percentage increase in the projected per capita 

amount of National Health Expenditures, as most recently 

published by the Secretary before the beginning of the fiscal 

year. 

‘‘(e) TERMINATION.—This section shall not apply to policy years 

ending after September 30, 2019. 

‘‘SEC. 4376. SELF-INSURED HEALTH PLANS. 

‘‘(a) IMPOSITION OF FEE.—In the case of any applicable self-insured health plan for each plan year ending after September 30, 

2012, there is hereby imposed a fee equal to $2 ($1 in the case of 

plan years ending during fiscal year 2013) multiplied by the average number of lives covered under the plan. 

‘‘(b) LIABILITY FOR FEE.— 

‘‘(1) IN GENERAL.—The fee imposed by subsection (a) shall 

be paid by the plan sponsor. 

‘‘(2) PLAN SPONSOR.—For purposes of paragraph (1) the 

term ‘plan sponsor’ means— 

‘‘(A) the employer in the case of a plan established or 

maintained by a single employer, 

‘‘(B) the employee organization in the case of a plan 

established or maintained by an employee organization, 

‘‘(C) in the case of— 
683 Sec. 6301 PPACA (Consolidated) \4377 IRC 

‘‘(i) a plan established or maintained by 2 or more 

employers or jointly by 1 or more employers and 1 or 

more employee organizations, 

‘‘(ii) a multiple employer welfare arrangement, or 

‘‘(iii) a voluntary employees’ beneficiary association described in section 501(c)(9), the association, 

committee, joint board of trustees, or other similar 

group of representatives of the parties who establish 

or maintain the plan, or 

‘‘(D) the cooperative or association described in subsection (c)(2)(F) in the case of a plan established or maintained by such a cooperative or association. 

‘‘(c) APPLICABLE SELF-INSURED HEALTH PLAN.—For purposes of 

this section, the term ‘applicable self-insured health plan’ means 

any plan for providing accident or health coverage if— 

‘‘(1) any portion of such coverage is provided other than 

through an insurance policy, and 

‘‘(2) such plan is established or maintained— 

‘‘(A) by 1 or more employers for the benefit of their 

employees or former employees, 

‘‘(B) by 1 or more employee organizations for the benefit of their members or former members, 

‘‘(C) jointly by 1 or more employers and 1 or more employee organizations for the benefit of employees or former 

employees, 

‘‘(D) by a voluntary employees’ beneficiary association 

described in section 501(c)(9), 

‘‘(E) by any organization described in section 501(c)(6), 

or 

‘‘(F) in the case of a plan not described in the preceding subparagraphs, by a multiple employer welfare arrangement (as defined in section 3(40) of Employee Retirement Income Security Act of 1974), a rural electric cooperative (as defined in section 3(40)(B)(iv) of such Act), or a 

rural telephone cooperative association (as defined in section 3(40)(B)(v) of such Act). 

‘‘(d) ADJUSTMENTS FOR INCREASES IN HEALTH CARE SPENDING.—In the case of any plan year ending in any fiscal year beginning after September 30, 2014, the dollar amount in effect under 

subsection (a) for such plan year shall be equal to the sum of such 

dollar amount for plan years ending in the previous fiscal year (determined after the application of this subsection), plus an amount 

equal to the product of— 

‘‘(1) such dollar amount for plan years ending in the previous fiscal year, multiplied by 

‘‘(2) the percentage increase in the projected per capita 

amount of National Health Expenditures, as most recently 

published by the Secretary before the beginning of the fiscal 

year. 

‘‘(e) TERMINATION.—This section shall not apply to plan years 

ending after September 30, 2019. 

‘‘SEC. 4377. DEFINITIONS AND SPECIAL RULES. 

‘‘(a) DEFINITIONS.—For purposes of this subchapter— 
Sec. 6301 PPACA (Consolidated) 684 

‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The term ‘accident 

and health coverage’ means any coverage which, if provided by 

an insurance policy, would cause such policy to be a specified 

health insurance policy (as defined in section 4375(c)). 

‘‘(2) INSURANCE POLICY.—The term ‘insurance policy’ 

means any policy or other instrument whereby a contract of insurance is issued, renewed, or extended. 

‘‘(3) UNITED STATES.—The term ‘United States’ includes 

any possession of the United States. 

‘‘(b) TREATMENT OF GOVERNMENTAL ENTITIES.— 

‘‘(1) IN GENERAL.—For purposes of this subchapter— 

‘‘(A) the term ‘person’ includes any governmental entity, and 

‘‘(B) notwithstanding any other law or rule of law, governmental entities shall not be exempt from the fees imposed by this subchapter except as provided in paragraph 

(2). 

‘‘(2) TREATMENT OF EXEMPT GOVERNMENTAL PROGRAMS.—In 

the case of an exempt governmental program, no fee shall be 

imposed under section 4375 or section 4376 on any covered life 

under such program. 

‘‘(3) EXEMPT GOVERNMENTAL PROGRAM DEFINED.—For purposes of this subchapter, the term ‘exempt governmental program’ means— 

‘‘(A) any insurance program established under title 

XVIII of the Social Security Act, 

‘‘(B) the medical assistance program established by 

title XIX or XXI of the Social Security Act, 

‘‘(C) any program established by Federal law for providing medical care (other than through insurance policies) 

to individuals (or the spouses and dependents thereof) by 

reason of such individuals being members of the Armed 

Forces of the United States or veterans, and 

‘‘(D) any program established by Federal law for providing medical care (other than through insurance policies) 

to members of Indian tribes (as defined in section 4(d) of 

the Indian Health Care Improvement Act). 

‘‘(c) TREATMENT AS TAX.—For purposes of subtitle F, the fees 

imposed by this subchapter shall be treated as if they were taxes. 

‘‘(d) NO COVER OVER TO POSSESSIONS.—Notwithstanding any 

other provision of law, no amount collected under this subchapter 

shall be covered over to any possession of the United States.’’. 

(B) CLERICAL AMENDMENTS.— 

(i) Chapter 34 of such Code is amended by striking the chapter heading and inserting the following: 
685 Sec. 6401 PPACA (Consolidated) 

‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE 

POLICIES 

‘‘SUBCHAPTER A. POLICIES ISSUED BY FOREIGN INSURERS

‘‘SUBCHAPTER B. INSURED AND SELF-INSURED HEALTH PLANS

‘‘Subchapter A—Policies Issued By Foreign Insurers’’. 

(ii) The table of chapters for subtitle D of such 

Code is amended by striking the item relating to chapter 34 and inserting the following new item: 

‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE POLICIES’’. 

(f) TAX-EXEMPT STATUS OF THE PATIENT-CENTERED OUTCOMES

RESEARCH INSTITUTE.—Subsection 501(l) of the Internal Revenue 

Code of 1986 is amended by adding at the end the following new 

paragraph: 

‘‘(4) The Patient-Centered Outcomes Research Institute established under section 1181(b) of the Social Security Act.’’. 

SEC. 6302. FEDERAL COORDINATING COUNCIL FOR COMPARATIVE EFFECTIVENESS RESEARCH. 

Notwithstanding any other provision of law, the Federal Coordinating Council for Comparative Effectiveness Research established under section 804 of Division A of the American Recovery 

and Reinvestment Act of 2009 (42 U.S.C. 299b–8), including the requirement under subsection (e)(2) of such section, shall terminate 

on the date of enactment of this Act. 

Subtitle E—Medicare, Medicaid, and CHIP 

Program Integrity Provisions 

SEC. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER MEDICARE, MEDICAID, AND CHIP. 

(a) MEDICARE.—Section 1866(j) of the Social Security Act (42 

U.S.C. 1395cc(j)) is amended— 

(1) in paragraph (1)(A), by adding at the end the following: 

‘‘Such process shall include screening of providers and suppliers in accordance with paragraph (2), a provisional period of 

enhanced oversight in accordance with paragraph (3), disclosure requirements in accordance with paragraph (4), the imposition of temporary enrollment moratoria in accordance with 

paragraph (5), and the establishment of compliance programs 

in accordance with paragraph (6).’’; 

(2) by redesignating paragraph (2) as paragraph (8); and 

øReplaced by section 10603(b)¿ 

(3) by inserting after paragraph (1) the following: 

‘‘(2) PROVIDER SCREENING.— 

‘‘(A) PROCEDURES.—Not later than 180 days after the 

date of enactment of this paragraph, the Secretary, in consultation with the Inspector General of the Department of 

Health and Human Services, shall establish procedures 

under which screening is conducted with respect to providers of medical or other items or services and suppliers 
Sec. 6401 PPACA (Consolidated) 686 

under the program under this title, the Medicaid program 

under title XIX, and the CHIP program under title XXI. 

‘‘(B) LEVEL OF SCREENING.—The Secretary shall determine the level of screening conducted under this paragraph according to the risk of fraud, waste, and abuse, as 

determined by the Secretary, with respect to the category 

of provider of medical or other items or services or supplier. Such screening— 

‘‘(i) shall include a licensure check, which may include such checks across States; and 

‘‘(ii) may, as the Secretary determines appropriate 

based on the risk of fraud, waste, and abuse described 

in the preceding sentence, include— 

‘‘(I) a criminal background check; 

‘‘(II) fingerprinting; 

‘‘(III) unscheduled and unannounced site visits, including preenrollment site visits; 

‘‘(IV) database checks (including such checks 

across States); and 

‘‘(V) such other screening as the Secretary determines appropriate. 

‘‘(C) APPLICATION FEES.—øAs revised by section 

10603(a)¿ 

‘‘(i) INSTITUTIONAL PROVIDERS.—Except as provided in clause (ii), the Secretary shall impose a fee on 

each institutional provider of medical or other items or 

services or supplier (such as a hospital or skilled nursing facility) with respect to which screening is conducted under this paragraph in an amount equal to— 

‘‘(I) for 2010, $500; and 

‘‘(II) for 2011 and each subsequent year, the 

amount determined under this clause for the preceding year, adjusted by the percentage change in 

the consumer price index for all urban consumers 

(all items; United States city average) for the 12- 

month period ending with June of the previous 

year. 

‘‘(ii) HARDSHIP EXCEPTION; WAIVER FOR CERTAIN

MEDICAID PROVIDERS.—The Secretary may, on a caseby-case basis, exempt a provider of medical or other 

items or services or supplier from the imposition of an 

application fee under this subparagraph if the Secretary determines that the imposition of the application fee would result in a hardship. The Secretary may 

waive the application fee under this subparagraph for 

providers enrolled in a State Medicaid program for 

whom the State demonstrates that imposition of the 

fee would impede beneficiary access to care. 

‘‘(iii) USE OF FUNDS.—Amounts collected as a result of the imposition of a fee under this subparagraph 

shall be used by the Secretary for program integrity 

efforts, including to cover the costs of conducting 

screening under this paragraph and to carry out this 

subsection and section 1128J. 
687 Sec. 6401 PPACA (Consolidated) 

‘‘(D) APPLICATION AND ENFORCEMENT.— ‘‘(i) NEW PROVIDERS OF SERVICES AND SUPPLIERS.— The screening under this paragraph shall apply, in the 

case of a provider of medical or other items or services 

or supplier who is not enrolled in the program under 

this title, title XIX , or title XXI as of the date of enactment of this paragraph, on or after the date that is 

1 year after such date of enactment. 

‘‘(ii) CURRENT PROVIDERS OF SERVICES AND SUP- PLIERS.—The screening under this paragraph shall 

apply, in the case of a provider of medical or other 

items or services or supplier who is enrolled in the 

program under this title, title XIX, or title XXI as of 

such date of enactment, on or after the date that is 2 

years after such date of enactment. 

‘‘(iii) REVALIDATION OF ENROLLMENT.—Effective 

beginning on the date that is 180 days after such date 

of enactment, the screening under this paragraph 

shall apply with respect to the revalidation of enrollment of a provider of medical or other items or services or supplier in the program under this title, title 

XIX, or title XXI. 

‘‘(iv) LIMITATION ON ENROLLMENT AND REVALIDA- TION OF ENROLLMENT.—In no case may a provider of 

medical or other items or services or supplier who has 

not been screened under this paragraph be initially 

enrolled or reenrolled in the program under this title, 

title XIX, or title XXI on or after the date that is 3 

years after such date of enactment. 

‘‘(E) EXPEDITED RULEMAKING.—The Secretary may promulgate an interim final rule to carry out this paragraph. 

‘‘(3) PROVISIONAL PERIOD OF ENHANCED OVERSIGHT FOR

NEW PROVIDERS OF SERVICES AND SUPPLIERS.— 

‘‘(A) IN GENERAL.—The Secretary shall establish procedures to provide for a provisional period of not less than 

30 days and not more than 1 year during which new providers of medical or other items or services and suppliers, 

as the Secretary determines appropriate, including categories of providers or suppliers, would be subject to enhanced oversight, such as prepayment review and payment 

caps, under the program under this title, the Medicaid program under title XIX. and the CHIP program under title 

XXI. 

‘‘(B) IMPLEMENTATION.—The Secretary may establish 

by program instruction or otherwise the procedures under 

this paragraph. 

‘‘(4) 90-DAY PERIOD OF ENHANCED OVERSIGHT FOR INITIAL

CLAIMS OF DME SUPPLIERS.—øAs added by section 1304 of 

HCERA¿ For periods beginning after January 1, 2011, if the 

Secretary determines that there is a significant risk of fraudulent activity among suppliers of durable medical equipment, in 

the case of a supplier of durable medical equipment who is 

within a category or geographic area under title XVIII identified pursuant to such determination and who is initially enroll-
Sec. 6401 PPACA (Consolidated) 688 

ing under such title, the Secretary shall, notwithstanding sections 1816(c), 1842(c), and 1869(a)(2), withhold payment under 

such title with respect to durable medical equipment furnished 

by such supplier during the 90-day period beginning on the 

date of the first submission of a claim under such title for durable medical equipment furnished by such supplier. 

øSubsequent paragraphs reflect redesignation by section 1304 of 

HCERA¿ 

‘‘(5) INCREASED DISCLOSURE REQUIREMENTS.— ‘‘(A) DISCLOSURE.—A provider of medical or other 

items or services or supplier who submits an application 

for enrollment or revalidation of enrollment in the program under this title, title XIX, or title XXI on or after the 

date that is 1 year after the date of enactment of this 

paragraph shall disclose (in a form and manner and at 

such time as determined by the Secretary) any current or 

previous affiliation (directly or indirectly) with a provider 

of medical or other items or services or supplier that has 

uncollected debt, has been or is subject to a payment suspension under a Federal health care program (as defined 

in section 1128B(f)), has been excluded from participation 

under the program under this title, the Medicaid program 

under title XIX, or the CHIP program under title XXI, or 

has had its billing privileges denied or revoked. 

‘‘(B) AUTHORITY TO DENY ENROLLMENT.—If the Secretary determines that such previous affiliation poses an 

undue risk of fraud, waste, or abuse, the Secretary may 

deny such application. Such a denial shall be subject to appeal in accordance with paragraph (7). 

‘‘(6) AUTHORITY TO ADJUST PAYMENTS OF PROVIDERS OF

SERVICES AND SUPPLIERS WITH THE SAME TAX IDENTIFICATION

NUMBER FOR PAST-DUE OBLIGATIONS.— 

‘‘(A) IN GENERAL.—Notwithstanding any other provision of this title, in the case of an applicable provider of 

services or supplier, the Secretary may make any necessary adjustments to payments to the applicable provider 

of services or supplier under the program under this title 

in order to satisfy any past-due obligations described in 

subparagraph (B)(ii) of an obligated provider of services or 

supplier. 

‘‘(B) DEFINITIONS.—In this paragraph: 

‘‘(i) IN GENERAL.—The term ‘applicable provider of 

services or supplier’ means a provider of services or 

supplier that has the same taxpayer identification 

number assigned under section 6109 of the Internal 

Revenue Code of 1986 as is assigned to the obligated 

provider of services or supplier under such section, regardless of whether the applicable provider of services 

or supplier is assigned a different billing number or 

national provider identification number under the program under this title than is assigned to the obligated 

provider of services or supplier. 

‘‘(ii) OBLIGATED PROVIDER OF SERVICES OR SUPPLIER.—The term ‘obligated provider of services or 
689 Sec. 6401 PPACA (Consolidated) 

supplier’ means a provider of services or supplier that 

owes a past-due obligation under the program under 

this title (as determined by the Secretary). 

‘‘(7) TEMPORARY MORATORIUM ON ENROLLMENT OF NEW

PROVIDERS.— 

‘‘(A) IN GENERAL.—The Secretary may impose a temporary moratorium on the enrollment of new providers of 

services and suppliers, including categories of providers of 

services and suppliers, in the program under this title, 

under the Medicaid program under title XIX, or under the 

CHIP program under title XXI if the Secretary determines 

such moratorium is necessary to prevent or combat fraud, 

waste, or abuse under either such program. 

‘‘(B) LIMITATION ON REVIEW.—There shall be no judicial review under section 1869, section 1878, or otherwise, 

of a temporary moratorium imposed under subparagraph 

(A). 

‘‘(8) COMPLIANCE PROGRAMS.— ‘‘(A) IN GENERAL.—On or after the date of implementation determined by the Secretary under subparagraph (C), 

a provider of medical or other items or services or supplier 

within a particular industry sector or category shall, as a 

condition of enrollment in the program under this title, 

title XIX, or title XXI, establish a compliance program that 

contains the core elements established under subparagraph (B) with respect to that provider or supplier and industry or category. 

‘‘(B) ESTABLISHMENT OF CORE ELEMENTS.—The Secretary, in consultation with the Inspector General of the 

Department of Health and Human Services, shall establish 

core elements for a compliance program under subparagraph (A) for providers or suppliers within a particular industry or category. 

‘‘(C) TIMELINE FOR IMPLEMENTATION.—The Secretary 

shall determine the timeline for the establishment of the 

core elements under subparagraph (B) and the date of the 

implementation of subparagraph (A) for providers or suppliers within a particular industry or category. The Secretary shall, in determining such date of implementation, 

consider the extent to which the adoption of compliance 

programs by a provider of medical or other items or services or supplier is widespread in a particular industry sector or with respect to a particular provider or supplier category.’’. 

(b) MEDICAID.— 

(1) STATE PLAN AMENDMENT.—Section 1902(a) of the Social 

Security Act (42 U.S.C. 1396a(a)), as amended by section 

4302(b), is amended— 

(A) in subsection (a)— 

(i) by striking ‘‘and’’ at the end of paragraph (75); 

(ii) by striking the period at the end of paragraph 

(76) and inserting a semicolon; and 

(iii) by inserting after paragraph (76) the following: 
Sec. 6401 PPACA (Consolidated) 690 

‘‘(77) provide that the State shall comply with provider and 

supplier screening, oversight, and reporting requirements in 

accordance with subsection (ii);’’; and 

(B) by adding at the end the following: 

‘‘(ii) PROVIDER AND SUPPLIER SCREENING, OVERSIGHT, AND RE- PORTING REQUIREMENTS.—For purposes of subsection (a)(77), the 

requirements of this subsection are the following: 

‘‘(1) SCREENING.—The State complies with the process for 

screening providers and suppliers under this title, as established by the Secretary under section 1886(j)(2). 

‘‘(2) PROVISIONAL PERIOD OF ENHANCED OVERSIGHT FOR

NEW PROVIDERS AND SUPPLIERS.—The State complies with procedures to provide for a provisional period of enhanced oversight for new providers and suppliers under this title, as established by the Secretary under section 1886(j)(3). 

‘‘(3) DISCLOSURE REQUIREMENTS.—The State requires providers and suppliers under the State plan or under a waiver 

of the plan to comply with the disclosure requirements established by the Secretary under section 1886(j)(4). 

‘‘(4) TEMPORARY MORATORIUM ON ENROLLMENT OF NEW

PROVIDERS OR SUPPLIERS.— ‘‘(A) TEMPORARY MORATORIUM IMPOSED BY THE SEC- RETARY.— 

‘‘(i) IN GENERAL.—Subject to clause (ii), the State 

complies with any temporary moratorium on the enrollment of new providers or suppliers imposed by the 

Secretary under section 1886(j)(6). 

‘‘(ii) EXCEPTION.—A State shall not be required to 

comply with a temporary moratorium described in 

clause (i) if the State determines that the imposition 

of such temporary moratorium would adversely impact 

beneficiaries’ access to medical assistance. 

‘‘(B) MORATORIUM ON ENROLLMENT OF PROVIDERS AND

SUPPLIERS.—At the option of the State, the State imposes, 

for purposes of entering into participation agreements with 

providers or suppliers under the State plan or under a 

waiver of the plan, periods of enrollment moratoria, or numerical caps or other limits, for providers or suppliers 

identified by the Secretary as being at high-risk for fraud, 

waste, or abuse as necessary to combat fraud, waste, or 

abuse, but only if the State determines that the imposition 

of any such period, cap, or other limits would not adversely 

impact beneficiaries’ access to medical assistance. 

‘‘(5) COMPLIANCE PROGRAMS.—The State requires providers 

and suppliers under the State plan or under a waiver of the 

plan to establish, in accordance with the requirements of section 1866(j)(7), a compliance program that contains the core 

elements established under subparagraph (B) of that section 

1866(j)(7) for providers or suppliers within a particular industry or category. 

‘‘(6) REPORTING OF ADVERSE PROVIDER ACTIONS.—The State 

complies with the national system for reporting criminal and 

civil convictions, sanctions, negative licensure actions, and 

other adverse provider actions to the Secretary, through the 
691 Sec. 6402 PPACA (Consolidated) \1128J SSA 

Administrator of the Centers for Medicare & Medicaid Services, in accordance with regulations of the Secretary. 

‘‘(7) ENROLLMENT AND NPI OF ORDERING OR REFERRING

PROVIDERS.—The State requires— 

‘‘(A) all ordering or referring physicians or other professionals to be enrolled under the State plan or under a 

waiver of the plan as a participating provider; and 

‘‘(B) the national provider identifier of any ordering or 

referring physician or other professional to be specified on 

any claim for payment that is based on an order or referral 

of the physician or other professional. 

‘‘(8) OTHER STATE OVERSIGHT.—Nothing in this subsection 

shall be interpreted to preclude or limit the ability of a State 

to engage in provider and supplier screening or enhanced provider and supplier oversight activities beyond those required 

by the Secretary.’’. 

(2) DISCLOSURE OF MEDICARE TERMINATED PROVIDERS AND

SUPPLIERS TO STATES.—The Administrator of the Centers for 

Medicare & Medicaid Services shall establish a process for 

making available to the each State agency with responsibility 

for administering a State Medicaid plan (or a waiver of such 

plan) under title XIX of the Social Security Act or a child 

health plan under title XXI the name, national provider identifier, and other identifying information for any provider of medical or other items or services or supplier under the Medicare 

program under title XVIII or under the CHIP program under 

title XXI that is terminated from participation under that program within 30 days of the termination (and, with respect to 

all such providers or suppliers who are terminated from the 

Medicare program on the date of enactment of this Act, within 

90 days of such date). 

(3) CONFORMING AMENDMENT.—Section 1902(a)(23) of the 

Social Security Act (42 U.S.C. 1396a), is amended by inserting 

before the semicolon at the end the following: ‘‘or by a provider 

or supplier to which a moratorium under subsection (ii)(4) is 

applied during the period of such moratorium’’. 

(c) CHIP.—Section 2107(e)(1) of the Social Security Act (42 

U.S.C. 1397gg(e)(1)), as amended by section 2101(d), is amended— 

(1) by redesignating subparagraphs (D) through (M) as 

subparagraphs (E) through (N), respectively; and 

(2) by inserting after subparagraph (C), the following: 

‘‘(D) Subsections (a)(77) and (ii) of section 1902 (relating to provider and supplier screening, oversight, and reporting requirements).’’. 

SEC. 6402. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS. 

(a) IN GENERAL.—Part A of title XI of the Social Security Act 

(42 U.S.C. 1301 et seq.), as amended by sections 6002, 6004, and 

6102, is amended by inserting after section 1128I the following new 

section: 

‘‘SEC. 1128J. ø42 U.S.C. 1320a–7k¿ MEDICARE AND MEDICAID PROGRAM 

INTEGRITY PROVISIONS. 

‘‘(a) DATA MATCHING.— 
Sec. 6402\1128J SSA PPACA (Consolidated) 692 

‘‘(1) INTEGRATED DATA REPOSITORY.— ‘‘(A) INCLUSION OF CERTAIN DATA.— ‘‘(i) IN GENERAL.—The Integrated Data Repository 

of the Centers for Medicare & Medicaid Services shall 

include, at a minimum, claims and payment data from 

the following: 

‘‘(I) The programs under titles XVIII and XIX 

(including parts A, B, C, and D of title XVIII). 

‘‘(II) The program under title XXI. 

‘‘(III) Health-related programs administered 

by the Secretary of Veterans Affairs. 

‘‘(IV) Health-related programs administered 

by the Secretary of Defense. 

‘‘(V) The program of old-age, survivors, and 

disability insurance benefits established under 

title II. 

‘‘(VI) The Indian Health Service and the Contract Health Service program. 

‘‘(ii) PRIORITY FOR INCLUSION OF CERTAIN DATA.— Inclusion of the data described in subclause (I) of such 

clause in the Integrated Data Repository shall be a 

priority. Data described in subclauses (II) through (VI) 

of such clause shall be included in the Integrated Data 

Repository as appropriate. 

‘‘(B) DATA SHARING AND MATCHING.— ‘‘(i) IN GENERAL.—The Secretary shall enter into 

agreements with the individuals described in clause 

(ii) under which such individuals share and match 

data in the system of records of the respective agencies of such individuals with data in the system of 

records of the Department of Health and Human Services for the purpose of identifying potential fraud, 

waste, and abuse under the programs under titles 

XVIII and XIX. 

‘‘(ii) INDIVIDUALS DESCRIBED.—The following individuals are described in this clause: 

‘‘(I) The Commissioner of Social Security. 

‘‘(II) The Secretary of Veterans Affairs. 

‘‘(III) The Secretary of Defense. 

‘‘(IV) The Director of the Indian Health Service. 

‘‘(iii) DEFINITION OF SYSTEM OF RECORDS.—For 

purposes of this paragraph, the term ‘system of 

records’ has the meaning given such term in section 

552a(a)(5) of title 5, United States Code. 

‘‘(2) ACCESS TO CLAIMS AND PAYMENT DATABASES.—For purposes of conducting law enforcement and oversight activities 

and to the extent consistent with applicable information, privacy, security, and disclosure laws, including the regulations 

promulgated under the Health Insurance Portability and Accountability Act of 1996 and section 552a of title 5, United 

States Code, and subject to any information systems security 

requirements under such laws or otherwise required by the 

Secretary, the Inspector General of the Department of Health 
693 Sec. 6402 PPACA (Consolidated) \1128J SSA 

and Human Services and the Attorney General shall have access to claims and payment data of the Department of Health 

and Human Services and its contractors related to titles XVIII, 

XIX, and XXI. 

‘‘(b) OIG AUTHORITY TO OBTAIN INFORMATION.— ‘‘(1) IN GENERAL.—Notwithstanding and in addition to any 

other provision of law, the Inspector General of the Department of Health and Human Services may, for purposes of protecting the integrity of the programs under titles XVIII and 

XIX, obtain information from any individual (including a beneficiary provided all applicable privacy protections are followed) 

or entity that— 

‘‘(A) is a provider of medical or other items or services, 

supplier, grant recipient, contractor, or subcontractor; or 

‘‘(B) directly or indirectly provides, orders, manufactures, distributes, arranges for, prescribes, supplies, or receives medical or other items or services payable by any 

Federal health care program (as defined in section 

1128B(f)) regardless of how the item or service is paid for, 

or to whom such payment is made. 

‘‘(2) INCLUSION OF CERTAIN INFORMATION.—Information 

which the Inspector General may obtain under paragraph (1) 

includes any supporting documentation necessary to validate 

claims for payment or payments under title XVIII or XIX, including a prescribing physician’s medical records for an individual who is prescribed an item or service which is covered 

under part B of title XVIII, a covered part D drug (as defined 

in section 1860D–2(e)) for which payment is made under an 

MA–PD plan under part C of such title, or a prescription drug 

plan under part D of such title, and any records necessary for 

evaluation of the economy, efficiency, and effectiveness of the 

programs under titles XVIII and XIX. 

‘‘(c) ADMINISTRATIVE REMEDY FOR KNOWING PARTICIPATION BY

BENEFICIARY IN HEALTH CARE FRAUD SCHEME.— 

‘‘(1) IN GENERAL.—In addition to any other applicable remedies, if an applicable individual has knowingly participated in 

a Federal health care fraud offense or a conspiracy to commit 

a Federal health care fraud offense, the Secretary shall impose 

an appropriate administrative penalty commensurate with the 

offense or conspiracy. 

‘‘(2) APPLICABLE INDIVIDUAL.—For purposes of paragraph 

(1), the term ‘applicable individual’ means an individual— 

‘‘(A) entitled to, or enrolled for, benefits under part A 

of title XVIII or enrolled under part B of such title; 

‘‘(B) eligible for medical assistance under a State plan 

under title XIX or under a waiver of such plan; or 

‘‘(C) eligible for child health assistance under a child 

health plan under title XXI. 

‘‘(d) REPORTING AND RETURNING OF OVERPAYMENTS.— 

‘‘(1) IN GENERAL.—If a person has received an overpayment, the person shall— 

‘‘(A) report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and 
Sec. 6402 PPACA (Consolidated) 694 

‘‘(B) notify the Secretary, State, intermediary, carrier, 

or contractor to whom the overpayment was returned in 

writing of the reason for the overpayment. 

‘‘(2) DEADLINE FOR REPORTING AND RETURNING OVERPAYMENTS.—An overpayment must be reported and returned 

under paragraph (1) by the later of— 

‘‘(A) the date which is 60 days after the date on which 

the overpayment was identified; or 

‘‘(B) the date any corresponding cost report is due, if 

applicable. 

‘‘(3) ENFORCEMENT.—Any overpayment retained by a person after the deadline for reporting and returning the overpayment under paragraph (2) is an obligation (as defined in section 3729(b)(3) of title 31, United States Code) for purposes of 

section 3729 of such title. 

‘‘(4) DEFINITIONS.—In this subsection: 

‘‘(A) KNOWING AND KNOWINGLY.—The terms ‘knowing’ 

and ‘knowingly’ have the meaning given those terms in 

section 3729(b) of title 31, United States Code. 

‘‘(B) OVERPAYMENT.—The term ‘‘overpayment’’ means 

any funds that a person receives or retains under title 

XVIII or XIX to which the person, after applicable reconciliation, is not entitled under such title. 

‘‘(C) PERSON.— 

‘‘(i) IN GENERAL.—The term ‘person’ means a provider of services, supplier, medicaid managed care organization (as defined in section 1903(m)(1)(A)), Medicare Advantage organization (as defined in section 

1859(a)(1)), or PDP sponsor (as defined in section 

1860D–41(a)(13)). 

‘‘(ii) EXCLUSION.—Such term does not include a 

beneficiary. 

‘‘(e) INCLUSION OF NATIONAL PROVIDER IDENTIFIER ON ALL APPLICATIONS AND CLAIMS.—The Secretary shall promulgate a regulation that requires, not later than January 1, 2011, all providers of 

medical or other items or services and suppliers under the programs under titles XVIII and XIX that qualify for a national provider identifier to include their national provider identifier on all 

applications to enroll in such programs and on all claims for payment submitted under such programs.’’. 

(b) ACCESS TO DATA.— 

(1) MEDICARE PART D.—Section 1860D–15(f)(2) of the Social Security Act (42 U.S.C. 1395w–116(f)(2)) is amended by 

striking ‘‘may be used by’’ and all that follows through the period at the end and inserting ‘‘may be used— 

‘‘(A) by officers, employees, and contractors of the Department of Health and Human Services for the purposes 

of, and to the extent necessary in— 

‘‘(i) carrying out this section; and 

‘‘(ii) conducting oversight, evaluation, and enforcement under this title; and 

‘‘(B) by the Attorney General and the Comptroller 

General of the United States for the purposes of, and to 
695 Sec. 6402 PPACA (Consolidated) 

the extent necessary in, carrying out health oversight activities.’’. 

(2) DATA MATCHING.—Section 552a(a)(8)(B) of title 5, 

United States Code, is amended— 

(A) in clause (vii), by striking ‘‘or’’ at the end; 

(B) in clause (viii), by inserting ‘‘or’’ after the semicolon; and 

(C) by adding at the end the following new clause: 

‘‘(ix) matches performed by the Secretary of 

Health and Human Services or the Inspector General 

of the Department of Health and Human Services 

with respect to potential fraud, waste, and abuse, including matches of a system of records with non-Federal records;’’. 

(3) MATCHING AGREEMENTS WITH THE COMMISSIONER OF

SOCIAL SECURITY.—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 or the Inspector General of the Department of Health and Human Services— 

‘‘(i) enter into an agreement with the Secretary or 

such Inspector General for the purpose of matching data 

in the system of records of the Social Security Administration and the system of records of the Department of Health 

and Human Services; and 

‘‘(ii) include in such agreement safeguards to assure 

the maintenance of the confidentiality of any information 

disclosed. 

‘‘(B) For purposes of this paragraph, the term ‘system of 

records’ has the meaning given such term in section 552a(a)(5) 

of title 5, United States Code.’’. 

(c) WITHHOLDING OF FEDERAL MATCHING PAYMENTS FOR

STATES THAT FAIL TO REPORT ENROLLEE ENCOUNTER DATA IN THE

MEDICAID STATISTICAL INFORMATION SYSTEM.—Section 1903(i) of 

the Social Security Act (42 U.S.C. 1396b(i)) is amended— 

(1) in paragraph (23), by striking ‘‘or’’ at the end; 

(2) in paragraph (24), by striking the period at the end and 

inserting ‘‘; or’’; and 

(3) by adding at the end the following new paragraph:. 

‘‘(25) with respect to any amounts expended for medical assistance for individuals for whom the State does not report enrollee encounter data (as defined by the Secretary) to the Medicaid Statistical Information System (MSIS) in a timely manner (as determined by the Secretary).’’. 

(d) PERMISSIVE EXCLUSIONS AND CIVIL MONETARY PENALTIES.— 

(1) PERMISSIVE EXCLUSIONS.—Section 1128(b) of the Social 

Security Act (42 U.S.C. 1320a–7(b)) is amended by adding at 

the end the following new paragraph: 

‘‘(16) MAKING FALSE STATEMENTS OR MISREPRESENTATION

OF MATERIAL FACTS.—Any individual or entity that knowingly 

makes or causes to be made any false statement, omission, or 

misrepresentation of a material fact in any application, agree-
Sec. 6402 PPACA (Consolidated) 696 

ment, bid, or contract to participate or enroll as a provider of 

services or supplier under a Federal health care program (as 

defined in section 1128B(f)), including Medicare Advantage organizations under part C of title XVIII, prescription drug plan 

sponsors under part D of title XVIII, medicaid managed care 

organizations under title XIX, and entities that apply to participate as providers of services or suppliers in such managed 

care organizations and such plans.’’. 

(2) CIVIL MONETARY PENALTIES.— 

(A) IN GENERAL.—Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a–7a(a)) is amended— 

(i) in paragraph (1)(D), by striking ‘‘was excluded’’ 

and all that follows through the period at the end and 

inserting ‘‘was excluded from the Federal health care 

program (as defined in section 1128B(f)) under which 

the claim was made pursuant to Federal law.’’; 

(ii) in paragraph (6), by striking ‘‘or’’ at the end; 

(iii) by inserting after paragraph (7), the following 

new paragraphs: 

‘‘(8) orders or prescribes a medical or other item or service 

during a period in which the person was excluded from a Federal health care program (as so defined), in the case where the 

person knows or should know that a claim for such medical or 

other item or service will be made under such a program; 

‘‘(9) knowingly makes or causes to be made any false statement, omission, or misrepresentation of a material fact in any 

application, bid, or contract to participate or enroll as a provider of services or a supplier under a Federal health care program (as so defined), including Medicare Advantage organizations under part C of title XVIII, prescription drug plan sponsors under part D of title XVIII, medicaid managed care organizations under title XIX, and entities that apply to participate 

as providers of services or suppliers in such managed care organizations and such plans; 

‘‘(10) knows of an overpayment (as defined in paragraph 

(4) of section 1128J(d)) and does not report and return the 

overpayment in accordance with such section;’’; 

(iv) in the first sentence— 

(I) by striking the ‘‘or’’ after ‘‘prohibited relationship occurs;’’; and 

(II) by striking ‘‘act)’’ and inserting ‘‘act; or in 

cases under paragraph (9), $50,000 for each false 

statement or misrepresentation of a material 

fact)’’; and 

(v) in the second sentence, by striking ‘‘purpose)’’ 

and inserting ‘‘purpose; or in cases under paragraph 

(9), an assessment of not more than 3 times the total 

amount claimed for each item or service for which payment was made based upon the application containing 

the false statement or misrepresentation of a material 

fact)’’. 

(B) CLARIFICATION OF TREATMENT OF CERTAIN CHARITABLE AND OTHER INNOCUOUS PROGRAMS.—Section 
697 Sec. 6402 PPACA (Consolidated) 

1128A(i)(6) of the Social Security Act (42 U.S.C. 1320a– 

7a(i)(6)) is amended— 

(i) in subparagraph (C), by striking ‘‘or’’ at the 

end; 

(ii) in subparagraph (D), as redesignated by section 4331(e) of the Balanced Budget Act of 1997 (Public Law 105–33), by striking the period at the end and 

inserting a semicolon; 

(iii) by redesignating subparagraph (D), as added 

by section 4523(c) of such Act, as subparagraph (E) 

and striking the period at the end and inserting ‘‘; or’’; 

and 

(iv) by adding at the end the following new subparagraphs: 

‘‘(F) any other remuneration which promotes access to 

care and poses a low risk of harm to patients and Federal 

health care programs (as defined in section 1128B(f) and 

designated by the Secretary under regulations); 

‘‘(G) the offer or transfer of items or services for free 

or less than fair market value by a person, if— 

‘‘(i) the items or services consist of coupons, rebates, or other rewards from a retailer; 

‘‘(ii) the items or services are offered or transferred on equal terms available to the general public, 

regardless of health insurance status; and 

‘‘(iii) the offer or transfer of the items or services 

is not tied to the provision of other items or services 

reimbursed in whole or in part by the program under 

title XVIII or a State health care program (as defined 

in section 1128(h)); 

‘‘(H) the offer or transfer of items or services for free 

or less than fair market value by a person, if— 

‘‘(i) the items or services are not offered as part of 

any advertisement or solicitation; 

‘‘(ii) the items or services are not tied to the provision of other services reimbursed in whole or in part 

by the program under title XVIII or a State health 

care program (as so defined); 

‘‘(iii) there is a reasonable connection between the 

items or services and the medical care of the individual; and 

‘‘(iv) the person provides the items or services 

after determining in good faith that the individual is 

in financial need; or 

‘‘(I) effective on a date specified by the Secretary (but 

not earlier than January 1, 2011), the waiver by a PDP 

sponsor of a prescription drug plan under part D of title 

XVIII or an MA organization offering an MA–PD plan 

under part C of such title of any copayment for the first 

fill of a covered part D drug (as defined in section 1860D– 

2(e)) that is a generic drug for individuals enrolled in the 

prescription drug plan or MA–PD plan, respectively.’’. 

(e) TESTIMONIAL SUBPOENA AUTHORITY IN EXCLUSION-ONLY

CASES.—Section 1128(f) of the Social Security Act (42 U.S.C. 
Sec. 6402 PPACA (Consolidated) 698 

1320a–7(f)) is amended by adding at the end the following new 

paragraph: 

‘‘(4) The provisions of subsections (d) and (e) of section 205 

shall apply with respect to this section to the same extent as 

they are applicable with respect to title II. The Secretary may 

delegate the authority granted by section 205(d) (as made applicable to this section) to the Inspector General of the Department of Health and Human Services for purposes of any investigation under this section.’’. 

(f) HEALTH CARE FRAUD.— (1) KICKBACKS.—Section 1128B of the Social Security Act 

(42 U.S.C. 1320a–7b) is amended by adding at the end the following new subsection: 

‘‘(g) In addition to the penalties provided for in this section or 

section 1128A, a claim that includes items or services resulting 

from a violation of this section constitutes a false or fraudulent 

claim for purposes of subchapter III of chapter 37 of title 31, 

United States Code.’’. 

(2) REVISING THE INTENT REQUIREMENT.—Section 1128B of 

the Social Security Act (42 U.S.C. 1320a–7b), as amended by 

paragraph (1), is amended by adding at the end the following 

new subsection: 

‘‘(h) 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.’’. 

(g) SURETY BOND REQUIREMENTS.— (1) DURABLE MEDICAL EQUIPMENT.—Section 1834(a)(16)(B) 

of the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is 

amended by inserting ‘‘that the Secretary determines is commensurate with the volume of the billing of the supplier’’ before the period at the end. 

(2) HOME HEALTH AGENCIES.—Section 1861(o)(7)(C) of the 

Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by inserting ‘‘that the Secretary determines is commensurate with 

the volume of the billing of the home health agency’’ before the 

semicolon at the end. 

(3) REQUIREMENTS FOR CERTAIN OTHER PROVIDERS OF SERVICES AND SUPPLIERS.—Section 1862 of the Social Security Act 

(42 U.S.C. 1395y) is amended by adding at the end the following new subsection: 

‘‘(n) REQUIREMENT OF A SURETY BOND FOR CERTAIN PROVIDERS

OF SERVICES AND SUPPLIERS.— 

‘‘(1) IN GENERAL.—The Secretary may require a provider of 

services or supplier described in paragraph (2) to provide the 

Secretary on a continuing basis with a surety bond in a form 

specified by the Secretary in an amount (not less than $50,000) 

that the Secretary determines is commensurate with the volume of the billing of the provider of services or supplier. The 

Secretary may waive the requirement of a bond under the preceding sentence in the case of a provider of services or supplier 

that provides a comparable surety bond under State law. 

‘‘(2) PROVIDER OF SERVICES OR SUPPLIER DESCRIBED.—A 

provider of services or supplier described in this paragraph is 

a provider of services or supplier the Secretary determines ap-
699 Sec. 6402 PPACA (Consolidated) 

propriate based on the level of risk involved with respect to the 

provider of services or supplier, and consistent with the surety 

bond requirements under sections 1834(a)(16)(B) and 

1861(o)(7)(C).’’. 

(h) SUSPENSION OF MEDICARE AND MEDICAID PAYMENTS PEND- ING INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD.— (1) MEDICARE.—Section 1862 of the Social Security Act (42 

U.S.C. 1395y), as amended by subsection (g)(3), is amended by 

adding at the end the following new subsection: 

‘‘(o) SUSPENSION OF PAYMENTS PENDING INVESTIGATION OF

CREDIBLE ALLEGATIONS OF FRAUD.— ‘‘(1) IN GENERAL.—The Secretary may suspend payments 

to a provider of services or supplier under this title pending an 

investigation of a credible allegation of fraud against the provider of services or supplier, unless the Secretary determines 

there is good cause not to suspend such payments. 

‘‘(2) CONSULTATION.—The Secretary shall consult with the 

Inspector General of the Department of Health and Human 

Services in determining whether there is a credible allegation 

of fraud against a provider of services or supplier. 

‘‘(3) PROMULGATION OF REGULATIONS.—The Secretary shall 

promulgate regulations to carry out this subsection and section 

1903(i)(2)(C).’’. 

(2) MEDICAID.—Section 1903(i)(2) of such Act (42 U.S.C. 

1396b(i)(2)) is amended— 

(A) in subparagraph (A), by striking ‘‘or’’ at the end; 

and 

(B) by inserting after subparagraph (B), the following: 

‘‘(C) by any individual or entity to whom the State has 

failed to suspend payments under the plan during any period when there is pending an investigation of a credible 

allegation of fraud against the individual or entity, as determined by the State in accordance with regulations promulgated by the Secretary for purposes of section 1862(o) 

and this subparagraph, unless the State determines in accordance with such regulations there is good cause not to 

suspend such payments; or’’. 

(i) INCREASED FUNDING TO FIGHT FRAUD AND ABUSE.— 

(1) IN GENERAL.—Section 1817(k) of the Social Security Act 

(42 U.S.C. 1395i(k)) is amended— 

(A) by adding at the end the following new paragraph: 

‘‘(7) ADDITIONAL FUNDING.—In addition to the funds otherwise appropriated to the Account from the Trust Fund under 

paragraphs (3) and (4) and for purposes described in paragraphs (3)(C) and (4)(A), there are hereby appropriated an additional $10,000,000 to such Account from such Trust Fund for 

each of fiscal years 2011 through 2020. The funds appropriated 

under this paragraph shall be allocated in the same proportion 

as the total funding appropriated with respect to paragraphs 

(3)(A) and (4)(A) was allocated with respect to fiscal year 2010, 

and shall be available without further appropriation until expended. 

øAdditional paragraph (8), providing additional funding, 

added by section 1303(a)(1)(A) of HCERA; text shown below¿ 
Sec. 6402 PPACA (Consolidated) 700 

ø‘‘(8) ADDITIONAL FUNDING.—¿ 

ø‘‘(A) IN GENERAL.—In addition to the funds otherwise 

appropriated to the Account from the Trust Fund under 

paragraphs (3)(C) and (4)(A) and for purposes described in 

paragraphs (3)(C) and (4)(A), there are hereby appropriated to such Account from such Trust Fund the following additional amounts:¿ 

ø‘‘(i) For fiscal year 2011, $95,000,000.¿ 

ø‘‘(ii) For fiscal year 2012, $55,000,000.¿ 

ø‘‘(iii) For each of fiscal years 2013 and 2014, 

$30,000,000.¿ 

ø‘‘(iv) For each of fiscal years 2015 and 2016, 

$20,000,000.¿ 

ø‘‘(B) ALLOCATION.—The funds appropriated under 

this paragraph shall be allocated in the same proportion as 

the total funding appropriated with respect to paragraphs 

(3)(A) and (4)(A) was allocated with respect to fiscal year 

2010, and shall be available without further appropriation 

until expended.’’; and¿ 

(B) in paragraph (4)(A), by inserting ‘‘until expended’’ 

after ‘‘appropriation’’. øNote: additional amendment made 

to paragraph (4)(A) by section 1303(a)(1)(B) of HCERA¿ 

(2) INDEXING OF AMOUNTS APPROPRIATED.— 

(A) DEPARTMENTS OF HEALTH AND HUMAN SERVICES

AND JUSTICE.—Section 1817(k)(3)(A)(i) of the Social Security Act (42 U.S.C. 1395i(k)(3)(A)(i)) is amended— 

(i) in subclause (III), by inserting ‘‘and’’ at the end; 

(ii) in subclause (IV)— 

(I) by striking ‘‘for each of fiscal years 2007, 

2008, 2009, and 2010’’ and inserting ‘‘for each fiscal year after fiscal year 2006’’; and 

(II) by striking ‘‘; and’’ and inserting a period; 

and 

(iii) by striking subclause (V). 

(B) OFFICE OF THE INSPECTOR GENERAL OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES.—Section 

1817(k)(3)(A)(ii) of such Act (42 U.S.C. 1395i(k)(3)(A)(ii)) is 

amended— 

(i) in subclause (VIII), by inserting ‘‘and’’ at the 

end; 

(ii) in subclause (IX)— 

(I) by striking ‘‘for each of fiscal years 2008, 

2009, and 2010’’ and inserting ‘‘for each fiscal year 

after fiscal year 2007’’; and 

(II) by striking ‘‘; and’’ and inserting a period; 

and 

(iii) by striking subclause (X). 

(C) FEDERAL BUREAU OF INVESTIGATION.—Section 

1817(k)(3)(B) of the Social Security Act (42 U.S.C. 

1395i(k)(3)(B)) is amended— 

(i) in clause (vii), by inserting ‘‘and’’ at the end; 

(ii) in clause (viii)— 
701 Sec. 6402 PPACA (Consolidated) 

(I) by striking ‘‘for each of fiscal years 2007, 

2008, 2009, and 2010’’ and inserting ‘‘for each fiscal year after fiscal year 2006’’; and 

(II) by striking ‘‘; and’’ and inserting a period; 

and 

(iii) by striking clause (ix). 

(D) MEDICARE INTEGRITY PROGRAM.—Section 

1817(k)(4)(C) of the Social Security Act (42 U.S.C. 

1395i(k)(4)(C)) is amended by adding at the end the following new clause: 

‘‘(ii) For each fiscal year after 2010, by the percentage increase in the consumer price index for all 

urban consumers (all items; United States city average) over the previous year.’’. 

(j) MEDICARE INTEGRITY PROGRAM AND MEDICAID INTEGRITY

PROGRAM.— 

(1) MEDICARE INTEGRITY PROGRAM.— 

(A) REQUIREMENT TO PROVIDE PERFORMANCE STATISTICS.—Section 1893(c) of the Social Security Act (42 U.S.C. 

1395ddd(c)) is amended— 

(i) in paragraph (3), by striking ‘‘and’’ at the end; 

(ii) by redesignating paragraph (4) as paragraph 

(5); and 

(iii) by inserting after paragraph (3) the following 

new paragraph: 

‘‘(4) the entity agrees to provide the Secretary and the Inspector General of the Department of Health and Human Services with such performance statistics (including the number 

and amount of overpayments recovered, the number of fraud 

referrals, and the return on investment of such activities by 

the entity) as the Secretary or the Inspector General may request; and’’. 

(B) EVALUATIONS AND ANNUAL REPORT.—Section 1893 

of the Social Security Act (42 U.S.C. 1395ddd) is amended 

by adding at the end the following new subsection: 

‘‘(i) EVALUATIONS AND ANNUAL REPORT.— 

‘‘(1) EVALUATIONS.—The Secretary shall conduct evaluations of eligible entities which the Secretary contracts with 

under the Program not less frequently than every 3 years. 

‘‘(2) ANNUAL REPORT.—Not later than 180 days after the 

end of each fiscal year (beginning with fiscal year 2011), the 

Secretary shall submit a report to Congress which identifies— 

‘‘(A) the use of funds, including funds transferred from 

the Federal Hospital Insurance Trust Fund under section 

1817 and the Federal Supplementary Insurance Trust 

Fund under section 1841, to carry out this section; and 

‘‘(B) the effectiveness of the use of such funds.’’. 

(C) FLEXIBILITY IN PURSUING FRAUD AND ABUSE.—Section 1893(a) of the Social Security Act (42 U.S.C. 

1395ddd(a)) is amended by inserting ‘‘, or otherwise,’’ after 

‘‘entities’’. 

(2) MEDICAID INTEGRITY PROGRAM.— 
Sec. 6403 PPACA (Consolidated) 702 

(A) REQUIREMENT TO PROVIDE PERFORMANCE STATIS- TICS.—Section 1936(c)(2) of the Social Security Act (42 

U.S.C. 1396u–6(c)(2)) is amended— 

(i) by redesignating subparagraph (D) as subparagraph (E); and 

(ii) by inserting after subparagraph (C) the following new subparagraph: 

‘‘(D) The entity agrees to provide the Secretary and 

the Inspector General of the Department of Health and 

Human Services with such performance statistics (including the number and amount of overpayments recovered, 

the number of fraud referrals, and the return on investment of such activities by the entity) as the Secretary or 

the Inspector General may request.’’. 

(B) EVALUATIONS AND ANNUAL REPORT.—Section 

1936(e) of the Social Security Act (42 U.S.C. 1396u–7(e)) is 

amended— 

(i) by redesignating paragraph (4) as paragraph 

(5); and 

(ii) by inserting after paragraph (3) the following 

new paragraph: 

‘‘(4) EVALUATIONS.—The Secretary shall conduct evaluations of eligible entities which the Secretary contracts with 

under the Program not less frequently than every 3 years.’’. 

øAdditional amendments to section 1936(e)(1) made by section 

1303(b) of HCERA, p. 945¿ 

(k) EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR EXCLU- SIONS.—Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 

1320a–7(c)(3)(B)) is amended by striking ‘‘individuals entitled to 

benefits under part A of title XVIII or enrolled under part B of 

such title, or both’’ and inserting ‘‘beneficiaries (as defined in section 1128A(i)(5)) of that program’’. 

SEC. 6403. ELIMINATION OF DUPLICATION BETWEEN THE 

HEALTHCARE INTEGRITY AND PROTECTION DATA BANK 

AND THE NATIONAL PRACTITIONER DATA BANK. 

(a) INFORMATION REPORTED BY FEDERAL AGENCIES AND

HEALTH PLANS.—Section 1128E of the Social Security Act (42 

U.S.C. 1320a–7e) is amended— 

(1) by striking subsection (a) and inserting the following: 

‘‘(a) IN GENERAL.—The Secretary shall maintain a national 

health care fraud and abuse data collection program under this section for the reporting of certain final adverse actions (not including 

settlements in which no findings of liability have been made) 

against health care providers, suppliers, or practitioners as required by subsection (b), with access as set forth in subsection (d), 

and shall furnish the information collected under this section to the 

National Practitioner Data Bank established pursuant to the 

Health Care Quality Improvement Act of 1986 (42 U.S.C. 11101 et 

seq.).’’; 

(2) by striking subsection (d) and inserting the following: 

‘‘(d) ACCESS TO REPORTED INFORMATION.— 

‘‘(1) AVAILABILITY.—The information collected under this 

section shall be available from the National Practitioner Data 

Bank to the agencies, authorities, and officials which are pro-
703 Sec. 6403 PPACA (Consolidated) 

vided under section 1921(b) information reported under section 

1921(a). 

‘‘(2) FEES FOR DISCLOSURE.—The Secretary may establish 

or approve reasonable fees for the disclosure of information 

under this section. The amount of such a fee may not exceed 

the costs of processing the requests for disclosure and of providing such information. Such fees shall be available to the 

Secretary to cover such costs.’’; 

(3) by striking subsection (f) and inserting the following: 

‘‘(f) APPROPRIATE COORDINATION.—In implementing this section, the Secretary shall provide for the maximum appropriate coordination with part B of the Health Care Quality Improvement 

Act of 1986 (42 U.S.C. 11131 et seq.) and section 1921.’’; and 

(4) in subsection (g)— 

(A) in paragraph (1)(A)— 

(i) in clause (iii)— 

(I) by striking ‘‘or State’’ each place it appears; 

(II) by redesignating subclauses (II) and (III) 

as subclauses (III) and (IV), respectively; and 

(III) by inserting after subclause (I) the following new subclause: 

‘‘(II) any dismissal or closure of the proceedings by reason of the provider, supplier, or 

practitioner surrendering their license or leaving 

the State or jurisdiction’’; and 

(ii) by striking clause (iv) and inserting the following: 

‘‘(iv) Exclusion from participation in a Federal 

health care program (as defined in section 1128B(f)).’’; 

(B) in paragraph (3)— 

(i) by striking subparagraphs (D) and (E); and 

(ii) by redesignating subparagraph (F) as subparagraph (D); and 

(C) in subparagraph (D) (as so redesignated), by striking ‘‘or State’’. 

(b) INFORMATION REPORTED BY STATE LAW OR FRAUD ENFORCEMENT AGENCIES.—Section 1921 of the Social Security Act (42 

U.S.C. 1396r–2) is amended— 

(1) in subsection (a)— 

(A) in paragraph (1)— 

(i) by striking ‘‘SYSTEM.—The State’’ and all that 

follows through the semicolon and inserting SYSTEM.— 

‘‘(A) LICENSING OR CERTIFICATION ACTIONS.—The State 

must have in effect a system of reporting the following information with respect to formal proceedings (as defined 

by the Secretary in regulations) concluded against a health 

care practitioner or entity by a State licensing or certification agency:’’; 

(ii) by redesignating subparagraphs (A) through 

(D) as clauses (i) through (iv), respectively, and indenting appropriately; 

(iii) in subparagraph (A)(iii) (as so redesignated)— 
Sec. 6403 PPACA (Consolidated) 704 

(I) by striking ‘‘the license of’’ and inserting 

‘‘license or the right to apply for, or renew, a license by’’; and 

(II) by inserting ‘‘nonrenewability,’’ after ‘‘voluntary surrender,’’; and 

(iv) by adding at the end the following new subparagraph: 

‘‘(B) OTHER FINAL ADVERSE ACTIONS.—The State must 

have in effect a system of reporting information with respect to any final adverse action (not including settlements 

in which no findings of liability have been made) taken 

against a health care provider, supplier, or practitioner by 

a State law or fraud enforcement agency.’’; and 

(B) in paragraph (2), by striking ‘‘the authority described in paragraph (1)’’ and inserting ‘‘a State licensing 

or certification agency or State law or fraud enforcement 

agency’’; 

(2) in subsection (b)— 

(A) by striking paragraph (2) and inserting the following: 

‘‘(2) to State licensing or certification agencies and Federal 

agencies responsible for the licensing and certification of health 

care providers, suppliers, and licensed health care practitioners;’’; 

(B) in each of paragraphs (4) and (6), by inserting ‘‘, 

but only with respect to information provided pursuant to 

subsection (a)(1)(A)’’ before the comma at the end; 

(C) by striking paragraph (5) and inserting the following: 

‘‘(5) to State law or fraud enforcement agencies,’’; 

(D) by redesignating paragraphs (7) and (8) as paragraphs (8) and (9), respectively; and 

(E) by inserting after paragraph (6) the following new 

paragraph: 

‘‘(7) to health plans (as defined in section 1128C(c));’’; 

(3) by redesignating subsection (d) as subsection (h), and 

by inserting after subsection (c) the following new subsections: 

‘‘(d) DISCLOSURE AND CORRECTION OF INFORMATION.— 

‘‘(1) DISCLOSURE.—With respect to information reported 

pursuant to subsection (a)(1), the Secretary shall— 

‘‘(A) provide for disclosure of the information, upon request, to the health care practitioner who, or the entity 

that, is the subject of the information reported; and 

‘‘(B) establish procedures for the case where the health 

care practitioner or entity disputes the accuracy of the information reported. 

‘‘(2) CORRECTIONS.—Each State licensing or certification 

agency and State law or fraud enforcement agency shall report 

corrections of information already reported about any formal 

proceeding or final adverse action described in subsection (a), 

in such form and manner as the Secretary prescribes by regulation. 

‘‘(e) FEES FOR DISCLOSURE.—The Secretary may establish or 

approve reasonable fees for the disclosure of information under this 
705 Sec. 6403 PPACA (Consolidated) 

section. The amount of such a fee may not exceed the costs of processing the requests for disclosure and of providing such information. Such fees shall be available to the Secretary to cover such 

costs. 

‘‘(f) PROTECTION FROM LIABILITY FOR REPORTING.—No person 

or entity, including any agency designated by the Secretary in subsection (b), shall be held liable in any civil action with respect to 

any reporting of information as required under this section, without knowledge of the falsity of the information contained in the report. 

‘‘(g) REFERENCES.—For purposes of this section: 

‘‘(1) STATE LICENSING OR CERTIFICATION AGENCY.—The 

term ‘State licensing or certification agency’ includes any authority of a State (or of a political subdivision thereof) responsible for the licensing of health care practitioners (or any peer 

review organization or private accreditation entity reviewing 

the services provided by health care practitioners) or entities. 

‘‘(2) STATE LAW OR FRAUD ENFORCEMENT AGENCY.—The 

term ‘State law or fraud enforcement agency’ includes— 

‘‘(A) a State law enforcement agency; and 

‘‘(B) a State medicaid fraud control unit (as defined in 

section 1903(q)). 

‘‘(3) FINAL ADVERSE ACTION.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

term ‘final adverse action’ includes— 

‘‘(i) civil judgments against a health care provider, 

supplier, or practitioner in State court related to the 

delivery of a health care item or service; 

‘‘(ii) State criminal convictions related to the delivery of a health care item or service; 

‘‘(iii) exclusion from participation in State health 

care programs (as defined in section 1128(h)); 

‘‘(iv) any licensing or certification action described 

in subsection (a)(1)(A) taken against a supplier by a 

State licensing or certification agency; and 

‘‘(v) any other adjudicated actions or decisions 

that the Secretary shall establish by regulation. 

‘‘(B) EXCEPTION.—Such term does not include any action with respect to a malpractice claim.’’; and 

(4) in subsection (h), as so redesignated, by striking ‘‘The 

Secretary’’ and all that follows through the period at the end 

and inserting ‘‘In implementing this section, the Secretary 

shall provide for the maximum appropriate coordination with 

part B of the Health Care Quality Improvement Act of 1986 

(42 U.S.C. 11131 et seq.) and section 1128E.’’. 

(c) CONFORMING AMENDMENT.—Section 1128C(a)(1) of the Social Security Act (42 U.S.C. 1320a–7c(a)(1)) is amended— 

(1) in subparagraph (C), by adding ‘‘and’’ after the comma 

at the end; 

(2) in subparagraph (D), by striking ‘‘, and’’ and inserting 

a period; and 

(3) by striking subparagraph (E). 

(d) TRANSITION PROCESS; EFFECTIVE DATE.— 
Sec. 6403 PPACA (Consolidated) 706 

(1) IN GENERAL.—Effective on the date of enactment of this 

Act, the Secretary of Health and Human Services (in this section referred to as the ‘‘Secretary’’) shall implement a transition process under which, by not later than the end of the transition period described in paragraph (5), the Secretary shall 

cease operating the Healthcare Integrity and Protection Data 

Bank established under section 1128E of the Social Security 

Act (as in effect before the effective date specified in paragraph 

(6)) and shall transfer all data collected in the Healthcare Integrity and Protection Data Bank to the National Practitioner 

Data Bank established pursuant to the Health Care Quality 

Improvement Act of 1986 (42 U.S.C. 11101 et seq.). During 

such transition process, the Secretary shall have in effect appropriate procedures to ensure that data collection and access 

to the Healthcare Integrity and Protection Data Bank and the 

National Practitioner Data Bank are not disrupted. 

(2) REGULATIONS.—The Secretary shall promulgate regulations to carry out the amendments made by subsections (a) and 

(b). 

(3) FUNDING.— (A) AVAILABILITY OF FEES.—Fees collected pursuant to 

section 1128E(d)(2) of the Social Security Act prior to the 

effective date specified in paragraph (6) for the disclosure 

of information in the Healthcare Integrity and Protection 

Data Bank shall be available to the Secretary, without fiscal year limitation, for payment of costs related to the 

transition process described in paragraph (1). Any such 

fees remaining after the transition period is complete shall 

be available to the Secretary, without fiscal year limitation, for payment of the costs of operating the National 

Practitioner Data Bank. 

(B) AVAILABILITY OF ADDITIONAL FUNDS.—In addition 

to the fees described in subparagraph (A), any funds available to the Secretary or to the Inspector General of the Department of Health and Human Services for a purpose related to combating health care fraud, waste, or abuse shall 

be available to the extent necessary for operating the 

Healthcare Integrity and Protection Data Bank during the 

transition period, including systems testing and other activities necessary to ensure that information formerly reported to the Healthcare Integrity and Protection Data 

Bank will be accessible through the National Practitioner 

Data Bank after the end of such transition period. 

(4) SPECIAL PROVISION FOR ACCESS TO THE NATIONAL PRACTITIONER DATA BANK BY THE DEPARTMENT OF VETERANS AFFAIRS.— 

(A) IN GENERAL.—Notwithstanding any other provision 

of law, during the 1-year period that begins on the effective date specified in paragraph (6), the information described in subparagraph (B) shall be available from the 

National Practitioner Data Bank to the Secretary of Veterans Affairs without charge. 

(B) INFORMATION DESCRIBED.—For purposes of subparagraph (A), the information described in this subpara-
707 Sec. 6404 PPACA (Consolidated) 

graph is the information that would, but for the amendments made by this section, have been available to the 

Secretary of Veterans Affairs from the Healthcare Integrity and Protection Data Bank. 

(5) TRANSITION PERIOD DEFINED.—For purposes of this subsection, the term ‘‘transition period’’ means the period that begins on the date of enactment of this Act and ends on the later 

of— 

(A) the date that is 1 year after such date of enactment; or 

(B) the effective date of the regulations promulgated 

under paragraph (2). 

(6) EFFECTIVE DATE.—The amendments made by subsections (a), (b), and (c) shall take effect on the first day after 

the final day of the transition period. 

SEC. 6404. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS 

REDUCED TO NOT MORE THAN 12 MONTHS. 

(a) REDUCING MAXIMUM PERIOD FOR SUBMISSION.— 

(1) PART A.—Section 1814(a) of the Social Security Act (42 

U.S.C. 1395f(a)(1)) is amended— 

(A) in paragraph (1), by striking ‘‘period of 3 calendar 

years’’ and all that follows through the semicolon and inserting ‘‘period ending 1 calendar year after the date of 

service;’’; and 

(B) by adding at the end the following new sentence: 

‘‘In applying paragraph (1), the Secretary may specify exceptions to the 1 calendar year period specified in such 

paragraph.’’ 

(2) PART B.— 

(A) Section 1842(b)(3) of such Act (42 U.S.C. 

1395u(b)(3)(B)) is amended— 

(i) in subparagraph (B), in the flush language following clause (ii), by striking ‘‘close of the calendar 

year following the year in which such service is furnished (deeming any service furnished in the last 3 

months of any calendar year to have been furnished in 

the succeeding calendar year)’’ and inserting ‘‘period 

ending 1 calendar year after the date of service’’; and 

(ii) by adding at the end the following new sentence: ‘‘In applying subparagraph (B), the Secretary 

may specify exceptions to the 1 calendar year period 

specified in such subparagraph.’’ 

(B) Section 1835(a) of such Act (42 U.S.C. 1395n(a)) is 

amended— 

(i) in paragraph (1), by striking ‘‘period of 3 calendar years’’ and all that follows through the semicolon and inserting ‘‘period ending 1 calendar year 

after the date of service;’’; and 

(ii) by adding at the end the following new sentence: ‘‘In applying paragraph (1), the Secretary may 

specify exceptions to the 1 calendar year period specified in such paragraph.’’ 

(b) EFFECTIVE DATE.— 
Sec. 6405 PPACA (Consolidated) 708 

(1) IN GENERAL.—The amendments made by subsection (a) 

shall apply to services furnished on or after January 1, 2010. 

(2) SERVICES FURNISHED BEFORE 2010.—In the case of services furnished before January 1, 2010, a bill or request for payment under section 1814(a)(1), 1842(b)(3)(B), or 1835(a) shall 

be filed not later that December 31, 2010. 

SEC. 6405. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED 

TO BE MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE 

PROFESSIONALS. 

(a) DME.—Section 1834(a)(11)(B) of the Social Security Act (42 

U.S.C. 1395m(a)(11)(B)) is amended by striking ‘‘physician’’ and inserting ‘‘physician enrolled under section 1866(j) or an eligible professional under section 1848(k)(3)(B) that is enrolled under section 

1866(j)’’. 

(b) HOME HEALTH SERVICES.—øReplaced by section 10603¿ 

(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’’. 

(c) APPLICATION TO OTHER ITEMS OR SERVICES.—The Secretary 

may extend the requirement applied by the amendments made by 

subsections (a) and (b) to durable medical equipment and home 

health services (relating to requiring certifications and written orders to be made by enrolled physicians and health professions) to 

all other categories of items or services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), including covered part D 

drugs as defined in section 1860D–2(e) of such Act (42 U.S.C. 

1395w–102), that are ordered, prescribed, or referred by a physician enrolled under section 1866(j) of such Act (42 U.S.C. 1395cc(j)) 

or an eligible professional under section 1848(k)(3)(B) of such Act 

(42 U.S.C. 1395w–4(k)(3)(B)). 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to written orders and certifications made on or after 

July 1, 2010. 

SEC. 6406. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON REFERRALS TO PROGRAMS AT HIGH RISK OF 

WASTE AND ABUSE. 

(a) PHYSICIANS AND OTHER SUPPLIERS.—Section 1842(h) of the 

Social Security Act (42 U.S.C. 1395u(h)) is amended by adding at 

the end the following new paragraph: 

‘‘(9) The Secretary may revoke enrollment, for a period of not 

more than one year for each act, for a physician or supplier under 

section 1866(j) if such physician or supplier fails to maintain and, 

upon request of the Secretary, provide access to documentation relating to written orders or requests for payment for durable medical equipment, certifications for home health services, or referrals 

for other items or services written or ordered by such physician or 

supplier under this title, as specified by the Secretary.’’. 
709 Sec. 6407 PPACA (Consolidated) 

(b) PROVIDERS OF SERVICES.—Section 1866(a)(1) of such Act (42 

U.S.C. 1395cc) is further amended— 

(1) in subparagraph (U), by striking at the end ‘‘and’’; 

(2) in subparagraph (V), by striking the period at the end 

and adding ‘‘; and’’; and 

(3) by adding at the end the following new subparagraph: 

‘‘(W) maintain and, upon request of the Secretary, provide access to documentation relating to written orders or 

requests for payment for durable medical equipment, certifications for home health services, or referrals for other 

items or services written or ordered by the provider under 

this title, as specified by the Secretary.’’. 

(c) OIG PERMISSIVE EXCLUSION AUTHORITY.—Section 

1128(b)(11) of the Social Security Act (42 U.S.C. 1320a–7(b)(11)) is 

amended by inserting ‘‘, ordering, referring for furnishing, or certifying the need for’’ after ‘‘furnishing’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to orders, certifications, and referrals made on or after 

January 1, 2010. 

SEC. 6407. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE PHYSICIANS MAY CERTIFY ELIGIBILITY FOR HOME 

HEALTH SERVICES OR DURABLE MEDICAL EQUIPMENT 

UNDER MEDICARE. 

(a) CONDITION OF PAYMENT FOR HOME HEALTH SERVICES.— (1) PART A.—Section 1814(a)(2)(C) of such Act is amended— 

(A) by striking ‘‘and such services’’ and inserting ‘‘such 

services’’; and 

(B) by inserting after ‘‘care of a physician’’ the following: ‘‘, and, in the case of a certification made by a physician after January 1, 2010, prior to making such certification the physician must document that the physician 

himself or herself, 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 nursemidwife (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, has 

had a face-to-face encounter (including through use of telehealth, subject to the requirements in section 1834(m), and 

other than with respect to encounters that are incident to 

services involved) with the individual within a reasonable 

timeframe as determined by the Secretary’’. øAs revised by 

section 10605(a)¿ 

(2) PART B.—Section 1835(a)(2)(A) of the Social Security 

Act is amended— 

(A) by striking ‘‘and’’ before ‘‘(iii)’’; and 

(B) by inserting after ‘‘care of a physician’’ the following: ‘‘, and (iv) in the case of a certification after January 1, 2010, prior to making such certification the physician must document that the physician, or a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) who is working in collabora-
Sec. 6408 PPACA (Consolidated) 710 

tion 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, has had a face-to-face encounter (including 

through use of telehealth and other than with respect to 

encounters that are incident to services involved) with the 

individual during the 6-month period preceding such certification, or other reasonable timeframe as determined by 

the Secretary’’. øAs revised by section 10605(b)¿ 

(b) CONDITION OF PAYMENT FOR DURABLE MEDICAL EQUIPMENT.—Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C. 

1395m(a)(11)(B)) is amended— 

(1) by striking ‘‘ORDER.—The Secretary’’ and inserting 

‘‘ORDER.— 

‘‘(i) IN GENERAL.—The Secretary’’; and 

(2) by adding at the end the following new clause: 

‘‘(ii) REQUIREMENT FOR FACE TO FACE ENCOUNTER.—The Secretary shall require that such an order 

be written pursuant to the physician documenting that 

a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist (as those terms are 

defined in section 1861(aa)(5)) has had a face-to-face 

encounter (including through use of telehealth under 

subsection (m) and other than with respect to encounters that are incident to services involved) with the individual involved during the 6-month period preceding 

such written order, or other reasonable timeframe as 

determined by the Secretary.’’. 

(c) APPLICATION TO OTHER AREAS UNDER MEDICARE.—The Secretary may apply the face-to-face encounter requirement described 

in the amendments made by subsections (a) and (b) to other items 

and services for which payment is provided under title XVIII of the 

Social Security Act based upon a finding that such an decision 

would reduce the risk of waste, fraud, or abuse. 

(d) APPLICATION TO MEDICAID.—The requirements pursuant to 

the amendments made by subsections (a) and (b) shall apply in the 

case of physicians making certifications for home health services 

under title XIX of the Social Security Act in the same manner and 

to the same extent as such requirements apply in the case of physicians making such certifications under title XVIII of such Act. 

SEC. 6408. ENHANCED PENALTIES. 

(a) CIVIL MONETARY PENALTIES FOR FALSE STATEMENTS OR DELAYING INSPECTIONS.—Section 1128A(a) of the Social Security Act 

(42 U.S.C. 1320a–7a(a)), as amended by section 5002(d)(2)(A), is 

amended— 

(1) in paragraph (6), by striking ‘‘or’’ at the end; and 

(2) by inserting after paragraph (7) the following new 

paragraphs: 

‘‘(8) knowingly makes, uses, or causes to be made or used, 

a false record or statement material to a false or fraudulent 

claim for payment for items and services furnished under a 

Federal health care program; or 
711 Sec. 6408 PPACA (Consolidated) 

‘‘(9) fails to grant timely access, upon reasonable request 

(as defined by the Secretary in regulations), to the Inspector 

General of the Department of Health and Human Services, for 

the purpose of audits, investigations, evaluations, or other statutory functions of the Inspector General of the Department of 

Health and Human Services;’’; and 

(3) in the first sentence— 

(A) by striking ‘‘or in cases under paragraph (7)’’ and 

inserting ‘‘in cases under paragraph (7)’’; and 

(B) by striking ‘‘act)’’ and inserting ‘‘act, in cases under 

paragraph (8), $50,000 for each false record or statement, 

or in cases under paragraph (9), $15,000 for each day of 

the failure described in such paragraph)’’. 

(b) MEDICARE ADVANTAGE AND PART D PLANS.— 

(1) ENSURING TIMELY INSPECTIONS RELATING TO CONTRACTS

WITH MA ORGANIZATIONS.—Section 1857(d)(2) of such Act (42 

U.S.C. 1395w–27(d)(2)) is amended— 

(A) in subparagraph (A), by inserting ‘‘timely’’ before 

‘‘inspect’’; and 

(B) in subparagraph (B), by inserting ‘‘timely’’ before 

‘‘audit and inspect’’. 

(2) MARKETING VIOLATIONS.—Section 1857(g)(1) of the Social Security Act (42 U.S.C. 1395w–27(g)(1)) is amended— 

(A) in subparagraph (F), by striking ‘‘or’’ at the end; 

(B) by inserting after subparagraph (G) the following 

new subparagraphs: 

‘‘(H) except as provided under subparagraph (C) or (D) 

of section 1860D–1(b)(1), enrolls an individual in any plan 

under this part without the prior consent of the individual 

or the designee of the individual; 

‘‘(I) transfers an individual enrolled under this part 

from one plan to another without the prior consent of the 

individual or the designee of the individual or solely for 

the purpose of earning a commission; 

‘‘(J) fails to comply with marketing restrictions described in subsections (h) and (j) of section 1851 or applicable implementing regulations or guidance; or 

‘‘(K) employs or contracts with any individual or entity 

who engages in the conduct described in subparagraphs 

(A) through (J) of this paragraph;’’; and 

(C) by adding at the end the following new sentence: 

‘‘The Secretary may provide, in addition to any other remedies authorized by law, for any of the remedies described 

in paragraph (2), if the Secretary determines that any employee or agent of such organization, or any provider or 

supplier who contracts with such organization, has engaged in any conduct described in subparagraphs (A) 

through (K) of this paragraph.’’. 

(3) PROVISION OF FALSE INFORMATION.—Section 

1857(g)(2)(A) of the Social Security Act (42 U.S.C. 1395w– 

27(g)(2)(A)) is amended by inserting ‘‘except with respect to a 

determination under subparagraph (E), an assessment of not 

more than the amount claimed by such plan or plan sponsor 
Sec. 6409 PPACA (Consolidated) 712 

based upon the misrepresentation or falsified information involved,’’ after ‘‘for each such determination,’’. 

(c) OBSTRUCTION OF PROGRAM AUDITS.—Section 1128(b)(2) of 

the Social Security Act (42 U.S.C. 1320a–7(b)(2)) is amended— 

(1) in the heading, by inserting ‘‘OR AUDIT’’ after ‘‘INVESTIGATION’’; and 

(2) by striking ‘‘investigation into’’ and all that follows 

through the period and inserting ‘‘investigation or audit related 

to—’’ 

‘‘(i) any offense described in paragraph (1) or in 

subsection (a); or 

‘‘(ii) the use of funds received, directly or indirectly, from any Federal health care program (as defined in section 1128B(f)).’’. 

(d) EFFECTIVE DATE.— 

(1) IN GENERAL.—Except as provided in paragraph (2), the 

amendments made by this section shall apply to acts committed on or after January 1, 2010. 

(2) EXCEPTION.—The amendments made by subsection 

(b)(1) take effect on the date of enactment of this Act. 

SEC. 6409. ø42 U.S.C. 1395nn note¿ MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL. 

(a) DEVELOPMENT OF SELF-REFERRAL DISCLOSURE PROTOCOL.— 

(1) IN GENERAL.—The Secretary of Health and Human 

Services, in cooperation with the Inspector General of the Department of Health and Human Services, shall establish, not 

later than 6 months after the date of the enactment of this Act, 

a protocol to enable health care providers of services and suppliers to disclose an actual or potential violation of section 

1877 of the Social Security Act (42 U.S.C. 1395nn) pursuant to 

a self-referral disclosure protocol (in this section referred to as 

an ‘‘SRDP’’). The SRDP shall include direction to health care 

providers of services and suppliers on— 

(A) a specific person, official, or office to whom such 

disclosures shall be made; and 

(B) instruction on the implication of the SRDP on corporate integrity agreements and corporate compliance 

agreements. 

(2) PUBLICATION ON INTERNET WEBSITE OF SRDP INFORMATION.—The Secretary of Health and Human Services shall post 

information on the public Internet website of the Centers for 

Medicare & Medicaid Services to inform relevant stakeholders 

of how to disclose actual or potential violations pursuant to an 

SRDP. 

(3) RELATION TO ADVISORY OPINIONS.—The SRDP shall be 

separate from the advisory opinion process set forth in regulations implementing section 1877(g) of the Social Security Act. 

(b) REDUCTION IN AMOUNTS OWED.—The Secretary of Health 

and Human Services is authorized to reduce the amount due and 

owing for all violations under section 1877 of the Social Security 

Act to an amount less than that specified in subsection (g) of such 

section. In establishing such amount for a violation, the Secretary 

may consider the following factors: 
713 Sec. 6410 PPACA (Consolidated) 

(1) The nature and extent of the improper or illegal practice. 

(2) The timeliness of such self-disclosure. 

(3) The cooperation in providing additional information related to the disclosure. 

(4) Such other factors as the Secretary considers appropriate. 

(c) REPORT.—Not later than 18 months after the date on which 

the SRDP protocol is established under subsection (a)(1), the Secretary shall submit to Congress a report on the implementation of 

this section. Such report shall include— 

(1) the number of health care providers of services and 

suppliers making disclosures pursuant to the SRDP; 

(2) the amounts collected pursuant to the SRDP; 

(3) the types of violations reported under the SRDP; and 

(4) such other information as may be necessary to evaluate 

the impact of this section. 

SEC. 6410. ADJUSTMENTS TO THE MEDICARE DURABLE MEDICAL 

EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES 

COMPETITIVE ACQUISITION PROGRAM. 

(a) EXPANSION OF ROUND 2 OF THE DME COMPETITIVE BIDDING

PROGRAM.—Section 1847(a)(1) of the Social Security Act (42 U.S.C. 

1395w–3(a)(1)) is amended— 

(1) in subparagraph (B)(i)(II), by striking ‘‘70’’ and inserting ‘‘91’’; and 

(2) in subparagraph (D)(ii)— 

(A) in subclause (I), by striking ‘‘and’’ at the end; 

(B) by redesignating subclause (II) as subclause (III); 

and 

(C) by inserting after subclause (I) the following new 

subclause: 

‘‘(II) the Secretary shall include the next 21 

largest metropolitan statistical areas by total population (after those selected under subclause (I)) 

for such round; and’’. 

(b) REQUIREMENT TO EITHER COMPETITIVELY BID AREAS OR

USE COMPETITIVE BID PRICES BY 2016.—Section 1834(a)(1)(F) of 

the Social Security Act (42 U.S.C. 1395m(a)(1)(F)) is amended— 

(1) in clause (i), by striking ‘‘and’’ at the end; 

(2) in clause (ii)— 

(A) by inserting ‘‘(and, in the case of covered items furnished on or after January 1, 2016, subject to clause (iii), 

shall)’’ after ‘‘may’’; and 

(B) by striking the period at the end and inserting ‘‘; 

and’’; and 

(3) by adding at the end the following new clause: 

‘‘(iii) in the case of covered items furnished on or 

after January 1, 2016, the Secretary shall continue to 

make such adjustments described in clause (ii) as, 

under such competitive acquisition programs, additional covered items are phased in or information is 

updated as contracts under section 1847 are recompeted in accordance with section 1847(b)(3)(B).’’. 
Sec. 6411 PPACA (Consolidated) 714 

SEC. 6411. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC) 

PROGRAM. 

(a) EXPANSION TO MEDICAID.— 

(1) STATE PLAN AMENDMENT.—Section 1902(a)(42) of the 

Social Security Act (42 U.S.C. 1396a(a)(42)) is amended— 

(A) by striking ‘‘that the records’’ and inserting ‘‘that— 

‘‘(A) the records’’; 

(B) by inserting ‘‘and’’ after the semicolon; and 

(C) by adding at the end the following: 

‘‘(B) not later than December 31, 2010, the State 

shall— 

‘‘(i) establish a program under which the State 

contracts (consistent with State law and in the same 

manner as the Secretary enters into contracts with recovery audit contractors under section 1893(h), subject 

to such exceptions or requirements as the Secretary 

may require for purposes of this title or a particular 

State) with 1 or more recovery audit contractors for 

the purpose of identifying underpayments and overpayments and recouping overpayments under the 

State plan and under any waiver of the State plan 

with respect to all services for which payment is made 

to any entity under such plan or waiver; and 

‘‘(ii) provide assurances satisfactory to the Secretary that— 

‘‘(I) under such contracts, payment shall be 

made to such a contractor only from amounts recovered; 

‘‘(II) from such amounts recovered, payment— 

‘‘(aa) shall be made on a contingent basis 

for collecting overpayments; and 

‘‘(bb) may be made in such amounts as 

the State may specify for identifying underpayments; 

‘‘(III) the State has an adequate process for 

entities to appeal any adverse determination 

made by such contractors; and 

‘‘(IV) such program is carried out in accordance with such requirements as the Secretary 

shall specify, including— 

‘‘(aa) for purposes of section 1903(a)(7), 

that amounts expended by the State to carry 

out the program shall be considered amounts 

expended as necessary for the proper and efficient administration of the State plan or a 

waiver of the plan; 

‘‘(bb) that section 1903(d) shall apply to 

amounts recovered under the program; and 

‘‘(cc) that the State and any such contractors under contract with the State shall coordinate such recovery audit efforts with 

other contractors or entities performing audits 

of entities receiving payments under the State 

plan or waiver in the State, including efforts 
715 Sec. 6411 PPACA (Consolidated) 

with Federal and State law enforcement with 

respect to the Department of Justice, including the Federal Bureau of Investigations, the 

Inspector General of the Department of 

Health and Human Services, and the State 

medicaid fraud control unit; and’’. 

(2) COORDINATION; REGULATIONS.— (A) IN GENERAL.—The Secretary of Health and Human 

Services, acting through the Administrator of the Centers 

for Medicare & Medicaid Services, shall coordinate the expansion of the Recovery Audit Contractor program to Medicaid with States, particularly with respect to each State 

that enters into a contract with a recovery audit contractor 

for purposes of the State’s Medicaid program prior to December 31, 2010. 

(B) REGULATIONS.—The Secretary of Health and 

Human Services shall promulgate regulations to carry out 

this subsection and the amendments made by this subsection, including with respect to conditions of Federal financial participation, as specified by the Secretary. 

(b) EXPANSION TO MEDICARE PARTS C AND D.—Section 1893(h) 

of the Social Security Act (42 U.S.C. 1395ddd(h)) is amended— 

(1) in paragraph (1), in the matter preceding subparagraph 

(A), by striking ‘‘part A or B’’ and inserting ‘‘this title’’; 

(2) in paragraph (2), by striking ‘‘parts A and B’’ and inserting ‘‘this title’’; 

(3) in paragraph (3), by inserting ‘‘(not later than December 31, 2010, in the case of contracts relating to payments 

made under part C or D)’’ after ‘‘2010’’; 

(4) in paragraph (4), in the matter preceding subparagraph 

(A), by striking ‘‘part A or B’’ and inserting ‘‘this title’’; and 

(5) by adding at the end the following: 

‘‘(9) SPECIAL RULES RELATING TO PARTS C AND D.—The Secretary shall enter into contracts under paragraph (1) to require 

recovery audit contractors to— 

‘‘(A) ensure that each MA plan under part C has an 

anti-fraud plan in effect and to review the effectiveness of 

each such anti-fraud plan; 

‘‘(B) ensure that each prescription drug plan under 

part D has an anti-fraud plan in effect and to review the 

effectiveness of each such anti-fraud plan; 

‘‘(C) examine claims for reinsurance payments under 

section 1860D–15(b) to determine whether prescription 

drug plans submitting such claims incurred costs in excess 

of the allowable reinsurance costs permitted under paragraph (2) of that section; and 

‘‘(D) review estimates submitted by prescription drug 

plans by private plans with respect to the enrollment of 

high cost beneficiaries (as defined by the Secretary) and to 

compare such estimates with the numbers of such beneficiaries actually enrolled by such plans.’’. 

(c) ANNUAL REPORT.—The Secretary of Health and Human 

Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall submit an annual report to Con-
Sec. 6501 PPACA (Consolidated) 716 

gress concerning the effectiveness of the Recovery Audit Contractor 

program under Medicaid and Medicare and shall include such reports recommendations for expanding or improving the program. 

Subtitle F—Additional Medicaid Program 

Integrity Provisions 

SEC. 6501. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID IF TERMINATED UNDER MEDICARE OR OTHER 

STATE PLAN. 

Section 1902(a)(39) of the Social Security Act (42 U.S.C. 42 

U.S.C. 1396a(a)) is amended by inserting after ‘‘1128A,’’ the following: ‘‘terminate the participation of any individual or entity in 

such program if (subject to such exceptions as are permitted with 

respect to exclusion under sections 1128(c)(3)(B) and 1128(d)(3)(B)) 

participation of such individual or entity is terminated under title 

XVIII or any other State plan under this title,’’. 

SEC. 6502. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO 

CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS. 

Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), 

as amended by section 6401(b), is amended by inserting after paragraph (77) the following: 

‘‘(78) provide that the State agency described in paragraph 

(9) exclude, with respect to a period, any individual or entity 

from participation in the program under the State plan if such 

individual or entity owns, controls, or manages an entity that 

(or if such entity is owned, controlled, or managed by an individual or entity that)— 

‘‘(A) has unpaid overpayments (as defined by the Secretary) under this title during such period determined by 

the Secretary or the State agency to be delinquent; 

‘‘(B) is suspended or excluded from participation under 

or whose participation is terminated under this title during such period; or 

‘‘(C) is affiliated with an individual or entity that has 

been suspended or excluded from participation under this 

title or whose participation is terminated under this title 

during such period;’’. 

SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICAID. 

(a) IN GENERAL.—Section 1902(a) of the Social Security Act (42 

U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is 

amended by inserting after paragraph (78), the following: 

‘‘(79) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims 

on behalf of a health care provider must register with the 

State and the Secretary in a form and manner specified by the 

Secretary;’’. 
717 Sec. 6506 PPACA (Consolidated) 

SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER MMIS TO DETECT FRAUD AND ABUSE. 

(a) IN GENERAL.—Section 1903(r)(1)(F) of the Social Security 

Act (42 U.S.C. 1396b(r)(1)(F)) is amended by inserting after ‘‘necessary’’ the following: ‘‘and including, for data submitted to the Secretary on or after January 1, 2010, data elements from the automated data system that the Secretary determines to be necessary 

for program integrity, program oversight, and administration, at 

such frequency as the Secretary shall determine’’. 

(b) MANAGED CARE ORGANIZATIONS.— 

(1) IN GENERAL.—Section 1903(m)(2)(A)(xi) of the Social 

Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by inserting ‘‘and for the provision of such data to the State at a frequency and level of detail to be specified by the Secretary’’ 

after ‘‘patients’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall apply with respect to contract years beginning on or 

after January 1, 2010. 

SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR ENTITIES LOCATED OUTSIDE OF THE UNITED STATES. 

Section 1902(a) of the Social Security Act (42 U.S.C. 1396b(a)), 

as amended by section 6503, is amended by inserting after paragraph (79) the following new paragraph: 

‘‘(80) provide that the State shall not provide any payments for items or services provided under the State plan or 

under a waiver to any financial institution or entity located 

outside of the United States;’’. 

SEC. 6506. OVERPAYMENTS. 

(a) EXTENSION OF PERIOD FOR COLLECTION OF OVERPAYMENTS

DUE TO FRAUD.— 

(1) IN GENERAL.—Section 1903(d)(2) of the Social Security 

Act (42 U.S.C. 1396b(d)(2)) is amended— 

(A) in subparagraph (C)— 

(i) in the first sentence, by striking ‘‘60 days’’ and 

inserting ‘‘1 year’’; and 

(ii) in the second sentence, by striking ‘‘60 days’’ 

and inserting ‘‘1-year period’’; and 

(B) in subparagraph (D)— 

(i) in inserting ‘‘(i)’’ after ‘‘(D)’’; and 

(ii) by adding at the end the following: 

‘‘(ii) In any case where the State is unable to recover a debt 

which represents an overpayment (or any portion thereof) made to 

a person or other entity due to fraud within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), including as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such State on 

account of such overpayment (or portion thereof) before the date 

that is 30 days after the date on which a final judgment (including, 

if applicable, a final determination on an appeal) is made.’’. 

(2) EFFECTIVE DATE.—The amendments made by this subsection take effect on the date of enactment of this Act and 

apply to overpayments discovered on or after that date. 
Sec. 6507 PPACA (Consolidated) 718 

(b) CORRECTIVE ACTION.—The Secretary shall promulgate regulations that require States to correct Federally identified claims 

overpayments, of an ongoing or recurring nature, with new Medicaid Management Information System (MMIS) edits, audits, or 

other appropriate corrective action. 

SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING 

INITIATIVE. 

Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) 

is amended— 

(1) in paragraph (1)(B)— 

(A) in clause (ii), by striking ‘‘and’’ at the end; 

(B) in clause (iii), by adding ‘‘and’’ after the semi-colon; 

and 

(C) by adding at the end the following new clause: 

‘‘(iv) effective for claims filed on or after October 

1, 2010, incorporate compatible methodologies of the 

National Correct Coding Initiative administered by the 

Secretary (or any successor initiative to promote correct coding and to control improper coding leading to 

inappropriate payment) and such other methodologies 

of that Initiative (or such other national correct coding 

methodologies) as the Secretary identifies in accordance with paragraph (4);’’; and 

(2) by adding at the end the following new paragraph: 

‘‘(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do 

the following: 

‘‘(A) Not later than September 1, 2010: 

‘‘(i) Identify those methodologies of the National Correct Coding Initiative administered by the Secretary (or 

any successor initiative to promote correct coding and to 

control improper coding leading to inappropriate payment) 

which are compatible to claims filed under this title. 

‘‘(ii) Identify those methodologies of such Initiative (or 

such other national correct coding methodologies) that 

should be incorporated into claims filed under this title 

with respect to items or services for which States provide 

medical assistance under this title and no national correct 

coding methodologies have been established under such 

Initiative with respect to title XVIII. 

‘‘(iii) Notify States of— 

‘‘(I) the methodologies identified under subparagraphs (A) and (B) (and of any other national correct 

coding methodologies identified under subparagraph 

(B)); and 

‘‘(II) how States are to incorporate such methodologies into claims filed under this title. 

‘‘(B) Not later than March 1, 2011, submit a report to Congress that includes the notice to States under clause (iii) of 

subparagraph (A) and an analysis supporting the identification 

of the methodologies made under clauses (i) and (ii) of subparagraph (A).’’. 
719 Sec. 6601 PPACA (Consolidated) \519 ERISA 

SEC. 6508. GENERAL EFFECTIVE DATE. 

(a) IN GENERAL.—Except as otherwise provided in this subtitle, 

this subtitle and the amendments made by this subtitle take effect 

on January 1, 2011, without regard to whether final regulations to 

carry out such amendments and subtitle have been promulgated by 

that date. 

(b) DELAY IF STATE LEGISLATION REQUIRED.—In the case of a 

State plan for medical assistance under title XIX of the Social Security Act or a child health plan under title XXI of such Act which 

the Secretary of Health and Human Services determines requires 

State legislation (other than legislation appropriating funds) in 

order for the plan to meet the additional requirement imposed by 

the amendments made by this subtitle, the State plan or child 

health plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet 

this additional requirement before the first day of the first calendar 

quarter beginning after the close of the first regular session of the 

State legislature that begins after the date of the enactment of this 

Act. For purposes of the previous sentence, in the case of a State 

that has a 2-year legislative session, each year of such session shall 

be deemed to be a separate regular session of the State legislature. 

Subtitle G—Additional Program Integrity 

Provisions 

SEC. 6601. PROHIBITION ON FALSE STATEMENTS AND REPRESENTATIONS. 

(a) PROHIBITION.—Part 5 of subtitle B of title I of the Employee 

Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is 

amended by adding at the end the following: 

‘‘SEC. 519. ø29 U.S.C. 1149¿ PROHIBITION ON FALSE STATEMENTS AND 

REPRESENTATIONS. 

‘‘No person, in connection with a plan or other arrangement 

that is multiple employer welfare arrangement described in section 

3(40), shall make a false statement or false representation of fact, 

knowing it to be false, in connection with the marketing or sale of 

such plan or arrangement, to any employee, any member of an employee organization, any beneficiary, any employer, any employee 

organization, the Secretary, or any State, or the representative or 

agent of any such person, State, or the Secretary, concerning— 

‘‘(1) the financial condition or solvency of such plan or arrangement; 

‘‘(2) the benefits provided by such plan or arrangement; 

‘‘(3) the regulatory status of such plan or other arrangement under any Federal or State law governing collective bargaining, labor management relations, or intern union affairs; 

or 

‘‘(4) the regulatory status of such plan or other arrangement regarding exemption from state regulatory authority 

under this Act. 

This section shall not apply to any plan or arrangement that does 

not fall within the meaning of the term ‘multiple employer welfare 

arrangement’ under section 3(40)(A).’’. 
Sec. 6601 PPACA (Consolidated) 720 

(b) CRIMINAL PENALTIES.—Section 501 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1131) is amended— 

(1) by inserting ‘‘(a)’’ before ‘‘Any person’’; and 

(2) by adding at the end the following: 

‘‘(b) Any person that violates section 519 shall upon conviction 

be imprisoned not more than 10 years or fined under title 18, 

United States Code, or both.’’. 

(c) CONFORMING AMENDMENT.—The table of sections for part 5 

of subtitle B of title I of the Employee Retirement Income Security 

Act of 1974 is amended by adding at the end the following: 

‘‘Sec. 519. Prohibition on false statement and representations.’’. 

SEC. 6602. CLARIFYING DEFINITION. 

Section 24(a)(2) of title 18, United States Code, is amended by 

inserting ‘‘or section 411, 518, or 511 of the Employee Retirement 

Income Security Act of 1974,’’ after ‘‘1954 of this title’’. 

SEC. 6603. DEVELOPMENT OF MODEL UNIFORM REPORT FORM. 

Part C of title XXVII of the Public Health Service Act (42 

U.S.C. 300gg–91 et seq.) is amended by adding at the end the following: 

‘‘SEC. 2794. ø42 U.S.C. 300gg–95¿ UNIFORM FRAUD AND ABUSE REFERRAL FORMAT. 

‘‘The Secretary shall request the National Association of Insurance Commissioners to develop a model uniform report form for 

private health insurance issuer seeking to refer suspected fraud 

and abuse to State insurance departments or other responsible 

State agencies for investigation. The Secretary shall request that 

the National Association of Insurance Commissioners develop recommendations for uniform reporting standards for such referrals.’’. 

SEC. 6604. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND 

ABUSE. 

(a) IN GENERAL.—Part 5 of subtitle B of title I of the Employee 

Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), 

as amended by section 6601, is further amended by adding at the 

end the following: 

‘‘SEC. 520. ø29 U.S.C. 1150¿ APPLICABILITY OF STATE LAW TO COMBAT 

FRAUD AND ABUSE. 

‘‘The Secretary may, for the purpose of identifying, preventing, 

or prosecuting fraud and abuse, adopt regulatory standards establishing, or issue an order relating to a specific person establishing, 

that a person engaged in the business of providing insurance 

through a multiple employer welfare arrangement described in section 3(40) is subject to the laws of the States in which such person 

operates which regulate insurance in such State, notwithstanding 

section 514(b)(6) of this Act or the Liability Risk Retention Act of 

1986, and regardless of whether the law of the State is otherwise 

preempted under any of such provisions. This section shall not 

apply to any plan or arrangement that does not fall within the 

meaning of the term ‘multiple employer welfare arrangement’ 

under section 3(40)(A).’’. 

(b) CONFORMING AMENDMENT.—The table of sections for part 5 

of subtitle B of title I of the Employee Retirement Income Security 
721 Sec. 6605 PPACA (Consolidated) 

Act of 1974, as amended by section 6601, is further amended by 

adding at the end the following: 

‘‘Sec. 520. Applicability of State law to combat fraud and abuse.’’. 

SEC. 6605. ENABLING THE DEPARTMENT OF LABOR TO ISSUE ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS AND 

SUMMARY SEIZURES ORDERS AGAINST PLANS THAT ARE 

IN FINANCIALLY HAZARDOUS CONDITION. 

(a) IN GENERAL.—Part 5 of subtitle B of title I of the Employee 

Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), 

as amended by section 6604, is further amended by adding at the 

end the following: 

‘‘SEC. 521. ø29 U.S.C. 1151¿ ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS AND SUMMARY SEIZURE ORDERS AGAINST 

MULTIPLE EMPLOYER WELFARE ARRANGEMENTS IN FINANCIALLY HAZARDOUS CONDITION. 

‘‘(a) IN GENERAL.—The Secretary may issue a cease and desist 

(ex parte) order under this title if it appears to the Secretary that 

the alleged conduct of a multiple employer welfare arrangement described in section 3(40), other than a plan or arrangement described in subsection (g), is fraudulent, or creates an immediate 

danger to the public safety or welfare, or is causing or can be reasonably expected to cause significant, imminent, and irreparable 

public injury. 

‘‘(b) HEARING.—A person that is adversely affected by the 

issuance of a cease and desist order under subsection (a) may request a hearing by the Secretary regarding such order. The Secretary may require that a proceeding under this section, including 

all related information and evidence, be conducted in a confidential 

manner. 

‘‘(c) BURDEN OF PROOF.—The burden of proof in any hearing 

conducted under subsection (b) shall be on the party requesting the 

hearing to show cause why the cease and desist order should be set 

aside. 

‘‘(d) DETERMINATION.—Based upon the evidence presented at a 

hearing under subsection (b), the cease and desist order involved 

may be affirmed, modified, or set aside by the Secretary in whole 

or in part. 

‘‘(e) SEIZURE.—The Secretary may issue a summary seizure 

order under this title if it appears that a multiple employer welfare 

arrangement is in a financially hazardous condition. 

‘‘(f) REGULATIONS.—The Secretary may promulgate such regulations or other guidance as may be necessary or appropriate to 

carry out this section. 

‘‘(g) EXCEPTION.—This section shall not apply to any plan or 

arrangement that does not fall within the meaning of the term 

‘multiple employer welfare arrangement’ under section 3(40)(A).’’. 

(b) CONFORMING AMENDMENT.—The table of sections for part 5 

of subtitle B of title I of the Employee Retirement Income Security 

Act of 1974, as amended by section 6604, is further amended by 

adding at the end the following: 

‘‘Sec. 521. Administrative summary cease and desist orders and summary seizure 

orders against health plans in financially hazardous condition.’’. 
Sec. 6606 PPACA (Consolidated) 722 

SEC. 6606. MEWA PLAN REGISTRATION WITH DEPARTMENT OF LABOR. 

Section 101(g) of the Employee Retirement Income Security Act 

of 1974 (29 U.S.C. 1021(g)) is amended— 

(1) by striking ‘‘Secretary may’’ and inserting ‘‘Secretary 

shall’’; and 

(2) by inserting ‘‘to register with the Secretary prior to operating in a State and may, by regulation, require such multiple employer welfare arrangements’’ after ‘‘not group health 

plans’’. 

SEC. 6607. PERMITTING EVIDENTIARY PRIVILEGE AND CONFIDENTIAL 

COMMUNICATIONS. 

Section 504 of the Employee Retirement Income Security Act 

of 1974 (29 U.S.C. 1134) is amended by adding at the end the following: 

‘‘(d) The Secretary may promulgate a regulation that provides 

an evidentiary privilege for, and provides for the confidentiality of 

communications between or among, any of the following entities or 

their agents, consultants, or employees: 

‘‘(1) A State insurance department. 

‘‘(2) A State attorney general. 

‘‘(3) The National Association of Insurance Commissioners. 

‘‘(4) The Department of Labor. 

‘‘(5) The Department of the Treasury. 

‘‘(6) The Department of Justice. 

‘‘(7) The Department of Health and Human Services. 

‘‘(8) Any other Federal or State authority that the Secretary determines is appropriate for the purposes of enforcing 

the provisions of this title. 

‘‘(e) The privilege established under subsection (d) shall apply 

to communications related to any investigation, audit, examination, 

or inquiry conducted or coordinated by any of the agencies. A communication that is privileged under subsection (d) shall not waive 

any privilege otherwise available to the communicating agency or 

to any person who provided the information that is communicated.’’. 

Subtitle H—Elder Justice Act 

SEC. 6701. ø42 U.S.C. 1305 note¿ SHORT TITLE OF SUBTITLE. 

This subtitle may be cited as the ‘‘Elder Justice Act of 2009’’. 

SEC. 6702. DEFINITIONS. 

Except as otherwise specifically provided, any term that is defined in section 2011 of the Social Security Act (as added by section 

6703(a)) and is used in this subtitle has the meaning given such 

term by such section. 

SEC. 6703. ELDER JUSTICE. 

(a) ELDER JUSTICE.— 

(1) IN GENERAL.—Title XX of the Social Security Act (42 

U.S.C. 1397 et seq.) is amended— 

(A) in the heading, by inserting ‘‘AND ELDER JUSTICE’’ after ‘‘SOCIAL SERVICES’’; 

(B) by inserting before section 2001 the following: 
723 Sec. 6703 PPACA (Consolidated) \2011 SSA 

‘‘Subtitle A—Block Grants to States for 

Social Services’’; 

and 

(C) by adding at the end the following: 

‘‘Subtitle B—Elder Justice 

‘‘SEC. 2011. ø42 U.S.C. 1397j¿ DEFINITIONS. 

‘‘In this subtitle: 

‘‘(1) ABUSE.—The term ‘abuse’ means the knowing infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential 

needs or to avoid physical or psychological harm. 

‘‘(2) ADULT PROTECTIVE SERVICES.—The term ‘adult protective services’ means such services provided to adults as the 

Secretary may specify and includes services such as— 

‘‘(A) receiving reports of adult abuse, neglect, or exploitation; 

‘‘(B) investigating the reports described in subparagraph (A); 

‘‘(C) case planning, monitoring, evaluation, and other 

case work and services; and 

‘‘(D) providing, arranging for, or facilitating the provision of medical, social service, economic, legal, housing, 

law enforcement, or other protective, emergency, or support services. 

‘‘(3) CAREGIVER.—The term ‘caregiver’ means an individual 

who has the responsibility for the care of an elder, either voluntarily, by contract, by receipt of payment for care, or as a result of the operation of law, and means a family member or 

other individual who provides (on behalf of such individual or 

of a public or private agency, organization, or institution) compensated or uncompensated care to an elder who needs supportive services in any setting. 

‘‘(4) DIRECT CARE.—The term ‘direct care’ means care by an 

employee or contractor who provides assistance or long-term 

care services to a recipient. 

‘‘(5) ELDER.—The term ‘elder’ means an individual age 60 

or older. 

‘‘(6) ELDER JUSTICE.—The term ‘elder justice’ means— 

‘‘(A) from a societal perspective, efforts to— 

‘‘(i) prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation; and 

‘‘(ii) protect elders with diminished capacity while 

maximizing their autonomy; and 

‘‘(B) from an individual perspective, the recognition of 

an elder’s rights, including the right to be free of abuse, 

neglect, and exploitation. 

‘‘(7) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a 

State or local government agency, Indian tribe or tribal organization, or any other public or private entity that is engaged in 
Sec. 6703\2011 SSA PPACA (Consolidated) 724 

and has expertise in issues relating to elder justice or in a field 

necessary to promote elder justice efforts. 

‘‘(8) EXPLOITATION.—The term ‘exploitation’ means the 

fraudulent or otherwise illegal, unauthorized, or improper act 

or process of an individual, including a caregiver or fiduciary, 

that uses the resources of an elder for monetary or personal 

benefit, profit, or gain, or that results in depriving an elder of 

rightful access to, or use of, benefits, resources, belongings, or 

assets. 

‘‘(9) FIDUCIARY.—The term ‘fiduciary’— 

‘‘(A) means a person or entity with the legal responsibility— 

‘‘(i) to make decisions on behalf of and for the benefit of another person; and 

‘‘(ii) to act in good faith and with fairness; and 

‘‘(B) includes a trustee, a guardian, a conservator, an 

executor, an agent under a financial power of attorney or 

health care power of attorney, or a representative payee. 

‘‘(10) GRANT.—The term ‘grant’ includes a contract, cooperative agreement, or other mechanism for providing financial 

assistance. 

‘‘(11) GUARDIANSHIP.—The term ‘guardianship’ means— 

‘‘(A) the process by which a State court determines 

that an adult individual lacks capacity to make decisions 

about self-care or property, and appoints another individual or entity known as a guardian, as a conservator, or 

by a similar term, as a surrogate decisionmaker; 

‘‘(B) the manner in which the court-appointed surrogate decisionmaker carries out duties to the individual and 

the court; or 

‘‘(C) the manner in which the court exercises oversight 

of the surrogate decisionmaker. 

‘‘(12) INDIAN TRIBE.— 

‘‘(A) IN GENERAL.—The term ‘Indian tribe’ has the 

meaning given such term in section 4 of the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 

450b). 

‘‘(B) INCLUSION OF PUEBLO AND RANCHERIA.—The term 

‘Indian tribe’ includes any Pueblo or Rancheria. 

‘‘(13) LAW ENFORCEMENT.—The term ‘law enforcement’ 

means the full range of potential responders to elder abuse, neglect, and exploitation including— 

‘‘(A) police, sheriffs, detectives, public safety officers, 

and corrections personnel; 

‘‘(B) prosecutors; 

‘‘(C) medical examiners; 

‘‘(D) investigators; and 

‘‘(E) coroners. 

‘‘(14) LONG-TERM CARE.— 

‘‘(A) IN GENERAL.—The term ‘long-term care’ means 

supportive and health services specified by the Secretary 

for individuals who need assistance because the individuals have a loss of capacity for self-care due to illness, disability, or vulnerability. 
725 Sec. 6703 PPACA (Consolidated) \2011 SSA 

‘‘(B) LOSS OF CAPACITY FOR SELF-CARE.—For purposes 

of subparagraph (A), the term ‘loss of capacity for self-care’ 

means an inability to engage in 1 or more activities of 

daily living, including eating, dressing, bathing, management of one’s financial affairs, and other activities the Secretary determines appropriate. 

‘‘(15) LONG-TERM CARE FACILITY.—The term ‘long-term care 

facility’ means a residential care provider that arranges for, or 

directly provides, long-term care. 

‘‘(16) NEGLECT.—The term ‘neglect’ means— 

‘‘(A) the failure of a caregiver or fiduciary to provide 

the goods or services that are necessary to maintain the 

health or safety of an elder; or 

‘‘(B) self-neglect. 

‘‘(17) NURSING FACILITY.— ‘‘(A) IN GENERAL.—The term ‘nursing facility’ has the 

meaning given such term under section 1919(a). 

‘‘(B) INCLUSION OF SKILLED NURSING FACILITY.—The 

term ‘nursing facility’ includes a skilled nursing facility (as 

defined in section 1819(a)). 

‘‘(18) SELF-NEGLECT.—The term ‘self-neglect’ means an 

adult’s inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks including— 

‘‘(A) obtaining essential food, clothing, shelter, and 

medical care; 

‘‘(B) obtaining goods and services necessary to maintain physical health, mental health, or general safety; or 

‘‘(C) managing one’s own financial affairs. 

‘‘(19) SERIOUS BODILY INJURY.— 

‘‘(A) IN GENERAL.—The term ‘serious bodily injury’ 

means an injury— 

‘‘(i) involving extreme physical pain; 

‘‘(ii) involving substantial risk of death; 

‘‘(iii) involving protracted loss or impairment of 

the function of a bodily member, organ, or mental faculty; or 

‘‘(iv) requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. 

‘‘(B) CRIMINAL SEXUAL ABUSE.—Serious bodily injury 

shall be considered to have occurred if the conduct causing 

the injury is conduct described in section 2241 (relating to 

aggravated sexual abuse) or 2242 (relating to sexual 

abuse) of title 18, United States Code, or any similar offense under State law. 

‘‘(20) SOCIAL.—The term ‘social’, when used with respect to 

a service, includes adult protective services. 

‘‘(21) STATE LEGAL ASSISTANCE DEVELOPER.—The term 

‘State legal assistance developer’ means an individual described in section 731 of the Older Americans Act of 1965. 

‘‘(22) STATE LONG-TERM CARE OMBUDSMAN.—The term 

‘State Long-Term Care Ombudsman’ means the State LongTerm Care Ombudsman described in section 712(a)(2) of the 

Older Americans Act of 1965. 
Sec. 6703\2012 SSA PPACA (Consolidated) 726 

‘‘SEC. 2012. ø42 U.S.C. 1397j–1¿ GENERAL PROVISIONS. 

‘‘(a) PROTECTION OF PRIVACY.—In pursuing activities under 

this subtitle, the Secretary shall ensure the protection of individual 

health privacy consistent with the regulations promulgated under 

section 264(c) of the Health Insurance Portability and Accountability Act of 1996 and applicable State and local privacy regulations. 

‘‘(b) RULE OF CONSTRUCTION.—Nothing in this subtitle shall be 

construed to interfere with or abridge an elder’s right to practice 

his or her religion through reliance on prayer alone for healing 

when this choice— 

‘‘(1) is contemporaneously expressed, either orally or in 

writing, with respect to a specific illness or injury which the 

elder has at the time of the decision by an elder who is competent at the time of the decision; 

‘‘(2) is previously set forth in a living will, health care 

proxy, or other advance directive document that is validly executed and applied under State law; or 

‘‘(3) may be unambiguously deduced from the elder’s life 

history. 

‘‘PART I—NATIONAL COORDINATION OF 

ELDER JUSTICE ACTIVITIES AND RESEARCH 

‘‘Subpart A—Elder Justice Coordinating Council 

and Advisory Board on Elder Abuse, Neglect, 

and Exploitation 

‘‘SEC. 2021. ø42 U.S.C. 1397k¿ ELDER JUSTICE COORDINATING COUNCIL. 

‘‘(a) ESTABLISHMENT.—There is established within the Office of 

the Secretary an Elder Justice Coordinating Council (in this section 

referred to as the ‘Council’). 

‘‘(b) MEMBERSHIP.— 

‘‘(1) IN GENERAL.—The Council shall be composed of the 

following members: 

‘‘(A) The Secretary (or the Secretary’s designee). 

‘‘(B) The Attorney General (or the Attorney General’s 

designee). 

‘‘(C) The head of each Federal department or agency 

or other governmental entity identified by the Chair referred to in subsection (d) as having responsibilities, or administering programs, relating to elder abuse, neglect, and 

exploitation. 

‘‘(2) REQUIREMENT.—Each member of the Council shall be 

an officer or employee of the Federal Government. 

‘‘(c) VACANCIES.—Any vacancy in the Council shall not affect 

its powers, but shall be filled in the same manner as the original 

appointment was made. 

‘‘(d) CHAIR.—The member described in subsection (b)(1)(A) 

shall be Chair of the Council. 

‘‘(e) MEETINGS.—The Council shall meet at least 2 times per 

year, as determined by the Chair. 

‘‘(f) DUTIES.— 
727 Sec. 6703 PPACA (Consolidated) \2021 SSA 

‘‘(1) IN GENERAL.—The Council shall make recommendations to the Secretary for the coordination of activities of the 

Department of Health and Human Services, the Department of 

Justice, and other relevant Federal, State, local, and private 

agencies and entities, relating to elder abuse, neglect, and exploitation and other crimes against elders. 

‘‘(2) REPORT.—Not later than the date that is 2 years after 

the date of enactment of the Elder Justice Act of 2009 and 

every 2 years thereafter, the Council shall submit to the Committee on Finance of the Senate and the Committee on Ways 

and Means and the Committee on Energy and Commerce of 

the House of Representatives a report that— 

‘‘(A) describes the activities and accomplishments of, 

and challenges faced by— 

‘‘(i) the Council; and 

‘‘(ii) the entities represented on the Council; and 

‘‘(B) makes such recommendations for legislation, 

model laws, or other action as the Council determines to 

be appropriate. 

‘‘(g) POWERS OF THE COUNCIL.— 

‘‘(1) INFORMATION FROM FEDERAL AGENCIES.—Subject to 

the requirements of section 2012(a), the Council may secure directly from any Federal department or agency such information as the Council considers necessary to carry out this section. Upon request of the Chair of the Council, the head of 

such department or agency shall furnish such information to 

the Council. 

‘‘(2) POSTAL SERVICES.—The Council may use the United 

States mails in the same manner and under the same conditions as other departments and agencies of the Federal Government. 

‘‘(h) TRAVEL EXPENSES.—The members of the Council shall not 

receive compensation for the performance of services for the Council. The members shall be allowed 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 

in the performance of services for the Council. Notwithstanding 

section 1342 of title 31, United States Code, the Secretary may accept the voluntary and uncompensated services of the members of 

the Council. 

‘‘(i) DETAIL OF GOVERNMENT EMPLOYEES.—Any Federal Government employee may be detailed to the Council without reimbursement, and such detail shall be without interruption or loss of 

civil service status or privilege. 

‘‘(j) STATUS AS PERMANENT COUNCIL.—Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the 

Council. 

‘‘(k) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary to carry out 

this section. 
Sec. 6703\2022 SSA PPACA (Consolidated) 728 

‘‘SEC. 2022. ø42 U.S.C. 1397k–1¿ ADVISORY BOARD ON ELDER ABUSE, NEGLECT, AND EXPLOITATION. 

‘‘(a) ESTABLISHMENT.—There is established a board to be 

known as the ‘Advisory Board on Elder Abuse, Neglect, and Exploitation’ (in this section referred to as the ‘Advisory Board’) to create 

short- and long-term multidisciplinary strategic plans for the development of the field of elder justice and to make recommendations 

to the Elder Justice Coordinating Council established under section 

2021. 

‘‘(b) COMPOSITION.—The Advisory Board shall be composed of 

27 members appointed by the Secretary from among members of 

the general public who are individuals with experience and expertise in elder abuse, neglect, and exploitation prevention, detection, 

treatment, intervention, or prosecution. 

‘‘(c) SOLICITATION OF NOMINATIONS.—The Secretary shall publish a notice in the Federal Register soliciting nominations for the 

appointment of members of the Advisory Board under subsection 

(b). 

‘‘(d) TERMS.— 

‘‘(1) IN GENERAL.—Each member of the Advisory Board 

shall be appointed for a term of 3 years, except that, of the 

members first appointed— 

‘‘(A) 9 shall be appointed for a term of 3 years; 

‘‘(B) 9 shall be appointed for a term of 2 years; and 

‘‘(C) 9 shall be appointed for a term of 1 year. 

‘‘(2) VACANCIES.— ‘‘(A) IN GENERAL.—Any vacancy on the Advisory Board 

shall not affect its powers, but shall be filled in the same 

manner as the original appointment was made. 

‘‘(B) FILLING UNEXPIRED TERM.—An individual chosen 

to fill a vacancy shall be appointed for the unexpired term 

of the member replaced. 

‘‘(3) EXPIRATION OF TERMS.—The term of any member shall 

not expire before the date on which the member’s successor 

takes office. 

‘‘(e) ELECTION OF OFFICERS.—The Advisory Board shall elect a 

Chair and Vice Chair from among its members. The Advisory 

Board shall elect its initial Chair and Vice Chair at its initial meeting. 

‘‘(f) DUTIES.— 

‘‘(1) ENHANCE COMMUNICATION ON PROMOTING QUALITY OF, 

AND PREVENTING ABUSE, NEGLECT, AND EXPLOITATION IN, LONGTERM CARE.—The Advisory Board shall develop collaborative 

and innovative approaches to improve the quality of, including 

preventing abuse, neglect, and exploitation in, long-term care. 

‘‘(2) COLLABORATIVE EFFORTS TO DEVELOP CONSENSUS

AROUND THE MANAGEMENT OF CERTAIN QUALITY-RELATED FAC- TORS.— 

‘‘(A) IN GENERAL.—The Advisory Board shall establish 

multidisciplinary panels to address, and develop consensus 

on, subjects relating to improving the quality of long-term 

care. At least 1 such panel shall address, and develop consensus on, methods for managing resident-to-resident 

abuse in long-term care. 
729 Sec. 6703 PPACA (Consolidated) \2022 SSA 

‘‘(B) ACTIVITIES CONDUCTED.—The multidisciplinary 

panels established under subparagraph (A) shall examine 

relevant research and data, identify best practices with respect to the subject of the panel, determine the best way 

to carry out those best practices in a practical and feasible 

manner, and determine an effective manner of distributing 

information on such subject. 

‘‘(3) REPORT.—Not later than the date that is 18 months 

after the date of enactment of the Elder Justice Act of 2009, 

and annually thereafter, the Advisory Board shall prepare and 

submit to the Elder Justice Coordinating Council, the Committee on Finance of the Senate, and the Committee on Ways 

and Means and the Committee on Energy and Commerce of 

the House of Representatives a report containing— 

‘‘(A) information on the status of Federal, State, and 

local public and private elder justice activities; 

‘‘(B) recommendations (including recommended priorities) regarding— 

‘‘(i) elder justice programs, research, training, 

services, practice, enforcement, and coordination; 

‘‘(ii) coordination between entities pursuing elder 

justice efforts and those involved in related areas that 

may inform or overlap with elder justice efforts, such 

as activities to combat violence against women and 

child abuse and neglect; and 

‘‘(iii) activities relating to adult fiduciary systems, 

including guardianship and other fiduciary arrangements; 

‘‘(C) recommendations for specific modifications needed 

in Federal and State laws (including regulations) or for 

programs, research, and training to enhance prevention, 

detection, and treatment (including diagnosis) of, intervention in (including investigation of), and prosecution of elder 

abuse, neglect, and exploitation; 

‘‘(D) recommendations on methods for the most effective coordinated national data collection with respect to 

elder justice, and elder abuse, neglect, and exploitation; 

and 

‘‘(E) recommendations for a multidisciplinary strategic 

plan to guide the effective and efficient development of the 

field of elder justice. 

‘‘(g) POWERS OF THE ADVISORY BOARD.— 

‘‘(1) INFORMATION FROM FEDERAL AGENCIES.—Subject to 

the requirements of section 2012(a), the Advisory Board may 

secure directly from any Federal department or agency such 

information as the Advisory Board considers necessary to carry 

out this section. Upon request of the Chair of the Advisory 

Board, the head of such department or agency shall furnish 

such information to the Advisory Board. 

‘‘(2) SHARING OF DATA AND REPORTS.—The Advisory Board 

may request from any entity pursuing elder justice activities 

under the Elder Justice Act of 2009 or an amendment made by 

that Act, any data, reports, or recommendations generated in 

connection with such activities. 
Sec. 6703\2023 SSA PPACA (Consolidated) 730 

‘‘(3) POSTAL SERVICES.—The Advisory Board may use the 

United States mails in the same manner and under the same 

conditions as other departments and agencies of the Federal 

Government. 

‘‘(h) TRAVEL EXPENSES.—The members of the Advisory Board 

shall not receive compensation for the performance of services for 

the Advisory Board. The members shall be allowed travel expenses 

for up to 4 meetings per year, 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 in the performance 

of services for the Advisory Board. Notwithstanding section 1342 of 

title 31, United States Code, the Secretary may accept the voluntary and uncompensated services of the members of the Advisory 

Board. 

‘‘(i) DETAIL OF GOVERNMENT EMPLOYEES.—Any Federal Government employee may be detailed to the Advisory Board without 

reimbursement, and such detail shall be without interruption or 

loss of civil service status or privilege. 

‘‘(j) STATUS AS PERMANENT ADVISORY COMMITTEE.—Section 14 

of the Federal Advisory Committee Act (5 U.S.C. App.) shall not 

apply to the advisory board. 

‘‘(k) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary to carry out 

this section. 

‘‘SEC. 2023. ø42 U.S.C. 1397k–2¿ RESEARCH PROTECTIONS. 

‘‘(a) GUIDELINES.—The Secretary shall promulgate guidelines 

to assist researchers working in the area of elder abuse, neglect, 

and exploitation, with issues relating to human subject protections. 

‘‘(b) DEFINITION OF LEGALLY AUTHORIZED REPRESENTATIVE FOR

APPLICATION OF REGULATIONS.—For purposes of the application of 

subpart A of part 46 of title 45, Code of Federal Regulations, to research conducted under this subpart, the term ‘legally authorized 

representative’ means, unless otherwise provided by law, the individual or judicial or other body authorized under the applicable law 

to consent to medical treatment on behalf of another person. 

‘‘SEC. 2024. ø42 U.S.C. 1397k–3¿ AUTHORIZATION OF APPROPRIATIONS. 

‘‘There are authorized to be appropriated to carry out this subpart— ‘‘(1) for fiscal year 2011, $6,500,000; and 

‘‘(2) for each of fiscal years 2012 through 2014, $7,000,000. 

‘‘Subpart B—Elder Abuse, Neglect, and 

Exploitation Forensic Centers 

‘‘SEC. 2031. ø42 U.S.C. 1397l¿ ESTABLISHMENT AND SUPPORT OF ELDER 

ABUSE, NEGLECT, AND EXPLOITATION FORENSIC CENTERS. 

‘‘(a) IN GENERAL.—The Secretary, in consultation with the Attorney General, shall make grants to eligible entities to establish 

and operate stationary and mobile forensic centers, to develop forensic expertise regarding, and provide services relating to, elder 

abuse, neglect, and exploitation. 
731 Sec. 6703 PPACA (Consolidated) \2041 SSA 

‘‘(b) STATIONARY FORENSIC CENTERS.—The Secretary shall 

make 4 of the grants described in subsection (a) to institutions of 

higher education with demonstrated expertise in forensics or commitment to preventing or treating elder abuse, neglect, or exploitation, to establish and operate stationary forensic centers. 

‘‘(c) MOBILE CENTERS.—The Secretary shall make 6 of the 

grants described in subsection (a) to appropriate entities to establish and operate mobile forensic centers. 

‘‘(d) AUTHORIZED ACTIVITIES.— 

‘‘(1) DEVELOPMENT OF FORENSIC MARKERS AND METHODOLOGIES.—An eligible entity that receives a grant under this section shall use funds made available through the grant to assist 

in determining whether abuse, neglect, or exploitation occurred 

and whether a crime was committed and to conduct research 

to describe and disseminate information on— 

‘‘(A) forensic markers that indicate a case in which 

elder abuse, neglect, or exploitation may have occurred; 

and 

‘‘(B) methodologies for determining, in such a case, 

when and how health care, emergency service, social and 

protective services, and legal service providers should intervene and when the providers should report the case to 

law enforcement authorities. 

‘‘(2) DEVELOPMENT OF FORENSIC EXPERTISE.—An eligible 

entity that receives a grant under this section shall use funds 

made available through the grant to develop forensic expertise 

regarding elder abuse, neglect, and exploitation in order to provide medical and forensic evaluation, therapeutic intervention, 

victim support and advocacy, case review, and case tracking. 

‘‘(3) COLLECTION OF EVIDENCE.—The Secretary, in coordination with the Attorney General, shall use data made available by grant recipients under this section to develop the capacity of geriatric health care professionals and law enforcement to collect forensic evidence, including collecting forensic 

evidence relating to a potential determination of elder abuse, 

neglect, or exploitation. 

‘‘(e) APPLICATION.—To be eligible to receive a grant under this 

section, an entity shall submit an application to the Secretary at 

such time, in such manner, and containing such information as the 

Secretary may require. 

‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated to carry out this section— 

‘‘(1) for fiscal year 2011, $4,000,000; 

‘‘(2) for fiscal year 2012, $6,000,000; and 

‘‘(3) for each of fiscal years 2013 and 2014, $8,000,000. 

‘‘PART II—PROGRAMS TO PROMOTE ELDER 

JUSTICE 

‘‘SEC. 2041. ø42 U.S.C. 1397m¿ ENHANCEMENT OF LONG-TERM CARE. 

‘‘(a) GRANTS AND INCENTIVES FOR LONG-TERM CARE STAFFING.— 
Sec. 6703\2041 SSA PPACA (Consolidated) 732 

‘‘(1) IN GENERAL.—The Secretary shall carry out activities, 

including activities described in paragraphs (2) and (3), to provide incentives for individuals to train for, seek, and maintain 

employment providing direct care in long-term care. 

‘‘(2) SPECIFIC PROGRAMS TO ENHANCE TRAINING, RECRUIT- MENT, AND RETENTION OF STAFF.— ‘‘(A) COORDINATION WITH SECRETARY OF LABOR TO RE- CRUIT AND TRAIN LONG-TERM CARE STAFF.—The Secretary 

shall coordinate activities under this subsection with the 

Secretary of Labor in order to provide incentives for individuals to train for and seek employment providing direct 

care in long-term care. 

‘‘(B) CAREER LADDERS AND WAGE OR BENEFIT IN- CREASES TO INCREASE STAFFING IN LONG-TERM CARE.— ‘‘(i) IN GENERAL.—The Secretary shall make 

grants to eligible entities to carry out programs 

through which the entities— 

‘‘(I) offer, to employees who provide direct care 

to residents of an eligible entity or individuals receiving community-based long-term care from an 

eligible entity, continuing training and varying 

levels of certification, based on observed clinical 

care practices and the amount of time the employees spend providing direct care; and 

‘‘(II) provide, or make arrangements to provide, bonuses or other increased compensation or 

benefits to employees who achieve certification 

under such a program. 

‘‘(ii) APPLICATION.—To be eligible to receive a 

grant under this subparagraph, an eligible entity shall 

submit an application to the Secretary at such time, in 

such manner, and containing such information as the 

Secretary may require (which may include evidence of 

consultation with the State in which the eligible entity 

is located with respect to carrying out activities funded under the grant). 

‘‘(iii) AUTHORITY TO LIMIT NUMBER OF APPLICANTS.—Nothing in this subparagraph shall be construed as prohibiting the Secretary from limiting the 

number of applicants for a grant under this subparagraph. 

‘‘(3) SPECIFIC PROGRAMS TO IMPROVE MANAGEMENT PRACTICES.— 

‘‘(A) IN GENERAL.—The Secretary shall make grants to 

eligible entities to enable the entities to provide training 

and technical assistance. 

‘‘(B) AUTHORIZED ACTIVITIES.—An eligible entity that 

receives a grant under subparagraph (A) shall use funds 

made available through the grant to provide training and 

technical assistance regarding management practices 

using methods that are demonstrated to promote retention 

of individuals who provide direct care, such as— 

‘‘(i) the establishment of standard human resource 

policies that reward high performance, including poli-
733 Sec. 6703 PPACA (Consolidated) \2041 SSA 

cies that provide for improved wages and benefits on 

the basis of job reviews; 

‘‘(ii) the establishment of motivational and 

thoughtful work organization practices; 

‘‘(iii) the creation of a workplace culture that respects and values caregivers and their needs; 

‘‘(iv) the promotion of a workplace culture that respects the rights of residents of an eligible entity or individuals receiving community-based long-term care 

from an eligible entity and results in improved care for 

the residents or the individuals; and 

‘‘(v) the establishment of other programs that promote the provision of high quality care, such as a continuing education program that provides additional 

hours of training, including on-the-job training, for 

employees who are certified nurse aides. 

‘‘(C) APPLICATION.—To be eligible to receive a grant 

under this paragraph, an eligible entity shall submit an 

application to the Secretary at such time, in such manner, 

and containing such information as the Secretary may require (which may include evidence of consultation with the 

State in which the eligible entity is located with respect to 

carrying out activities funded under the grant). 

‘‘(D) AUTHORITY TO LIMIT NUMBER OF APPLICANTS.— Nothing in this paragraph shall be construed as prohibiting the Secretary from limiting the number of applicants 

for a grant under this paragraph. 

‘‘(4) ACCOUNTABILITY MEASURES.—The Secretary shall develop accountability measures to ensure that the activities conducted using funds made available under this subsection benefit individuals who provide direct care and increase the stability of the long-term care workforce. 

‘‘(5) DEFINITIONS.—In this subsection: 

‘‘(A) COMMUNITY-BASED LONG-TERM CARE.—The term 

‘community-based long-term care’ has the meaning given 

such term by the Secretary. 

‘‘(B) ELIGIBLE ENTITY.—The term ‘eligible entity’ 

means the following: 

‘‘(i) A long-term care facility. 

‘‘(ii) A community-based long-term care entity (as 

defined by the Secretary). 

‘‘(b) CERTIFIED EHR TECHNOLOGY GRANT PROGRAM.— 

‘‘(1) GRANTS AUTHORIZED.—The Secretary is authorized to 

make grants to long-term care facilities for the purpose of assisting such entities in offsetting the costs related to purchasing, leasing, developing, and implementing certified EHR 

technology (as defined in section 1848(o)(4)) designed to improve patient safety and reduce adverse events and health care 

complications resulting from medication errors. 

‘‘(2) USE OF GRANT FUNDS.—Funds provided under grants 

under this subsection may be used for any of the following: 

‘‘(A) Purchasing, leasing, and installing computer software and hardware, including handheld computer technologies. 
Sec. 6703\2041 SSA PPACA (Consolidated) 734 

‘‘(B) Making improvements to existing computer software and hardware. 

‘‘(C) Making upgrades and other improvements to existing computer software and hardware to enable e-prescribing. 

‘‘(D) Providing education and training to eligible longterm care facility staff on the use of such technology to implement the electronic transmission of prescription and patient information. 

‘‘(3) APPLICATION.— 

‘‘(A) IN GENERAL.—To be eligible to receive a grant 

under this subsection, a long-term care facility shall submit an application to the Secretary at such time, in such 

manner, and containing such information as the Secretary 

may require (which may include evidence of consultation 

with the State in which the long-term care facility is located with respect to carrying out activities funded under 

the grant). 

‘‘(B) AUTHORITY TO LIMIT NUMBER OF APPLICANTS.— 

Nothing in this subsection shall be construed as prohibiting the Secretary from limiting the number of applicants 

for a grant under this subsection. 

‘‘(4) PARTICIPATION IN STATE HEALTH EXCHANGES.—A longterm care facility that receives a grant under this subsection 

shall, where available, participate in activities conducted by a 

State or a qualified State-designated entity (as defined in section 3013(f) of the Public Health Service Act) under a grant 

under section 3013 of the Public Health Service Act to coordinate care and for other purposes determined appropriate by 

the Secretary. 

‘‘(5) ACCOUNTABILITY MEASURES.—The Secretary shall develop accountability measures to ensure that the activities conducted using funds made available under this subsection help 

improve patient safety and reduce adverse events and health 

care complications resulting from medication errors. 

‘‘(c) ADOPTION OF STANDARDS FOR TRANSACTIONS INVOLVING

CLINICAL DATA BY LONG-TERM CARE FACILITIES.— 

‘‘(1) STANDARDS AND COMPATIBILITY.—The Secretary shall 

adopt electronic standards for the exchange of clinical data by 

long-term care facilities, including, where available, standards 

for messaging and nomenclature. Standards adopted by the 

Secretary under the preceding sentence shall be compatible 

with standards established under part C of title XI, standards 

established under subsections (b)(2)(B)(i) and (e)(4) of section 

1860D–4, standards adopted under section 3004 of the Public 

Health Service Act, and general health information technology 

standards. 

‘‘(2) ELECTRONIC SUBMISSION OF DATA TO THE SECRETARY.— 

‘‘(A) IN GENERAL.—Not later than 10 years after the 

date of enactment of the Elder Justice Act of 2009, the 

Secretary shall have procedures in place to accept the optional electronic submission of clinical data by long-term 
735 Sec. 6703 PPACA (Consolidated) \2042 SSA 

care facilities pursuant to the standards adopted under 

paragraph (1). 

‘‘(B) RULE OF CONSTRUCTION.—Nothing in this subsection shall be construed to require a long-term care facility to submit clinical data electronically to the Secretary. 

‘‘(3) REGULATIONS.—The Secretary shall promulgate regulations to carry out this subsection. Such regulations shall require a State, as a condition of the receipt of funds under this 

part, to conduct such data collection and reporting as the Secretary determines are necessary to satisfy the requirements of 

this subsection. 

‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this section— ‘‘(1) for fiscal year 2011, $20,000,000; 

‘‘(2) for fiscal year 2012, $17,500,000; and 

‘‘(3) for each of fiscal years 2013 and 2014, $15,000,000. 

‘‘SEC. 2042. ø42 U.S.C. 1397m–1¿ ADULT PROTECTIVE SERVICES FUNCTIONS AND GRANT PROGRAMS. 

‘‘(a) SECRETARIAL RESPONSIBILITIES.— ‘‘(1) IN GENERAL.—The Secretary shall ensure that the Department of Health and Human Services— 

‘‘(A) provides funding authorized by this part to State 

and local adult protective services offices that investigate 

reports of the abuse, neglect, and exploitation of elders; 

‘‘(B) collects and disseminates data annually relating 

to the abuse, exploitation, and neglect of elders in coordination with the Department of Justice; 

‘‘(C) develops and disseminates information on best 

practices regarding, and provides training on, carrying out 

adult protective services; 

‘‘(D) conducts research related to the provision of adult 

protective services; and 

‘‘(E) provides technical assistance to States and other 

entities that provide or fund the provision of adult protective services, including through grants made under subsections (b) and (c). 

‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection, 

$3,000,000 for fiscal year 2011 and $4,000,000 for each of fiscal 

years 2012 through 2014. 

‘‘(b) GRANTS TO ENHANCE THE PROVISION OF ADULT PROTECTIVE SERVICES.— 

‘‘(1) ESTABLISHMENT.—There is established an adult protective services grant program under which the Secretary shall 

annually award grants to States in the amounts calculated 

under paragraph (2) for the purposes of enhancing adult protective services provided by States and local units of government. 

‘‘(2) AMOUNT OF PAYMENT.— 

‘‘(A) IN GENERAL.—Subject to the availability of appropriations and subparagraphs (B) and (C), the amount paid 

to a State for a fiscal year under the program under this 

subsection shall equal the amount appropriated for that 

year to carry out this subsection multiplied by the percent-
Sec. 6703\2042 SSA PPACA (Consolidated) 736 

age of the total number of elders who reside in the United 

States who reside in that State. 

‘‘(B) GUARANTEED MINIMUM PAYMENT AMOUNT.— ‘‘(i) 50 STATES.—Subject to clause (ii), if the 

amount determined under subparagraph (A) for a 

State for a fiscal year is less than 0.75 percent of the 

amount appropriated for such year, the Secretary shall 

increase such determined amount so that the total 

amount paid under this subsection to the State for the 

year is equal to 0.75 percent of the amount so appropriated. 

‘‘(ii) TERRITORIES.—In the case of a State other 

than 1 of the 50 States, clause (i) shall be applied as 

if each reference to ‘0.75’ were a reference to ‘0.1’. 

‘‘(C) PRO RATA REDUCTIONS.—The Secretary shall 

make such pro rata reductions to the amounts described in 

subparagraph (A) as are necessary to comply with the requirements of subparagraph (B). 

‘‘(3) AUTHORIZED ACTIVITIES.— ‘‘(A) ADULT PROTECTIVE SERVICES.—Funds made available pursuant to this subsection may only be used by 

States and local units of government to provide adult protective services and may not be used for any other purpose. 

‘‘(B) USE BY AGENCY.—Each State receiving funds pursuant to this subsection shall provide such funds to the 

agency or unit of State government having legal responsibility for providing adult protective services within the 

State. 

‘‘(C) SUPPLEMENT NOT SUPPLANT.—Each State or local 

unit of government shall use funds made available pursuant to this subsection to supplement and not supplant 

other Federal, State, and local public funds expended to 

provide adult protective services in the State. 

‘‘(4) STATE REPORTS.—Each State receiving funds under 

this subsection shall submit to the Secretary, at such time and 

in such manner as the Secretary may require, a report on the 

number of elders served by the grants awarded under this subsection. 

‘‘(5) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection, 

$100,000,000 for each of fiscal years 2011 through 2014. 

‘‘(c) STATE DEMONSTRATION PROGRAMS.— 

‘‘(1) ESTABLISHMENT.—The Secretary shall award grants to 

States for the purposes of conducting demonstration programs 

in accordance with paragraph (2). 

‘‘(2) DEMONSTRATION PROGRAMS.—Funds made available 

pursuant to this subsection may be used by States and local 

units of government to conduct demonstration programs that 

test— 

‘‘(A) training modules developed for the purpose of detecting or preventing elder abuse; 

‘‘(B) methods to detect or prevent financial exploitation 

of elders; 
737 Sec. 6703 PPACA (Consolidated) \2043 SSA 

‘‘(C) methods to detect elder abuse; 

‘‘(D) whether training on elder abuse forensics enhances the detection of elder abuse by employees of the 

State or local unit of government; or 

‘‘(E) other matters relating to the detection or prevention of elder abuse. 

‘‘(3) APPLICATION.—To be eligible to receive a grant under 

this subsection, a State shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. 

‘‘(4) STATE REPORTS.—Each State that receives funds under 

this subsection shall submit to the Secretary a report at such 

time, in such manner, and containing such information as the 

Secretary may require on the results of the demonstration program conducted by the State using funds made available under 

this subsection. 

‘‘(5) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection, 

$25,000,000 for each of fiscal years 2011 through 2014. 

‘‘SEC. 2043. ø42 U.S.C. 1397m–2¿ LONG-TERM CARE OMBUDSMAN PROGRAM GRANTS AND TRAINING. 

‘‘(a) GRANTS TO SUPPORT THE LONG-TERM CARE OMBUDSMAN

PROGRAM.— 

‘‘(1) IN GENERAL.—The Secretary shall make grants to eligible entities with relevant expertise and experience in abuse 

and neglect in long-term care facilities or long-term care ombudsman programs and responsibilities, for the purpose of— 

‘‘(A) improving the capacity of State long-term care 

ombudsman programs to respond to and resolve complaints about abuse and neglect; 

‘‘(B) conducting pilot programs with State long-term 

care ombudsman offices or local ombudsman entities; and 

‘‘(C) providing support for such State long-term care 

ombudsman programs and such pilot programs (such as 

through the establishment of a national long-term care 

ombudsman resource center). 

‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection— 

‘‘(A) for fiscal year 2011, $5,000,000; 

‘‘(B) for fiscal year 2012, $7,500,000; and 

‘‘(C) for each of fiscal years 2013 and 2014, 

$10,000,000. 

‘‘(b) OMBUDSMAN TRAINING PROGRAMS.— 

‘‘(1) IN GENERAL.—The Secretary shall establish programs 

to provide and improve ombudsman training with respect to 

elder abuse, neglect, and exploitation for national organizations and State long-term care ombudsman programs. 

‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection, for 

each of fiscal years 2011 through 2014, $10,000,000. 
Sec. 6703\2044 SSA PPACA (Consolidated) 738 

‘‘SEC. 2044. ø42 U.S.C. 1397m–3¿ PROVISION OF INFORMATION REGARDING, AND EVALUATIONS OF, ELDER JUSTICE PROGRAMS. 

‘‘(a) PROVISION OF INFORMATION.—To be eligible to receive a 

grant under this part, an applicant shall agree— 

‘‘(1) except as provided in paragraph (2), to provide the eligible entity conducting an evaluation under subsection (b) of 

the activities funded through the grant with such information 

as the eligible entity may require in order to conduct such 

evaluation; or 

‘‘(2) in the case of an applicant for a grant under section 

2041(b), to provide the Secretary with such information as the 

Secretary may require to conduct an evaluation or audit under 

subsection (c). 

‘‘(b) USE OF ELIGIBLE ENTITIES TO CONDUCT EVALUATIONS.— 

‘‘(1) EVALUATIONS REQUIRED.—Except as provided in paragraph (2), the Secretary shall— 

‘‘(A) reserve a portion (not less than 2 percent) of the 

funds appropriated with respect to each program carried 

out under this part; and 

‘‘(B) use the funds reserved under subparagraph (A) to 

provide assistance to eligible entities to conduct evaluations of the activities funded under each program carried 

out under this part. 

‘‘(2) CERTIFIED EHR TECHNOLOGY GRANT PROGRAM NOT INCLUDED.—The provisions of this subsection shall not apply to 

the certified EHR technology grant program under section 

2041(b). 

‘‘(3) AUTHORIZED ACTIVITIES.—A recipient of assistance described in paragraph (1)(B) shall use the funds made available 

through the assistance to conduct a validated evaluation of the 

effectiveness of the activities funded under a program carried 

out under this part. 

‘‘(4) APPLICATIONS.—To be eligible to receive assistance 

under paragraph (1)(B), an entity shall submit an application 

to the Secretary at such time, in such manner, and containing 

such information as the Secretary may require, including a 

proposal for the evaluation. 

‘‘(5) REPORTS.—Not later than a date specified by the Secretary, an eligible entity receiving assistance under paragraph 

(1)(B) shall submit to the Secretary, the Committee on Ways 

and Means and the Committee on Energy and Commerce of 

the House of Representatives, and the Committee on Finance 

of the Senate a report containing the results of the evaluation 

conducted using such assistance together with such recommendations as the entity determines to be appropriate. 

‘‘(c) EVALUATIONS AND AUDITS OF CERTIFIED EHR TECHNOLOGY

GRANT PROGRAM BY THE SECRETARY.— 

‘‘(1) EVALUATIONS.—The Secretary shall conduct an evaluation of the activities funded under the certified EHR technology grant program under section 2041(b). Such evaluation 

shall include an evaluation of whether the funding provided 

under the grant is expended only for the purposes for which it 

is made. 
739 Sec. 6703 PPACA (Consolidated) 

‘‘(2) AUDITS.—The Secretary shall conduct appropriate audits of grants made under section 2041(b). 

‘‘SEC. 2045. ø42 U.S.C. 1397m–4¿ REPORT. 

‘‘Not later than October 1, 2014, the Secretary shall submit to 

the Elder Justice Coordinating Council established under section 

2021, the Committee on Ways and Means and the Committee on 

Energy and Commerce of the House of Representatives, and the 

Committee on Finance of the Senate a report— 

‘‘(1) compiling, summarizing, and analyzing the information contained in the State reports submitted under subsections (b)(4) and (c)(4) of section 2042; and 

‘‘(2) containing such recommendations for legislative or administrative action as the Secretary determines to be appropriate. 

‘‘SEC. 2046. ø42 U.S.C. 1397m–5¿ RULE OF CONSTRUCTION. 

‘‘Nothing in this subtitle shall be construed as— 

‘‘(1) limiting any cause of action or other relief related to 

obligations under this subtitle that is available under the law 

of any State, or political subdivision thereof; or 

‘‘(2) creating a private cause of action for a violation of this 

subtitle.’’. 

(2) OPTION FOR STATE PLAN UNDER PROGRAM FOR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES.— 

(A) IN GENERAL.—Section 402(a)(1)(B) of the Social Security Act (42 U.S.C. 602(a)(1)(B)) is amended by adding at 

the end the following new clause: 

‘‘(v) The document shall indicate whether the 

State intends to assist individuals to train for, seek, 

and maintain employment— 

‘‘(I) providing direct care in a long-term care 

facility (as such terms are defined under section 

2011); or 

‘‘(II) in other occupations related to elder care 

determined appropriate by the State for which the 

State identifies an unmet need for service personnel, 

and, if so, shall include an overview of such assistance.’’. 

(B) EFFECTIVE DATE.—The amendment made by subparagraph (A) shall take effect on January 1, 2011. 

(b) PROTECTING RESIDENTS OF LONG-TERM CARE FACILITIES.— 

ø42 U.S.C. 1395i–3a¿ 

(1) NATIONAL TRAINING INSTITUTE FOR SURVEYORS.— 

(A) IN GENERAL.—The Secretary of Health and Human 

Services shall enter into a contract with an entity for the 

purpose of establishing and operating a National Training 

Institute for Federal and State surveyors. Such Institute 

shall provide and improve the training of surveyors with 

respect to investigating allegations of abuse, neglect, and 

misappropriation of property in programs and long-term 

care facilities that receive payments under title XVIII or 

XIX of the Social Security Act. 
Sec. 6703 PPACA (Consolidated) 740 

(B) ACTIVITIES CARRIED OUT BY THE INSTITUTE.—The 

contract entered into under subparagraph (A) shall require 

the Institute established and operated under such contract 

to carry out the following activities: 

(i) Assess the extent to which State agencies use 

specialized surveyors for the investigation of reported 

allegations of abuse, neglect, and misappropriation of 

property in such programs and long-term care facilities. 

(ii) Evaluate how the competencies of surveyors 

may be improved to more effectively investigate reported allegations of such abuse, neglect, and misappropriation of property, and provide feedback to 

Federal and State agencies on the evaluations conducted. 

(iii) Provide a national program of training, tools, 

and technical assistance to Federal and State surveyors on investigating reports of such abuse, neglect, 

and misappropriation of property. 

(iv) Develop and disseminate information on best 

practices for the investigation of such abuse, neglect, 

and misappropriation of property. 

(v) Assess the performance of State complaint intake systems, in order to ensure that the intake of 

complaints occurs 24 hours per day, 7 days a week (including holidays). 

(vi) To the extent approved by the Secretary of 

Health and Human Services, provide a national 24 

hours per day, 7 days a week (including holidays), 

back-up system to State complaint intake systems in 

order to ensure optimum national responsiveness to 

complaints of such abuse, neglect, and misappropriation of property. 

(vii) Analyze and report annually on the following: 

(I) The total number and sources of complaints of such abuse, neglect, and misappropriation of property. 

(II) The extent to which such complaints are 

referred to law enforcement agencies. 

(III) General results of Federal and State investigations of such complaints. 

(viii) Conduct a national study of the cost to State 

agencies of conducting complaint investigations of 

skilled nursing facilities and nursing facilities under 

sections 1819 and 1919, respectively, of the Social Security Act (42 U.S.C. 1395i–3; 1396r), and making recommendations to the Secretary of Health and Human 

Services with respect to options to increase the efficiency and cost-effectiveness of such investigations. 

(C) AUTHORIZATION.—There are authorized to be appropriated to carry out this paragraph, for the period of 

fiscal years 2011 through 2014, $12,000,000. 

(2) GRANTS TO STATE SURVEY AGENCIES.— 
741 Sec. 6703 PPACA (Consolidated) \1150 SSA 

(A) IN GENERAL.—The Secretary of Health and Human 

Services shall make grants to State agencies that perform 

surveys of skilled nursing facilities or nursing facilities 

under sections 1819 or 1919, respectively, of the Social Security Act (42 U.S.C. 1395i–3; 1395r). 

(B) USE OF FUNDS.—A grant awarded under subparagraph (A) shall be used for the purpose of designing and 

implementing complaint investigations systems that— 

(i) promptly prioritize complaints in order to ensure a rapid response to the most serious and urgent 

complaints; 

(ii) respond to complaints with optimum effectiveness and timeliness; and 

(iii) optimize the collaboration between local authorities, consumers, and providers, including— 

(I) such State agency; 

(II) the State Long-Term Care Ombudsman; 

(III) local law enforcement agencies; 

(IV) advocacy and consumer organizations; 

(V) State aging units; 

(VI) Area Agencies on Aging; and 

(VII) other appropriate entities. 

(C) AUTHORIZATION.—There are authorized to be appropriated to carry out this paragraph, for each of fiscal 

years 2011 through 2014, $5,000,000. 

(3) REPORTING OF CRIMES IN FEDERALLY FUNDED LONG- TERM CARE FACILITIES.—Part A of title XI of the Social Security 

Act (42 U.S.C. 1301 et seq.), as amended by section 6005, is 

amended by inserting after section 1150A the following new 

section: 

‘‘REPORTING TO LAW ENFORCEMENT OF CRIMES OCCURRING IN

FEDERALLY FUNDED LONG-TERM CARE FACILITIES

‘‘SEC. 1150B. ø42 U.S.C. 1320b–25¿ (a) DETERMINATION AND

NOTIFICATION.— ‘‘(1) DETERMINATION.—The owner or operator of each longterm care facility that receives Federal funds under this Act 

shall annually determine whether the facility received at least 

$10,000 in such Federal funds during the preceding year. 

‘‘(2) NOTIFICATION.—If the owner or operator determines under paragraph (1) that the facility received at least $10,000 

in such Federal funds during the preceding year, such owner 

or operator shall annually notify each covered individual (as 

defined in paragraph (3)) of that individual’s obligation to comply with the reporting requirements described in subsection 

(b). 

‘‘(3) COVERED INDIVIDUAL DEFINED.—In this section, the 

term ‘covered individual’ means each individual who is an 

owner, operator, employee, manager, agent, or contractor of a 

long-term care facility that is the subject of a determination 

described in paragraph (1). 

‘‘(b) REPORTING REQUIREMENTS.— 

‘‘(1) IN GENERAL.—Each covered individual shall report to 

the Secretary and 1 or more law enforcement entities for the 
Sec. 6703\1150 SSA PPACA (Consolidated) 742 

political subdivision in which the facility is located any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against any individual who is a resident of, or is receiving care from, the facility. 

‘‘(2) TIMING.—If the events that cause the suspicion— 

‘‘(A) result in serious bodily injury, the individual shall 

report the suspicion immediately, but not later than 2 

hours after forming the suspicion; and 

‘‘(B) do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours 

after forming the suspicion. 

‘‘(c) PENALTIES.— ‘‘(1) IN GENERAL.—If a covered individual violates subsection (b)— 

‘‘(A) the covered individual shall be subject to a civil money penalty of not more than $200,000; and 

‘‘(B) the Secretary may make a determination in the 

same proceeding to exclude the covered individual from 

participation in any Federal health care program (as defined in section 1128B(f)). 

‘‘(2) INCREASED HARM.—If a covered individual violates 

subsection (b) and the violation exacerbates the harm to the 

victim of the crime or results in harm to another individual— 

‘‘(A) the covered individual shall be subject to a civil money penalty of not more than $300,000; and 

‘‘(B) the Secretary may make a determination in the 

same proceeding to exclude the covered individual from 

participation in any Federal health care program (as defined in section 1128B(f)). 

‘‘(3) EXCLUDED INDIVIDUAL.—During any period for which 

a covered individual is classified as an excluded individual 

under paragraph (1)(B) or (2)(B), a long-term care facility that 

employs such individual shall be ineligible to receive Federal 

funds under this Act. 

‘‘(4) EXTENUATING CIRCUMSTANCES.— 

‘‘(A) IN GENERAL.—The Secretary may take into account the financial burden on providers with underserved 

populations in determining any penalty to be imposed 

under this subsection. 

‘‘(B) UNDERSERVED POPULATION DEFINED.—In this 

paragraph, the term ‘underserved population’ means the 

population of an area designated by the Secretary as an 

area with a shortage of elder justice programs or a population group designated by the Secretary as having a 

shortage of such programs. Such areas or groups designated by the Secretary may include— 

‘‘(i) areas or groups that are geographically isolated (such as isolated in a rural area); 

‘‘(ii) racial and ethnic minority populations; and 

‘‘(iii) populations underserved because of special 

needs (such as language barriers, disabilities, alien 

status, or age). 

‘‘(d) ADDITIONAL PENALTIES FOR RETALIATION.— 

‘‘(1) IN GENERAL.—A long-term care facility may not— 
743 Sec. 6703 PPACA (Consolidated) 

‘‘(A) discharge, demote, suspend, threaten, harass, or 

deny a promotion or other employment-related benefit to 

an employee, or in any other manner discriminate against 

an employee in the terms and conditions of employment 

because of lawful acts done by the employee; or 

‘‘(B) file a complaint or a report against a nurse or 

other employee with the appropriate State professional 

disciplinary agency because of lawful acts done by the 

nurse or employee, 

for making a report, causing a report to be made, or for taking 

steps in furtherance of making a report pursuant to subsection 

(b)(1). 

‘‘(2) PENALTIES FOR RETALIATION.—If a long-term care facility violates subparagraph (A) or (B) of paragraph (1) the facility shall be subject to a civil money penalty of not more than 

$200,000 or the Secretary may classify the entity as an excluded entity for a period of 2 years pursuant to section 

1128(b), or both. 

‘‘(3) REQUIREMENT TO POST NOTICE.—Each long-term care 

facility shall post conspicuously in an appropriate location a 

sign (in a form specified by the Secretary) specifying the rights 

of employees under this section. Such sign shall include a 

statement that an employee may file a complaint with the Secretary against a long-term care facility that violates the provisions of this subsection and information with respect to the 

manner of filing such a complaint. 

‘‘(e) PROCEDURE.—The provisions of section 1128A (other than 

subsections (a) and (b) and the second sentence of subsection (f)) 

shall apply to a civil money penalty or exclusion under this section 

in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). 

‘‘(f) DEFINITIONS.—In this section, the terms ‘elder justice’, 

‘long-term care facility’, and ‘law enforcement’ have the meanings 

given those terms in section 2011.’’. 

(c) NATIONAL NURSE AIDE REGISTRY.— 

(1) DEFINITION OF NURSE AIDE.—In this subsection, the 

term ‘‘nurse aide’’ has the meaning given that term in sections 

1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act (42 

U.S.C. 1395i–3(b)(5)(F); 1396r(b)(5)(F)). 

(2) STUDY AND REPORT.— 

(A) IN GENERAL.—The Secretary, in consultation with 

appropriate government agencies and private sector organizations, shall conduct a study on establishing a national 

nurse aide registry. 

(B) AREAS EVALUATED.—The study conducted under 

this subsection shall include an evaluation of— 

(i) who should be included in the registry; 

(ii) how such a registry would comply with Federal and State privacy laws and regulations; 

(iii) how data would be collected for the registry; 

(iv) what entities and individuals would have access to the data collected; 
Sec. 6703 PPACA (Consolidated) 744 

(v) how the registry would provide appropriate information regarding violations of Federal and State 

law by individuals included in the registry; 

(vi) how the functions of a national nurse aide registry would be coordinated with the nationwide program for national and State background checks on direct patient access employees of long-term care facilities and providers under section 4301; and 

(vii) how the information included in State nurse 

aide registries developed and maintained under sections 1819(e)(2) and 1919(e)(2) of the Social Security 

Act (42 U.S.C. 1395i–3(e)(2); 1396r(e)(2)(2)) would be 

provided as part of a national nurse aide registry. 

(C) CONSIDERATIONS.—In conducting the study and 

preparing the report required under this subsection, the 

Secretary shall take into consideration the findings and 

conclusions of relevant reports and other relevant resources, including the following: 

(i) The Department of Health and Human Services Office of Inspector General Report, Nurse Aide 

Registries: State Compliance and Practices (February 

2005). 

(ii) The General Accounting Office (now known as 

the Government Accountability Office) Report, Nursing Homes: More Can Be Done to Protect Residents 

from Abuse (March 2002). 

(iii) The Department of Health and Human Services Office of the Inspector General Report, Nurse Aide 

Registries: Long-Term Care Facility Compliance and 

Practices (July 2005). 

(iv) The Department of Health and Human Services Health Resources and Services Administration Report, Nursing Aides, Home Health Aides, and Related 

Health Care Occupations—National and Local Workforce Shortages and Associated Data Needs (2004) (in 

particular with respect to chapter 7 and appendix F). 

(v) The 2001 Report to CMS from the School of 

Rural Public Health, Texas A&M University, Preventing Abuse and Neglect in Nursing Homes: The 

Role of Nurse Aide Registries. 

(vi) Information included in State nurse aide registries developed and maintained under sections 

1819(e)(2) and 1919(e)(2) of the Social Security Act (42 

U.S.C. 1395i–3(e)(2); 1396r(e)(2)(2)). 

(D) REPORT.—Not later than 18 months after the date 

of enactment of this Act, the Secretary shall submit to the 

Elder Justice Coordinating Council established under section 2021 of the Social Security Act, as added by section 

1805(a), the Committee on Finance of the Senate, and the 

Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives a report containing the findings and recommendations of the 

study conducted under this paragraph. 
745 Sec. 6801 PPACA (Consolidated) 

(E) FUNDING LIMITATION.—Funding for the study conducted under this subsection shall not exceed $500,000. 

(3) CONGRESSIONAL ACTION.—After receiving the report 

submitted by the Secretary under paragraph (2)(D), the Committee on Finance of the Senate and the Committee on Ways 

and Means and the Committee on Energy and Commerce of 

the House of Representatives shall, as they deem appropriate, 

take action based on the recommendations contained in the report. 

(4) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are necessary for the purpose of carrying out this subsection. 

(d) CONFORMING AMENDMENTS.— 

(1) TITLE XX.—Title XX of the Social Security Act (42 

U.S.C. 1397 et seq.), as amended by section 6703(a), is amended— 

(A) in the heading of section 2001, by striking ‘‘TITLE’’ 

and inserting ‘‘SUBTITLE’’; and 

(B) in subtitle 1, by striking ‘‘this title’’ each place it 

appears and inserting ‘‘this subtitle’’. 

(2) TITLE IV.—Title IV of the Social Security Act (42 U.S.C. 

601 et seq.) is amended— 

(A) in section 404(d)— 

(i) in paragraphs (1)(A), (2)(A), and (3)(B), by inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’ each place it 

appears; 

(ii) in the heading of paragraph (2), by inserting 

‘‘SUBTITLE 1 OF’’ before ‘‘TITLE XX’’; and 

(iii) in the heading of paragraph (3)(B), by inserting ‘‘SUBTITLE 1 OF’’ before ‘‘TITLE XX’’; and 

(B) in sections 422(b), 471(a)(4), 472(h)(1), and 

473(b)(2), by inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’ each 

place it appears. 

(3) TITLE XI.—Title XI of the Social Security Act (42 U.S.C. 

1301 et seq.) is amended— 

(A) in section 1128(h)(3)— 

(i) by inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’; 

and 

(ii) by striking ‘‘such title’’ and inserting ‘‘such 

subtitle’’; and 

(B) in section 1128A(i)(1), by inserting ‘‘subtitle 1 of’’ 

before ‘‘title XX’’. 

Subtitle I—Sense of the Senate Regarding 

Medical Malpractice 

SEC. 6801. SENSE OF THE SENATE REGARDING MEDICAL MALPRACTICE. 

It is the sense of the Senate that— 

(1) health care reform presents an opportunity to address 

issues related to medical malpractice and medical liability insurance; 
Sec. 6801 PPACA (Consolidated) 746 

(2) States should be encouraged to develop and test alternatives to the existing civil litigation system as a way of improving patient safety, reducing medical errors, encouraging 

the efficient resolution of disputes, increasing the availability 

of prompt and fair resolution of disputes, and improving access 

to liability insurance, while preserving an individual’s right to 

seek redress in court; and 

(3) Congress should consider establishing a State demonstration program to evaluate alternatives to the existing civil 

litigation system with respect to the resolution of medical malpractice claims. 
747 Sec. 7002 PPACA (Consolidated) 

TITLE VII—IMPROVING ACCESS TO 

INNOVATIVE MEDICAL THERAPIES 

Subtitle A—Biologics Price Competition 

and Innovation 

SEC. 7001. SHORT TITLE. 

(a) IN GENERAL.—This subtitle may be cited as the ‘‘Biologics 

Price Competition and Innovation Act of 2009’’. 

(b) SENSE OF THE SENATE.—It is the sense of the Senate that 

a biosimilars pathway balancing innovation and consumer interests 

should be established. 

SEC. 7002. APPROVAL PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS. 

(a) LICENSURE OF BIOLOGICAL PRODUCTS AS BIOSIMILAR OR

INTERCHANGEABLE.—Section 351 of the Public Health Service Act 

(42 U.S.C. 262) is amended— 

(1) in subsection (a)(1)(A), by inserting ‘‘under this subsection or subsection (k)’’ after ‘‘biologics license’’; and 

(2) by adding at the end the following: 

‘‘(k) LICENSURE OF BIOLOGICAL PRODUCTS AS BIOSIMILAR OR

INTERCHANGEABLE.— ‘‘(1) IN GENERAL.—Any person may submit an application 

for licensure of a biological product under this subsection. 

‘‘(2) CONTENT.— ‘‘(A) IN GENERAL.— ‘‘(i) REQUIRED INFORMATION.—An application submitted under this subsection shall include information 

demonstrating that— 

‘‘(I) the biological product is biosimilar to a 

reference product based upon data derived from— 

‘‘(aa) analytical studies that demonstrate 

that the biological product is highly similar to 

the reference product notwithstanding minor 

differences in clinically inactive components; 

‘‘(bb) animal studies (including the assessment of toxicity); and 

‘‘(cc) a clinical study or studies (including 

the assessment of immunogenicity and pharmacokinetics or pharmacodynamics) that are 

sufficient to demonstrate safety, purity, and 

potency in 1 or more appropriate conditions of 

use for which the reference product is licensed 

and intended to be used and for which licensure is sought for the biological product; 

‘‘(II) the biological product and reference product utilize the same mechanism or mechanisms of 

action for the condition or conditions of use prescribed, recommended, or suggested in the proposed labeling, but only to the extent the mechanism or mechanisms of action are known for the 

reference product; 
Sec. 7002 PPACA (Consolidated) 748 

‘‘(III) the condition or conditions of use prescribed, recommended, or suggested in the labeling proposed for the biological product have been 

previously approved for the reference product; 

‘‘(IV) the route of administration, the dosage 

form, and the strength of the biological product 

are the same as those of the reference product; 

and 

‘‘(V) the facility in which the biological product is manufactured, processed, packed, or held 

meets standards designed to assure that the biological product continues to be safe, pure, and potent. 

‘‘(ii) DETERMINATION BY SECRETARY.—The Secretary may determine, in the Secretary’s discretion, 

that an element described in clause (i)(I) is unnecessary in an application submitted under this subsection. 

‘‘(iii) ADDITIONAL INFORMATION.—An application 

submitted under this subsection— 

‘‘(I) shall include publicly-available information regarding the Secretary’s previous determination that the reference product is safe, pure, and 

potent; and 

‘‘(II) may include any additional information 

in support of the application, including publiclyavailable information with respect to the reference 

product or another biological product. 

‘‘(B) INTERCHANGEABILITY.—An application (or a supplement to an application) submitted under this subsection 

may include information demonstrating that the biological 

product meets the standards described in paragraph (4). 

‘‘(3) EVALUATION BY SECRETARY.—Upon review of an application (or a supplement to an application) submitted under this 

subsection, the Secretary shall license the biological product 

under this subsection if— 

‘‘(A) the Secretary determines that the information 

submitted in the application (or the supplement) is sufficient to show that the biological product— 

‘‘(i) is biosimilar to the reference product; or 

‘‘(ii) meets the standards described in paragraph 

(4), and therefore is interchangeable with the reference product; and 

‘‘(B) the applicant (or other appropriate person) consents to the inspection of the facility that is the subject of 

the application, in accordance with subsection (c). 

‘‘(4) SAFETY STANDARDS FOR DETERMINING INTERCHANGE- ABILITY.—Upon review of an application submitted under this 

subsection or any supplement to such application, the Secretary shall determine the biological product to be interchangeable with the reference product if the Secretary determines 

that the information submitted in the application (or a supplement to such application) is sufficient to show that— 

‘‘(A) the biological product— 
749 Sec. 7002 PPACA (Consolidated) 

‘‘(i) is biosimilar to the reference product; and 

‘‘(ii) can be expected to produce the same clinical 

result as the reference product in any given patient; 

and 

‘‘(B) for a biological product that is administered more 

than once to an individual, the risk in terms of safety or 

diminished efficacy of alternating or switching between 

use of the biological product and the reference product is 

not greater than the risk of using the reference product 

without such alternation or switch. 

‘‘(5) GENERAL RULES.— ‘‘(A) ONE REFERENCE PRODUCT PER APPLICATION.—A 

biological product, in an application submitted under this 

subsection, may not be evaluated against more than 1 reference product. 

‘‘(B) REVIEW.—An application submitted under this 

subsection shall be reviewed by the division within the 

Food and Drug Administration that is responsible for the 

review and approval of the application under which the 

reference product is licensed. 

‘‘(C) RISK EVALUATION AND MITIGATION STRATEGIES.— The authority of the Secretary with respect to risk evaluation and mitigation strategies under the Federal Food, 

Drug, and Cosmetic Act shall apply to biological products 

licensed under this subsection in the same manner as such 

authority applies to biological products licensed under subsection (a). 

‘‘(6) EXCLUSIVITY FOR FIRST INTERCHANGEABLE BIOLOGICAL

PRODUCT.—Upon review of an application submitted under this 

subsection relying on the same reference product for which a 

prior biological product has received a determination of interchangeability for any condition of use, the Secretary shall not 

make a determination under paragraph (4) that the second or 

subsequent biological product is interchangeable for any condition of use until the earlier of— 

‘‘(A) 1 year after the first commercial marketing of the 

first interchangeable biosimilar biological product to be approved as interchangeable for that reference product; 

‘‘(B) 18 months after— 

‘‘(i) a final court decision on all patents in suit in 

an action instituted under subsection (l)(6) against the 

applicant that submitted the application for the first 

approved interchangeable biosimilar biological product; or 

‘‘(ii) the dismissal with or without prejudice of an 

action instituted under subsection (l)(6) against the 

applicant that submitted the application for the first 

approved interchangeable biosimilar biological product; or 

‘‘(C)(i) 42 months after approval of the first interchangeable biosimilar biological product if the applicant 

that submitted such application has been sued under subsection (l)(6) and such litigation is still ongoing within 

such 42-month period; or 
Sec. 7002 PPACA (Consolidated) 750 

‘‘(ii) 18 months after approval of the first interchangeable biosimilar biological product if the applicant that submitted such application has not been sued under subsection (l)(6). 

For purposes of this paragraph, the term ‘final court decision’ 

means a final decision of a court from which no appeal (other 

than a petition to the United States Supreme Court for a writ 

of certiorari) has been or can be taken. 

‘‘(7) EXCLUSIVITY FOR REFERENCE PRODUCT.— ‘‘(A) EFFECTIVE DATE OF BIOSIMILAR APPLICATION AP- PROVAL.—Approval of an application under this subsection 

may not be made effective by the Secretary until the date 

that is 12 years after the date on which the reference product was first licensed under subsection (a). 

‘‘(B) FILING PERIOD.—An application under this subsection may not be submitted to the Secretary until the 

date that is 4 years after the date on which the reference 

product was first licensed under subsection (a). 

‘‘(C) FIRST LICENSURE.—Subparagraphs (A) and (B) 

shall not apply to a license for or approval of— 

‘‘(i) a supplement for the biological product that is 

the reference product; or 

‘‘(ii) a subsequent application filed by the same 

sponsor or manufacturer of the biological product that 

is the reference product (or a licensor, predecessor in 

interest, or other related entity) for— 

‘‘(I) a change (not including a modification to 

the structure of the biological product) that results 

in a new indication, route of administration, dosing schedule, dosage form, delivery system, delivery device, or strength; or 

‘‘(II) a modification to the structure of the biological product that does not result in a change in 

safety, purity, or potency. 

‘‘(8) GUIDANCE DOCUMENTS.— 

‘‘(A) IN GENERAL.—The Secretary may, after opportunity for public comment, issue guidance in accordance, 

except as provided in subparagraph (B)(i), with section 

701(h) of the Federal Food, Drug, and Cosmetic Act with 

respect to the licensure of a biological product under this 

subsection. Any such guidance may be general or specific. 

‘‘(B) PUBLIC COMMENT.— 

‘‘(i) IN GENERAL.—The Secretary shall provide the 

public an opportunity to comment on any proposed 

guidance issued under subparagraph (A) before 

issuing final guidance. 

‘‘(ii) INPUT REGARDING MOST VALUABLE GUID- ANCE.—The Secretary shall establish a process 

through which the public may provide the Secretary 

with input regarding priorities for issuing guidance. 

‘‘(C) NO REQUIREMENT FOR APPLICATION CONSIDERATION.—The issuance (or non-issuance) of guidance under 

subparagraph (A) shall not preclude the review of, or action on, an application submitted under this subsection. 
751 Sec. 7002 PPACA (Consolidated) 

‘‘(D) REQUIREMENT FOR PRODUCT CLASS-SPECIFIC GUID- ANCE.—If the Secretary issues product class-specific guidance under subparagraph (A), such guidance shall include 

a description of— 

‘‘(i) the criteria that the Secretary will use to determine whether a biological product is highly similar 

to a reference product in such product class; and 

‘‘(ii) the criteria, if available, that the Secretary 

will use to determine whether a biological product 

meets the standards described in paragraph (4). 

‘‘(E) CERTAIN PRODUCT CLASSES.— ‘‘(i) GUIDANCE.—The Secretary may indicate in a 

guidance document that the science and experience, as 

of the date of such guidance, with respect to a product 

or product class (not including any recombinant protein) does not allow approval of an application for a license as provided under this subsection for such product or product class. 

‘‘(ii) MODIFICATION OR REVERSAL.—The Secretary 

may issue a subsequent guidance document under 

subparagraph (A) to modify or reverse a guidance document under clause (i). 

‘‘(iii) NO EFFECT ON ABILITY TO DENY LICENSE.— Clause (i) shall not be construed to require the Secretary to approve a product with respect to which the 

Secretary has not indicated in a guidance document 

that the science and experience, as described in clause 

(i), does not allow approval of such an application. 

‘‘(l) PATENTS.— 

‘‘(1) CONFIDENTIAL ACCESS TO SUBSECTION (k) APPLICATION.— 

‘‘(A) APPLICATION OF PARAGRAPH.—Unless otherwise 

agreed to by a person that submits an application under 

subsection (k) (referred to in this subsection as the ‘subsection (k) applicant’) and the sponsor of the application 

for the reference product (referred to in this subsection as 

the ‘reference product sponsor’), the provisions of this 

paragraph shall apply to the exchange of information described in this subsection. 

‘‘(B) IN GENERAL.— 

‘‘(i) PROVISION OF CONFIDENTIAL INFORMATION.— 

When a subsection (k) applicant submits an application under subsection (k), such applicant shall provide 

to the persons described in clause (ii), subject to the 

terms of this paragraph, confidential access to the information required to be produced pursuant to paragraph (2) and any other information that the subsection (k) applicant determines, in its sole discretion, 

to be appropriate (referred to in this subsection as the 

‘confidential information’). 

‘‘(ii) RECIPIENTS OF INFORMATION.—The persons 

described in this clause are the following: 

‘‘(I) OUTSIDE COUNSEL.—One or more attorneys designated by the reference product sponsor 
Sec. 7002 PPACA (Consolidated) 752 

who are employees of an entity other than the reference product sponsor (referred to in this paragraph as the ‘outside counsel’), provided that such 

attorneys do not engage, formally or informally, in 

patent prosecution relevant or related to the reference product. 

‘‘(II) IN-HOUSE COUNSEL.—One attorney that 

represents the reference product sponsor who is 

an employee of the reference product sponsor, provided that such attorney does not engage, formally 

or informally, in patent prosecution relevant or related to the reference product. 

‘‘(iii) PATENT OWNER ACCESS.—A representative of 

the owner of a patent exclusively licensed to a reference product sponsor with respect to the reference 

product and who has retained a right to assert the 

patent or participate in litigation concerning the patent may be provided the confidential information, provided that the representative informs the reference 

product sponsor and the subsection (k) applicant of his 

or her agreement to be subject to the confidentiality 

provisions set forth in this paragraph, including those 

under clause (ii). 

‘‘(C) LIMITATION ON DISCLOSURE.—No person that receives confidential information pursuant to subparagraph 

(B) shall disclose any confidential information to any other 

person or entity, including the reference product sponsor 

employees, outside scientific consultants, or other outside 

counsel retained by the reference product sponsor, without 

the prior written consent of the subsection (k) applicant, 

which shall not be unreasonably withheld. 

‘‘(D) USE OF CONFIDENTIAL INFORMATION.—Confidential information shall be used for the sole and exclusive 

purpose of determining, with respect to each patent assigned to or exclusively licensed by the reference product 

sponsor, whether a claim of patent infringement could reasonably be asserted if the subsection (k) applicant engaged 

in the manufacture, use, offering for sale, sale, or importation into the United States of the biological product that 

is the subject of the application under subsection (k). 

‘‘(E) OWNERSHIP OF CONFIDENTIAL INFORMATION.—The 

confidential information disclosed under this paragraph is, 

and shall remain, the property of the subsection (k) applicant. By providing the confidential information pursuant 

to this paragraph, the subsection (k) applicant does not 

provide the reference product sponsor or the outside counsel any interest in or license to use the confidential information, for purposes other than those specified in subparagraph (D). 

‘‘(F) EFFECT OF INFRINGEMENT ACTION.—In the event 

that the reference product sponsor files a patent infringement suit, the use of confidential information shall continue to be governed by the terms of this paragraph until 

such time as a court enters a protective order regarding 
753 Sec. 7002 PPACA (Consolidated) 

the information. Upon entry of such order, the subsection 

(k) applicant may redesignate confidential information in 

accordance with the terms of that order. No confidential 

information shall be included in any publicly-available 

complaint or other pleading. In the event that the reference product sponsor does not file an infringement action 

by the date specified in paragraph (6), the reference product sponsor shall return or destroy all confidential information received under this paragraph, provided that if the 

reference product sponsor opts to destroy such information, 

it will confirm destruction in writing to the subsection (k) 

applicant. 

‘‘(G) RULE OF CONSTRUCTION.—Nothing in this paragraph shall be construed— 

‘‘(i) as an admission by the subsection (k) applicant regarding the validity, enforceability, or infringement of any patent; or 

‘‘(ii) as an agreement or admission by the subsection (k) applicant with respect to the competency, 

relevance, or materiality of any confidential information. 

‘‘(H) EFFECT OF VIOLATION.—The disclosure of any confidential information in violation of this paragraph shall be 

deemed to cause the subsection (k) applicant to suffer irreparable harm for which there is no adequate legal remedy and the court shall consider immediate injunctive relief to be an appropriate and necessary remedy for any violation or threatened violation of this paragraph. 

‘‘(2) SUBSECTION (k) APPLICATION INFORMATION.—Not later 

than 20 days after the Secretary notifies the subsection (k) applicant that the application has been accepted for review, the 

subsection (k) applicant— 

‘‘(A) shall provide to the reference product sponsor a 

copy of the application submitted to the Secretary under 

subsection (k), and such other information that describes 

the process or processes used to manufacture the biological 

product that is the subject of such application; and 

‘‘(B) may provide to the reference product sponsor additional information requested by or on behalf of the reference product sponsor. 

‘‘(3) LIST AND DESCRIPTION OF PATENTS.— 

‘‘(A) LIST BY REFERENCE PRODUCT SPONSOR.—Not later 

than 60 days after the receipt of the application and information under paragraph (2), the reference product sponsor 

shall provide to the subsection (k) applicant— 

‘‘(i) a list of patents for which the reference product sponsor believes a claim of patent infringement 

could reasonably be asserted by the reference product 

sponsor, or by a patent owner that has granted an exclusive license to the reference product sponsor with 

respect to the reference product, if a person not licensed by the reference product sponsor engaged in 

the making, using, offering to sell, selling, or importing into the United States of the biological product 
Sec. 7002 PPACA (Consolidated) 754 

that is the subject of the subsection (k) application; 

and 

‘‘(ii) an identification of the patents on such list 

that the reference product sponsor would be prepared 

to license to the subsection (k) applicant. 

‘‘(B) LIST AND DESCRIPTION BY SUBSECTION (k) APPLI- CANT.—Not later than 60 days after receipt of the list 

under subparagraph (A), the subsection (k) applicant— 

‘‘(i) may provide to the reference product sponsor 

a list of patents to which the subsection (k) applicant 

believes a claim of patent infringement could reasonably be asserted by the reference product sponsor if a 

person not licensed by the reference product sponsor 

engaged in the making, using, offering to sell, selling, 

or importing into the United States of the biological 

product that is the subject of the subsection (k) application; 

‘‘(ii) shall provide to the reference product sponsor, 

with respect to each patent listed by the reference 

product sponsor under subparagraph (A) or listed by 

the subsection (k) applicant under clause (i)— 

‘‘(I) a detailed statement that describes, on a 

claim by claim basis, the factual and legal basis of 

the opinion of the subsection (k) applicant that 

such patent is invalid, unenforceable, or will not 

be infringed by the commercial marketing of the 

biological product that is the subject of the subsection (k) application; or 

‘‘(II) a statement that the subsection (k) applicant does not intend to begin commercial marketing of the biological product before the date 

that such patent expires; and 

‘‘(iii) shall provide to the reference product sponsor 

a response regarding each patent identified by the reference product sponsor under subparagraph (A)(ii). 

‘‘(C) DESCRIPTION BY REFERENCE PRODUCT SPONSOR.— 

Not later than 60 days after receipt of the list and statement under subparagraph (B), the reference product sponsor shall provide to the subsection (k) applicant a detailed 

statement that describes, with respect to each patent described in subparagraph (B)(ii)(I), on a claim by claim 

basis, the factual and legal basis of the opinion of the reference product sponsor that such patent will be infringed 

by the commercial marketing of the biological product that 

is the subject of the subsection (k) application and a response to the statement concerning validity and enforceability provided under subparagraph (B)(ii)(I). 

‘‘(4) PATENT RESOLUTION NEGOTIATIONS.— 

‘‘(A) IN GENERAL.—After receipt by the subsection (k) 

applicant of the statement under paragraph (3)(C), the reference product sponsor and the subsection (k) applicant 

shall engage in good faith negotiations to agree on which, 

if any, patents listed under paragraph (3) by the subsection (k) applicant or the reference product sponsor shall 
755 Sec. 7002 PPACA (Consolidated) 

be the subject of an action for patent infringement under 

paragraph (6). 

‘‘(B) FAILURE TO REACH AGREEMENT.—If, within 15 

days of beginning negotiations under subparagraph (A), 

the subsection (k) applicant and the reference product 

sponsor fail to agree on a final and complete list of which, 

if any, patents listed under paragraph (3) by the subsection (k) applicant or the reference product sponsor shall 

be the subject of an action for patent infringement under 

paragraph (6), the provisions of paragraph (5) shall apply 

to the parties. 

‘‘(5) PATENT RESOLUTION IF NO AGREEMENT.— ‘‘(A) NUMBER OF PATENTS.—The subsection (k) applicant shall notify the reference product sponsor of the number of patents that such applicant will provide to the reference product sponsor under subparagraph (B)(i)(I). 

‘‘(B) EXCHANGE OF PATENT LISTS.— ‘‘(i) IN GENERAL.—On a date agreed to by the subsection (k) applicant and the reference product sponsor, but in no case later than 5 days after the subsection (k) applicant notifies the reference product 

sponsor under subparagraph (A), the subsection (k) 

applicant and the reference product sponsor shall simultaneously exchange— 

‘‘(I) the list of patents that the subsection (k) 

applicant believes should be the subject of an action for patent infringement under paragraph (6); 

and 

‘‘(II) the list of patents, in accordance with 

clause (ii), that the reference product sponsor believes should be the subject of an action for patent 

infringement under paragraph (6). 

‘‘(ii) NUMBER OF PATENTS LISTED BY REFERENCE

PRODUCT SPONSOR.— 

‘‘(I) IN GENERAL.—Subject to subclause (II), 

the number of patents listed by the reference 

product sponsor under clause (i)(II) may not exceed the number of patents listed by the subsection (k) applicant under clause (i)(I). 

‘‘(II) EXCEPTION.—If a subsection (k) applicant 

does not list any patent under clause (i)(I), the reference product sponsor may list 1 patent under 

clause (i)(II). 

‘‘(6) IMMEDIATE PATENT INFRINGEMENT ACTION.— 

‘‘(A) ACTION IF AGREEMENT ON PATENT LIST.—If the 

subsection (k) applicant and the reference product sponsor 

agree on patents as described in paragraph (4), not later 

than 30 days after such agreement, the reference product 

sponsor shall bring an action for patent infringement with 

respect to each such patent. 

‘‘(B) ACTION IF NO AGREEMENT ON PATENT LIST.—If the 

provisions of paragraph (5) apply to the parties as described in paragraph (4)(B), not later than 30 days after 

the exchange of lists under paragraph (5)(B), the reference 
Sec. 7002 PPACA (Consolidated) 756 

product sponsor shall bring an action for patent infringement with respect to each patent that is included on such 

lists. 

‘‘(C) NOTIFICATION AND PUBLICATION OF COMPLAINT.— 

‘‘(i) NOTIFICATION TO SECRETARY.—Not later than 

30 days after a complaint is served to a subsection (k) 

applicant in an action for patent infringement described under this paragraph, the subsection (k) applicant shall provide the Secretary with notice and a 

copy of such complaint. 

‘‘(ii) PUBLICATION BY SECRETARY.—The Secretary 

shall publish in the Federal Register notice of a complaint received under clause (i). 

‘‘(7) NEWLY ISSUED OR LICENSED PATENTS.—In the case of 

a patent that— 

‘‘(A) is issued to, or exclusively licensed by, the reference product sponsor after the date that the reference 

product sponsor provided the list to the subsection (k) applicant under paragraph (3)(A); and 

‘‘(B) the reference product sponsor reasonably believes 

that, due to the issuance of such patent, a claim of patent 

infringement could reasonably be asserted by the reference 

product sponsor if a person not licensed by the reference 

product sponsor engaged in the making, using, offering to 

sell, selling, or importing into the United States of the biological product that is the subject of the subsection (k) application, 

not later than 30 days after such issuance or licensing, the reference product sponsor shall provide to the subsection (k) applicant a supplement to the list provided by the reference product sponsor under paragraph (3)(A) that includes such patent, 

not later than 30 days after such supplement is provided, the 

subsection (k) applicant shall provide a statement to the reference product sponsor in accordance with paragraph (3)(B), 

and such patent shall be subject to paragraph (8). 

‘‘(8) NOTICE OF COMMERCIAL MARKETING AND PRELIMINARY

INJUNCTION.— 

‘‘(A) NOTICE OF COMMERCIAL MARKETING.—The subsection (k) applicant shall provide notice to the reference 

product sponsor not later than 180 days before the date of 

the first commercial marketing of the biological product licensed under subsection (k). 

‘‘(B) PRELIMINARY INJUNCTION.—After receiving the 

notice under subparagraph (A) and before such date of the 

first commercial marketing of such biological product, the 

reference product sponsor may seek a preliminary injunction prohibiting the subsection (k) applicant from engaging 

in the commercial manufacture or sale of such biological 

product until the court decides the issue of patent validity, 

enforcement, and infringement with respect to any patent 

that is— 

‘‘(i) included in the list provided by the reference 

product sponsor under paragraph (3)(A) or in the list 
757 Sec. 7002 PPACA (Consolidated) 

provided by the subsection (k) applicant under paragraph (3)(B); and 

‘‘(ii) not included, as applicable, on— 

‘‘(I) the list of patents described in paragraph 

(4); or 

‘‘(II) the lists of patents described in paragraph (5)(B). 

‘‘(C) REASONABLE COOPERATION.—If the reference 

product sponsor has sought a preliminary injunction under 

subparagraph (B), the reference product sponsor and the 

subsection (k) applicant shall reasonably cooperate to expedite such further discovery as is needed in connection with 

the preliminary injunction motion. 

‘‘(9) LIMITATION ON DECLARATORY JUDGMENT ACTION.— 

‘‘(A) SUBSECTION (k) APPLICATION PROVIDED.—If a subsection (k) applicant provides the application and information required under paragraph (2)(A), neither the reference 

product sponsor nor the subsection (k) applicant may, prior 

to the date notice is received under paragraph (8)(A), bring 

any action under section 2201 of title 28, United States 

Code, for a declaration of infringement, validity, or enforceability of any patent that is described in clauses (i) 

and (ii) of paragraph (8)(B). 

‘‘(B) SUBSEQUENT FAILURE TO ACT BY SUBSECTION (k) 

APPLICANT.—If a subsection (k) applicant fails to complete 

an action required of the subsection (k) applicant under 

paragraph (3)(B)(ii), paragraph (5), paragraph (6)(C)(i), 

paragraph (7), or paragraph (8)(A), the reference product 

sponsor, but not the subsection (k) applicant, may bring an 

action under section 2201 of title 28, United States Code, 

for a declaration of infringement, validity, or enforceability 

of any patent included in the list described in paragraph 

(3)(A), including as provided under paragraph (7). 

‘‘(C) SUBSECTION (k) APPLICATION NOT PROVIDED.—If a 

subsection (k) applicant fails to provide the application and 

information required under paragraph (2)(A), the reference 

product sponsor, but not the subsection (k) applicant, may 

bring an action under section 2201 of title 28, United 

States Code, for a declaration of infringement, validity, or 

enforceability of any patent that claims the biological product or a use of the biological product.’’. 

(b) DEFINITIONS.—Section 351(i) of the Public Health Service 

Act (42 U.S.C. 262(i)) is amended— 

(1) by striking ‘‘In this section, the term ‘biological product’ 

means’’ and inserting the following: ‘‘In this section: 

‘‘(1) The term ‘biological product’ means’’; 

(2) in paragraph (1), as so designated, by inserting ‘‘protein 

(except any chemically synthesized polypeptide),’’ after ‘‘allergenic product,’’; and 

(3) by adding at the end the following: 

‘‘(2) The term ‘biosimilar’ or ‘biosimilarity’, in reference to 

a biological product that is the subject of an application under 

subsection (k), means— 
Sec. 7002 PPACA (Consolidated) 758 

‘‘(A) that the biological product is highly similar to the 

reference product notwithstanding minor differences in 

clinically inactive components; and 

‘‘(B) there are no clinically meaningful differences between the biological product and the reference product in 

terms of the safety, purity, and potency of the product. 

‘‘(3) The term ‘interchangeable’ or ‘interchangeability’, in 

reference to a biological product that is shown to meet the 

standards described in subsection (k)(4), means that the biological product may be substituted for the reference product 

without the intervention of the health care provider who prescribed the reference product. 

‘‘(4) The term ‘reference product’ means the single biological product licensed under subsection (a) against which a biological product is evaluated in an application submitted under 

subsection (k).’’. 

(c) CONFORMING AMENDMENTS RELATING TO PATENTS.— 

(1) PATENTS.—Section 271(e) of title 35, United States 

Code, is amended— 

(A) in paragraph (2)— 

(i) in subparagraph (A), by striking ‘‘or’’ at the 

end; 

(ii) in subparagraph (B), by adding ‘‘or’’ at the end; 

and 

(iii) by inserting after subparagraph (B) the following: 

‘‘(C)(i) with respect to a patent that is identified in the list 

of patents described in section 351(l)(3) of the Public Health 

Service Act (including as provided under section 351(l)(7) of 

such Act), an application seeking approval of a biological product, or 

‘‘(ii) if the applicant for the application fails to provide the 

application and information required under section 351(l)(2)(A) 

of such Act, an application seeking approval of a biological 

product for a patent that could be identified pursuant to section 351(l)(3)(A)(i) of such Act,’’; and 

(iv) in the matter following subparagraph (C) (as 

added by clause (iii)), by striking ‘‘or veterinary biological product’’ and inserting ‘‘, veterinary biological 

product, or biological product’’; 

(B) in paragraph (4)— 

(i) in subparagraph (B), by— 

(I) striking ‘‘or veterinary biological product’’ 

and inserting ‘‘, veterinary biological product, or 

biological product’’; and 

(II) striking ‘‘and’’ at the end; 

(ii) in subparagraph (C), by— 

(I) striking ‘‘or veterinary biological product’’ 

and inserting ‘‘, veterinary biological product, or 

biological product’’; and 

(II) striking the period and inserting ‘‘, and’’; 

(iii) by inserting after subparagraph (C) the following: 
759 Sec. 7002 PPACA (Consolidated) 

‘‘(D) the court shall order a permanent injunction prohibiting any infringement of the patent by the biological product 

involved in the infringement until a date which is not earlier 

than the date of the expiration of the patent that has been infringed under paragraph (2)(C), provided the patent is the subject of a final court decision, as defined in section 351(k)(6) of 

the Public Health Service Act, in an action for infringement of 

the patent under section 351(l)(6) of such Act, and the biological product has not yet been approved because of section 

351(k)(7) of such Act.’’; and 

(iv) in the matter following subparagraph (D) (as 

added by clause (iii)), by striking ‘‘and (C)’’ and inserting ‘‘(C), and (D)’’; and 

(C) by adding at the end the following: 

‘‘(6)(A) Subparagraph (B) applies, in lieu of paragraph (4), in 

the case of a patent— 

‘‘(i) that is identified, as applicable, in the list of patents 

described in section 351(l)(4) of the Public Health Service Act 

or the lists of patents described in section 351(l)(5)(B) of such 

Act with respect to a biological product; and 

‘‘(ii) for which an action for infringement of the patent with 

respect to the biological product— 

‘‘(I) was brought after the expiration of the 30-day period described in subparagraph (A) or (B), as applicable, of 

section 351(l)(6) of such Act; or 

‘‘(II) was brought before the expiration of the 30-day 

period described in subclause (I), but which was dismissed 

without prejudice or was not prosecuted to judgment in 

good faith. 

‘‘(B) In an action for infringement of a patent described in subparagraph (A), the sole and exclusive remedy that may be granted 

by a court, upon a finding that the making, using, offering to sell, 

selling, or importation into the United States of the biological product that is the subject of the action infringed the patent, shall be 

a reasonable royalty. 

‘‘(C) The owner of a patent that should have been included in 

the list described in section 351(l)(3)(A) of the Public Health Service Act, including as provided under section 351(l)(7) of such Act for 

a biological product, but was not timely included in such list, may 

not bring an action under this section for infringement of the patent with respect to the biological product.’’. 

(2) CONFORMING AMENDMENT UNDER TITLE 28.—Section 

2201(b) of title 28, United States Code, is amended by inserting before the period the following: ‘‘, or section 351 of the Public Health Service Act’’. 

(d) CONFORMING AMENDMENTS UNDER THE FEDERAL FOOD, 

DRUG, AND COSMETIC ACT.— 

(1) CONTENT AND REVIEW OF APPLICATIONS.—Section 

505(b)(5)(B) of the Federal Food, Drug, and Cosmetic Act (21 

U.S.C. 355(b)(5)(B)) is amended by inserting before the period 

at the end of the first sentence the following: ‘‘or, with respect 

to an applicant for approval of a biological product under section 351(k) of the Public Health Service Act, any necessary 

clinical study or studies’’. 
Sec. 7002 PPACA (Consolidated) 760 

(2) NEW ACTIVE INGREDIENT.—Section 505B of the Federal 

Food, Drug, and Cosmetic Act (21 U.S.C. 355c) is amended by 

adding at the end the following: 

‘‘(n) NEW ACTIVE INGREDIENT.— 

‘‘(1) NON-INTERCHANGEABLE BIOSIMILAR BIOLOGICAL PRODUCT.—A biological product that is biosimilar to a reference 

product under section 351 of the Public Health Service Act, 

and that the Secretary has not determined to meet the standards described in subsection (k)(4) of such section for interchangeability with the reference product, shall be considered to 

have a new active ingredient under this section. 

‘‘(2) INTERCHANGEABLE BIOSIMILAR BIOLOGICAL PRODUCT.— 

A biological product that is interchangeable with a reference 

product under section 351 of the Public Health Service Act 

shall not be considered to have a new active ingredient under 

this section.’’. 

(e) PRODUCTS PREVIOUSLY APPROVED UNDER SECTION 505.— 

(1) REQUIREMENT TO FOLLOW SECTION 351.—Except as provided in paragraph (2), an application for a biological product 

shall be submitted under section 351 of the Public Health 

Service Act (42 U.S.C. 262) (as amended by this Act). 

(2) EXCEPTION.—An application for a biological product 

may be submitted under section 505 of the Federal Food, Drug, 

and Cosmetic Act (21 U.S.C. 355) if— 

(A) such biological product is in a product class for 

which a biological product in such product class is the subject of an application approved under such section 505 not 

later than the date of enactment of this Act; and 

(B) such application— 

(i) has been submitted to the Secretary of Health 

and Human Services (referred to in this subtitle as the 

‘‘Secretary’’) before the date of enactment of this Act; 

or 

(ii) is submitted to the Secretary not later than 

the date that is 10 years after the date of enactment 

of this Act. 

(3) LIMITATION.—Notwithstanding paragraph (2), an application for a biological product may not be submitted under section 505 of the Federal Food, Drug, and Cosmetic Act (21 

U.S.C. 355) if there is another biological product approved 

under subsection (a) of section 351 of the Public Health Service 

Act that could be a reference product with respect to such application (within the meaning of such section 351) if such application were submitted under subsection (k) of such section 

351. 

(4) DEEMED APPROVED UNDER SECTION 351.—An approved 

application for a biological product under section 505 of the 

Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be 

deemed to be a license for the biological product under such 

section 351 on the date that is 10 years after the date of enactment of this Act. 

(5) DEFINITIONS.—For purposes of this subsection, the 

term ‘‘biological product’’ has the meaning given such term 
761 Sec. 7002 PPACA (Consolidated) 

under section 351 of the Public Health Service Act (42 U.S.C. 

262) (as amended by this Act). 

(f) FOLLOW-ON BIOLOGICS USER FEES.— 

(1) DEVELOPMENT OF USER FEES FOR BIOSIMILAR BIOLOGICAL PRODUCTS.— 

(A) IN GENERAL.—Beginning not later than October 1, 

2010, the Secretary shall develop recommendations to 

present to Congress with respect to the goals, and plans 

for meeting the goals, for the process for the review of biosimilar biological product applications submitted under 

section 351(k) of the Public Health Service Act (as added 

by this Act) for the first 5 fiscal years after fiscal year 

2012. In developing such recommendations, the Secretary 

shall consult with— 

(i) the Committee on Health, Education, Labor, 

and Pensions of the Senate; 

(ii) the Committee on Energy and Commerce of 

the House of Representatives; 

(iii) scientific and academic experts; 

(iv) health care professionals; 

(v) representatives of patient and consumer advocacy groups; and 

(vi) the regulated industry. 

(B) PUBLIC REVIEW OF RECOMMENDATIONS.—After negotiations with the regulated industry, the Secretary 

shall— 

(i) present the recommendations developed under 

subparagraph (A) to the Congressional committees 

specified in such subparagraph; 

(ii) publish such recommendations in the Federal 

Register; 

(iii) provide for a period of 30 days for the public 

to provide written comments on such recommendations; 

(iv) hold a meeting at which the public may 

present its views on such recommendations; and 

(v) after consideration of such public views and 

comments, revise such recommendations as necessary. 

(C) TRANSMITTAL OF RECOMMENDATIONS.—Not later 

than January 15, 2012, the Secretary shall transmit to 

Congress the revised recommendations under subparagraph (B), a summary of the views and comments received 

under such subparagraph, and any changes made to the 

recommendations in response to such views and comments. 

(2) ESTABLISHMENT OF USER FEE PROGRAM.—It is the sense 

of the Senate that, based on the recommendations transmitted 

to Congress by the Secretary pursuant to paragraph (1)(C), 

Congress should authorize a program, effective on October 1, 

2012, for the collection of user fees relating to the submission 

of biosimilar biological product applications under section 

351(k) of the Public Health Service Act (as added by this Act). 

(3) TRANSITIONAL PROVISIONS FOR USER FEES FOR BIOSIMILAR BIOLOGICAL PRODUCTS.— 
Sec. 7002 PPACA (Consolidated) 762 

(A) APPLICATION OF THE PRESCRIPTION DRUG USER FEE

PROVISIONS.—Section 735(1)(B) of the Federal Food, Drug, 

and Cosmetic Act (21 U.S.C. 379g(1)(B)) is amended by 

striking ‘‘section 351’’ and inserting ‘‘subsection (a) or (k) 

of section 351’’. 

(B) EVALUATION OF COSTS OF REVIEWING BIOSIMILAR

BIOLOGICAL PRODUCT APPLICATIONS.—During the period beginning on the date of enactment of this Act and ending 

on October 1, 2010, the Secretary shall collect and evaluate data regarding the costs of reviewing applications for 

biological products submitted under section 351(k) of the 

Public Health Service Act (as added by this Act) during 

such period. 

(C) AUDIT.— (i) IN GENERAL.—On the date that is 2 years after 

first receiving a user fee applicable to an application 

for a biological product under section 351(k) of the 

Public Health Service Act (as added by this Act), and 

on a biennial basis thereafter until October 1, 2013, 

the Secretary shall perform an audit of the costs of reviewing such applications under such section 351(k). 

Such an audit shall compare— 

(I) the costs of reviewing such applications 

under such section 351(k) to the amount of the 

user fee applicable to such applications; and 

(II)(aa) such ratio determined under subclause 

(I); to 

(bb) the ratio of the costs of reviewing applications for biological products under section 351(a) 

of such Act (as amended by this Act) to the 

amount of the user fee applicable to such applications under such section 351(a). 

(ii) ALTERATION OF USER FEE.—If the audit performed under clause (i) indicates that the ratios compared under subclause (II) of such clause differ by 

more than 5 percent, then the Secretary shall alter the 

user fee applicable to applications submitted under 

such section 351(k) to more appropriately account for 

the costs of reviewing such applications. 

(iii) ACCOUNTING STANDARDS.—The Secretary shall 

perform an audit under clause (i) in conformance with 

the accounting principles, standards, and requirements prescribed by the Comptroller General of the 

United States under section 3511 of title 31, United 

State Code, to ensure the validity of any potential variability. 

(4) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this subsection such sums 

as may be necessary for each of fiscal years 2010 through 2012. 

(g) PEDIATRIC STUDIES OF BIOLOGICAL PRODUCTS.— 

(1) IN GENERAL.—Section 351 of the Public Health Service 

Act (42 U.S.C. 262) is amended by adding at the end the following: 

‘‘(m) PEDIATRIC STUDIES.— 
763 Sec. 7002 PPACA (Consolidated) 

‘‘(1) APPLICATION OF CERTAIN PROVISIONS.—The provisions 

of subsections (a), (d), (e), (f), (i), (j), (k), (l), (p), and (q) of section 505A of the Federal Food, Drug, and Cosmetic Act shall 

apply with respect to the extension of a period under paragraphs (2) and (3) to the same extent and in the same manner 

as such provisions apply with respect to the extension of a period under subsection (b) or (c) of section 505A of the Federal 

Food, Drug, and Cosmetic Act. 

‘‘(2) MARKET EXCLUSIVITY FOR NEW BIOLOGICAL PROD- UCTS.—If, prior to approval of an application that is submitted 

under subsection (a), the Secretary determines that information relating to the use of a new biological product in the pediatric population may produce health benefits in that population, the Secretary makes a written request for pediatric 

studies (which shall include a timeframe for completing such 

studies), the applicant agrees to the request, such studies are 

completed using appropriate formulations for each age group 

for which the study is requested within any such timeframe, 

and the reports thereof are submitted and accepted in accordance with section 505A(d)(3) of the Federal Food, Drug, and 

Cosmetic Act— 

‘‘(A) the periods for such biological product referred to 

in subsection (k)(7) are deemed to be 4 years and 6 months 

rather than 4 years and 12 years and 6 months rather 

than 12 years; and 

‘‘(B) if the biological product is designated under section 526 for a rare disease or condition, the period for such 

biological product referred to in section 527(a) is deemed 

to be 7 years and 6 months rather than 7 years. 

‘‘(3) MARKET EXCLUSIVITY FOR ALREADY-MARKETED BIOLOGICAL PRODUCTS.—If the Secretary determines that information 

relating to the use of a licensed biological product in the pediatric population may produce health benefits in that population and makes a written request to the holder of an approved application under subsection (a) for pediatric studies 

(which shall include a timeframe for completing such studies), 

the holder agrees to the request, such studies are completed 

using appropriate formulations for each age group for which 

the study is requested within any such timeframe, and the reports thereof are submitted and accepted in accordance with 

section 505A(d)(3) of the Federal Food, Drug, and Cosmetic 

Act— 

‘‘(A) the periods for such biological product referred to 

in subsection (k)(7) are deemed to be 4 years and 6 months 

rather than 4 years and 12 years and 6 months rather 

than 12 years; and 

‘‘(B) if the biological product is designated under section 526 for a rare disease or condition, the period for such 

biological product referred to in section 527(a) is deemed 

to be 7 years and 6 months rather than 7 years. 

‘‘(4) EXCEPTION.—The Secretary shall not extend a period 

referred to in paragraph (2)(A), (2)(B), (3)(A), or (3)(B) if the 

determination under section 505A(d)(3) is made later than 9 

months prior to the expiration of such period.’’. 
Sec. 7003 PPACA (Consolidated) 764 

(2) STUDIES REGARDING PEDIATRIC RESEARCH.— 

(A) PROGRAM FOR PEDIATRIC STUDY OF DRUGS.—Subsection (a)(1) of section 409I of the Public Health Service 

Act (42 U.S.C. 284m) is amended by inserting ‘‘, biological 

products,’’ after ‘‘including drugs’’. 

(B) INSTITUTE OF MEDICINE STUDY.—Section 505A(p) of 

the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 

355b(p)) is amended by striking paragraphs (4) and (5) and 

inserting the following: 

‘‘(4) review and assess the number and importance of biological products for children that are being tested as a result 

of the amendments made by the Biologics Price Competition 

and Innovation Act of 2009 and the importance for children, 

health care providers, parents, and others of labeling changes 

made as a result of such testing; 

‘‘(5) review and assess the number, importance, and 

prioritization of any biological products that are not being tested for pediatric use; and 

‘‘(6) offer recommendations for ensuring pediatric testing of 

biological products, including consideration of any incentives, 

such as those provided under this section or section 351(m) of 

the Public Health Service Act.’’. 

(h) ORPHAN PRODUCTS.—If a reference product, as defined in 

section 351 of the Public Health Service Act (42 U.S.C. 262) (as 

amended by this Act) has been designated under section 526 of the 

Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360bb) for a rare 

disease or condition, a biological product seeking approval for such 

disease or condition under subsection (k) of such section 351 as biosimilar to, or interchangeable with, such reference product may be 

licensed by the Secretary only after the expiration for such reference product of the later of— 

(1) the 7-year period described in section 527(a) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360cc(a)); and 

(2) the 12-year period described in subsection (k)(7) of such 

section 351. 

SEC. 7003. SAVINGS. 

(a) DETERMINATION.—The Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall 

for each fiscal year determine the amount of savings to the Federal 

Government as a result of the enactment of this subtitle. 

(b) USE.—Notwithstanding any other provision of this subtitle 

(or an amendment made by this subtitle), the savings to the Federal Government generated as a result of the enactment of this 

subtitle shall be used for deficit reduction. 

Subtitle B—More Affordable Medicines for 

Children and Underserved Communities 

SEC. 7101. EXPANDED PARTICIPATION IN 340B PROGRAM. 

(a) EXPANSION OF COVERED ENTITIES RECEIVING DISCOUNTED

PRICES.—Section 340B(a)(4) of the Public Health Service Act (42 

U.S.C. 256b(a)(4)) is amended by adding at the end the following: 
765 Sec. 7101 PPACA (Consolidated) 

‘‘(M) A children’s hospital excluded from the Medicare 

prospective payment system pursuant to section 

1886(d)(1)(B)(iii) of the Social Security Act, or a free-standing cancer hospital excluded from the Medicare prospective 

payment system pursuant to section 1886(d)(1)(B)(v) of the 

Social Security Act, that would meet the requirements of 

subparagraph (L), including the disproportionate share adjustment percentage requirement under clause (ii) of such 

subparagraph, if the hospital were a subsection (d) hospital as defined by section 1886(d)(1)(B) of the Social Security Act. 

‘‘(N) An entity that is a critical access hospital (as determined under section 1820(c)(2) of the Social Security 

Act), and that meets the requirements of subparagraph 

(L)(i). 

‘‘(O) An entity that is a rural referral center, as defined by section 1886(d)(5)(C)(i) of the Social Security Act, 

or a sole community hospital, as defined by section 

1886(d)(5)(C)(iii) of such Act, and that both meets the requirements of subparagraph (L)(i) and has a disproportionate share adjustment percentage equal to or greater 

than 8 percent.’’. 

øSee additional amendments to section 340B of PHSA made by 

section 2302 of HCERA, p. 954¿ 

(b) EXTENSION OF DISCOUNT TO INPATIENT DRUGS.—Section 

340B of the Public Health Service Act (42 U.S.C. 256b) is amended— 

(1) in paragraphs (2), (5), (7), and (9) of subsection (a), by 

striking ‘‘outpatient’’ each place it appears øBut see amendments made by section 2302(1) of HCERA on p. 954¿; and 

(2) in subsection (b)— 

(A) by striking ‘‘OTHER DEFINITION’’ and all that follows through ‘‘In this section’’ and inserting the following: 

‘‘OTHER DEFINITIONS.— 

‘‘(1) IN GENERAL.—In this section’’; and 

(B) by adding at the end the following new paragraph: 

‘‘(2) COVERED DRUG.—In this section, the term ‘covered 

drug’— 

‘‘(A) means a covered outpatient drug (as defined in 

section 1927(k)(2) of the Social Security Act); and 

‘‘(B) includes, notwithstanding paragraph (3)(A) of section 1927(k) of such Act, a drug used in connection with 

an inpatient or outpatient service provided by a hospital 

described in subparagraph (L), (M), (N), or (O) of subsection (a)(4) that is enrolled to participate in the drug discount program under this section.’’. 

(c) PROHIBITION ON GROUP PURCHASING ARRANGEMENTS.—Section 340B(a) of the Public Health Service Act (42 U.S.C. 256b(a)) 

is amended—øBut see amendments made by section 2302(1) of 

HCERA on p. 954¿ 

ø(1) in paragraph (4)(L)—¿ 

ø(A) in clause (i), by adding ‘‘and’’ at the end;¿ 

ø(B) in clause (ii), by striking ‘‘; and’’ and inserting a 

period; and¿ 
Sec. 7101 PPACA (Consolidated) 766 

ø(C) by striking clause (iii); and¿ 

ø(2) in paragraph (5), as amended by subsection (b)—¿ 

ø(A) by redesignating subparagraphs (C) and (D) as 

subparagraphs (D) and (E); respectively; and¿ 

ø(B) by inserting after subparagraph (B), the following:¿ 

ø‘‘(C) PROHIBITION ON GROUP PURCHASING ARRANGE- MENTS.—¿ 

ø‘‘(i) IN GENERAL.—A hospital described in subparagraph (L), (M), (N), or (O) of paragraph (4) shall 

not obtain covered outpatient drugs through a group 

purchasing organization or other group purchasing arrangement, except as permitted or provided for pursuant to clauses (ii) or (iii).¿ 

ø‘‘(ii) INPATIENT DRUGS.—Clause (i) shall not apply 

to drugs purchased for inpatient use.¿ 

ø‘‘(iii) EXCEPTIONS.—The Secretary shall establish 

reasonable exceptions to clause (i)—¿ 

ø‘‘(I) with respect to a covered outpatient drug 

that is unavailable to be purchased through the 

program under this section due to a drug shortage 

problem, manufacturer noncompliance, or any 

other circumstance beyond the hospital’s control;¿ 

ø‘‘(II) to facilitate generic substitution when a 

generic covered outpatient drug is available at a 

lower price; or¿ 

ø‘‘(III) to reduce in other ways the administrative burdens of managing both inventories of 

drugs subject to this section and inventories of 

drugs that are not subject to this section, so long 

as the exceptions do not create a duplicate discount problem in violation of subparagraph (A) or 

a diversion problem in violation of subparagraph 

(B).¿ 

ø‘‘(iv) PURCHASING ARRANGEMENTS FOR INPATIENT

DRUGS.—The Secretary shall ensure that a hospital 

described in subparagraph (L), (M), (N), or (O) of subsection (a)(4) that is enrolled to participate in the drug 

discount program under this section shall have multiple options for purchasing covered drugs for inpatients, including by utilizing a group purchasing organization or other group purchasing arrangement, establishing and utilizing its own group purchasing program, purchasing directly from a manufacturer, and 

any other purchasing arrangements that the Secretary 

determines is appropriate to ensure access to drug discount pricing under this section for inpatient drugs 

taking into account the particular needs of small and 

rural hospitals.’’.¿ 

ø(d) MEDICAID CREDITS ON INPATIENT DRUGS.—Section 340B of 

the Public Health Service Act (42 U.S.C. 256b) is amended by striking subsection (c) and inserting the following: øSection 2502(f)(1)(B) 

of PPACA strikes subsection (c) of section 340B of PHSA, as in effect 

on the date of PPACA, and redesignates subsection (d) of section 
767 Sec. 7102 PPACA (Consolidated) 

340B of PHSA, as in effect on such date, as subsection (c). This subsection strikes and replaces the redesignated version of subsection 

(c). Section 2302(a)(2) of HCERA strikes the version of subsection (c) 

inserted by this subsection.¿¿ 

ø‘‘(c) MEDICAID CREDIT.—Not later than 90 days after the date 

of filing of the hospital’s most recently filed Medicare cost report, 

the hospital shall issue a credit as determined by the Secretary to 

the State Medicaid program for inpatient covered drugs provided to 

Medicaid recipients.’’.¿ 

(e) EFFECTIVE DATES.— 

(1) IN GENERAL.—The amendments made by this section 

and section 7102 shall take effect on January 1, 2010, and 

shall apply to drugs purchased on or after January 1, 2010. 

(2) EFFECTIVENESS.—The amendments made by this section and section 7102 shall be effective and shall be taken into 

account in determining whether a manufacturer is deemed to 

meet the requirements of section 340B(a) of the Public Health 

Service Act (42 U.S.C. 256b(a)), notwithstanding any other provision of law. 

SEC. 7102. IMPROVEMENTS TO 340B PROGRAM INTEGRITY. 

(a) INTEGRITY IMPROVEMENTS.—Subsection (d) of section 340B 

of the Public Health Service Act (42 U.S.C. 256b) is amended to 

read as follows: 

‘‘(d) IMPROVEMENTS IN PROGRAM INTEGRITY.— 

‘‘(1) MANUFACTURER COMPLIANCE.— 

‘‘(A) IN GENERAL.—From amounts appropriated under 

paragraph (4), the Secretary shall provide for improvements in compliance by manufacturers with the requirements of this section in order to prevent overcharges and 

other violations of the discounted pricing requirements 

specified in this section. 

‘‘(B) IMPROVEMENTS.—The improvements described in 

subparagraph (A) shall include the following: 

‘‘(i) The development of a system to enable the 

Secretary to verify the accuracy of ceiling prices calculated by manufacturers under subsection (a)(1) and 

charged to covered entities, which shall include the 

following: 

‘‘(I) Developing and publishing through an appropriate policy or regulatory issuance, precisely 

defined standards and methodology for the calculation of ceiling prices under such subsection. 

‘‘(II) Comparing regularly the ceiling prices 

calculated by the Secretary with the quarterly 

pricing data that is reported by manufacturers to 

the Secretary. 

‘‘(III) Performing spot checks of sales transactions by covered entities. 

‘‘(IV) Inquiring into the cause of any pricing 

discrepancies that may be identified and either 

taking, or requiring manufacturers to take, such 

corrective action as is appropriate in response to 

such price discrepancies. 
Sec. 7102 PPACA (Consolidated) 768 

‘‘(ii) The establishment of procedures for manufacturers to issue refunds to covered entities in the event 

that there is an overcharge by the manufacturers, including the following: 

‘‘(I) Providing the Secretary with an explanation of why and how the overcharge occurred, 

how the refunds will be calculated, and to whom 

the refunds will be issued. 

‘‘(II) Oversight by the Secretary to ensure that 

the refunds are issued accurately and within a 

reasonable period of time, both in routine instances of retroactive adjustment to relevant pricing data and exceptional circumstances such as 

erroneous or intentional overcharging for covered 

drugs. 

‘‘(iii) The provision of access through the Internet 

website of the Department of Health and Human 

Services to the applicable ceiling prices for covered 

drugs as calculated and verified by the Secretary in 

accordance with this section, in a manner (such as 

through the use of password protection) that limits 

such access to covered entities and adequately assures 

security and protection of privileged pricing data from 

unauthorized re-disclosure. 

‘‘(iv) The development of a mechanism by which— 

‘‘(I) rebates and other discounts provided by 

manufacturers to other purchasers subsequent to 

the sale of covered drugs to covered entities are 

reported to the Secretary; and 

‘‘(II) appropriate credits and refunds are 

issued to covered entities if such discounts or rebates have the effect of lowering the applicable 

ceiling price for the relevant quarter for the drugs 

involved. 

‘‘(v) Selective auditing of manufacturers and 

wholesalers to ensure the integrity of the drug discount program under this section. 

‘‘(vi) The imposition of sanctions in the form of 

civil monetary penalties, which— 

‘‘(I) shall be assessed according to standards 

established in regulations to be promulgated by 

the Secretary not later than 180 days after the 

date of enactment of the Patient Protection and 

Affordable Care Act; 

‘‘(II) shall not exceed $5,000 for each instance 

of overcharging a covered entity that may have occurred; and 

‘‘(III) shall apply to any manufacturer with an 

agreement under this section that knowingly and 

intentionally charges a covered entity a price for 

purchase of a drug that exceeds the maximum applicable price under subsection (a)(1). 

‘‘(2) COVERED ENTITY COMPLIANCE.— 
769 Sec. 7102 PPACA (Consolidated) 

‘‘(A) IN GENERAL.—From amounts appropriated under 

paragraph (4), the Secretary shall provide for improvements in compliance by covered entities with the requirements of this section in order to prevent diversion and violations of the duplicate discount provision and other requirements specified under subsection (a)(5). 

‘‘(B) IMPROVEMENTS.—The improvements described in 

subparagraph (A) shall include the following: 

‘‘(i) The development of procedures to enable and 

require covered entities to regularly update (at least 

annually) the information on the Internet website of 

the Department of Health and Human Services relating to this section. 

‘‘(ii) The development of a system for the Secretary to verify the accuracy of information regarding 

covered entities that is listed on the website described 

in clause (i). 

‘‘(iii) The development of more detailed guidance 

describing methodologies and options available to covered entities for billing covered drugs to State Medicaid agencies in a manner that avoids duplicate discounts pursuant to subsection (a)(5)(A). 

‘‘(iv) The establishment of a single, universal, and 

standardized identification system by which each covered entity site can be identified by manufacturers, 

distributors, covered entities, and the Secretary for 

purposes of facilitating the ordering, purchasing, and 

delivery of covered drugs under this section, including 

the processing of chargebacks for such drugs. 

‘‘(v) The imposition of sanctions, in appropriate 

cases as determined by the Secretary, additional to 

those to which covered entities are subject under subsection (a)(5)(E), through one or more of the following 

actions: 

‘‘(I) Where a covered entity knowingly and intentionally violates subsection (a)(5)(B), the covered entity shall be required to pay a monetary 

penalty to a manufacturer or manufacturers in 

the form of interest on sums for which the covered 

entity is found liable under subsection (a)(5)(E), 

such interest to be compounded monthly and 

equal to the current short term interest rate as 

determined by the Federal Reserve for the time 

period for which the covered entity is liable. 

‘‘(II) Where the Secretary determines a violation of subsection (a)(5)(B) was systematic and 

egregious as well as knowing and intentional, removing the covered entity from the drug discount 

program under this section and disqualifying the 

entity from re-entry into such program for a reasonable period of time to be determined by the 

Secretary. 

‘‘(III) Referring matters to appropriate Federal authorities within the Food and Drug Admin-
Sec. 7102 PPACA (Consolidated) 770 

istration, the Office of Inspector General of Department of Health and Human Services, or other 

Federal agencies for consideration of appropriate 

action under other Federal statutes, such as the 

Prescription Drug Marketing Act (21 U.S.C. 353). 

‘‘(3) ADMINISTRATIVE DISPUTE RESOLUTION PROCESS.— ‘‘(A) IN GENERAL.—Not later than 180 days after the 

date of enactment of the Patient Protection and Affordable 

Care Act, the Secretary shall promulgate regulations to establish and implement an administrative process for the 

resolution of claims by covered entities that they have 

been overcharged for drugs purchased under this section, 

and claims by manufacturers, after the conduct of audits 

as authorized by subsection (a)(5)(D), of violations of subsections (a)(5)(A) or (a)(5)(B), including appropriate procedures for the provision of remedies and enforcement of determinations made pursuant to such process through 

mechanisms and sanctions described in paragraphs (1)(B) 

and (2)(B). 

‘‘(B) DEADLINES AND PROCEDURES.—Regulations promulgated by the Secretary under subparagraph (A) shall— 

‘‘(i) designate or establish a decision-making official or decision-making body within the Department of 

Health and Human Services to be responsible for reviewing and finally resolving claims by covered entities that they have been charged prices for covered 

drugs in excess of the ceiling price described in subsection (a)(1), and claims by manufacturers that violations of subsection (a)(5)(A) or (a)(5)(B) have occurred; 

‘‘(ii) establish such deadlines and procedures as 

may be necessary to ensure that claims shall be resolved fairly, efficiently, and expeditiously; 

‘‘(iii) establish procedures by which a covered entity may discover and obtain such information and documents from manufacturers and third parties as may 

be relevant to demonstrate the merits of a claim that 

charges for a manufacturer’s product have exceeded 

the applicable ceiling price under this section, and 

may submit such documents and information to the 

administrative official or body responsible for adjudicating such claim; 

‘‘(iv) require that a manufacturer conduct an audit 

of a covered entity pursuant to subsection (a)(5)(D) as 

a prerequisite to initiating administrative dispute resolution proceedings against a covered entity; 

‘‘(v) permit the official or body designated under 

clause (i), at the request of a manufacturer or manufacturers, to consolidate claims brought by more than 

one manufacturer against the same covered entity 

where, in the judgment of such official or body, consolidation is appropriate and consistent with the goals 

of fairness and economy of resources; and 

‘‘(vi) include provisions and procedures to permit 

multiple covered entities to jointly assert claims of 
771 Sec. 7103 PPACA (Consolidated) 

overcharges by the same manufacturer for the same 

drug or drugs in one administrative proceeding, and 

permit such claims to be asserted on behalf of covered 

entities by associations or organizations representing 

the interests of such covered entities and of which the 

covered entities are members. 

‘‘(C) FINALITY OF ADMINISTRATIVE RESOLUTION.—The 

administrative resolution of a claim or claims under the 

regulations promulgated under subparagraph (A) shall be 

a final agency decision and shall be binding upon the parties involved, unless invalidated by an order of a court of 

competent jurisdiction. 

‘‘(4) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this subsection, such 

sums as may be necessary for fiscal year 2010 and each succeeding fiscal year.’’. 

(b) CONFORMING AMENDMENTS.—Section 340B(a) of the Public 

Health Service Act (42 U.S.C. 256b(a)) is amended— 

(1) in subsection (a)(1), by adding at the end the following: 

‘‘Each such agreement shall require that the manufacturer furnish the Secretary with reports, on a quarterly basis, of the 

price for each covered drug subject to the agreement that, according to the manufacturer, represents the maximum price 

that covered entities may permissibly be required to pay for 

the drug (referred to in this section as the ‘ceiling price’), and 

shall require that the manufacturer offer each covered entity 

covered drugs for purchase at or below the applicable ceiling 

price if such drug is made available to any other purchaser at 

any price.’’; and 

(2) in the first sentence of subsection (a)(5)(E), as redesignated by section 7101(c), by inserting ‘‘after audit as described 

in subparagraph (D) and’’ after ‘‘finds,’’. 

SEC. 7103. GAO STUDY TO MAKE RECOMMENDATIONS ON IMPROVING 

THE 340B PROGRAM. 

(a) REPORT.—Not later than 18 months after the date of enactment of this Act, the Comptroller General of the United States 

shall submit to Congress a report that examines whether those individuals served by the covered entities under the program under 

section 340B of the Public Health Service Act (42 U.S.C. 256b) (referred to in this section as the ‘‘340B program’’) are receiving optimal health care services. 

(b) RECOMMENDATIONS.—The report under subsection (a) shall 

include recommendations on the following: 

(1) Whether the 340B program should be expanded since 

it is anticipated that the 47,000,000 individuals who are uninsured as of the date of enactment of this Act will have health 

care coverage once this Act is implemented. 

(2) Whether mandatory sales of certain products by the 

340B program could hinder patients access to those therapies 

through any provider. 

(3) Whether income from the 340B program is being used 

by the covered entities under the program to further the program objectives. 
Sec. 8001 PPACA (Consolidated) 772 

TITLE VIII—CLASS ACT 

SEC. 8001. SHORT TITLE OF TITLE. 

This title may be cited as the ‘‘Community Living Assistance 

Services and Supports Act’’ or the ‘‘CLASS Act’’. 

SEC. 8002. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE 

PROGRAM FOR PURCHASING COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORT. 

(a) ESTABLISHMENT OF CLASS PROGRAM.— 

(1) IN GENERAL.—The Public Health Service Act (42 U.S.C. 

201 et seq.), as amended by section 4302(a), is amended by 

adding at the end the following: 

‘‘TITLE XXXII—COMMUNITY LIVING 

ASSISTANCE SERVICES AND SUPPORTS 

‘‘SEC. 3201. ø42 U.S.C. 30011¿ PURPOSE. 

‘‘The purpose of this title is to establish a national voluntary 

insurance program for purchasing community living assistance 

services and supports in order to— 

‘‘(1) provide individuals with functional limitations with 

tools that will allow them to maintain their personal and financial independence and live in the community through a 

new financing strategy for community living assistance services and supports; 

‘‘(2) establish an infrastructure that will help address the 

Nation’s community living assistance services and supports 

needs; 

‘‘(3) alleviate burdens on family caregivers; and 

‘‘(4) address institutional bias by providing a financing 

mechanism that supports personal choice and independence to 

live in the community. 

‘‘SEC. 3202. ø42 U.S.C. 30011–1¿ DEFINITIONS. 

‘‘In this title: 

‘‘(1) ACTIVE ENROLLEE.—The term ‘active enrollee’ means 

an individual who is enrolled in the CLASS program in accordance with section 3204 and who has paid any premiums due 

to maintain such enrollment. 

‘‘(2) ACTIVELY EMPLOYED.—The term ‘actively employed’ 

means an individual who— 

‘‘(A) is reporting for work at the individual’s usual 

place of employment or at another location to which the individual is required to travel because of the individual’s 

employment (or in the case of an individual who is a member of the uniformed services, is on active duty and is 

physically able to perform the duties of the individual’s position); and 

‘‘(B) is able to perform all the usual and customary duties of the individual’s employment on the individual’s regular work schedule. 
773 Sec. 8002 PPACA (Consolidated) \3202 PHSA 

‘‘(3) ACTIVITIES OF DAILY LIVING.—The term ‘activities of 

daily living’ means each of the following activities specified in 

section 7702B(c)(2)(B) of the Internal Revenue Code of 1986: 

‘‘(A) Eating. 

‘‘(B) Toileting. 

‘‘(C) Transferring. 

‘‘(D) Bathing. 

‘‘(E) Dressing. 

‘‘(F) Continence. 

‘‘(4) CLASS PROGRAM.—The term ‘CLASS program’ means 

the program established under this title. 

‘‘(5) ELIGIBILITY ASSESSMENT SYSTEM.—The term ‘Eligibility Assessment System’ means the entity established by the 

Secretary under section 3205(a)(2) to make functional eligibility determinations for the CLASS program. 

‘‘(6) ELIGIBLE BENEFICIARY.— 

‘‘(A) IN GENERAL.—The term ‘eligible beneficiary’ 

means any individual who is an active enrollee in the 

CLASS program and, as of the date described in subparagraph (B)— 

‘‘(i) has paid premiums for enrollment in such program for at least 60 months; 

‘‘(ii) has earned, with respect to at least 3 calendar 

years that occur during the first 60 months for which 

the individual has paid premiums for enrollment in 

the program, at least an amount equal to the amount 

of wages and self-employment income which an individual must have in order to be credited with a quarter of coverage under section 213(d) of the Social Security Act for the year; and 

‘‘(iii) has paid premiums for enrollment in such 

program for at least 24 consecutive months, if a lapse 

in premium payments of more than 3 months has occurred during the period that begins on the date of the 

individual’s enrollment and ends on the date of such 

determination. 

‘‘(B) DATE DESCRIBED.—For purposes of subparagraph 

(A), the date described in this subparagraph is the date on 

which the individual is determined to have a functional 

limitation described in section 3203(a)(1)(C) that is expected to last for a continuous period of more than 90 

days. 

‘‘(C) REGULATIONS.—The Secretary shall promulgate 

regulations specifying exceptions to the minimum earnings 

requirements under subparagraph (A)(ii) for purposes of 

being considered an eligible beneficiary for certain populations. 

‘‘(7) HOSPITAL; NURSING FACILITY; INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED; INSTITUTION FOR MENTAL

DISEASES.—The terms ‘hospital’, ‘nursing facility’, ‘intermediate 

care facility for the mentally retarded’, and ‘institution for 

mental diseases’ have the meanings given such terms for purposes of Medicaid. 
Sec. 8002\3203 PHSA PPACA (Consolidated) 774 

‘‘(8) CLASS INDEPENDENCE ADVISORY COUNCIL.—The term 

‘CLASS Independence Advisory Council’ or ‘Council’ means the 

Advisory Council established under section 3207 to advise the 

Secretary. 

‘‘(9) CLASS INDEPENDENCE BENEFIT PLAN.—The term 

‘CLASS Independence Benefit Plan’ means the benefit plan developed and designated by the Secretary in accordance with 

section 3203. 

‘‘(10) CLASS INDEPENDENCE FUND.—The term ‘CLASS 

Independence Fund’ or ‘Fund’ means the fund established 

under section 3206. 

‘‘(11) MEDICAID.—The term ‘Medicaid’ means the program 

established under title XIX of the Social Security Act (42 

U.S.C. 1396 et seq.). 

‘‘(12) 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)). 

‘‘(13) PROTECTION AND ADVOCACY SYSTEM.—The term ‘Protection and Advocacy System’ means the system for each State 

established under section 143 of the Developmental Disabilities 

Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15043). 

‘‘SEC. 3203. ø42 U.S.C. 30011–2¿ CLASS INDEPENDENCE BENEFIT PLAN. 

‘‘(a) PROCESS FOR DEVELOPMENT.— 

‘‘(1) IN GENERAL.—The Secretary, in consultation with appropriate actuaries and other experts, shall develop at least 3 

actuarially sound benefit plans as alternatives for consideration for designation by the Secretary as the CLASS Independence Benefit Plan under which eligible beneficiaries shall receive benefits under this title. Each of the plan alternatives developed shall be designed to provide eligible beneficiaries with 

the benefits described in section 3205 consistent with the following requirements: 

‘‘(A) PREMIUMS.— 

‘‘(i) IN GENERAL.—Beginning with the first year of 

the CLASS program, and for each year thereafter, subject to clauses (ii) and (iii), the Secretary shall establish all premiums to be paid by enrollees for the year 

based on an actuarial analysis of the 75-year costs of 

the program that ensures solvency throughout such 

75-year period. 

‘‘(ii) NOMINAL PREMIUM FOR POOREST INDIVIDUALS

AND FULL-TIME STUDENTS.— 

‘‘(I) IN GENERAL.—The monthly premium for 

enrollment in the CLASS program shall not exceed the applicable dollar amount per month determined under subclause (II) for— 

‘‘(aa) any individual whose income does 

not exceed the poverty line; and 

‘‘(bb) any individual who has not attained 

age 22, and is actively employed during any 

period in which the individual is a full-time 

student (as determined by the Secretary). 
775 Sec. 8002 PPACA (Consolidated) \3203 PHSA 

‘‘(II) APPLICABLE DOLLAR AMOUNT.—The applicable dollar amount described in this subclause is 

the amount equal to $5, increased by the percentage increase in the consumer price index for all 

urban consumers (U.S. city average) for each year 

occurring after 2009 and before such year. 

‘‘(iii) CLASS INDEPENDENCE FUND RESERVES.—At 

such time as the CLASS program has been in operation for 10 years, the Secretary shall establish all 

premiums to be paid by enrollees for the year based on 

an actuarial analysis that accumulated reserves in the 

CLASS Independence Fund would not decrease in that 

year. At such time as the Secretary determines the 

CLASS program demonstrates a sustained ability to finance expected yearly expenses with expected yearly 

premiums and interest credited to the CLASS Independence Fund, the Secretary may decrease the required amount of CLASS Independence Fund reserves. 

‘‘(B) VESTING PERIOD.—A 5-year vesting period for eligibility for benefits. 

‘‘(C) BENEFIT TRIGGERS.—A benefit trigger for provision of benefits that requires a determination that an individual has a functional limitation, as certified by a licensed health care practitioner, described in any of the following clauses that is expected to last for a continuous period of more than 90 days: 

‘‘(i) The individual is determined to be unable to 

perform at least the minimum number (which may be 

2 or 3) of activities of daily living as are required 

under the plan for the provision of benefits without 

substantial assistance (as defined by the Secretary) 

from another individual. 

‘‘(ii) The individual requires substantial supervision to protect the individual from threats to health 

and safety due to substantial cognitive impairment. 

‘‘(iii) The individual has a level of functional limitation similar (as determined under regulations prescribed by the Secretary) to the level of functional limitation described in clause (i) or (ii). 

‘‘(D) CASH BENEFIT.—Payment of a cash benefit that 

satisfies the following requirements: 

‘‘(i) MINIMUM REQUIRED AMOUNT.—The benefit 

amount provides an eligible beneficiary with not less 

than an average of $50 per day (as determined based 

on the reasonably expected distribution of beneficiaries receiving benefits at various benefit levels). 

‘‘(ii) AMOUNT SCALED TO FUNCTIONAL ABILITY.— 

The benefit amount is varied based on a scale of functional ability, with not less than 2, and not more than 

6, benefit level amounts. 

‘‘(iii) DAILY OR WEEKLY.—The benefit is paid on a 

daily or weekly basis. 

‘‘(iv) NO LIFETIME OR AGGREGATE LIMIT.—The benefit is not subject to any lifetime or aggregate limit. 
Sec. 8002\3203 PHSA PPACA (Consolidated) 776 

øSubparagraph (E) stricken by section 10801(a)(1)(A)¿ 

‘‘(2) REVIEW AND RECOMMENDATION BY THE CLASS INDE- PENDENCE ADVISORY COUNCIL.—The CLASS Independence Advisory Council shall— 

‘‘(A) evaluate the alternative benefit plans developed 

under paragraph (1); and 

‘‘(B) recommend for designation as the CLASS Independence Benefit Plan for offering to the public the plan 

that the Council determines best balances price and benefits to meet enrollees’ needs in an actuarially sound manner, while optimizing the probability of the long-term sustainability of the CLASS program. 

‘‘(3) DESIGNATION BY THE SECRETARY.—Not later than October 1, 2012, the Secretary, taking into consideration the recommendation of the CLASS Independence Advisory Council 

under paragraph (2)(B), shall designate a benefit plan as the 

CLASS Independence Benefit Plan. The Secretary shall publish such designation, along with details of the plan and the 

reasons for the selection by the Secretary, in a final rule that 

allows for a period of public comment. 

‘‘(b) ADDITIONAL PREMIUM REQUIREMENTS.— ‘‘(1) ADJUSTMENT OF PREMIUMS.— ‘‘(A) IN GENERAL.—Except as provided in subparagraphs (B), (C), (D), and (E), the amount of the monthly 

premium determined for an individual upon such individual’s enrollment in the CLASS program shall remain the 

same for as long as the individual is an active enrollee in 

the program. 

‘‘(B) RECALCULATED PREMIUM IF REQUIRED FOR PROGRAM SOLVENCY.— 

‘‘(i) IN GENERAL.—Subject to clause (ii), if the Secretary determines, based on the most recent report of 

the Board of Trustees of the CLASS Independence 

Fund, the advice of the CLASS Independence Advisory 

Council, and the annual report of the Inspector General of the Department of Health and Human Services, and waste, fraud, and abuse, or such other information as the Secretary determines appropriate, that 

the monthly premiums and income to the CLASS 

Independence Fund for a year are projected to be insufficient with respect to the 20-year period that begins with that year, the Secretary shall adjust the 

monthly premiums for individuals enrolled in the 

CLASS program as necessary (but maintaining a 

nominal premium for enrollees whose income is below 

the poverty line or who are full-time students actively 

employed). 

‘‘(ii) EXEMPTION FROM INCREASE.—Any increase in 

a monthly premium imposed as result of a determination described in clause (i) shall not apply with respect 

to the monthly premium of any active enrollee who— 

‘‘(I) has attained age 65; 

‘‘(II) has paid premiums for enrollment in the 

program for at least 20 years; and 
777 Sec. 8002 PPACA (Consolidated) \3203 PHSA 

‘‘(III) is not actively employed. 

‘‘(C) RECALCULATED PREMIUM IF REENROLLMENT AFTER

MORE THAN A 3-MONTH LAPSE.— 

‘‘(i) IN GENERAL.—The reenrollment of an individual after a 90-day period during which the individual failed to pay the monthly premium required to 

maintain the individual’s enrollment in the CLASS 

program shall be treated as an initial enrollment for 

purposes of age-adjusting the premium for reenrollment in the program. øAs revised by section 

10801(a)(1)(B)¿ 

‘‘(ii) CREDIT FOR PRIOR MONTHS IF REENROLLED

WITHIN 5 YEARS.—An individual who reenrolls in the 

CLASS program after such a 90-day period and before 

the end of the 5-year period that begins with the first 

month for which the individual failed to pay the 

monthly premium required to maintain the individual’s enrollment in the program shall be— 

‘‘(I) credited with any months of paid premiums that accrued prior to the individual’s lapse 

in enrollment; and 

‘‘(II) notwithstanding the total amount of any 

such credited months, required to satisfy section 

3202(6)(A)(ii) before being eligible to receive benefits. 

‘‘(D) NO LONGER STATUS AS A FULL-TIME STUDENT.—An 

individual subject to a nominal premium on the basis of 

being described in subsection (a)(1)(A)(ii)(I)(bb) who ceases 

to be described in that subsection, beginning with the first 

month following the month in which the individual ceases 

to be so described, shall be subject to the same monthly 

premium as the monthly premium that applies to an individual of the same age who first enrolls in the program 

under the most similar circumstances as the individual 

(such as the first year of eligibility for enrollment in the 

program or in a subsequent year). 

‘‘(E) PENALTY FOR REENOLLMENT AFTER 5-YEAR

LAPSE.—In the case of an individual who reenrolls in the 

CLASS program after the end of the 5-year period described in subparagraph (C)(ii), the monthly premium required for the individual shall be the age-adjusted premium that would be applicable to an initially enrolling individual who is the same age as the reenrolling individual, 

increased by the greater of— 

‘‘(i) an amount that the Secretary determines is 

actuarially sound for each month that occurs during 

the period that begins with the first month for which 

the individual failed to pay the monthly premium required to maintain the individual’s enrollment in the 

CLASS program and ends with the month preceding 

the month in which the reenollment is effective; or 

‘‘(ii) 1 percent of the applicable age-adjusted premium for each such month occurring in such period. 
Sec. 8002\3204 PHSA PPACA (Consolidated) 778 

‘‘(2) ADMINISTRATIVE EXPENSES.—In determining the 

monthly premiums for the CLASS program the Secretary may 

factor in costs for administering the program, not to exceed for 

any year in which the program is in effect under this title, an 

amount equal to 3 percent of all premiums paid during the 

year. 

‘‘(3) NO UNDERWRITING REQUIREMENTS.—No underwriting 

(other than on the basis of age in accordance with subparagraphs (D) and (E) of paragraph (1)) shall be used to— 

‘‘(A) determine the monthly premium for enrollment in 

the CLASS program; or 

‘‘(B) prevent an individual from enrolling in the program. 

‘‘(c) SELF-ATTESTATION AND VERIFICATION OF INCOME.—The 

Secretary shall establish procedures to— 

‘‘(1) permit an individual who is eligible for the nominal 

premium required under subsection (a)(1)(A)(ii) to self-attest 

that their income does not exceed the poverty line or that their 

status as a full-time student who is actively employed; øAs revised by section 10801(a)(1)(C)¿ 

‘‘(2) verify, using procedures similar to the procedures used 

by the Commissioner of Social Security under section 

1631(e)(1)(B)(ii) of the Social Security Act and consistent with 

the requirements applicable to the conveyance of data and information under section 1942 of such Act, the validity of such 

self-attestation; and 

‘‘(3) require an individual to confirm, on at least an annual 

basis, that their income does not exceed the poverty line or 

that they continue to maintain such status. 

‘‘SEC. 3204. ø42 U.S.C. 30011–3¿ ENROLLMENT AND DISENROLLMENT REQUIREMENTS. 

‘‘(a) AUTOMATIC ENROLLMENT.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary, 

in coordination with the Secretary of the Treasury, shall establish procedures under which each individual described in subsection (c) may be automatically enrolled in the CLASS program by an employer of such individual in the same manner 

as an employer may elect to automatically enroll employees in 

a plan under section 401(k), 403(b), or 457 of the Internal Revenue Code of 1986. 

‘‘(2) ALTERNATIVE ENROLLMENT PROCEDURES.—The procedures established under paragraph (1) shall provide for an alternative enrollment process for an individual described in subsection (c) in the case of such an individual— 

‘‘(A) who is self-employed; 

‘‘(B) who has more than 1 employer; or 

‘‘(C) whose employer does not elect to participate in 

the automatic enrollment process established by the Secretary. 

‘‘(3) ADMINISTRATION.— 

‘‘(A) IN GENERAL.—The Secretary and the Secretary of 

the Treasury shall, by regulation, establish procedures to 

ensure that an individual is not automatically enrolled in 

the CLASS program by more than 1 employer. 
779 Sec. 8002 PPACA (Consolidated) \3204 PHSA 

‘‘(B) FORM.—Enrollment in the CLASS program shall 

be made in such manner as the Secretary may prescribe 

in order to ensure ease of administration. 

‘‘(b) ELECTION TO OPT-OUT.—An individual described in subsection (c) may elect to waive enrollment in the CLASS program at 

any time in such form and manner as the Secretary and the Secretary of the Treasury shall prescribe. 

‘‘(c) INDIVIDUAL DESCRIBED.—For purposes of enrolling in the 

CLASS program, an individual described in this paragraph is an 

individual— 

‘‘(1) who has attained age 18; 

‘‘(2) who— 

‘‘(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 øReplaced by section 

10802(a)(2)(A)¿ 

‘‘(B) derives self-employment income on which there is 

imposed a tax under section 1401(a) of the Internal Revenue Code of 1986; 

‘‘(3) who is actively employed; and 

‘‘(4) who is not— 

‘‘(A) a patient in a hospital or nursing facility, an intermediate care facility for the mentally retarded, or an institution for mental diseases and receiving medical assistance under Medicaid; or 

‘‘(B) confined in a jail, prison, other penal institution 

or correctional facility, or by court order pursuant to conviction of a criminal offense or in connection with a verdict 

or finding described in section 202(x)(1)(A)(ii) of the Social 

Security Act (42 U.S.C. 402(x)(1)(A)(ii)). 

‘‘(d) RULE OF CONSTRUCTION.—Nothing in this title shall be 

construed as requiring an active enrollee to continue to satisfy subparagraph (A) or (B) of subsection (c)(2) in order to maintain enrollment in the CLASS program. øAs revised by section 10801(a)(2)(B)¿ 

‘‘(e) PAYMENT.— 

‘‘(1) PAYROLL DEDUCTION.—An amount equal to the monthly premium for the enrollment in the CLASS program of an individual shall be deducted from the wages or self-employment 

income of such individual in accordance with such procedures 

as the Secretary, in coordination with the Secretary of the 

Treasury, shall establish for employers who elect to deduct and 

withhold such premiums on behalf of enrolled employees. 

‘‘(2) ALTERNATIVE PAYMENT MECHANISM.—The Secretary, in 

coordination with the Secretary of the Treasury, shall establish 

alternative procedures for the payment of monthly premiums 

by an individual enrolled in the CLASS program— 

‘‘(A) who does not have an employer who elects to deduct and withhold premiums in accordance with paragraph 

(1); or øAs revised by section 10801(a)(2)(C)¿ 

‘‘(B) who does not earn wages or derive self-employment income. 

‘‘(f) TRANSFER OF PREMIUMS COLLECTED.— 

‘‘(1) IN GENERAL.—During each calendar year the Secretary 

of the Treasury shall deposit into the CLASS Independence 
Sec. 8002\3205 PHSA PPACA (Consolidated) 780 

Fund a total amount equal, in the aggregate, to 100 percent of 

the premiums collected during that year. 

‘‘(2) TRANSFERS BASED ON ESTIMATES.—The amount deposited pursuant to paragraph (1) shall be transferred in at least 

monthly payments to the CLASS Independence Fund on the 

basis of estimates by the Secretary and certified to the Secretary of the Treasury of the amounts collected in accordance 

with subparagraphs (A) and (B) of paragraph (5). Proper adjustments shall be made in amounts subsequently transferred 

to the Fund to the extent prior estimates were in excess of, or 

were less than, actual amounts collected. 

‘‘(g) OTHER ENROLLMENT AND DISENROLLMENT OPPORTUNITIES.—The Secretary, in coordination with the Secretary of the 

Treasury, shall establish procedures under which— 

‘‘(1) an individual who, in the year of the individual’s initial eligibility to enroll in the CLASS program, has not enrolled 

in the program, is eligible to elect to enroll in the program, in 

such form and manner as the Secretaries shall establish, only 

during an open enrollment period established by the Secretaries that is specific to the individual and that may not occur 

more frequently than biennially after the date on which the individual first elected to waive enrollment in the program; and 

øAs revised by section 10801(a)(2)(D)¿ 

‘‘(2) an individual shall only be permitted to disenroll from 

the program (other than for nonpayment of premiums) during 

an annual disenrollment period established by the Secretaries 

and in such form and manner as the Secretaries shall establish. 

‘‘SEC. 3205. ø42 U.S.C. 30011–4¿ BENEFITS. 

‘‘(a) DETERMINATION OF ELIGIBILITY.— 

‘‘(1) APPLICATION FOR RECEIPT OF BENEFITS.—The Secretary shall establish procedures under which an active enrollee shall apply for receipt of benefits under the CLASS Independence Benefit Plan. 

‘‘(2) ELIGIBILITY ASSESSMENTS.— 

‘‘(A) IN GENERAL.—Not later than January 1, 2012, the 

Secretary shall— 

‘‘(i) establish an Eligibility Assessment System 

(other than a service with which the Commissioner of 

Social Security has entered into an agreement, with 

respect to any State, to make disability determinations 

for purposes of title II or XVI of the Social Security 

Act) to provide for eligibility assessments of active enrollees who apply for receipt of benefits; 

‘‘(ii) enter into an agreement with the Protection 

and Advocacy System for each State to provide advocacy services in accordance with subsection (d); and 

‘‘(iii) enter into an agreement with public and private entities to provide advice and assistance counseling in accordance with subsection (e). 

‘‘(B) REGULATIONS.—The Secretary shall promulgate 

regulations to develop an expedited nationally equitable 

eligibility determination process, as certified by a licensed 
781 Sec. 8002 PPACA (Consolidated) \3205 PHSA 

health care practitioner, an appeals process, and a redetermination process, as certified by a licensed health care 

practitioner, including whether an active enrollee is eligible for a cash benefit under the program and if so, the 

amount of the cash benefit (in accordance the sliding scale 

established under the plan). 

‘‘(C) PRESUMPTIVE ELIGIBILITY FOR CERTAIN INSTITUTIONALIZED ENROLLEES PLANNING TO DISCHARGE.—An active enrollee shall be deemed presumptively eligible if the 

enrollee— 

‘‘(i) has applied for, and attests is eligible for, the 

maximum cash benefit available under the sliding 

scale established under the CLASS Independence Benefit Plan; 

‘‘(ii) is a patient in a hospital (but only if the hospitalization is for long-term care), nursing facility, intermediate care facility for the mentally retarded, or 

an institution for mental diseases; and 

‘‘(iii) is in the process of, or about to begin the 

process of, planning to discharge from the hospital, facility, or institution, or within 60 days from the date 

of discharge from the hospital, facility, or institution. 

‘‘(D) APPEALS.—The Secretary shall establish procedures under which an applicant for benefits under the 

CLASS Independence Benefit Plan shall be guaranteed the 

right to appeal an adverse determination. 

‘‘(b) BENEFITS.—An eligible beneficiary shall receive the following benefits under the CLASS Independence Benefit Plan: 

‘‘(1) CASH BENEFIT.—A cash benefit established by the Secretary in accordance with the requirements of section 

3203(a)(1)(D) that— 

‘‘(A) the first year in which beneficiaries receive the 

benefits under the plan, is not less than the average dollar 

amount specified in clause (i) of such section; and 

‘‘(B) for any subsequent year, is not less than the average per day dollar limit applicable under this subparagraph for the preceding year, increased by the percentage 

increase in the consumer price index for all urban consumers (U.S. city average) over the previous year. 

‘‘(2) ADVOCACY SERVICES.—Advocacy services in accordance 

with subsection (d). 

‘‘(3) ADVICE AND ASSISTANCE COUNSELING.—Advice and assistance counseling in accordance with subsection (e). 

‘‘(4) ADMINISTRATIVE EXPENSES.—Advocacy services and 

advise and assistance counseling services under paragraphs (2) 

and (3) of this subsection shall be included as administrative 

expenses under section 3203(b)(3). 

‘‘(c) PAYMENT OF BENEFITS.— 

‘‘(1) LIFE INDEPENDENCE ACCOUNT.— 

‘‘(A) IN GENERAL.—The Secretary shall establish procedures for administering the provision of benefits to eligible 

beneficiaries under the CLASS Independence Benefit Plan, 

including the payment of the cash benefit for the bene-
Sec. 8002\3205 PHSA PPACA (Consolidated) 782 

ficiary into a Life Independence Account established by the 

Secretary on behalf of each eligible beneficiary. 

‘‘(B) USE OF CASH BENEFITS.—Cash benefits paid into 

a Life Independence Account of an eligible beneficiary 

shall be used to purchase nonmedical services and supports that the beneficiary needs to maintain his or her 

independence at home or in another residential setting of 

their choice in the community, including (but not limited 

to) home modifications, assistive technology, accessible 

transportation, homemaker services, respite care, personal 

assistance services, home care aides, and nursing support. 

Nothing in the preceding sentence shall prevent an eligible 

beneficiary from using cash benefits paid into a Life Independence Account for obtaining assistance with decision 

making concerning medical care, including the right to accept or refuse medical or surgical treatment and the right 

to formulate advance directives or other written instructions recognized under State law, such as a living will or 

durable power of attorney for health care, in the case that 

an injury or illness causes the individual to be unable to 

make health care decisions. 

‘‘(C) ELECTRONIC MANAGEMENT OF FUNDS.—The Secretary shall establish procedures for— 

‘‘(i) crediting an account established on behalf of a 

beneficiary with the beneficiary’s cash daily benefit; 

‘‘(ii) allowing the beneficiary to access such account through debit cards; and 

‘‘(iii) accounting for withdrawals by the beneficiary 

from such account. 

‘‘(D) PRIMARY PAYOR RULES FOR BENEFICIARIES WHO

ARE ENROLLED IN MEDICAID.—In the case of an eligible 

beneficiary who is enrolled in Medicaid, the following payment rules shall apply: 

‘‘(i) INSTITUTIONALIZED BENEFICIARY.—If the beneficiary is a patient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or an 

institution for mental diseases, the beneficiary shall 

retain an amount equal to 5 percent of the beneficiary’s daily or weekly cash benefit (as applicable) 

(which shall be in addition to the amount of the beneficiary’s personal needs allowance provided under 

Medicaid), and the remainder of such benefit shall be 

applied toward the facility’s cost of providing the beneficiary’s care, and Medicaid shall provide secondary 

coverage for such care. 

‘‘(ii) BENEFICIARIES RECEIVING HOME AND COMMUNITY-BASED SERVICES.— 

‘‘(I) 50 PERCENT OF BENEFIT RETAINED BY BENEFICIARY.—Subject to subclause (II), if a beneficiary is receiving medical assistance under Medicaid for home and community based services, the 

beneficiary shall retain an amount equal to 50 

percent of the beneficiary’s daily or weekly cash 

benefit (as applicable), and the remainder of the 
783 Sec. 8002 PPACA (Consolidated) \3205 PHSA 

daily or weekly cash benefit shall be applied toward the cost to the State of providing such assistance (and shall not be used to claim Federal 

matching funds under Medicaid), and Medicaid 

shall provide secondary coverage for the remainder of any costs incurred in providing such assistance. 

‘‘(II) REQUIREMENT FOR STATE OFFSET.—A 

State shall be paid the remainder of a beneficiary’s daily or weekly cash benefit under subclause (I) only if the State home and communitybased waiver under section 1115 of the Social Security Act (42 U.S.C. 1315) or subsection (c) or (d) 

of section 1915 of such Act (42 U.S.C. 1396n), or 

the State plan amendment under subsection (i) of 

such section does not include a waiver of the requirements of section 1902(a)(1) of the Social Security Act (relating to statewideness) or of section 

1902(a)(10)(B) of such Act (relating to comparability) and the State offers at a minimum case 

management services, personal care services, habilitation services, and respite care under such a 

waiver or State plan amendment. 

‘‘(III) DEFINITION OF HOME AND COMMUNITY- BASED SERVICES.—In this clause, the term ‘home 

and community-based services’ means any services which may be offered under a home and community-based waiver authorized for a State under 

section 1115 of the Social Security Act (42 U.S.C. 

1315) or subsection (c) or (d) of section 1915 of 

such Act (42 U.S.C. 1396n) or under a State plan 

amendment under subsection (i) of such section. 

‘‘(iii) BENEFICIARIES ENROLLED IN PROGRAMS OF

ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE).— 

‘‘(I) IN GENERAL.—Subject to subclause (II), if 

a beneficiary is receiving medical assistance under 

Medicaid for PACE program services under section 1934 of the Social Security Act (42 U.S.C. 

1396u–4), the beneficiary shall retain an amount 

equal to 50 percent of the beneficiary’s daily or 

weekly cash benefit (as applicable), and the remainder of the daily or weekly cash benefit shall 

be applied toward the cost to the State of providing such assistance (and shall not be used to 

claim Federal matching funds under Medicaid), 

and Medicaid shall provide secondary coverage for 

the remainder of any costs incurred in providing 

such assistance. 

‘‘(II) INSTITUTIONALIZED RECIPIENTS OF PACE

PROGRAM SERVICES.—If a beneficiary receiving assistance under Medicaid for PACE program services is a patient in a hospital, nursing facility, intermediate care facility for the mentally retarded, 

or an institution for mental diseases, the bene-
Sec. 8002\3205 PHSA PPACA (Consolidated) 784 

ficiary shall be treated as in institutionalized beneficiary under clause (i). 

‘‘(2) AUTHORIZED REPRESENTATIVES.— 

‘‘(A) IN GENERAL.—The Secretary shall establish procedures to allow access to a beneficiary’s cash benefits by an 

authorized representative of the eligible beneficiary on 

whose behalf such benefits are paid. 

‘‘(B) QUALITY ASSURANCE AND PROTECTION AGAINST

FRAUD AND ABUSE.—The procedures established under subparagraph (A) shall ensure that authorized representatives 

of eligible beneficiaries comply with standards of conduct 

established by the Secretary, including standards requiring that such representatives provide quality services on 

behalf of such beneficiaries, do not have conflicts of interest, and do not misuse benefits paid on behalf of such 

beneficiaries or otherwise engage in fraud or abuse. 

‘‘(3) COMMENCEMENT OF BENEFITS.—Benefits shall be paid 

to, or on behalf of, an eligible beneficiary beginning with the 

first month in which an application for such benefits is approved. 

‘‘(4) ROLLOVER OPTION FOR LUMP-SUM PAYMENT.—An eligible beneficiary may elect to— 

‘‘(A) defer payment of their daily or weekly benefit and 

to rollover any such deferred benefits from month-tomonth, but not from year-to-year; and 

‘‘(B) receive a lump-sum payment of such deferred benefits in an amount that may not exceed the lesser of— 

‘‘(i) the total amount of the accrued deferred benefits; or 

‘‘(ii) the applicable annual benefit. 

‘‘(5) PERIOD FOR DETERMINATION OF ANNUAL BENEFITS.— 

‘‘(A) IN GENERAL.—The applicable period for determining with respect to an eligible beneficiary the applicable annual benefit and the amount of any accrued deferred 

benefits is the 12-month period that commences with the 

first month in which the beneficiary began to receive such 

benefits, and each 12-month period thereafter. 

‘‘(B) INCLUSION OF INCREASED BENEFITS.—The Secretary shall establish procedures under which cash benefits paid to an eligible beneficiary that increase or decrease 

as a result of a change in the functional status of the beneficiary before the end of a 12-month benefit period shall be 

included in the determination of the applicable annual 

benefit paid to the eligible beneficiary. 

‘‘(C) RECOUPMENT OF UNPAID, ACCRUED BENEFITS.— 

‘‘(i) IN GENERAL.—The Secretary, in coordination 

with the Secretary of the Treasury, shall recoup any 

accrued benefits in the event of— 

‘‘(I) the death of a beneficiary; or 

‘‘(II) the failure of a beneficiary to elect under 

paragraph (4)(B) to receive such benefits as a 

lump-sum payment before the end of the 12- 

month period in which such benefits accrued. 
785 Sec. 8002 PPACA (Consolidated) \3205 PHSA 

‘‘(ii) PAYMENT INTO CLASS INDEPENDENCE FUND.— Any benefits recouped in accordance with clause (i) 

shall be paid into the CLASS Independence Fund and 

used in accordance with section 3206. 

‘‘(6) REQUIREMENT TO RECERTIFY ELIGIBILITY FOR RECEIPT

OF BENEFITS.—An eligible beneficiary shall periodically, as determined by the Secretary— 

‘‘(A) recertify by submission of medical evidence the 

beneficiary’s continued eligibility for receipt of benefits; 

and 

‘‘(B) submit records of expenditures attributable to the 

aggregate cash benefit received by the beneficiary during 

the preceding year. 

‘‘(7) SUPPLEMENT, NOT SUPPLANT OTHER HEALTH CARE BEN- EFITS.—Subject to the Medicaid payment rules under paragraph (1)(D), benefits received by an eligible beneficiary shall 

supplement, but not supplant, other health care benefits for 

which the beneficiary is eligible under Medicaid or any other 

Federally funded program that provides health care benefits or 

assistance. 

‘‘(d) ADVOCACY SERVICES.—An agreement entered into under 

subsection (a)(2)(A)(ii) shall require the Protection and Advocacy 

System for the State to— 

‘‘(1) assign, as needed, an advocacy counselor to each eligible beneficiary that is covered by such agreement and who 

shall provide an eligible beneficiary with— 

‘‘(A) information regarding how to access the appeals 

process established for the program; 

‘‘(B) assistance with respect to the annual recertification and notification required under subsection (c)(6); 

and 

‘‘(C) such other assistance with obtaining services as 

the Secretary, by regulation, shall require; and 

‘‘(2) ensure that the System and such counselors comply 

with the requirements of subsection (h). 

‘‘(e) ADVICE AND ASSISTANCE COUNSELING.—An agreement entered into under subsection (a)(2)(A)(iii) shall require the entity to 

assign, as requested by an eligible beneficiary that is covered by 

such agreement, an advice and assistance counselor who shall provide an eligible beneficiary with information regarding— 

‘‘(1) accessing and coordinating long-term services and supports in the most integrated setting; 

‘‘(2) possible eligibility for other benefits and services; 

‘‘(3) development of a service and support plan; 

‘‘(4) information about programs established under the Assistive Technology Act of 1998 and the services offered under 

such programs; 

‘‘(5) available assistance with decision making concerning 

medical care, including the right to accept or refuse medical or 

surgical treatment and the right to formulate advance directives or other written instructions recognized under State law, 

such as a living will or durable power of attorney for health 

care, in the case that an injury or illness causes the individual 

to be unable to make health care decisions; and 
Sec. 8002\3206 PHSA PPACA (Consolidated) 786 

‘‘(6) such other services as the Secretary, by regulation, 

may require. 

‘‘(f) NO EFFECT ON ELIGIBILITY FOR OTHER BENEFITS.—Benefits 

paid to an eligible beneficiary under the CLASS program shall be 

disregarded for purposes of determining or continuing the beneficiary’s eligibility for receipt of benefits under any other Federal, 

State, or locally funded assistance program, including benefits paid 

under titles II, XVI, XVIII, XIX, or XXI of the Social Security Act 

(42 U.S.C. 401 et seq., 1381 et seq., 1395 et seq., 1396 et seq., 

1397aa et seq.), under the laws administered by the Secretary of 

Veterans Affairs, under low-income housing assistance programs, 

or under the supplemental nutrition assistance program established under the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et 

seq.). 

‘‘(g) RULE OF CONSTRUCTION.—Nothing in this title shall be 

construed as prohibiting benefits paid under the CLASS Independence Benefit Plan from being used to compensate a family caregiver 

for providing community living assistance services and supports to 

an eligible beneficiary. 

‘‘(h) PROTECTION AGAINST CONFLICT OF INTERESTS.—The Secretary shall establish procedures to ensure that the Eligibility Assessment System, the Protection and Advocacy System for a State, 

advocacy counselors for eligible beneficiaries, and any other entities 

that provide services to active enrollees and eligible beneficiaries 

under the CLASS program comply with the following: 

‘‘(1) If the entity provides counseling or planning services, 

such services are provided in a manner that fosters the best interests of the active enrollee or beneficiary. 

‘‘(2) The entity has established operating procedures that 

are designed to avoid or minimize conflicts of interest between 

the entity and an active enrollee or beneficiary. 

‘‘(3) The entity provides information about all services and 

options available to the active enrollee or beneficiary, to the 

best of its knowledge, including services available through 

other entities or providers. 

‘‘(4) The entity assists the active enrollee or beneficiary to 

access desired services, regardless of the provider. 

‘‘(5) The entity reports the number of active enrollees and 

beneficiaries provided with assistance by age, disability, and 

whether such enrollees and beneficiaries received services from 

the entity or another entity. 

‘‘(6) If the entity provides counseling or planning services, 

the entity ensures that an active enrollee or beneficiary is informed of any financial interest that the entity has in a service 

provider. 

‘‘(7) The entity provides an active enrollee or beneficiary 

with a list of available service providers that can meet the 

needs of the active enrollee or beneficiary. 

‘‘SEC. 3206. ø42 U.S.C. 30011–5¿ CLASS INDEPENDENCE FUND. 

‘‘(a) ESTABLISHMENT OF CLASS INDEPENDENCE FUND.—There 

is established in the Treasury of the United States a trust fund to 

be known as the ‘CLASS Independence Fund’. The Secretary of the 

Treasury shall serve as Managing Trustee of such Fund. The Fund 
787 Sec. 8002 PPACA (Consolidated) \3206 PHSA 

shall consist of all amounts derived from payments into the Fund 

under sections 3204(f) and 3205(c)(5)(C)(ii), and remaining after investment of such amounts under subsection (b), including additional amounts derived as income from such investments. The 

amounts held in the Fund are appropriated and shall remain available without fiscal year limitation— 

‘‘(1) to be held for investment on behalf of individuals enrolled in the CLASS program; 

‘‘(2) to pay the administrative expenses related to the Fund 

and to investment under subsection (b); and 

‘‘(3) to pay cash benefits to eligible beneficiaries under the 

CLASS Independence Benefit Plan. 

‘‘(b) INVESTMENT OF FUND BALANCE.—The Secretary of the 

Treasury shall invest and manage the CLASS Independence Fund 

in the same manner, and to the same extent, as the Federal Supplementary Medical Insurance Trust Fund may be invested and 

managed under subsections (c), (d), and (e) of section 1841(d) of the 

Social Security Act (42 U.S.C. 1395t). 

‘‘(c) BOARD OF TRUSTEES.— 

‘‘(1) IN GENERAL.—With respect to the CLASS Independence Fund, there is hereby created a body to be known as the 

Board of Trustees of the CLASS Independence Fund (hereinafter in this section referred to as the ‘Board of Trustees’) composed of the Secretary of the Treasury, the Secretary of Labor, 

and the Secretary of Health and Human Services, all ex officio, 

and of two members of the public (both of whom may not be 

from the same political party), who shall be nominated by the 

President for a term of 4 years and subject to confirmation by 

the Senate. A member of the Board of Trustees serving as a 

member of the public and nominated and confirmed to fill a vacancy occurring during a term shall be nominated and confirmed only for the remainder of such term. An individual nominated and confirmed as a member of the public may serve in 

such position after the expiration of such member’s term until 

the earlier of the time at which the member’s successor takes 

office or the time at which a report of the Board is first issued 

under paragraph (2) after the expiration of the member’s term. 

The Secretary of the Treasury shall be the Managing Trustee 

of the Board of Trustees. The Board of Trustees shall meet not 

less frequently than once each calendar year. A person serving 

on the Board of Trustees shall not be considered to be a fiduciary and shall not be personally liable for actions taken in 

such capacity with respect to the Trust Fund. 

‘‘(2) DUTIES.— 

‘‘(A) IN GENERAL.—It shall be the duty of the Board of 

Trustees to do the following: 

‘‘(i) Hold the CLASS Independence Fund. 

‘‘(ii) Report to the Congress not later than the first 

day of April of each year on the operation and status 

of the CLASS Independence Fund during the preceding fiscal year and on its expected operation and 

status during the current fiscal year and the next 2 

fiscal years. 
Sec. 8002\3207 PHSA PPACA (Consolidated) 788 

‘‘(iii) Report immediately to the Congress whenever the Board is of the opinion that the amount of the 

CLASS Independence Fund is not actuarially sound in 

regards to the projection under section 3203(b)(1)(B)(i). 

‘‘(iv) Review the general policies followed in managing the CLASS Independence Fund, and recommend 

changes in such policies, including necessary changes 

in the provisions of law which govern the way in 

which the CLASS Independence Fund is to be managed. 

‘‘(B) REPORT.—The report provided for in subparagraph (A)(ii) shall— 

‘‘(i) include— 

‘‘(I) a statement of the assets of, and the disbursements made from, the CLASS Independence 

Fund during the preceding fiscal year; 

‘‘(II) an estimate of the expected income to, 

and disbursements to be made from, the CLASS 

Independence Fund during the current fiscal year 

and each of the next 2 fiscal years; 

‘‘(III) a statement of the actuarial status of 

the CLASS Independence Fund for the current fiscal year, each of the next 2 fiscal years, and as 

projected over the 75-year period beginning with 

the current fiscal year; and 

‘‘(IV) an actuarial opinion by the Chief Actuary of the Centers for Medicare & Medicaid Services certifying that the techniques and methodologies used are generally accepted within the actuarial profession and that the assumptions and cost 

estimates used are reasonable; and 

‘‘(ii) be printed as a House document of the session 

of the Congress to which the report is made. 

‘‘(C) RECOMMENDATIONS.—If the Board of Trustees determines that enrollment trends and expected future benefit claims on the CLASS Independence Fund are not actuarially sound in regards to the projection under section 

3203(b)(1)(B)(i) and are unlikely to be resolved with reasonable premium increases or through other means, the 

Board of Trustees shall include in the report provided for 

in subparagraph (A)(ii) recommendations for such legislative action as the Board of Trustees determine to be appropriate, including whether to adjust monthly premiums or 

impose a temporary moratorium on new enrollments. 

‘‘SEC. 3207. ø42 U.S.C. 30011–6¿ CLASS INDEPENDENCE ADVISORY COUNCIL. 

‘‘(a) ESTABLISHMENT.—There is hereby created an Advisory 

Committee to be known as the ‘CLASS Independence Advisory 

Council’. 

‘‘(b) MEMBERSHIP.— 

‘‘(1) IN GENERAL.—The CLASS Independence Advisory 

Council shall be composed of not more than 15 individuals, not 

otherwise in the employ of the United States— 
789 Sec. 8002 PPACA (Consolidated) \3208 PHSA 

‘‘(A) who shall be appointed by the President without 

regard to the civil service laws and regulations; and 

‘‘(B) a majority of whom shall be representatives of individuals who participate or are likely to participate in the 

CLASS program, and shall include representatives of older 

and younger workers, individuals with disabilities, family 

caregivers of individuals who require services and supports 

to maintain their independence at home or in another residential setting of their choice in the community, individuals with expertise in long-term care or disability insurance, actuarial science, economics, and other relevant disciplines, as determined by the Secretary. 

‘‘(2) TERMS.— 

‘‘(A) IN GENERAL.—The members of the CLASS Independence Advisory Council shall serve overlapping terms 

of 3 years (unless appointed to fill a vacancy occurring 

prior to the expiration of a term, in which case the individual shall serve for the remainder of the term). 

‘‘(B) LIMITATION.—A member shall not be eligible to 

serve for more than 2 consecutive terms. 

‘‘(3) CHAIR.—The President shall, from time to time, appoint one of the members of the CLASS Independence Advisory 

Council to serve as the Chair. 

‘‘(c) DUTIES.—The CLASS Independence Advisory Council shall 

advise the Secretary on matters of general policy in the administration of the CLASS program established under this title and in the 

formulation of regulations under this title including with respect 

to— 

‘‘(1) the development of the CLASS Independence Benefit 

Plan under section 3203; 

‘‘(2) the determination of monthly premiums under such 

plan; and 

‘‘(3) the financial solvency of the program. 

‘‘(d) APPLICATION OF FACA.—The Federal Advisory Committee 

Act (5 U.S.C. App.), other than section 14 of that Act, shall apply 

to the CLASS Independence Advisory Council. 

‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— 

‘‘(1) IN GENERAL.—There are authorized to be appropriated 

to the CLASS Independence Advisory Council to carry out its 

duties under this section, such sums as may be necessary for 

fiscal year 2011 and for each fiscal year thereafter. 

‘‘(2) AVAILABILITY.—Any sums appropriated under the authorization contained in this section shall remain available, 

without fiscal year limitation, until expended. 

‘‘SEC. 3208. ø42 U.S.C. 30011–7¿ SOLVENCY AND FISCAL INDEPENDENCE; 

REGULATIONS; ANNUAL REPORT. 

‘‘(a) SOLVENCY.—The Secretary shall regularly consult with the 

Board of Trustees of the CLASS Independence Fund and the 

CLASS Independence Advisory Council, for purposes of ensuring 

that enrollees premiums are adequate to ensure the financial solvency of the CLASS program, both with respect to fiscal years occurring in the near-term and fiscal years occurring over 20- and 75- 

year periods, taking into account the projections required for such 
Sec. 8002\3209 PHSA PPACA (Consolidated) 790 

periods under subsections (a)(1)(A)(i) and (b)(1)(B)(i) of section 

3202. 

‘‘(b) NO TAXPAYER FUNDS USED TO PAY BENEFITS.—No taxpayer funds shall be used for payment of benefits under a CLASS 

Independent Benefit Plan. For purposes of this subsection, the 

term ‘taxpayer funds’ means any Federal funds from a source other 

than premiums deposited by CLASS program participants in the 

CLASS Independence Fund and any associated interest earnings. 

‘‘(c) REGULATIONS.—The Secretary shall promulgate such regulations as are necessary to carry out the CLASS program in accordance with this title. Such regulations shall include provisions to 

prevent fraud and abuse under the program. 

‘‘(d) ANNUAL REPORT.—Beginning January 1, 2014, the Secretary shall submit an annual report to Congress on the CLASS 

program. Each report shall include the following: 

‘‘(1) The total number of enrollees in the program. 

‘‘(2) The total number of eligible beneficiaries during the 

fiscal year. 

‘‘(3) The total amount of cash benefits provided during the 

fiscal year. 

‘‘(4) A description of instances of fraud or abuse identified 

during the fiscal year. 

‘‘(5) Recommendations for such administrative or legislative action as the Secretary determines is necessary to improve 

the program, ensure the solvency of the program, or to prevent 

the occurrence of fraud or abuse. 

‘‘SEC. 3209. ø42 U.S.C. 30011–8¿ INSPECTOR GENERAL’S REPORT. 

‘‘The Inspector General of the Department of Health and 

Human Services shall submit an annual report to the Secretary 

and Congress relating to the overall progress of the CLASS program and of the existence of waste, fraud, and abuse in the CLASS 

program. Each such report shall include findings in the following 

areas: 

‘‘(1) The eligibility determination process. 

‘‘(2) The provision of cash benefits. 

‘‘(3) Quality assurance and protection against waste, fraud, 

and abuse. 

‘‘(4) Recouping of unpaid and accrued benefits. 

‘‘SEC. 3210. ø42 U.S.C. 30011–9¿ TAX TREATMENT OF PROGRAM. 

‘‘The CLASS program shall be treated for purposes of the Internal Revenue Code of 1986 in the same manner as a qualified 

long-term care insurance contract for qualified long-term care services.’’. 

(2) CONFORMING AMENDMENTS TO MEDICAID.—Section 

1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as 

amended by section 6505, is amended by inserting after paragraph (80) the following: 

‘‘(81) provide that the State will comply with such regulations regarding the application of primary and secondary payor 

rules with respect to individuals who are eligible for medical 

assistance under this title and are eligible beneficiaries under 

the CLASS program established under title XXXII of the Public Health Service Act as the Secretary shall establish; and’’. 
791 Sec. 8002 PPACA (Consolidated) 

(b) ASSURANCE OF ADEQUATE INFRASTRUCTURE FOR THE PROVI- SION OF PERSONAL CARE ATTENDANT WORKERS.—Section 1902(a) of 

the Social Security Act (42 U.S.C. 1396a(a)), as amended by subsection (a)(2), is amended by inserting after paragraph (81) the following: 

‘‘(82) provide that, not later than 2 years after the date of 

enactment of the Community Living Assistance Services and 

Supports Act, each State shall— 

‘‘(A) assess the extent to which entities such as providers of home care, home health services, home and community service providers, public authorities created to provide personal care services to individuals eligible for medical assistance under the State plan, and nonprofit organizations, are serving or have the capacity to serve as fiscal 

agents for, employers of, and providers of employment-related benefits for, personal care attendant workers who 

provide personal care services to individuals receiving benefits under the CLASS program established under title 

XXXII of the Public Health Service Act, including in rural 

and underserved areas; 

‘‘(B) designate or create such entities to serve as fiscal 

agents for, employers of, and providers of employment-related benefits for, such workers to ensure an adequate supply of the workers for individuals receiving benefits under 

the CLASS program, including in rural and underserved 

areas; and 

‘‘(C) ensure that the designation or creation of such 

entities will not negatively alter or impede existing programs, models, methods, or administration of service delivery that provide for consumer controlled or self-directed 

home and community services and further ensure that 

such entities will not impede the ability of individuals to 

direct and control their home and community services, including the ability to select, manage, dismiss, co-employ, 

or employ such workers or inhibit such individuals from 

relying on family members for the provision of personal 

care services.’’. 

(c) PERSONAL CARE ATTENDANTS WORKFORCE ADVISORY

PANEL.— 

(1) ESTABLISHMENT.—Not later than 90 days after the date 

of enactment of this Act, the Secretary of Health and Human 

Services shall establish a Personal Care Attendants Workforce 

Advisory Panel for the purpose of examining and advising the 

Secretary and Congress on workforce issues related to personal 

care attendant workers, including with respect to the adequacy 

of the number of such workers, the salaries, wages, and benefits of such workers, and access to the services provided by 

such workers. 

(2) MEMBERSHIP.—In appointing members to the Personal 

Care Attendants Workforce Advisory Panel, the Secretary shall 

ensure that such members include the following: 

(A) Individuals with disabilities of all ages. 

(B) Senior individuals. 

(C) Representatives of individuals with disabilities. 
Sec. 8002 PPACA (Consolidated) 792 

(D) Representatives of senior individuals. 

(E) Representatives of workforce and labor organizations. 

(F) Representatives of home and community-based 

service providers. 

(G) Representatives of assisted living providers. 

(d) INCLUSION OF CLASS PROGRAM INFORMATION IN THE NA- TIONAL CLEARINGHOUSE FOR LONG-TERM CARE INFORMATION; EXTENSION OF FUNDING.—øAs revised by section 10801(b)¿ Section 

6021(d) of the Deficit Reduction Act of 2005 (42 U.S.C. 1396p note) 

is amended— 

(1) in paragraph (2)(A)— 

(A) in clause (ii), by striking ‘‘and’’ at the end; 

(B) in clause (iii), by striking the period at the end and 

inserting ‘‘; and’’; and 

(C) by adding at the end the following: 

‘‘(iv) include information regarding the CLASS 

program established under title XXXII of the Public 

Health Service Act and information regarding how 

benefits provided under a CLASS Independence Benefit Plan differ from disability insurance benefits. øAs 

revised by section 10801(c)¿’’; and 

(2) in paragraph (3), by striking ‘‘2010’’ and inserting 

‘‘2015’’. 

(e) EFFECTIVE DATE.—The amendments made by subsections 

(a), (b), and (d) take effect on January 1, 2011. 

(f) RULE OF CONSTRUCTION.—Nothing in this title or the 

amendments made by this title are intended to replace or displace 

public or private disability insurance benefits, including such benefits that are for income replacement. 
793 Sec. 9001 PPACA (Consolidated) \4980I IRC 

TITLE IX—REVENUE PROVISIONS 

Subtitle A—Revenue Offset Provisions 

SEC. 9001. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED 

HEALTH COVERAGE. 

(a) IN GENERAL.—Chapter 43 of the Internal Revenue Code of 

1986, as amended by section 1513, is amended by adding at the 

end the following: 

‘‘SEC. 4980I. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED 

HEALTH COVERAGE. 

‘‘(a) IMPOSITION OF TAX.—If— 

‘‘(1) an employee is covered under any applicable employersponsored coverage of an employer at any time during a taxable period, and 

‘‘(2) there is any excess benefit with respect to the coverage, 

there is hereby imposed a tax equal to 40 percent of the excess benefit. 

‘‘(b) EXCESS BENEFIT.—For purposes of this section— 

‘‘(1) IN GENERAL.—The term ‘excess benefit’ means, with 

respect to any applicable employer-sponsored coverage made 

available by an employer to an employee during any taxable 

period, the sum of the excess amounts determined under paragraph (2) for months during the taxable period. 

‘‘(2) MONTHLY EXCESS AMOUNT.—The excess amount determined under this paragraph for any month is the excess (if 

any) of— 

‘‘(A) the aggregate cost of the applicable employersponsored coverage of the employee for the month, over 

‘‘(B) an amount equal to 1⁄12 of the annual limitation 

under paragraph (3) for the calendar year in which the 

month occurs. 

‘‘(3) ANNUAL LIMITATION.—For purposes of this subsection— 

‘‘(A) IN GENERAL.—The annual limitation under this 

paragraph for any calendar year is the dollar limit determined under subparagraph (C) for the calendar year. 

‘‘(B) APPLICABLE ANNUAL LIMITATION.—øAs revised by 

section 1401(a) of HCERA¿ 

‘‘(i) IN GENERAL.—Except as provided in clause (ii), 

the annual limitation which applies for any month 

shall be determined on the basis of the type of coverage (as determined under subsection (f)(1)) provided 

to the employee by the employer as of the beginning 

of the month. 

‘‘(ii) MULTIEMPLOYER PLAN COVERAGE.—Any coverage provided under a multiemployer plan (as defined 

in section 414(f)) shall be treated as coverage other 

than self-only coverage. øAs added by section 

1401(a)(1)(B)of HCERA¿ 

‘‘(C) APPLICABLE DOLLAR LIMIT.—øAs revised by section 

1401(a)(2) of HCERA¿ 
Sec. 9001\4980I IRC PPACA (Consolidated) 794 

‘‘(i) 2018.—In the case of 2018, the dollar limit 

under this subparagraph is— 

‘‘(I) in the case of an employee with self-only 

coverage, $10,200 multiplied by the health cost 

adjustment percentage (determined by only taking 

into account self-only coverage), and 

‘‘(II) in the case of an employee with coverage 

other than self-only coverage, $27,500 multiplied 

by the health cost adjustment percentage (determined by only taking into account coverage other 

than self-only coverage). 

‘‘(ii) HEALTH COST ADJUSTMENT PERCENTAGE.—For 

purposes of clause (i), the health cost adjustment percentage is equal to 100 percent plus the excess (if any) 

of— 

‘‘(I) the percentage by which the per employee 

cost for providing coverage under the Blue Cross/ 

Blue Shield standard benefit option under the 

Federal Employees Health Benefits Plan for plan 

year 2018 (determined by using the benefit package for such coverage in 2010) exceeds such cost 

for plan year 2010, over 

‘‘(II) 55 percent. 

‘‘(iii) AGE AND GENDER ADJUSTMENT.— 

‘‘(I) IN GENERAL.—The amount determined 

under subclause (I) or (II) of clause (i), whichever 

is applicable, for any taxable period shall be increased by the amount determined under subclause (II). 

‘‘(II) AMOUNT DETERMINED.—The amount determined under this subclause is an amount equal 

to the excess (if any) of— 

‘‘(aa) the premium cost of the Blue Cross/ 

Blue Shield standard benefit option under the 

Federal Employees Health Benefits Plan for 

the type of coverage provided such individual 

in such taxable period if priced for the age 

and gender characteristics of all employees of 

the individual’s employer, over 

‘‘(bb) that premium cost for the provision 

of such coverage under such option in such 

taxable period if priced for the age and gender 

characteristics of the national workforce. 

‘‘(iv) EXCEPTION FOR CERTAIN INDIVIDUALS.—In the 

case of an individual who is a qualified retiree or who 

participates in a plan sponsored by an employer the 

majority of whose employees covered by the plan are 

engaged in a high-risk profession or employed to repair or install electrical or telecommunications lines— 

øAs revised by section 1401(a)(2) of HCERA¿ 

‘‘(I) the dollar amount in clause (i)(I) shall be 

increased by $1,650, and 
795 Sec. 9001 PPACA (Consolidated) \4980I IRC 

‘‘(II) the dollar amount in clause (i)(II) shall 

be increased by $3,450, øsic-final punctuation incorrect¿ 

‘‘(v) SUBSEQUENT YEARS.—In the case of any calendar year after 2018, each of the dollar amounts 

under clauses (i) (after the application of clause (ii)) 

and (iv) shall be increased to the amount equal to such 

amount as in effect for the calendar year preceding 

such year, increased by an amount equal to the product of— 

‘‘(I) such amount as so in effect, multiplied by 

‘‘(II) the cost-of-living adjustment determined 

under section 1(f)(3) for such year (determined by 

substituting the calendar year that is 2 years before such year for ‘1992’ in subparagraph (B) 

thereof), increased by 1 percentage point in the 

case of determinations for calendar years beginning before 2020. 

If any amount determined under this clause is not a 

multiple of $50, such amount shall be rounded to the 

nearest multiple of $50. øNote: a subparagraph (D) 

was stricken by section 1401(a)(3) of HCERA¿ 

‘‘(c) LIABILITY TO PAY TAX.— 

‘‘(1) IN GENERAL.—Each coverage provider shall pay the 

tax imposed by subsection (a) on its applicable share of the excess benefit with respect to an employee for any taxable period. 

‘‘(2) COVERAGE PROVIDER.—For purposes of this subsection, 

the term ‘coverage provider’ means each of the following: 

‘‘(A) HEALTH INSURANCE COVERAGE.—If the applicable 

employer-sponsored coverage consists of coverage under a 

group health plan which provides health insurance coverage, the health insurance issuer. 

‘‘(B) HSA AND MSA CONTRIBUTIONS.—If the applicable 

employer-sponsored coverage consists of coverage under an 

arrangement under which the employer makes contributions described in subsection (b) or (d) of section 106, the 

employer. 

‘‘(C) OTHER COVERAGE.—In the case of any other applicable employer-sponsored coverage, the person that administers the plan benefits. 

‘‘(3) APPLICABLE SHARE.—For purposes of this subsection, a 

coverage provider’s applicable share of an excess benefit for 

any taxable period is the amount which bears the same ratio 

to the amount of such excess benefit as— 

‘‘(A) the cost of the applicable employer-sponsored coverage provided by the provider to the employee during 

such period, bears to 

‘‘(B) the aggregate cost of all applicable employer-sponsored coverage provided to the employee by all coverage 

providers during such period. 

‘‘(4) RESPONSIBILITY TO CALCULATE TAX AND APPLICABLE

SHARES.— 

‘‘(A) IN GENERAL.—Each employer shall— 
Sec. 9001\4980I IRC PPACA (Consolidated) 796 

‘‘(i) calculate for each taxable period the amount of 

the excess benefit subject to the tax imposed by subsection (a) and the applicable share of such excess benefit for each coverage provider, and 

‘‘(ii) notify, at such time and in such manner as 

the Secretary may prescribe, the Secretary and each 

coverage provider of the amount so determined for the 

provider. 

‘‘(B) SPECIAL RULE FOR MULTIEMPLOYER PLANS.—In the 

case of applicable employer-sponsored coverage made 

available to employees through a multiemployer plan (as 

defined in section 414(f)), the plan sponsor shall make the 

calculations, and provide the notice, required under subparagraph (A). 

‘‘(d) APPLICABLE EMPLOYER-SPONSORED COVERAGE; COST.—For 

purposes of this section— 

‘‘(1) APPLICABLE EMPLOYER-SPONSORED COVERAGE.— ‘‘(A) IN GENERAL.—The term ‘applicable employersponsored coverage’ means, with respect to any employee, 

coverage under any group health plan made available to 

the employee by an employer which is excludable from the 

employee’s gross income under section 106, or would be so 

excludable if it were employer-provided coverage (within 

the meaning of such section 106). 

‘‘(B) EXCEPTIONS.—The term ‘applicable employersponsored coverage’ shall not include— 

‘‘(i) any coverage (whether through insurance or 

otherwise) described in section 9832(c)(1) (other than 

subparagraph (G) thereof) or for long-term care, or øAs 

revised by section 10901(b)¿ 

‘‘(ii) any policy under a separate policy, certificate, 

or contract of insurance which provides benefits substantially all of which are for treatment of the mouth 

(including any organ or structure within the mouth) or 

for treatment of the eye, or ¿As added by section 

1401(a)(4) of HCERA¿ 

‘‘(iii) any coverage described in section 9832(c)(3) 

the payment for which is not excludable from gross income and for which a deduction under section 162(l) is 

not allowable. 

‘‘(C) COVERAGE INCLUDES EMPLOYEE PAID PORTION.— 

Coverage shall be treated as applicable employer-sponsored coverage without regard to whether the employer or 

employee pays for the coverage. 

‘‘(D) SELF-EMPLOYED INDIVIDUAL.—In the case of an individual who is an employee within the meaning of section 

401(c)(1), coverage under any group health plan providing 

health insurance coverage shall be treated as applicable 

employer-sponsored coverage if a deduction is allowable 

under section 162(l) with respect to all or any portion of 

the cost of the coverage. 

‘‘(E) GOVERNMENTAL PLANS INCLUDED.—Applicable employer-sponsored coverage shall include coverage under 

any group health plan established and maintained pri-
797 Sec. 9001 PPACA (Consolidated) \4980I IRC 

marily for its civilian employees by the Government of the 

United States, by the government of any State or political 

subdivision thereof, or by any agency or instrumentality of 

any such government. 

‘‘(2) DETERMINATION OF COST.— 

‘‘(A) IN GENERAL.—The cost of applicable employersponsored coverage shall be determined under rules similar to the rules of section 4980B(f)(4), except that in determining such cost, any portion of the cost of such coverage 

which is attributable to the tax imposed under this section 

shall not be taken into account and the amount of such 

cost shall be calculated separately for self-only coverage 

and other coverage. In the case of applicable employersponsored coverage which provides coverage to retired employees, the plan may elect to treat a retired employee who 

has not attained the age of 65 and a retired employee who 

has attained the age of 65 as similarly situated beneficiaries. 

‘‘(B) HEALTH FSAS.—In the case of applicable employer-sponsored coverage consisting of coverage under a 

flexible spending arrangement (as defined in section 

106(c)(2)), the cost of the coverage shall be equal to the 

sum of— 

‘‘(i) the amount of employer contributions under 

any salary reduction election under the arrangement, 

plus 

‘‘(ii) the amount determined under subparagraph 

(A) with respect to any reimbursement under the arrangement in excess of the contributions described in 

clause (i). 

‘‘(C) ARCHER MSAS AND HSAS.—In the case of applicable employer-sponsored coverage consisting of coverage 

under an arrangement under which the employer makes 

contributions described in subsection (b) or (d) of section 

106, the cost of the coverage shall be equal to the amount 

of employer contributions under the arrangement. 

‘‘(D) ALLOCATION ON A MONTHLY BASIS.—If cost is determined on other than a monthly basis, the cost shall be 

allocated to months in a taxable period on such basis as 

the Secretary may prescribe. 

‘‘(3) EMPLOYEE.—The term ‘employee’ includes any former 

employee, surviving spouse, or other primary insured individual. øAs added by section 1401(a)(5) of HCERA¿ 

‘‘(e) PENALTY FOR FAILURE TO PROPERLY CALCULATE EXCESS

BENEFIT.— 

‘‘(1) IN GENERAL.—If, for any taxable period, the tax imposed by subsection (a) exceeds the tax determined under such 

subsection with respect to the total excess benefit calculated by 

the employer or plan sponsor under subsection (c)(4)— 

‘‘(A) each coverage provider shall pay the tax on its applicable share (determined in the same manner as under 

subsection (c)(4)) of the excess, but no penalty shall be imposed on the provider with respect to such amount, and 
Sec. 9001\4980I IRC PPACA (Consolidated) 798 

‘‘(B) the employer or plan sponsor shall, in addition to 

any tax imposed by subsection (a), pay a penalty in an 

amount equal to such excess, plus interest at the underpayment rate determined under section 6621 for the period 

beginning on the due date for the payment of tax imposed 

by subsection (a) to which the excess relates and ending on 

the date of payment of the penalty. 

‘‘(2) LIMITATIONS ON PENALTY.— 

‘‘(A) PENALTY NOT TO APPLY WHERE FAILURE NOT DISCOVERED EXERCISING REASONABLE DILIGENCE.—No penalty 

shall be imposed by paragraph (1)(B) on any failure to 

properly calculate the excess benefit during any period for 

which it is established to the satisfaction of the Secretary 

that the employer or plan sponsor neither knew, nor exercising reasonable diligence would have known, that such 

failure existed. 

‘‘(B) PENALTY NOT TO APPLY TO FAILURES CORRECTED

WITHIN 30 DAYS.—No penalty shall be imposed by paragraph (1)(B) on any such failure if— 

‘‘(i) such failure was due to reasonable cause and 

not to willful neglect, and 

‘‘(ii) such failure is corrected during the 30-day period beginning on the 1st date that the employer 

knew, or exercising reasonable diligence would have 

known, that such failure existed. 

‘‘(C) WAIVER BY SECRETARY.—In the case of any such 

failure which is due to reasonable cause and not to willful 

neglect, the Secretary may waive part or all of the penalty 

imposed by paragraph (1), to the extent that the payment 

of such penalty would be excessive or otherwise inequitable relative to the failure involved. 

‘‘(f) OTHER DEFINITIONS AND SPECIAL RULES.—For purposes of 

this section— 

‘‘(1) COVERAGE DETERMINATIONS.— 

‘‘(A) IN GENERAL.—Except as provided in subparagraph (B), an employee shall be treated as having self-only 

coverage with respect to any applicable employer-sponsored coverage of an employer. 

‘‘(B) MINIMUM ESSENTIAL COVERAGE.—An employee 

shall be treated as having coverage other than self-only 

coverage only if the employee is enrolled in coverage other 

than self-only coverage in a group health plan which provides minimum essential coverage (as defined in section 

5000A(f)) to the employee and at least one other beneficiary, and the benefits provided under such minimum essential coverage do not vary based on whether any individual covered under such coverage is the employee or another beneficiary. 

‘‘(2) QUALIFIED RETIREE.—The term ‘qualified retiree’ 

means any individual who— 

‘‘(A) is receiving coverage by reason of being a retiree, 

‘‘(B) has attained age 55, and 
799 Sec. 9001 PPACA (Consolidated) \4980I IRC 

‘‘(C) is not entitled to benefits or eligible for enrollment under the Medicare program under title XVIII of the 

Social Security Act. 

‘‘(3) EMPLOYEES ENGAGED IN HIGH-RISK PROFESSION.—The 

term ‘employees engaged in a high-risk profession’ means law 

enforcement officers (as such term is defined in section 1204 of 

the Omnibus Crime Control and Safe Streets Act of 1968), employees in fire protection activities (as such term is defined in 

section 3(y) of the Fair Labor Standards Act of 1938), individuals who provide out-of-hospital emergency medical care (including emergency medical technicians, paramedics, and firstresponders), 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), and individuals engaged in the construction, mining, agriculture (not including food processing), 

forestry, and fishing industries. Such term includes an employee who is retired from a high-risk profession described in 

the preceding sentence, if such employee satisfied the requirements of such sentence for a period of not less than 20 years 

during the employee’s employment. øAs revised by section 

10901(a)¿ 

‘‘(4) GROUP HEALTH PLAN.—The term ‘group health plan’ 

has the meaning given such term by section 5000(b)(1). 

‘‘(5) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE

ISSUER.— 

‘‘(A) HEALTH INSURANCE COVERAGE.—The term ‘health 

insurance coverage’ has the meaning given such term by 

section 9832(b)(1) (applied without regard to subparagraph 

(B) thereof, except as provided by the Secretary in regulations). 

‘‘(B) HEALTH INSURANCE ISSUER.—The term ‘health insurance issuer’ has the meaning given such term by section 9832(b)(2). 

‘‘(6) PERSON THAT ADMINISTERS THE PLAN BENEFITS.—The 

term ‘person that administers the plan benefits’ shall include 

the plan sponsor if the plan sponsor administers benefits under 

the plan. 

‘‘(7) PLAN SPONSOR.—The term ‘plan sponsor’ has the 

meaning given such term in section 3(16)(B) of the Employee 

Retirement Income Security Act of 1974. 

‘‘(8) TAXABLE PERIOD.—The term ‘taxable period’ means the 

calendar year or such shorter period as the Secretary may prescribe. The Secretary may have different taxable periods for 

employers of varying sizes. 

‘‘(9) AGGREGATION RULES.—All employers treated as a single employer under subsection (b), (c), (m), or (o) of section 414 

shall be treated as a single employer. 

‘‘(10) DENIAL OF DEDUCTION.—For denial of a deduction for 

the tax imposed by this section, see section 275(a)(6). 

‘‘(g) REGULATIONS.—The Secretary shall prescribe such regulations as may be necessary to carry out this section.’’. 
Sec. 9001 PPACA (Consolidated) 800 

(b) CLERICAL AMENDMENT.—The table of sections for chapter 

43 of such Code, as amended by section 1513, is amended by adding at the end the following new item: 

‘‘Sec. 4980I. Excise tax on high cost employer-sponsored health coverage.’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2017. 

øAs revised by section 1401(b)(1) of HCERA¿ 

SEC. 9002. INCLUSION OF COST OF EMPLOYER-SPONSORED HEALTH 

COVERAGE ON W–2. 

(a) IN GENERAL.—Section 6051(a) of the Internal Revenue Code 

of 1986 (relating to receipts for employees) 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 adding after 

paragraph (13) the following new paragraph: 

‘‘(14) the aggregate cost (determined under rules similar to 

the rules of section 4980B(f)(4)) of applicable employer-sponsored coverage (as defined in section 4980I(d)(1)), except that 

this paragraph shall not apply to— 

‘‘(A) coverage to which paragraphs (11) and (12) apply, 

or 

‘‘(B) the amount of any salary reduction contributions 

to a flexible spending arrangement (within the meaning of 

section 125).’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2010. 

SEC. 9003. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR 

PRESCRIBED DRUG OR INSULIN. 

(a) HSAS.—Subparagraph (A) of section 223(d)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following: ‘‘Such term shall include an amount paid for medicine or 

a drug only if such medicine or drug is a prescribed drug (determined without regard to whether such drug is available without a 

prescription) or is insulin.’’. 

(b) ARCHER MSAS.—Subparagraph (A) of section 220(d)(2) of 

the Internal Revenue Code of 1986 is amended by adding at the 

end the following: ‘‘Such term shall include an amount paid for 

medicine or a drug only if such medicine or drug is a prescribed 

drug (determined without regard to whether such drug is available 

without a prescription) or is insulin.’’. 

(c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS AND HEALTH

REIMBURSEMENT ARRANGEMENTS.—Section 106 of the Internal Revenue Code of 1986 is amended by adding at the end the following 

new subsection: 

‘‘(f) REIMBURSEMENTS FOR MEDICINE RESTRICTED TO PRESCRIBED DRUGS AND INSULIN.—For purposes of this section and section 105, reimbursement for expenses incurred for a medicine or a 

drug shall be treated as a reimbursement for medical expenses only 

if such medicine or drug is a prescribed drug (determined without 

regard to whether such drug is available without a prescription) or 

is insulin.’’. 

(d) EFFECTIVE DATES.— 

(1) DISTRIBUTIONS FROM SAVINGS ACCOUNTS.—The amendments made by subsections (a) and (b) shall apply to amounts 
801 Sec. 9006 PPACA (Consolidated) 

paid with respect to taxable years beginning after December 

31, 2010. 

(2) REIMBURSEMENTS.—The amendment made by subsection (c) shall apply to expenses incurred with respect to taxable years beginning after December 31, 2010. 

SEC. 9004. INCREASE IN ADDITIONAL TAX ON DISTRIBUTIONS FROM 

HSAS AND ARCHER MSAS NOT USED FOR QUALIFIED MEDICAL EXPENSES. 

(a) HSAS.—Section 223(f)(4)(A) of the Internal Revenue Code of 

1986 is amended by striking ‘‘10 percent’’ and inserting ‘‘20 percent’’. 

(b) ARCHER MSAS.—Section 220(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking ‘‘15 percent’’ and inserting ‘‘20 percent’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to distributions made after December 31, 2010. 

SEC. 9005. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS UNDER CAFETERIA PLANS. 

(a) IN GENERAL.—Section 125 of the Internal Revenue Code of 

1986 is amended— 

(1) by redesignating subsections (i) and (j) as subsections 

(j) and (k), respectively, and 

(2) by inserting after subsection (h) the following new subsection: 

‘‘(i) LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS.—øReplaced by section 10902(a)¿ 

‘‘(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.—øAs revised by section 

1403(b) of HCERA¿ In the case of any taxable year beginning 

after December 31, 2013, 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 2012’ for ‘calendar year 1992’ in subparagraph (B) thereof. 

If any increase determined under this paragraph is not a multiple of $50, such increase shall be rounded to the next lowest 

multiple of $50.’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2010 

øHowever, likely intent was to substitute ‘‘2012’’ for ‘‘2010’’ under 

section 10902(b), as revised by section 1403(a) of HCERA.¿ 

SEC. 9006. EXPANSION OF INFORMATION REPORTING REQUIREMENTS. 

(a) IN GENERAL.—Section 6041 of the Internal Revenue Code 

of 1986 is amended by adding at the end the following new subsections: 
Sec. 9007 PPACA (Consolidated) 802 

‘‘(h) APPLICATION TO CORPORATIONS.—Notwithstanding any 

regulation prescribed by the Secretary before the date of the enactment of this subsection, for purposes of this section the term ‘person’ includes any corporation that is not an organization exempt 

from tax under section 501(a). 

‘‘(i) REGULATIONS.—The Secretary may prescribe such regulations and other guidance as may be appropriate or necessary to 

carry out the purposes of this section, including rules to prevent 

duplicative reporting of transactions.’’. 

(b) PAYMENTS FOR PROPERTY AND OTHER GROSS PROCEEDS.— Subsection (a) of section 6041 of the Internal Revenue Code of 1986 

is amended— 

(1) by inserting ‘‘amounts in consideration for property,’’ 

after ‘‘wages,’’, 

(2) by inserting ‘‘gross proceeds,’’ after ‘‘emoluments, or 

other’’, and 

(3) by inserting ‘‘gross proceeds,’’ after ‘‘setting forth the 

amount of such’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to payments made after December 31, 2011. 

SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS. 

(a) REQUIREMENTS TO QUALIFY AS SECTION 501(C)(3) CHARI- TABLE HOSPITAL ORGANIZATION.—Section 501 of the Internal Revenue Code of 1986 (relating to exemption from tax on corporations, 

certain trusts, etc.) is amended by redesignating subsection (r) as 

subsection (s) and by inserting after subsection (q) the following 

new subsection: 

‘‘(r) ADDITIONAL REQUIREMENTS FOR CERTAIN HOSPITALS.— ‘‘(1) IN GENERAL.—A hospital organization to which this 

subsection applies shall not be treated as described in subsection (c)(3) unless the organization— 

‘‘(A) meets the community health needs assessment requirements described in paragraph (3), 

‘‘(B) meets the financial assistance policy requirements 

described in paragraph (4), 

‘‘(C) meets the requirements on charges described in 

paragraph (5), and 

‘‘(D) meets the billing and collection requirement described in paragraph (6). 

‘‘(2) HOSPITAL ORGANIZATIONS TO WHICH SUBSECTION APPLIES.— 

‘‘(A) IN GENERAL.—This subsection shall apply to— 

‘‘(i) an organization which operates a facility 

which is required by a State to be licensed, registered, 

or similarly recognized as a hospital, and 

‘‘(ii) any other organization which the Secretary 

determines has the provision of hospital care as its 

principal function or purpose constituting the basis for 

its exemption under subsection (c)(3) (determined 

without regard to this subsection). 

‘‘(B) ORGANIZATIONS WITH MORE THAN 1 HOSPITAL FACILITY.—If a hospital organization operates more than 1 

hospital facility— 
803 Sec. 9007 PPACA (Consolidated) 

‘‘(i) the organization shall meet the requirements 

of this subsection separately with respect to each such 

facility, and 

‘‘(ii) the organization shall not be treated as described in subsection (c)(3) with respect to any such facility for which such requirements are not separately 

met. 

‘‘(3) COMMUNITY HEALTH NEEDS ASSESSMENTS.— ‘‘(A) IN GENERAL.—An organization meets the requirements of this paragraph with respect to any taxable year 

only if the organization— 

‘‘(i) has conducted a community health needs assessment which meets the requirements of subparagraph (B) in such taxable year or in either of the 2 

taxable years immediately preceding such taxable 

year, and 

‘‘(ii) has adopted an implementation strategy to 

meet the community health needs identified through 

such assessment. 

‘‘(B) COMMUNITY HEALTH NEEDS ASSESSMENT.—A community health needs assessment meets the requirements 

of this paragraph if such community health needs assessment— 

‘‘(i) takes into account input from persons who 

represent the broad interests of the community served 

by the hospital facility, including those with special 

knowledge of or expertise in public health, and 

‘‘(ii) is made widely available to the public. 

‘‘(4) FINANCIAL ASSISTANCE POLICY.—An organization 

meets the requirements of this paragraph if the organization 

establishes the following policies: 

‘‘(A) FINANCIAL ASSISTANCE POLICY.—A written financial assistance policy which includes— 

‘‘(i) eligibility criteria for financial assistance, and 

whether such assistance includes free or discounted 

care, 

‘‘(ii) the basis for calculating amounts charged to 

patients, 

‘‘(iii) the method for applying for financial assistance, 

‘‘(iv) in the case of an organization which does not 

have a separate billing and collections policy, the actions the organization may take in the event of nonpayment, including collections action and reporting to 

credit agencies, and 

‘‘(v) measures to widely publicize the policy within 

the community to be served by the organization. 

‘‘(B) POLICY RELATING TO EMERGENCY MEDICAL CARE.— 

A written policy requiring the organization to provide, 

without discrimination, care for emergency medical conditions (within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd)) to individuals regardless of 

their eligibility under the financial assistance policy described in subparagraph (A). 
Sec. 9007\4959 IRC PPACA (Consolidated) 804 

‘‘(5) LIMITATION ON CHARGES.—An organization meets the 

requirements of this paragraph if the organization— 

‘‘(A) limits amounts charged for emergency or other 

medically necessary care provided to individuals eligible 

for assistance under the financial assistance policy described in paragraph (4)(A) to not more than the amounts 

generally billed to individuals who have insurance covering such care, and øAs revised by section 10903(a)¿ 

‘‘(B) prohibits the use of gross charges. 

‘‘(6) BILLING AND COLLECTION REQUIREMENTS.—An organization meets the requirement of this paragraph only if the organization does not engage in extraordinary collection actions 

before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the 

financial assistance policy described in paragraph (4)(A). 

‘‘(7) REGULATORY AUTHORITY.—The Secretary shall issue 

such regulations and guidance as may be necessary to carry 

out the provisions of this subsection, including guidance relating to what constitutes reasonable efforts to determine the eligibility of a patient under a financial assistance policy for purposes of paragraph (6).’’. 

(b) EXCISE TAX FOR FAILURES TO MEET HOSPITAL EXEMPTION

REQUIREMENTS.— 

(1) IN GENERAL.—Subchapter D of chapter 42 of the Internal Revenue Code of 1986 (relating to failure by certain charitable organizations to meet certain qualification requirements) 

is amended by adding at the end the following new section: 

‘‘SEC. 4959. TAXES ON FAILURES BY HOSPITAL ORGANIZATIONS. 

‘‘If a hospital organization to which section 501(r) applies fails 

to meet the requirement of section 501(r)(3) for any taxable year, 

there is imposed on the organization a tax equal to $50,000.’’. 

(2) CONFORMING AMENDMENT.—The table of sections for 

subchapter D of chapter 42 of such Code is amended by adding 

at the end the following new item: 

‘‘Sec. 4959. Taxes on failures by hospital organizations.’’. 

(c) MANDATORY REVIEW OF TAX EXEMPTION FOR HOSPITALS.— 

The Secretary of the Treasury or the Secretary’s delegate shall review at least once every 3 years the community benefit activities 

of each hospital organization to which section 501(r) of the Internal 

Revenue Code of 1986 (as added by this section) applies. 

(d) ADDITIONAL REPORTING REQUIREMENTS.— 

(1) COMMUNITY HEALTH NEEDS ASSESSMENTS AND AUDITED

FINANCIAL STATEMENTS.—Section 6033(b) of the Internal Revenue Code of 1986 (relating to certain organizations described 

in section 501(c)(3)) is amended by striking ‘‘and’’ at the end 

of paragraph (14), by redesignating paragraph (15) as paragraph (16), and by inserting after paragraph (14) the following 

new paragraph: 

‘‘(15) in the case of an organization to which the requirements of section 501(r) apply for the taxable year— 

‘‘(A) a description of how the organization is addressing the needs identified in each community health needs 

assessment conducted under section 501(r)(3) and a de-
805 Sec. 9007 PPACA (Consolidated) 

scription of any such needs that are not being addressed 

together with the reasons why such needs are not being 

addressed, and 

‘‘(B) the audited financial statements of such organization (or, in the case of an organization the financial statements of which are included in a consolidated financial 

statement with other organizations, such consolidated financial statement).’’. 

(2) TAXES.—Section 6033(b)(10) of such Code is amended 

by striking ‘‘and’’ at the end of subparagraph (B), by inserting 

‘‘and’’ at the end of subparagraph (C), and by adding at the end 

the following new subparagraph: 

‘‘(D) section 4959 (relating to taxes on failures by hospital organizations),’’. 

(e) REPORTS.— (1) REPORT ON LEVELS OF CHARITY CARE.—The Secretary of 

the Treasury, in consultation with the Secretary of Health and 

Human Services, shall submit to the Committees on Ways and 

Means, Education and Labor, and Energy and Commerce of 

the House of Representatives and to the Committees on Finance and Health, Education, Labor, and Pensions of the Senate an annual report on the following: 

(A) Information with respect to private tax-exempt, 

taxable, and government-owned hospitals regarding— 

(i) levels of charity care provided, 

(ii) bad debt expenses, 

(iii) unreimbursed costs for services provided with 

respect to means-tested government programs, and 

(iv) unreimbursed costs for services provided with 

respect to non-means tested government programs. 

(B) Information with respect to private tax-exempt 

hospitals regarding costs incurred for community benefit 

activities. 

(2) REPORT ON TRENDS.— 

(A) STUDY.—The Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall conduct a study on trends in the information required to be reported under paragraph (1). 

(B) REPORT.—Not later than 5 years after the date of 

the enactment of this Act, the Secretary of the Treasury, 

in consultation with the Secretary of Health and Human 

Services, shall submit a report on the study conducted 

under subparagraph (A) to the Committees on Ways and 

Means, Education and Labor, and Energy and Commerce 

of the House of Representatives and to the Committees on 

Finance and Health, Education, Labor, and Pensions of the 

Senate. 

(f) EFFECTIVE DATES.— 

(1) IN GENERAL.—Except as provided in paragraphs (2) and 

(3), the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this 

Act. 

(2) COMMUNITY HEALTH NEEDS ASSESSMENT.—The requirements of section 501(r)(3) of the Internal Revenue Code of 
Sec. 9008 PPACA (Consolidated) 806 

1986, as added by subsection (a), shall apply to taxable years 

beginning after the date which is 2 years after the date of the 

enactment of this Act. 

(3) EXCISE TAX.—The amendments made by subsection (b) 

shall apply to failures occurring after the date of the enactment of this Act. 

SEC. 9008. IMPOSITION OF ANNUAL FEE ON BRANDED PRESCRIPTION 

PHARMACEUTICAL MANUFACTURERS AND IMPORTERS. 

(a) IMPOSITION OF FEE.— (1) IN GENERAL.—Each covered entity engaged in the business of manufacturing or importing branded prescription drugs 

shall pay to the Secretary of the Treasury not later than the 

annual payment date of each calendar year beginning after 

2010 a fee in an amount determined under subsection (b). øAs 

revised by section 1404(a)(1) of HCERA¿ 

(2) ANNUAL PAYMENT DATE.—For purposes of this section, 

the term ‘‘annual payment date’’ means with respect to any 

calendar year the date determined by the Secretary, but in no 

event later than September 30 of such calendar year. 

(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—øAs revised by section 1404(a)(2)(A) of HCERA¿ 

(A) the covered entity’s branded prescription drug 

sales taken into account during the preceding calendar 

year, bear to 

(B) the aggregate branded prescription drug sales of 

all covered entities taken into account during such preceding calendar year. 

(2) SALES TAKEN INTO ACCOUNT.—For purposes of paragraph (1), the branded prescription drug sales 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 aggregate branded prescription drug sales during the calendar year that are: 

The percentage of such 

sales taken into account 

is: 

Not more than $5,000,000 .......................................... 0 percent 

More than $5,000,000 but not more than 

$125,000,000.

10 percent 

More than $125,000,000 but not more than 

$225,000,000.

40 percent 

More than $225,000,000 but not more than 

$400,000,000.

75 percent 

More than $400,000,000 ............................................. 100 percent. 

(3) SECRETARIAL DETERMINATION.—The Secretary of the 

Treasury shall calculate the amount of each covered entity’s 

fee for any calendar year under paragraph (1). In calculating 
807 Sec. 9008 PPACA (Consolidated) 

such amount, the Secretary of the Treasury shall determine 

such covered entity’s branded prescription drug sales on the 

basis of reports submitted under subsection (g) and through 

the use of any other source of information available to the Secretary of the Treasury. 

(4) APPLICABLE AMOUNT.—øAs added by section 

1404(a)(2)(B) of HCERA¿ For purposes of paragraph (1), the 

applicable amount shall be determined in accordance with the 

following table: 

Calendar year Applicable amount 

2011 ..................................................................................................... $2,500,000,000 

2012 ..................................................................................................... $2,800,000,000 

2013 ..................................................................................................... $2,800,000,000 

2014 ..................................................................................................... $3,000,000,000 

2015 ..................................................................................................... $3,000,000,000 

2016 ..................................................................................................... $3,000,000,000 

2017 ..................................................................................................... $4,000,000,000 

2018 ..................................................................................................... $4,100,000,000 

2019 and thereafter ............................................................................. $2,800,000,000. 

(c) TRANSFER OF FEES TO MEDICARE PART B TRUST FUND.— 

There is hereby appropriated to the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of the 

Social Security Act an amount equal to the fees received by the 

Secretary of the Treasury under subsection (a). 

(d) COVERED ENTITY.— 

(1) IN GENERAL.—For purposes of this section, the term 

‘‘covered entity’’ means any manufacturer or importer with 

gross receipts from branded prescription drug sales. 

(2) CONTROLLED GROUPS.— 

(A) IN GENERAL.—For purposes of this subsection, all 

persons treated as a single employer under subsection (a) 

or (b) of section 52 of the Internal Revenue Code of 1986 

or subsection (m) or (o) of section 414 of such Code shall 

be treated as a single covered entity. 

(B) INCLUSION OF FOREIGN CORPORATIONS.—For purposes of subparagraph (A), in applying subsections (a) and 

(b) of section 52 of such Code to this section, section 1563 

of such Code shall be applied without regard to subsection 

(b)(2)(C) thereof. 

(3) JOINT AND SEVERAL LIABILITY.—If more than one person is liable for payment of the fee under subsection (a) with 

respect to a single covered entity by reason of the application 

of paragraph (2), all such persons shall be jointly and severally 

liable for payment of such fee. øAs added by section 1404(a)(3) 

of HCERA¿ 

(e) BRANDED PRESCRIPTION DRUG SALES.—For purposes of this 

section— 

(1) IN GENERAL.—The term ‘‘branded prescription drug 

sales’’ means sales of branded prescription drugs to any specified government program or pursuant to coverage under any 

such program. 

(2) BRANDED PRESCRIPTION DRUGS.— 
Sec. 9008 PPACA (Consolidated) 808 

(A) IN GENERAL.—The term ‘‘branded prescription 

drug’’ means— 

(i) any prescription drug the application for which 

was submitted under section 505(b) of the Federal 

Food, Drug, and Cosmetic Act (21 U.S.C. 355(b)), or 

(ii) any biological product the license for which 

was submitted under section 351(a) of the Public 

Health Service Act (42 U.S.C. 262(a)). 

(B) PRESCRIPTION DRUG.—For purposes of subparagraph (A)(i), the term ‘‘prescription drug’’ means any drug 

which is subject to section 503(b) of the Federal Food, 

Drug, and Cosmetic Act (21 U.S.C. 353(b)). 

(3) EXCLUSION OF ORPHAN DRUG SALES.—The term ‘‘branded prescription drug sales’’ shall not include sales of any drug 

or biological product with respect to which a credit was allowed 

for any taxable year under section 45C of the Internal Revenue 

Code of 1986. The preceding sentence shall not apply with respect to any such drug or biological product after the date on 

which such drug or biological product is approved by the Food 

and Drug Administration for marketing for any indication 

other than the treatment of the rare disease or condition with 

respect to which such credit was allowed. 

(4) SPECIFIED GOVERNMENT PROGRAM.—The term ‘‘specified 

government program’’ means— 

(A) the Medicare Part D program under part D of title 

XVIII of the Social Security Act, 

(B) the Medicare Part B program under part B of title 

XVIII of the Social Security Act, 

(C) the Medicaid program under title XIX of the Social 

Security Act, 

(D) any program under which branded prescription 

drugs are procured by the Department of Veterans Affairs, 

(E) any program under which branded prescription 

drugs are procured by the Department of Defense, or 

(F) the TRICARE retail pharmacy program under section 1074g of title 10, United States Code. 

(f) TAX TREATMENT OF FEES.—The fees imposed by this section— 

(1) for purposes of subtitle F of the Internal Revenue Code 

of 1986, shall be treated as excise taxes with respect to which 

only civil actions for refund under procedures of such subtitle 

shall apply, and 

(2) for purposes of section 275 of such Code, shall be considered to be a tax described in section 275(a)(6). 

(g) REPORTING REQUIREMENT.—Not later than the date determined by the Secretary of the Treasury following the end of any 

calendar year, the Secretary of Health and Human Services, the 

Secretary of Veterans Affairs, and the Secretary of Defense shall 

report to the Secretary of the Treasury, in such manner as the Secretary of the Treasury prescribes, the total branded prescription 

drug sales for each covered entity with respect to each specified 

government program under such Secretary’s jurisdiction using the 

following methodology: 
809 Sec. 9008 PPACA (Consolidated) 

(1) MEDICARE PART D PROGRAM.—The Secretary of Health 

and Human Services shall report, for each covered entity and 

for each branded prescription drug of the covered entity covered by the Medicare Part D program, the product of— 

(A) the per-unit ingredient cost, as reported to the Secretary of Health and Human Services by prescription drug 

plans and Medicare Advantage prescription drug plans, 

minus any per-unit rebate, discount, or other price concession provided by the covered entity, as reported to the Secretary of Health and Human Services by the prescription 

drug plans and Medicare Advantage prescription drug 

plans, and 

(B) the number of units of the branded prescription 

drug paid for under the Medicare Part D program. 

(2) MEDICARE PART B PROGRAM.—The Secretary of Health 

and Human Services shall report, for each covered entity and 

for each branded prescription drug of the covered entity covered by the Medicare Part B program under section 1862(a) of 

the Social Security Act, the product of— 

(A) the per-unit average sales price (as defined in section 1847A(c) of the Social Security Act) or the per-unit 

Part B payment rate for a separately paid branded prescription drug without a reported average sales price, and 

(B) the number of units of the branded prescription 

drug paid for under the Medicare Part B program. 

The Centers for Medicare and Medicaid Services shall establish a process for determining the units and the allocated price 

for purposes of this section for those branded prescription 

drugs that are not separately payable or for which National 

Drug Codes are not reported. 

(3) MEDICAID PROGRAM.—The Secretary of Health and 

Human Services shall report, for each covered entity and for 

each branded prescription drug of the covered entity covered 

under the Medicaid program, the product of— 

(A) the per-unit ingredient cost paid to pharmacies by 

States for the branded prescription drug dispensed to Medicaid beneficiaries, minus any per-unit rebate paid by the 

covered entity under section 1927 of the Social Security 

Act and any State supplemental rebate, and 

(B) the number of units of the branded prescription 

drug paid for under the Medicaid program. 

(4) DEPARTMENT OF VETERANS AFFAIRS PROGRAMS.—The 

Secretary of Veterans Affairs shall report, for each covered entity and for each branded prescription drug of the covered entity the total amount paid for each such branded prescription 

drug procured by the Department of Veterans Affairs for its 

beneficiaries. 

(5) DEPARTMENT OF DEFENSE PROGRAMS AND TRICARE.— 

The Secretary of Defense shall report, for each covered entity 

and for each branded prescription drug of the covered entity, 

the sum of— 

(A) the total amount paid for each such branded prescription drug procured by the Department of Defense for 

its beneficiaries, and 
Sec. 9009 PPACA (Consolidated) 810 

(B) for each such branded prescription drug dispensed 

under the TRICARE retail pharmacy program, the product 

of— 

(i) the per-unit ingredient cost, minus any perunit rebate paid by the covered entity, and 

(ii) the number of units of the branded prescription drug dispensed under such program. 

(h) SECRETARY.—For purposes of this section, the term ‘‘Secretary’’ includes the Secretary’s delegate. 

(i) GUIDANCE.—The Secretary of the Treasury shall publish 

guidance necessary to carry out the purposes of this section. 

(j) EFFECTIVE DATE.—øReplaced by section 1404(a)(4) of 

HCERA¿ This section shall apply to calendar years beginning after 

December 31, 2010. 

(k) CONFORMING AMENDMENT.—Section 1841(a) of the Social 

Security Act is amended by inserting ‘‘or section 9008(c) of the Patient Protection and Affordable Care Act of 2009’’ after ‘‘this part’’. 

SEC. 9009. øIMPOSITION OF ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS AND IMPORTERS¿øREPEALED AND REPLACED¿. 

øRepealed by section 1405(d) of HCERA, without redesignation 

of succeeding sections; previously amended by section 10904(a) of 

PPACA. Note section 1405(a)-(c) of HCERA amended the IRC to 

provide an excise tax on medical device manufacturers, as follows:¿ 

(a) ƒSec. 1405(a) of HCERA≈ In General.— Chapter 32 of the 

Internal Revenue Code of 1986 is amended— 

(1) by inserting after subchapter D the following new subchapter: 

‘‘Subchapter E—Medical Devices 

‘‘Sec. 4191. Medical devices. 

‘‘SEC. 4191. MEDICAL DEVICES. 

‘‘(a) IN GENERAL.—There is hereby imposed on the sale of any 

taxable medical device by the manufacturer, producer, or importer 

a tax equal to 2.3 percent of the price for which so sold. 

‘‘(b) TAXABLE MEDICAL DEVICE.—For purposes of this section— 

‘‘(1) IN GENERAL.—The term ‘taxable medical device’ means 

any device (as defined in section 201(h) of the Federal Food, 

Drug, and Cosmetic Act) intended for humans. 

‘‘(2) EXEMPTIONS.—Such term shall not include— 

‘‘(A) eyeglasses, 

‘‘(B) contact lenses, 

‘‘(C) hearing aids, and 

‘‘(D) any other medical device determined by the Secretary to be of a type which is generally purchased by the 

general public at retail for individual use.’’, and 

(2) by inserting after the item relating to subchapter D in 

the table of subchapters for such chapter the following new 

item: 

‘‘SUBCHAPTER E. MEDICAL DEVICES’’. 

(b) ƒSec. 1405(b) of HCERA:≈ Certain Exemptions Not to 

Apply.— 
811 Sec. 9010 PPACA (Consolidated) 

(1) Section 4221(a) of the Internal Revenue Code of 1986 is 

amended by adding at the end the following new sentence: ‘‘In 

the case of the tax imposed by section 4191, paragraphs (3), (4), 

(5), and (6) shall not apply.’’. 

(2) Section 6416(b)(2) of such Code is amended by adding 

at the end the following: ‘‘In the case of the tax imposed by section 4191, subparagraphs (B), (C), (D), and (E) shall not 

apply.’’. 

(c) ƒSec. 1405(c) of HCERA:≈ Effective Date.—The amendments 

made by this section shall apply to sales after December 31, 2012. 

SEC. 9010. IMPOSITION OF ANNUAL FEE ON HEALTH INSURANCE PROVIDERS. 

(a) IMPOSITION OF FEE.— 

(1) IN GENERAL.—Each covered entity engaged in the business of providing health insurance shall pay to the Secretary 

not later than the annual payment date of each calendar year 

beginning after 2013 a fee in an amount determined under 

subsection (b). øAmended by section 10905(f)(1) and section 

1406(a)(1) of HCERA¿ 

(2) ANNUAL PAYMENT DATE.—For purposes of this section, 

the term ‘‘annual payment date’’ means with respect to any 

calendar year the date determined by the Secretary, but in no 

event later than September 30 of such calendar year. 

(b) DETERMINATION OF FEE AMOUNT.—øReplaced by section 

10905(b)¿ 

(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)—øAs revised by section 1406(a)(2) of HCERA¿ 

(A) IN GENERAL.—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 net premiums written 

during the calendar year that are: 

The percentage of net 

premiums written that are 

taken into account is: 

Not more than $25,000,000 ........................................ 0 percent 

More than $25,000,000 but not more than 

$50,000,000.

50 percent 

More than $50,000,000 ............................................... 100 percent. 
Sec. 9010 PPACA (Consolidated) 812 

(B) PARTIAL EXCLUSION FOR CERTAIN EXEMPT ACTIVI- TIES.—After the application of subparagraph (A), only 50 

percent of the remaining net premiums written with respect to health insurance for any United States health risk 

that are attributable to the activities (other than activities 

of an unrelated trade or business as defined in section 513 

of the Internal Revenue Code of 1986) of any covered entity qualifying under paragraph (3), (4), (26), or (29) of section 501(c) of such Code and exempt from tax under section 501(a) of such Code shall be taken into account. 

(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. 

(c) COVERED ENTITY.—øAs revised by section 1406(a)(3) of 

HCERA¿ 

(1) IN GENERAL.—For purposes of this section, the term 

‘‘covered entity’’ means any entity which provides health insurance for any United States health risk during the calendar 

year in which the fee under this section is due. 

(2) EXCLUSION.—Such term does not include— 

(A) any employer to the extent that such employer 

self-insures its employees’ health risks, 

(B) any governmental entity, øAs revised by section 

10905(f)(2)¿ 

(C) any entity— øSubparagraphs (C) through (E) revised by section 10905(c) and subsequently rewritten in entirety, including striking subparagraph (E), by section 

1406(a)(3) of HCERA¿ 

(i) which is incorporated as a nonprofit corporation under a State law, 

(ii) no part of the net earnings of which inures to 

the benefit of any private shareholder or individual, no 

substantial part of the activities of which is carrying 

on propaganda, or otherwise attempting, to influence 

legislation (except as otherwise provided in section 

501(h) of the Internal Revenue Code of 1986), and 

which does not participate in, or intervene in (including the publishing or distributing of statements), any 

political campaign on behalf of (or in opposition to) 

any candidate for public office, and 

(iii) more than 80 percent of the gross revenues of 

which is received from government programs that target low-income, elderly, or disabled populations under 

titles XVIII, XIX, and XXI of the Social Security Act, 

and 

(D) any entity which is described in section 501(c)(9) 

of such Code and which is established by an entity (other 

than by an employer or employers) for purposes of providing health care benefits. 
813 Sec. 9010 PPACA (Consolidated) 

(3) CONTROLLED GROUPS.— 

(A) IN GENERAL.—For purposes of this subsection, all 

persons treated as a single employer under subsection (a) 

or (b) of section 52 of the Internal Revenue Code of 1986 

or subsection (m) or (o) of section 414 of such Code shall 

be treated as a single covered entity (or employer for purposes of paragraph (2)). øNote: sentence at end should have 

been inserted at end of this subparagraph¿ 

(B) INCLUSION OF FOREIGN CORPORATIONS.—For purposes of subparagraph (A), in applying subsections (a) and 

(b) of section 52 of such Code to this section, section 1563 

of such Code shall be applied without regard to subsection 

(b)(2)(C) thereof. 

If any entity described in ƒexecuted to reflect probable intent of 

amendment made by section 1406(a)(3)(C) of HCERA≈ subparagraph (C) or (D) 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. øPrevious sentence added 

by section 10905(f)(3) ‘‘at the end’’ of this paragraph; likely 

placement should have been at end of subparagraph (A).¿ 

(4) JOINT AND SEVERAL LIABILITY.—øAs added by section 

1406(a)(3)(D) of HCERA¿ If more than one person is liable for 

payment of the fee under subsection (a) with respect to a single 

covered entity by reason of the application of paragraph (3), all 

such persons shall be jointly and severally liable for payment 

of such fee. 

(d) UNITED STATES HEALTH RISK.—For purposes of this section, 

the term ‘‘United States health risk’’ means the health risk of any 

individual who is— 

(1) a United States citizen, 

(2) a resident of the United States (within the meaning of 

section 7701(b)(1)(A) of the Internal Revenue Code of 1986), or 

(3) located in the United States, with respect to the period 

such individual is so located. 

(e) APPLICABLE AMOUNT.—øReplaced by section 10905(b) and 

subsequently revised by section 1306(a)(4) of HCERA¿ For purposes 

of subsection (b)(1)— 

(1) YEARS BEFORE 2019.—In the case of calendar years beginning before 2019, the applicable amount shall be determined in accordance with the following table: 

Calendar year Applicable amount 

2014 ..................................................................................................... $8,000,000,000 

2015 ..................................................................................................... $11,300,000,000 

2016 ..................................................................................................... $11,300,000,000 

2017 ..................................................................................................... $13,900,000,000 

2018 ..................................................................................................... $14,300,000,000. 

(2) YEARS AFTER 2018.—In the case of any calendar year beginning after 2018, the applicable amount shall be the applicable amount for the preceding calendar year increased by the 

rate of premium growth (within the meaning of section 
Sec. 9010 PPACA (Consolidated) 814 

36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986) for such 

preceding calendar year. 

(f) TAX TREATMENT OF FEES.—The fees imposed by this section— 

(1) for purposes of subtitle F of the Internal Revenue Code 

of 1986, shall be treated as excise taxes with respect to which 

only civil actions for refund under procedures of such subtitle 

shall apply, and 

(2) for purposes of section 275 of such Code shall be considered to be a tax described in section 275(a)(6). 

(g) REPORTING REQUIREMENT.— 

(1) IN GENERAL.—Not later than the date determined by 

the Secretary following the end of any calendar year, each covered entity shall report to the Secretary, in such manner as the 

Secretary prescribes, the covered entity’s net premiums written 

with respect to health insurance for any United States health 

risk for such calendar year. øAs revised by section 10904(f)(4)¿ 

(2) PENALTY FOR FAILURE TO REPORT.— 

(A) IN GENERAL.—In the case of any failure to make 

a report containing the information required by paragraph 

(1) on the date prescribed therefor (determined with regard 

to any extension of time for filing), unless it is shown that 

such failure is due to reasonable cause, there shall be paid 

by the covered entity failing to file such report, an amount 

equal to— 

(i) $10,000, plus 

(ii) the lesser of— 

(I) an amount equal to $1,000, multiplied by 

the number of days during which such failure continues, or 

(II) the amount of the fee imposed by this section for which such report was required. 

(B) TREATMENT OF PENALTY.—The penalty imposed 

under subparagraph (A)— 

(i) shall be treated as a penalty for purposes of 

subtitle F of the Internal Revenue Code of 1986, 

(ii) shall be paid on notice and demand by the Secretary and in the same manner as tax under such 

Code, and 

(iii) with respect to which only civil actions for refund under procedures of such subtitle F shall apply. 

(3) ACCURACY-RELATED PENALTY.—øAs added by section 

1406(a)(5) of HCERA¿ 

(A) IN GENERAL.—In the case of any understatement of 

a covered entity’s net premiums written with respect to 

health insurance for any United States health risk for any 

calendar year, there shall be paid by the covered entity 

making such understatement, an amount equal to the excess of— 

(i) the amount of the covered entity’s fee under 

this section for the calendar year the Secretary determines should have been paid in the absence of any 

such understatement, over 
815 Sec. 9011 PPACA (Consolidated) 

(ii) the amount of such fee the Secretary determined based on such understatement. 

(B) UNDERSTATEMENT.—For purposes of this paragraph, an understatement of a covered entity’s net premiums written with respect to health insurance for any 

United States health risk for any calendar year is the difference between the amount of such net premiums written 

as reported on the return filed by the covered entity under 

paragraph (1) and the amount of such net premiums written that should have been reported on such return. 

(C) TREATMENT OF PENALTY.—The penalty imposed 

under subparagraph (A) shall be subject to the provisions 

of subtitle F of the Internal Revenue Code of 1986 that 

apply to assessable penalties imposed under chapter 68 of 

such Code. 

(4) TREATMENT OF INFORMATION.—øAs added by section 

1406(a)(5) of HCERA¿ Section 6103 of the Internal Revenue 

Code of 1986 shall not apply to any information reported under 

this subsection. 

(h) ADDITIONAL DEFINITIONS.—For purposes of this section— 

(1) SECRETARY.—The term ‘‘Secretary’’ means the Secretary of the Treasury or the Secretary’s delegate. 

(2) UNITED STATES.—The term ‘‘United States’’ means the 

several States, the District of Columbia, the Commonwealth of 

Puerto Rico, and the possessions of the United States. 

(3) HEALTH INSURANCE.—øReplaced by section 10905(d)¿ 

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). 

(i) GUIDANCE.—The Secretary shall publish guidance necessary 

to carry out the purposes of this section and shall prescribe such 

regulations as are necessary or appropriate to prevent avoidance of 

the purposes of this section, including inappropriate actions taken 

to qualify as an exempt entity under subsection (c)(2). øAs revised 

by section 10905(e)¿ 

(j) EFFECTIVE DATE.—øReplaced by section 1406(a)(6) of 

HCERA; previous amendment by section 19095(f)(5)(A) was 

unexecutable¿ This section shall apply to calendar years beginning 

after December 31, 2013. 

SEC. 9011. STUDY AND REPORT OF EFFECT ON VETERANS HEALTH 

CARE. 

(a) IN GENERAL.—The Secretary of Veterans Affairs shall conduct a study on the effect (if any) of the provisions of sections 9008, 

9009, and 9010 on— 

(1) the cost of medical care provided to veterans, and 

(2) veterans’ access to medical devices and branded prescription drugs. 

(b) REPORT.—The Secretary of Veterans Affairs shall report the 

results of the study under subsection (a) to the Committee on Ways 
Sec. 9012 PPACA (Consolidated) 816 

and Means of the House of Representatives and to the Committee 

on Finance of the Senate not later than December 31, 2012. 

SEC. 9012. ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE 

TO MEDICARE PART D SUBSIDY. 

(a) IN GENERAL.—Section 139A of the Internal Revenue Code 

of 1986 is amended by striking the second sentence. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall apply to taxable years beginning after December 31, 2012. 

SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL 

EXPENSES. 

(a) IN GENERAL.—Subsection (a) of section 213 of the Internal 

Revenue Code of 1986 is amended by striking ‘‘7.5 percent’’ and inserting ‘‘10 percent’’. 

(b) TEMPORARY WAIVER OF INCREASE FOR CERTAIN SENIORS.— 

Section 213 of the Internal Revenue Code of 1986 is amended by 

adding at the end the following new subsection: 

‘‘(f) SPECIAL RULE FOR 2013, 2014, 2015, AND 2016.—In the 

case of any taxable year beginning after December 31, 2012, and 

ending before January 1, 2017, subsection (a) shall be applied with 

respect to a taxpayer by substituting ‘7.5 percent’ for ‘10 percent’ 

if such taxpayer or such taxpayer’s spouse has attained age 65 before the close of such taxable year.’’. 

(c) CONFORMING AMENDMENT.—Section 56(b)(1)(B) of the Internal Revenue Code of 1986 is amended by striking ‘‘by substituting 

‘10 percent’ for ‘7.5 percent’ ’’ and inserting ‘‘without regard to subsection (f) of such section’’. 

(d) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2012. 

SEC. 9014. LIMITATION ON EXCESSIVE REMUNERATION PAID BY CERTAIN HEALTH INSURANCE PROVIDERS. 

(a) IN GENERAL.—Section 162(m) of the Internal Revenue Code 

of 1986 is amended by adding at the end the following new subparagraph: 

‘‘(6) SPECIAL RULE FOR APPLICATION TO CERTAIN HEALTH INSURANCE PROVIDERS.— 

‘‘(A) IN GENERAL.—No deduction shall be allowed 

under this chapter— 

‘‘(i) in the case of applicable individual remuneration which is for any disqualified taxable year beginning after December 31, 2012, and which is attributable to services performed by an applicable individual during such taxable year, to the extent that the 

amount of such remuneration exceeds $500,000, or 

‘‘(ii) in the case of deferred deduction remuneration for any taxable year beginning after December 31, 

2012, which is attributable to services performed by 

an applicable individual during any disqualified taxable year beginning after December 31, 2009, to the 

extent that the amount of such remuneration exceeds 

$500,000 reduced (but not below zero) by the sum of— 

‘‘(I) the applicable individual remuneration for 

such disqualified taxable year, plus 
817 Sec. 9014 PPACA (Consolidated) 

‘‘(II) the portion of the deferred deduction remuneration for such services which was taken 

into account under this clause in a preceding taxable year (or which would have been taken into 

account under this clause in a preceding taxable 

year if this clause were applied by substituting 

‘December 31, 2009’ for ‘December 31, 2012’ in the 

matter preceding subclause (I)). 

‘‘(B) DISQUALIFIED TAXABLE YEAR.—For purposes of 

this paragraph, the term ‘disqualified taxable year’ means, 

with respect to any employer, any taxable year for which 

such employer is a covered health insurance provider. 

‘‘(C) COVERED HEALTH INSURANCE PROVIDER.—For purposes of this paragraph— 

‘‘(i) IN GENERAL.—The term ‘covered health insurance provider’ means— 

‘‘(I) with respect to taxable years beginning 

after December 31, 2009, and before January 1, 

2013, any employer which is a health insurance 

issuer (as defined in section 9832(b)(2)) and which 

receives premiums from providing health insurance coverage (as defined in section 9832(b)(1)), 

and 

‘‘(II) with respect to taxable years beginning 

after December 31, 2012, any employer which is a 

health insurance issuer (as defined in section 

9832(b)(2)) and with respect to which not less 

than 25 percent of the gross premiums received 

from providing health insurance coverage (as defined in section 9832(b)(1)) is from minimum essential coverage (as defined in section 5000A(f)). 

‘‘(ii) AGGREGATION RULES.—Two or more persons 

who are treated as a single employer under subsection 

(b), (c), (m), or (o) of section 414 shall be treated as a 

single employer, except that in applying section 

1563(a) for purposes of any such subsection, paragraphs (2) and (3) thereof shall be disregarded. 

‘‘(D) APPLICABLE INDIVIDUAL REMUNERATION.—For 

purposes of this paragraph, the term ‘applicable individual 

remuneration’ means, with respect to any applicable individual for any disqualified taxable year, the aggregate 

amount allowable as a deduction under this chapter for 

such taxable year (determined without regard to this subsection) for remuneration (as defined in paragraph (4) 

without regard to subparagraphs (B), (C), and (D) thereof) 

for services performed by such individual (whether or not 

during the taxable year). Such term shall not include any 

deferred deduction remuneration with respect to services 

performed during the disqualified taxable year. 

‘‘(E) DEFERRED DEDUCTION REMUNERATION.—For purposes of this paragraph, the term ‘deferred deduction remuneration’ means remuneration which would be applicable individual remuneration for services performed in a 

disqualified taxable year but for the fact that the deduc-
Sec. 9015 PPACA (Consolidated) 818 

tion under this chapter (determined without regard to this 

paragraph) for such remuneration is allowable in a subsequent taxable year. 

‘‘(F) APPLICABLE INDIVIDUAL.—For purposes of this 

paragraph, the term ‘applicable individual’ means, with respect to any covered health insurance provider for any disqualified taxable year, any individual— 

‘‘(i) who is an officer, director, or employee in such 

taxable year, or 

‘‘(ii) who provides services for or on behalf of such 

covered health insurance provider during such taxable 

year. 

‘‘(G) COORDINATION.—Rules similar to the rules of subparagraphs (F) and (G) of paragraph (4) shall apply for 

purposes of this paragraph. 

‘‘(H) REGULATORY AUTHORITY.—The Secretary may 

prescribe such guidance, rules, or regulations as are necessary to carry out the purposes of this paragraph.’’. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall apply to taxable years beginning after December 31, 2009, 

with respect to services performed after such date. 

SEC. 9015. ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-INCOME 

TAXPAYERS. 

(a) FICA.— 

(1) IN GENERAL.—Section 3101(b) of the Internal Revenue 

Code of 1986 is amended— 

(A) by striking ‘‘In addition’’ and inserting the following: 

‘‘(1) IN GENERAL.—In addition’’, 

(B) by striking ‘‘the following percentages of the’’ and 

inserting ‘‘1.45 percent of the’’, 

(C) by striking ‘‘(as defined in section 3121(b))—’’ and 

all that follows and inserting ‘‘(as defined in section 

3121(b)).’’, and 

(D) by adding at the end the following new paragraph: 

øAs revised by section 10906(a)¿ 

‘‘(2) ADDITIONAL TAX.—In addition to the tax imposed by 

paragraph (1) and the preceding subsection, there is hereby 

imposed on every taxpayer (other than a corporation, estate, or 

trust) a tax equal to 0.9 percent of wages which are received 

with respect to employment (as defined in section 3121(b)) during any taxable year beginning after December 31, 2012, and 

which are in excess of—øAs revised by section 1402(b)(1)(A) of 

HCERA¿ 

‘‘(A) in the case of a joint return, $250,000, 

‘‘(B) in the case of a married taxpayer (as defined in 

section 7703) filing a separate return, 1⁄2 of the dollar 

amount determined under subparagraph (A), and 

‘‘(C) in any other case, $200,000.’’. 

(2) COLLECTION OF TAX.—Section 3102 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: 

‘‘(f) SPECIAL RULES FOR ADDITIONAL TAX.— 
819 Sec. 9015 PPACA (Consolidated) 

‘‘(1) IN GENERAL.—In the case of any tax imposed by section 3101(b)(2), subsection (a) shall only apply to the extent to 

which the taxpayer receives wages from the employer in excess 

of $200,000, and the employer may disregard the amount of 

wages received by such taxpayer’s spouse. 

‘‘(2) COLLECTION OF AMOUNTS NOT WITHHELD.—To the extent that the amount of any tax imposed by section 3101(b)(2) 

is not collected by the employer, such tax shall be paid by the 

employee. 

‘‘(3) TAX PAID BY RECIPIENT.—If an employer, in violation 

of this chapter, fails to deduct and withhold the tax imposed 

by section 3101(b)(2) and thereafter the tax is paid by the employee, the tax so required to be deducted and withheld shall 

not be collected from the employer, but this paragraph shall in 

no case relieve the employer from liability for any penalties or 

additions to tax otherwise applicable in respect of such failure 

to deduct and withhold.’’. 

(b) SECA.— 

(1) IN GENERAL.—Section 1401(b) of the Internal Revenue 

Code of 1986 is amended— 

(A) by striking ‘‘In addition’’ and inserting the following: 

‘‘(1) IN GENERAL.—In addition’’, and 

(B) by adding at the end the following new paragraph: 

‘‘(2) ADDITIONAL TAX.—øAs revised by section 10906(b)¿ 

‘‘(A) IN GENERAL.—In addition to the tax imposed by 

paragraph (1) and the preceding subsection, there is hereby imposed on every taxpayer (other than a corporation, 

estate, or trust) for each taxable year beginning after December 31, 2012, a tax equal to 0.9 percent of the self-employment income for such taxable year which is in excess 

of—øAs revised by section 1402(b)(1)(B) of HCERA¿ 

‘‘(i) in the case of a joint return, $250,000, 

‘‘(ii) in the case of a married taxpayer (as defined 

in section 7703) filing a separate return, 1⁄2 of the dollar amount determined under clause (i), and 

‘‘(iii) in any other case, $200,000. 

‘‘(B) COORDINATION WITH FICA.—øAs revised by section 

1402(b)(1)(B) of HCERA¿ The amounts under clause (i), 

(ii), or (iii) (whichever is applicable) of subparagraph (A) 

shall be reduced (but not below zero) by the amount of 

wages taken into account in determining the tax imposed 

under section 3121(b)(2) with respect to the taxpayer.’’. 

(2) NO DEDUCTION FOR ADDITIONAL TAX.— 

(A) IN GENERAL.—Section 164(f) of such Code is 

amended by inserting ‘‘(other than the taxes imposed by 

section 1401(b)(2))’’ after ‘‘section 1401)’’. 

(B) DEDUCTION FOR NET EARNINGS FROM SELF-EMPLOYMENT.—Subparagraph (B) of section 1402(a)(12) is amended by inserting ‘‘(determined without regard to the rate 

imposed under paragraph (2) of section 1401(b))’’ after ‘‘for 

such year’’. 
Sec. 9016 PPACA (Consolidated) 820 

(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. 9016. MODIFICATION OF SECTION 833 TREATMENT OF CERTAIN 

HEALTH ORGANIZATIONS. 

(a) IN GENERAL.—Subsection (c) of section 833 of the Internal 

Revenue Code of 1986 is amended by adding at the end the following new paragraph: 

‘‘(5) NONAPPLICATION OF SECTION IN CASE OF LOW MEDICAL

LOSS RATIO.—Notwithstanding the preceding paragraphs, this 

section shall not apply to any organization unless such organization’s percentage of total premium revenue expended on reimbursement for clinical services provided to enrollees under 

its policies during such taxable year (as reported under section 

2718 of the Public Health Service Act) is not less than 85 percent.’’. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall apply to taxable years beginning after December 31, 2009. 

øSEC. 9017. øEXCISE TAX ON ELECTIVE COSMETIC MEDICAL PROCEDURES¿øNULLIFIED¿.¿ 

øThis section, and the amendments made by this section, are 

null, void, and of no effect under section 10907(a), but was not formally repealed; section 10907(b), which provides for an excise tax on 

indoor tanning services, effectively substitutes for this section.¿ 

ø(a) IN GENERAL.—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:¿ 

ø‘‘CHAPTER 49—ELECTIVE COSMETIC MEDICAL 

PROCEDURES¿ 

‘‘Sec. 5000B. Imposition of tax on elective cosmetic medical procedures. 

ø‘‘SEC. 5000B. IMPOSITION OF TAX ON ELECTIVE COSMETIC MEDICAL 

PROCEDURES.¿ 

ø‘‘(a) IN GENERAL.—There is hereby imposed on any cosmetic 

surgery and medical procedure a tax equal to 5 percent of the 

amount paid for such procedure (determined without regard to this 

section), whether paid by insurance or otherwise.¿ 

ø‘‘(b) COSMETIC SURGERY AND MEDICAL PROCEDURE.—For purposes of this section, the term ‘cosmetic surgery and medical procedure’ means any cosmetic surgery (as defined in section 

213(d)(9)(B)) or other similar procedure which—¿ 

ø‘‘(1) is performed by a licensed medical professional, and¿ 

ø‘‘(2) is not necessary to ameliorate a deformity arising 

from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.¿ 

ø‘‘(c) PAYMENT OF TAX.—¿ 

ø‘‘(1) IN GENERAL.—The tax imposed by this section shall 

be paid by the individual on whom the procedure is performed.¿ 

ø‘‘(2) COLLECTION.—Every person receiving a payment for 

procedures on which a tax is imposed under subsection (a) 

shall collect the amount of the tax from the individual on 
821 Sec. 9021 PPACA (Consolidated) \139D IRC 

whom the procedure is performed and remit such tax quarterly 

to the Secretary at such time and in such manner as provided 

by the Secretary.¿ 

ø‘‘(3) SECONDARY LIABILITY.—Where any tax imposed by 

subsection (a) is not paid at the time payments for cosmetic 

surgery and medical procedures are made, then to the extent 

that such tax is not collected, such tax shall be paid by the person who performs the procedure.’’.¿ 

ø(b) CLERICAL AMENDMENT.—The table of chapters 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—ELECTIVE COSMETIC MEDICAL PROCEDURES’’. 

ø(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to procedures performed on or after January 1, 2010.¿ 

Subtitle B—Other Provisions 

SEC. 9021. EXCLUSION OF HEALTH BENEFITS PROVIDED BY INDIAN 

TRIBAL GOVERNMENTS. 

(a) 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. INDIAN HEALTH CARE BENEFITS. 

‘‘(a) GENERAL RULE.—Except as otherwise provided in this section, gross income does not include the value of any qualified Indian health care benefit. 

‘‘(b) QUALIFIED INDIAN HEALTH CARE BENEFIT.—For purposes 

of this section, the term ‘qualified Indian health care benefit’ 

means— 

‘‘(1) any health service or benefit provided or purchased, 

directly or indirectly, by the Indian Health Service through a 

grant to or a contract or compact with an Indian tribe or tribal 

organization, or through a third-party program funded by the 

Indian Health Service, 

‘‘(2) medical care provided or purchased by, or amounts to 

reimburse for such medical care provided by, an Indian tribe 

or tribal organization for, or to, a member of an Indian tribe, 

including a spouse or dependent of such a member, 

‘‘(3) coverage under accident or health insurance (or an arrangement having the effect of accident or health insurance), 

or an accident or health plan, provided by an Indian tribe or 

tribal organization for medical care to a member of an Indian 

tribe, include a spouse or dependent of such a member, and 

‘‘(4) any other medical care provided by an Indian tribe or 

tribal organization that supplements, replaces, or substitutes 

for a program or service relating to medical care provided by 

the Federal government to Indian tribes or members of such a 

tribe. 

‘‘(c) DEFINITIONS.—For purposes of this section— 

‘‘(1) INDIAN TRIBE.—The term ‘Indian tribe’ has the meaning given such term by section 45A(c)(6). 
Sec. 9021 PPACA (Consolidated) 822 

‘‘(2) TRIBAL ORGANIZATION.—The term ‘tribal organization’ 

has the meaning given such term by section 4(l) of the Indian 

Self-Determination and Education Assistance Act. 

‘‘(3) MEDICAL CARE.—The term ‘medical care’ has the same 

meaning as when used in section 213. 

‘‘(4) ACCIDENT OR HEALTH INSURANCE; ACCIDENT OR

HEALTH PLAN.—The terms ‘accident or health insurance’ and 

‘accident or health plan’ have the same meaning as when used 

in section 105. 

‘‘(5) 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. 

‘‘(d) DENIAL OF DOUBLE BENEFIT.—Subsection (a) shall not 

apply to the amount of any qualified Indian health care benefit 

which is not includible in gross income of the beneficiary of such 

benefit under any other provision of this chapter, or to the amount 

of any such benefit for which a deduction is allowed to such beneficiary under any other provision of this chapter.’’. 

(b) CLERICAL AMENDMENT.—The table of sections for part III of 

subchapter B of chapter 1 of the Internal Revenue Code of 1986 is 

amended by inserting after the item relating to section 139C the 

following new item: 

‘‘Sec. 139D. Indian health care benefits.’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to benefits and coverage provided after the date of the 

enactment of this Act. 

(d) NO INFERENCE.—Nothing in the amendments made by this 

section shall be construed to create an inference with respect to the 

exclusion from gross income of— 

(1) benefits provided by an Indian tribe or tribal organization that are not within the scope of this section, and 

(2) benefits provided prior to the date of the enactment of 

this Act. 

SEC. 9022. ESTABLISHMENT OF SIMPLE CAFETERIA PLANS FOR SMALL 

BUSINESSES. 

(a) IN GENERAL.—Section 125 of the Internal Revenue Code of 

1986 (relating to cafeteria plans), as amended by this Act, is 

amended by redesignating subsections (j) and (k) as subsections (k) 

and (l), respectively, and by inserting after subsection (i) the following new subsection: 

‘‘(j) SIMPLE CAFETERIA PLANS FOR SMALL BUSINESSES.— 

‘‘(1) IN GENERAL.—An eligible employer maintaining a simple cafeteria plan with respect to which the requirements of 

this subsection are met for any year shall be treated as meeting any applicable nondiscrimination requirement during such 

year. 

‘‘(2) SIMPLE CAFETERIA PLAN.—For purposes of this subsection, the term ‘simple cafeteria plan’ means a cafeteria 

plan— 

‘‘(A) which is established and maintained by an eligible employer, and 
823 Sec. 9011 PPACA (Consolidated) 

‘‘(B) with respect to which the contribution requirements of paragraph (3), and the eligibility and participation requirements of paragraph (4), are met. 

‘‘(3) CONTRIBUTION REQUIREMENTS.— 

‘‘(A) IN GENERAL.—The requirements of this paragraph 

are met if, under the plan the employer is required, without regard to whether a qualified employee makes any salary reduction contribution, to make a contribution to provide qualified benefits under the plan on behalf of each 

qualified employee in an amount equal to— 

‘‘(i) a uniform percentage (not less than 2 percent) 

of the employee’s compensation for the plan year, or 

‘‘(ii) an amount which is not less than the lesser 

of— 

‘‘(I) 6 percent of the employee’s compensation 

for the plan year, or 

‘‘(II) twice the amount of the salary reduction 

contributions of each qualified employee. 

‘‘(B) MATCHING CONTRIBUTIONS ON BEHALF OF HIGHLY

COMPENSATED AND KEY EMPLOYEES.—The requirements of 

subparagraph (A)(ii) shall not be treated as met if, under 

the plan, the rate of contributions with respect to any salary reduction contribution of a highly compensated or key 

employee at any rate of contribution is greater than that 

with respect to an employee who is not a highly compensated or key employee. 

‘‘(C) ADDITIONAL CONTRIBUTIONS.—Subject to subparagraph (B), nothing in this paragraph shall be treated as 

prohibiting an employer from making contributions to provide qualified benefits under the plan in addition to contributions required under subparagraph (A). 

‘‘(D) DEFINITIONS.—For purposes of this paragraph— 

‘‘(i) SALARY REDUCTION CONTRIBUTION.—The term 

‘salary reduction contribution’ means, with respect to 

a cafeteria plan, any amount which is contributed to 

the plan at the election of the employee and which is 

not includible in gross income by reason of this section. 

‘‘(ii) QUALIFIED EMPLOYEE.—The term ‘qualified 

employee’ means, with respect to a cafeteria plan, any 

employee who is not a highly compensated or key employee and who is eligible to participate in the plan. 

‘‘(iii) HIGHLY COMPENSATED EMPLOYEE.—The term 

‘highly compensated employee’ has the meaning given 

such term by section 414(q). 

‘‘(iv) KEY EMPLOYEE.—The term ‘key employee’ 

has the meaning given such term by section 416(i). 

‘‘(4) MINIMUM ELIGIBILITY AND PARTICIPATION REQUIREMENTS.— 

‘‘(A) IN GENERAL.—The requirements of this paragraph 

shall be treated as met with respect to any year if, under 

the plan— 
Sec. 9011 PPACA (Consolidated) 824 

‘‘(i) all employees who had at least 1,000 hours of 

service for the preceding plan year are eligible to participate, and 

‘‘(ii) each employee eligible to participate in the 

plan may, subject to terms and conditions applicable 

to all participants, elect any benefit available under 

the plan. 

‘‘(B) CERTAIN EMPLOYEES MAY BE EXCLUDED.—For purposes of subparagraph (A)(i), an employer may elect to exclude under the plan employees— 

‘‘(i) who have not attained the age of 21 before the 

close of a plan year, 

‘‘(ii) who have less than 1 year of service with the 

employer as of any day during the plan year, 

‘‘(iii) who are covered under an agreement which 

the Secretary of Labor finds to be a collective bargaining agreement if there is evidence that the benefits covered under the cafeteria plan were the subject 

of good faith bargaining between employee representatives and the employer, or 

‘‘(iv) who are described in section 410(b)(3)(C) (relating to nonresident aliens working outside the 

United States). 

A plan may provide a shorter period of service or younger 

age for purposes of clause (i) or (ii). 

‘‘(5) ELIGIBLE EMPLOYER.—For purposes of this subsection— 

‘‘(A) IN GENERAL.—The term ‘eligible employer’ means, 

with respect to any year, any employer if such employer 

employed an average of 100 or fewer employees on business days during either of the 2 preceding years. For purposes of this subparagraph, a year may only be taken into 

account if the employer was in existence throughout the 

year. 

‘‘(B) EMPLOYERS NOT IN EXISTENCE DURING PRECEDING

YEAR.—If an employer was not in existence throughout the 

preceding year, the determination under subparagraph (A) 

shall be based on the average number of employees that 

it is reasonably expected such employer will employ on 

business days in the current year. 

‘‘(C) GROWING EMPLOYERS RETAIN TREATMENT AS

SMALL EMPLOYER.— 

‘‘(i) IN GENERAL.—If— 

‘‘(I) an employer was an eligible employer for 

any year (a ‘qualified year’), and 

‘‘(II) such employer establishes a simple cafeteria plan for its employees for such year, 

then, notwithstanding the fact the employer fails to 

meet the requirements of subparagraph (A) for any 

subsequent year, such employer shall be treated as an 

eligible employer for such subsequent year with respect to employees (whether or not employees during 

a qualified year) of any trade or business which was 

covered by the plan during any qualified year. 
825 Sec. 9023 PPACA (Consolidated) \48D IRC 

‘‘(ii) EXCEPTION.—This subparagraph shall cease 

to apply if the employer employs an average of 200 or 

more employees on business days during any year preceding any such subsequent year. 

‘‘(D) SPECIAL RULES.— 

‘‘(i) PREDECESSORS.—Any reference in this paragraph to an employer shall include a reference to any 

predecessor of such employer. 

‘‘(ii) AGGREGATION RULES.—All persons treated as 

a single employer under subsection (a) or (b) of section 

52, or subsection (n) or (o) of section 414, shall be 

treated as one person. 

‘‘(6) APPLICABLE NONDISCRIMINATION REQUIREMENT.—For 

purposes of this subsection, the term ‘applicable nondiscrimination requirement’ means any requirement under subsection (b) 

of this section, section 79(d), section 105(h), or paragraph (2), 

(3), (4), or (8) of section 129(d). 

‘‘(7) COMPENSATION.—The term ‘compensation’ has the 

meaning given such term by section 414(s).’’. 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall apply to years beginning after December 31, 2010. 

SEC. 9023. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT. 

(a) IN GENERAL.—Subpart E of part IV of subchapter A of 

chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after section 48C the following new section: 

‘‘SEC. 48D. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT. 

‘‘(a) IN GENERAL.—For purposes of section 46, the qualifying 

therapeutic discovery project credit for any taxable year is an 

amount equal to 50 percent of the qualified investment for such 

taxable year with respect to any qualifying therapeutic discovery 

project of an eligible taxpayer. 

‘‘(b) QUALIFIED INVESTMENT.— 

‘‘(1) IN GENERAL.—For purposes of subsection (a), the 

qualified investment for any taxable year is the aggregate 

amount of the costs paid or incurred in such taxable year for 

expenses necessary for and directly related to the conduct of a 

qualifying therapeutic discovery project. 

‘‘(2) LIMITATION.—The amount which is treated as qualified investment for all taxable years with respect to any qualifying therapeutic discovery project shall not exceed the amount 

certified by the Secretary as eligible for the credit under this 

section. 

‘‘(3) EXCLUSIONS.—The qualified investment for any taxable year with respect to any qualifying therapeutic discovery 

project shall not take into account any cost— 

‘‘(A) for remuneration for an employee described in 

section 162(m)(3), 

‘‘(B) for interest expenses, 

‘‘(C) for facility maintenance expenses, 

‘‘(D) which is identified as a service cost under section 

1.263A–1(e)(4) of title 26, Code of Federal Regulations, or 
Sec. 9023\48D IRC PPACA (Consolidated) 826 

‘‘(E) for any other expense as determined by the Secretary as appropriate to carry out the purposes of this section. 

‘‘(4) CERTAIN PROGRESS EXPENDITURE RULES MADE APPLICA- BLE.—In the case of costs described in paragraph (1) that are 

paid for property of a character subject to an allowance for depreciation, rules similar to the rules of subsections (c)(4) and 

(d) of section 46 (as in effect on the day before the date of the 

enactment of the Revenue Reconciliation Act of 1990) shall 

apply for purposes of this section. 

‘‘(5) APPLICATION OF SUBSECTION.—An investment shall be 

considered a qualified investment under this subsection only if 

such investment is made in a taxable year beginning in 2009 

or 2010. 

‘‘(c) DEFINITIONS.— ‘‘(1) QUALIFYING THERAPEUTIC DISCOVERY PROJECT.—The 

term ‘qualifying therapeutic discovery project’ means a project 

which is designed— 

‘‘(A) to treat or prevent diseases or conditions by conducting pre-clinical activities, clinical trials, and clinical 

studies, or carrying out research protocols, for the purpose 

of securing approval of a product under section 505(b) of 

the Federal Food, Drug, and Cosmetic Act or section 351(a) 

of the Public Health Service Act, 

‘‘(B) to diagnose diseases or conditions or to determine 

molecular factors related to diseases or conditions by developing molecular diagnostics to guide therapeutic decisions, or 

‘‘(C) to develop a product, process, or technology to further the delivery or administration of therapeutics. 

‘‘(2) ELIGIBLE TAXPAYER.— 

‘‘(A) IN GENERAL.—The term ‘eligible taxpayer’ means 

a taxpayer which employs not more than 250 employees in 

all businesses of the taxpayer at the time of the submission of the application under subsection (d)(2). 

‘‘(B) AGGREGATION RULES.—All persons treated as a 

single employer under subsection (a) or (b) of section 52, 

or subsection (m) or (o) of section 414, shall be so treated 

for purposes of this paragraph. 

‘‘(3) FACILITY MAINTENANCE EXPENSES.—The term ‘facility 

maintenance expenses’ means costs paid or incurred to maintain a facility, including— 

‘‘(A) mortgage or rent payments, 

‘‘(B) insurance payments, 

‘‘(C) utility and maintenance costs, and 

‘‘(D) costs of employment of maintenance personnel. 

‘‘(d) QUALIFYING THERAPEUTIC DISCOVERY PROJECT PRO- GRAM.— 

‘‘(1) ESTABLISHMENT.— 

‘‘(A) IN GENERAL.—Not later than 60 days after the 

date of the enactment of this section, the Secretary, in consultation with the Secretary of Health and Human Services, shall establish a qualifying therapeutic discovery 

project program to consider and award certifications for 
827 Sec. 9023 PPACA (Consolidated) \48D IRC 

qualified investments eligible for credits under this section 

to qualifying therapeutic discovery project sponsors. 

‘‘(B) LIMITATION.—The total amount of credits that 

may be allocated under the program shall not exceed 

$1,000,000,000 for the 2-year period beginning with 2009. 

‘‘(2) CERTIFICATION.— 

‘‘(A) APPLICATION PERIOD.—Each applicant for certification under this paragraph shall submit an application 

containing such information as the Secretary may require 

during the period beginning on the date the Secretary establishes the program under paragraph (1). 

‘‘(B) TIME FOR REVIEW OF APPLICATIONS.—The Secretary shall take action to approve or deny any application 

under subparagraph (A) within 30 days of the submission 

of such application. 

‘‘(C) MULTI-YEAR APPLICATIONS.—An application for 

certification under subparagraph (A) may include a request for an allocation of credits for more than 1 of the 

years described in paragraph (1)(B). 

‘‘(3) SELECTION CRITERIA.—In determining the qualifying 

therapeutic discovery projects with respect to which qualified 

investments may be certified under this section, the Secretary— 

‘‘(A) shall take into consideration only those projects 

that show reasonable potential— 

‘‘(i) to result in new therapies— 

‘‘(I) to treat areas of unmet medical need, or 

‘‘(II) to prevent, detect, or treat chronic or 

acute diseases and conditions, 

‘‘(ii) to reduce long-term health care costs in the 

United States, or 

‘‘(iii) to significantly advance the goal of curing 

cancer within the 30-year period beginning on the date 

the Secretary establishes the program under paragraph (1), and 

‘‘(B) shall take into consideration which projects have 

the greatest potential— 

‘‘(i) to create and sustain (directly or indirectly) 

high quality, high-paying jobs in the United States, 

and 

‘‘(ii) to advance United States competitiveness in 

the fields of life, biological, and medical sciences. 

‘‘(4) DISCLOSURE OF ALLOCATIONS.—The Secretary shall, 

upon making a certification under this subsection, publicly disclose the identity of the applicant and the amount of the credit 

with respect to such applicant. 

‘‘(e) SPECIAL RULES.— 

‘‘(1) BASIS ADJUSTMENT.—For purposes of this subtitle, if a 

credit is allowed under this section for an expenditure related 

to property of a character subject to an allowance for depreciation, the basis of such property shall be reduced by the amount 

of such credit. 

‘‘(2) DENIAL OF DOUBLE BENEFIT.— 
Sec. 9023 PPACA (Consolidated) 828 

‘‘(A) BONUS DEPRECIATION.—A credit shall not be allowed under this section for any investment for which 

bonus depreciation is allowed under section 168(k), 

1400L(b)(1), or 1400N(d)(1). 

‘‘(B) DEDUCTIONS.—No deduction under this subtitle 

shall be allowed for the portion of the expenses otherwise 

allowable as a deduction taken into account in determining 

the credit under this section for the taxable year which is 

equal to the amount of the credit determined for such taxable year under subsection (a) attributable to such portion. 

This subparagraph shall not apply to expenses related to 

property of a character subject to an allowance for depreciation the basis of which is reduced under paragraph (1), 

or which are described in section 280C(g). 

‘‘(C) CREDIT FOR RESEARCH ACTIVITIES.— ‘‘(i) IN GENERAL.—Except as provided in clause (ii), 

any expenses taken into account under this section for 

a taxable year shall not be taken into account for purposes of determining the credit allowable under section 41 or 45C for such taxable year. 

‘‘(ii) EXPENSES INCLUDED IN DETERMINING BASE PE- RIOD RESEARCH EXPENSES.—Any expenses for any taxable year which are qualified research expenses (within the meaning of section 41(b)) shall be taken into account in determining base period research expenses 

for purposes of applying section 41 to subsequent taxable years. 

‘‘(f) COORDINATION WITH DEPARTMENT OF TREASURY GRANTS.— In the case of any investment with respect to which the Secretary 

makes a grant under section 9023(e) of the Patient Protection and 

Affordable Care Act of 2009— 

‘‘(1) DENIAL OF CREDIT.—No credit shall be determined 

under this section with respect to such investment for the taxable year in which such grant is made or any subsequent taxable year. 

‘‘(2) RECAPTURE OF CREDITS FOR PROGRESS EXPENDITURES

MADE BEFORE GRANT.—If a credit was determined under this 

section with respect to such investment for any taxable year 

ending before such grant is made— 

‘‘(A) the tax imposed under subtitle A on the taxpayer 

for the taxable year in which such grant is made shall be 

increased by so much of such credit as was allowed under 

section 38, 

‘‘(B) the general business carryforwards under section 

39 shall be adjusted so as to recapture the portion of such 

credit which was not so allowed, and 

‘‘(C) the amount of such grant shall be determined 

without regard to any reduction in the basis of any property of a character subject to an allowance for depreciation 

by reason of such credit. 

‘‘(3) TREATMENT OF GRANTS.—Any such grant shall not be 

includible in the gross income of the taxpayer.’’. 

(b) INCLUSION AS PART OF INVESTMENT CREDIT.—Section 46 of 

the Internal Revenue Code of 1986 is amended— 
829 Sec. 9023 PPACA (Consolidated) 

(1) by adding a comma at the end of paragraph (2), 

(2) by striking the period at the end of paragraph (5) and 

inserting ‘‘, and’’, and 

(3) by adding at the end the following new paragraph: 

‘‘(6) the qualifying therapeutic discovery project credit.’’. 

(c) CONFORMING AMENDMENTS.— 

(1) Section 49(a)(1)(C) of the Internal Revenue Code of 

1986 is amended— 

(A) by striking ‘‘and’’ at the end of clause (iv), 

(B) by striking the period at the end of clause (v) and 

inserting ‘‘, and’’, and 

(C) by adding at the end the following new clause: 

‘‘(vi) the basis of any property to which paragraph 

(1) of section 48D(e) applies which is part of a qualifying therapeutic discovery project under such section 

48D.’’. 

(2) Section 280C of such Code is amended by adding at the 

end the following new subsection: 

‘‘(g) QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.— 

‘‘(1) IN GENERAL.—No deduction shall be allowed for that 

portion of the qualified investment (as defined in section 

48D(b)) otherwise allowable as a deduction for the taxable year 

which— 

‘‘(A) would be qualified research expenses (as defined 

in section 41(b)), basic research expenses (as defined in 

section 41(e)(2)), or qualified clinical testing expenses (as 

defined in section 45C(b)) if the credit under section 41 or 

section 45C were allowed with respect to such expenses for 

such taxable year, and 

‘‘(B) is equal to the amount of the credit determined 

for such taxable year under section 48D(a), reduced by— 

‘‘(i) the amount disallowed as a deduction by reason of section 48D(e)(2)(B), and 

‘‘(ii) the amount of any basis reduction under section 48D(e)(1). 

‘‘(2) SIMILAR RULE WHERE TAXPAYER CAPITALIZES RATHER

THAN DEDUCTS EXPENSES.—In the case of expenses described in 

paragraph (1)(A) taken into account in determining the credit 

under section 48D for the taxable year, if— 

‘‘(A) the amount of the portion of the credit determined 

under such section with respect to such expenses, exceeds 

‘‘(B) the amount allowable as a deduction for such taxable year for such expenses (determined without regard to 

paragraph (1)), 

the amount chargeable to capital account for the taxable year 

for such expenses shall be reduced by the amount of such excess. 

‘‘(3) CONTROLLED GROUPS.—Paragraph (3) of subsection (b) 

shall apply for purposes of this subsection.’’. 

(d) CLERICAL AMENDMENT.—The table of sections for subpart E 

of part IV of subchapter A of chapter 1 of the Internal Revenue 

Code of 1986 is amended by inserting after the item relating to section 48C the following new item: 

‘‘Sec. 48D. Qualifying therapeutic discovery project credit.’’. 
Sec. 9023 PPACA (Consolidated) 830 

(e) GRANTS FOR QUALIFIED INVESTMENTS IN THERAPEUTIC DIS- COVERY PROJECTS IN LIEU OF TAX CREDITS.— (1) IN GENERAL.—Upon application, the Secretary of the 

Treasury shall, subject to the requirements of this subsection, 

provide a grant to each person who makes a qualified investment in a qualifying therapeutic discovery project in the 

amount of 50 percent of such investment. No grant shall be 

made under this subsection with respect to any investment unless such investment is made during a taxable year beginning 

in 2009 or 2010. 

(2) APPLICATION.— (A) IN GENERAL.—At the stated election of the applicant, an application for certification under section 

48D(d)(2) of the Internal Revenue Code of 1986 for a credit 

under such section for the taxable year of the applicant 

which begins in 2009 shall be considered to be an application for a grant under paragraph (1) for such taxable year. 

(B) TAXABLE YEARS BEGINNING IN 2010.—An application 

for a grant under paragraph (1) for a taxable year beginning in 2010 shall be submitted— 

(i) not earlier than the day after the last day of 

such taxable year, and 

(ii) not later than the due date (including extensions) for filing the return of tax for such taxable year. 

(C) INFORMATION TO BE SUBMITTED.—An application 

for a grant under paragraph (1) shall include such information and be in such form as the Secretary may require 

to state the amount of the credit allowable (but for the receipt of a grant under this subsection) under section 48D 

for the taxable year for the qualified investment with respect to which such application is made. 

(3) TIME FOR PAYMENT OF GRANT.— 

(A) IN GENERAL.—The Secretary of the Treasury shall 

make payment of the amount of any grant under paragraph (1) during the 30-day period beginning on the later 

of— 

(i) the date of the application for such grant, or 

(ii) the date the qualified investment for which the 

grant is being made is made. 

(B) REGULATIONS.—In the case of investments of an 

ongoing nature, the Secretary shall issue regulations to determine the date on which a qualified investment shall be 

deemed to have been made for purposes of this paragraph. 

(4) QUALIFIED INVESTMENT.—For purposes of this subsection, the term ‘‘qualified investment’’ means a qualified investment that is certified under section 48D(d) of the Internal 

Revenue Code of 1986 for purposes of the credit under such 

section 48D. 

(5) APPLICATION OF CERTAIN RULES.— 

(A) IN GENERAL.—In making grants under this subsection, the Secretary of the Treasury shall apply rules 

similar to the rules of section 50 of the Internal Revenue 

Code of 1986. In applying such rules, any increase in tax 

under chapter 1 of such Code by reason of an investment 
831 Sec. 9023 PPACA (Consolidated) 

ceasing to be a qualified investment shall be imposed on 

the person to whom the grant was made. 

(B) SPECIAL RULES.— 

(i) RECAPTURE OF EXCESSIVE GRANT AMOUNTS.—If 

the amount of a grant made under this subsection exceeds the amount allowable as a grant under this subsection, such excess shall be recaptured under subparagraph (A) as if the investment to which such excess portion of the grant relates had ceased to be a 

qualified investment immediately after such grant was 

made. 

(ii) GRANT INFORMATION NOT TREATED AS RETURN

INFORMATION.—In no event shall the amount of a 

grant made under paragraph (1), the identity of the 

person to whom such grant was made, or a description 

of the investment with respect to which such grant 

was made be treated as return information for purposes of section 6103 of the Internal Revenue Code of 

1986. 

(6) EXCEPTION FOR CERTAIN NON-TAXPAYERS.—The Secretary of the Treasury shall not make any grant under this 

subsection to— 

(A) any Federal, State, or local government (or any political subdivision, agency, or instrumentality thereof), 

(B) any organization described in section 501(c) of the 

Internal Revenue Code of 1986 and exempt from tax under 

section 501(a) of such Code, 

(C) any entity referred to in paragraph (4) of section 

54(j) of such Code, or 

(D) any partnership or other pass-thru entity any 

partner (or other holder of an equity or profits interest) of 

which is described in subparagraph (A), (B) or (C). 

In the case of a partnership or other pass-thru entity described 

in subparagraph (D), partners and other holders of any equity 

or profits interest shall provide to such partnership or entity 

such information as the Secretary of the Treasury may require 

to carry out the purposes of this paragraph. 

(7) SECRETARY.—Any reference in this subsection to the 

Secretary of the Treasury shall be treated as including the Secretary’s delegate. 

(8) OTHER TERMS.—Any term used in this subsection which 

is also used in section 48D of the Internal Revenue Code of 

1986 shall have the same meaning for purposes of this subsection as when used in such section. 

(9) DENIAL OF DOUBLE BENEFIT.—No credit shall be allowed under section 46(6) of the Internal Revenue Code of 1986 

by reason of section 48D of such Code for any investment for 

which a grant is awarded under this subsection. 

(10) APPROPRIATIONS.—There is hereby appropriated to the 

Secretary of the Treasury such sums as may be necessary to 

carry out this subsection. 

(11) TERMINATION.—The Secretary of the Treasury shall 

not make any grant to any person under this subsection unless 
Sec. 9023 PPACA (Consolidated) 832 

the application of such person for such grant is received before 

January 1, 2013. 

(12) PROTECTING MIDDLE CLASS FAMILIES FROM TAX INCREASES.—It is the sense of the Senate that the Senate should 

reject any procedural maneuver that would raise taxes on middle class families, such as a motion to commit the pending legislation to the Committee on Finance, which is designed to kill 

legislation that provides tax cuts for American workers and 

families, including the affordability tax credit and the small 

business tax credit. 

(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. 

øSection 10908, p. 923, provided an exclusion for assistance 

provided to participants in State student loan repayment programs 

for certain health professionals¿ 

øNote: Amendments made by title X to provisions in titles I-IX 

have been incorporated into the provisions above and the text of the 

amendments are not repeated below. For any section in title X for 

which all of the provisions are so incorporated, the notation 

‘‘[amendments fully incorporated above]’’¿ 
833 Sec. 10103 PPACA (Consolidated) 

TITLE X—STRENGTHENING QUALITY, 

AFFORDABLE HEALTH CARE FOR ALL 

AMERICANS 

Subtitle A—Provisions Relating to Title I 

SEC. 10101. AMENDMENTS TO SUBTITLE A øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øReplaced section 2711 of the Public Health Service Act, as 

added by section 1001(5)¿ 

(b) øStruck and inserted language in section 2715(a) of the Public Health Service Act, as added by section 1001(5)¿ 

(c) øInserted a new section 2715A into subpart II of part A of 

title XXVII of the Public Health Service Act, as added by section 

1001(5)¿ 

(d) øReplaced section 2716 of the Public Health Service Act, as 

added by section 1001(5)¿ 

(e) øAmended section 2717 of the Public Health Service Act, as 

added by section 1001(5), by redesignating subsections (c) and (d) 

and inserting a new subsection (c)¿ 

(f) øReplaced section 2718 of the Public Health Service Act, as 

added by section 1001(5)¿ 

(g) øReplaced section 2719 of the Public Health Service Act, as 

added by section 1001(4)¿ 

(h) øInserted a new section 2719A into subpart II of part A of 

title XXVII of the Public Health Service Act, as added by section 

1001(5)¿ 

(i) øAdded a subparagraph (C) to subsection (c)(1) and a new 

subsection (d) to section 2794 of the Public Health Service Act, as 

added by section 1003¿ 

SEC. 10102. AMENDMENTS TO SUBTITLE B øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 1102(a)(2)(B)¿ 

(b) øAmended section 1103(a), including rewriting paragraph 

(2) of such section¿ 

SEC. 10103. AMENDMENTS TO SUBTITLE C øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øMade an insertion into section 2701(a)(5) of the Public 

Health Service Act, as added by section 1201(4)¿ 

(b) øStruck language in section 2708 of the Public Health Service Act, as added by section 1201(4)¿ 

(c) øAdded a section 2709 into subpart I of part A of title XXVII 

of the Public Health Service Act, as added by section 1201(4)¿ 

(d) øAmended section 1251(a) in paragraph (2) and by adding 

a new paragraph (3); further amended by section 2301(a) of HCERA 

by adding an additional paragraph (4)¿ 

(e) øInserted additional matter into section 1253¿ 

(f) øRedesignated section 1253 of subtitle C of title I as section 

1255 and inserted a new sections 1253 (relating to annual report on 

self-insured plans) and 1254 (relating to study of large group market)¿ 
Sec. 10104 PPACA (Consolidated) 834 

SEC. 10104. AMENDMENTS TO SUBTITLE D. 

(a) øReplaced section 1301(a)(2)¿ 

(b) øAmended section 1302 in subsection (d)(2)(B) and adding 

a new subsection (g)¿ 

(c) øReplaced section 1303¿ 

(d) øAmended section 1304 by adding a new subsection (e)¿ 

(e) øAmended section 1311(d) by replacing paragraph (3)(B)(ii) 

and by inserting language in paragraph (6)(A)¿ 

(f) øAmended section 1311(e) in paragraph (2) and by adding 

a new paragraph (3)¿ 

(g) øAmended section 1311(g)(1) by adding a new subparagraph 

(E)¿ 

(h) øAmended language in section 1311(i)(2)(B)¿ 

(i) øAmended subsections (a)(1), (e), and (f)(1)(A)(ii) of section 

1312¿ 

(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) øInserted new paragraph (4) in section 1313(b)¿ 

(l) øInserted new paragraph (2) in section 1322(b)¿ 

(m) øStruck section 1323¿ 

(n) øAmended section 1324(a)¿ 

(o) øAmended subsections (d)(3)(A)(i) and (e)(1)(B) of section 

1331¿ 

(p) øStruck subsection (b) of section 1333¿ 

(q) øAdded section 1334 to part IV of subtitle D of title I¿ 

SEC. 10105. AMENDMENTS TO SUBTITLE E øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 36B(b)(3)(A)(ii) of the IRC, as added by 

section 1401(a)¿ 
835 Sec. 10108 PPACA (Consolidated) 

(b) øAmended section 36B(c)(1)(A) of the IRC, as added by section 1401(a)¿ 

(c) øAmended section 36B(c)(2)(C)(iv) of the IRC, as added by 

section 1401(a)¿ 

(d) øAdded paragraph (3) of section 1401(d)¿ 

(e)(1) øAmended subparagraph (B) of section 45R(d)(3) of the 

IRC, added by section 1421(a)¿ 

(2) øAmended section 45R of the IRC, added by section 1421(a)¿ 

(3) øAmended section 280C(h) of the IRC, added by section 

1421(d)(1)¿ 

(4) øAmended section 1421(f)¿ 

(f) øAdded section 1416¿ 

SEC. 10106. AMENDMENTS TO SUBTITLE F øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øReplaced section 1501(a)(2)¿ 

(b)(1) øReplaced section 5000A(b)(1) of the IRC, added by section 1501(b)¿ 

(2) øReplaced paragraphs (1) and (2) of section 5000A(c) of the 

IRC, added by section 1501(b)¿ 

(3) øAmended section 5000A(c)(3) of the IRC, added by section 

1501(b)¿ 

(c) øReplaced section 5000A(d)(2)(A) of the IRC, added by section 1501(b)¿ 

(d) øReplaced section 5000A(e)(1)(C) of the IRC, added by section 1501(b)¿ 

(e) øReplaced section 4980H(b) of the IRC, added by section 

1513(a)¿ 

(f)(1) øAmended section 4980H(d)(4)(A) of the IRC, added by 

section 1513(a)¿ 

(2) øReplaced section 4980H(d)(2)(D) of the IRC, added by section 1513(a)¿ 

(g) øAdded matter at the end of section 6056(b) of the IRC, 

added by section 1514(a)¿ 

SEC. 10107. AMENDMENTS TO SUBTITLE G øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 1562¿ 

(b) øRedesignated section 1562 as section 1563 and inserted 

new sections 1562 (relating to a GAO study) & 1563 (relating to 

small business procurement¿ 

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— 
Sec. 10108 PPACA (Consolidated) 836 

(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.— 
837 Sec. 10108 PPACA (Consolidated) 

(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) øAdded a subparagraph (D) to section 36(c)(2) of the 

IRC, added by section 1401¿ 

(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) øAdded a paragraph (3) to section 4980H(c) of the 

IRC, added by section 1513¿ 

(B) EFFECTIVE DATE.—The amendment made by this 

paragraph shall apply to months beginning after December 

31, 2013. 

(2) øAmended section 18B(a)(3) of FLSA, added by section 

1512¿ 

(j) EMPLOYER REPORTING.— 

(1) øAmended section 6056(a) of the IRC, added by section 

1514¿ 

(2) øReplaced subsection (f) of section 6056 of the IRC, 

added by section 1514¿ 

(3) øMade miscellaneous conforming amendments to sections 6056 and 6724(d) of the IRC, added by section 1514, as 

well as a table of sections amendment¿ 
Sec. 10109 PPACA (Consolidated) 838 

(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)). 
839 Sec. 10201 PPACA (Consolidated) 

(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 1—MEDICAID AND CHIP 

SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE 

II OF THIS ACT. 

(a)(1) øReplaced section 1902(a)(10)(A)(i)(IX) of the Social Security Act, as added by section 2004(a)¿ 

(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 
Sec. 10201 PPACA (Consolidated) 840 

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) øAmended section 2004(d)¿ 

(b) øAmended section 1902(k)(2) of the Social Security Act, as 

added by section 2001(a)(4)(A)¿ 

(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 øsubclause (II) was 

redesignated by section 1201(1)(A) of HCERA¿ 

(B) øAmended paragraph (2)(A)¿ 

(4) by inserting after subsection (y) the following: 

‘‘(z) EQUITABLE SUPPORT FOR CERTAIN STATES.— ‘‘(1) øAs revised by section 1201(2)(A) of HCERA¿ (A) During the period that begins on January 1, 2014, and ends on December 31, 2015, 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 paragraph (3); 

‘‘(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) øParagraph (2)—shown below—substituted for previous paragraphs (2) - (4) by section 1201(2)(B) of HCERA¿ (A) 

For calendar quarters in 2014 and each year thereafter, the 

Federal medical assistance percentage otherwise determined 

under subsection (b) for an expansion State described in paragraph (3) with respect to medical assistance for individuals described in section 1902(a)(10)(A)(i)(VIII) who are nonpregnant 
841 Sec. 10201 PPACA (Consolidated) 

childless adults with respect to whom the State may require 

enrollment in benchmark coverage under section 1937 shall be 

equal to the percent specified in subparagraph (B)(i) for such 

year. 

‘‘(B)(i) The percent specified in this subparagraph for a 

State for a year is equal to the Federal medical assistance percentage (as defined in the first sentence of subsection (b)) for 

the State increased by a number of percentage points equal to 

the transition percentage (specified in clause (ii) for the year) 

of the number of percentage points by which— 

‘‘(I) such Federal medical assistance percentage for the 

State, is less than 

‘‘(II) the percent specified in subsection (y)(1) for the 

year. 

‘‘(ii) The transition percentage specified in this clause for— 

‘‘(I) 2014 is 50 percent; 

‘‘(II) 2015 is 60 percent; 

‘‘(III) 2016 is 70 percent; 

‘‘(IV) 2017 is 80 percent; 

‘‘(V) 2018 is 90 percent; and 

‘‘(VI) 2019 and each subsequent year is 100 percent. 

øPrevious paragraphs (3) and (4) stricken by section 1201(2)(B) 

of HCERA¿ 

‘‘(3) øthis paragraph added originally as a subclause (II) of 

paragraph (1)(B)(ii) of subsection (y) by section 2001(a)(3), 

amended by section 10201(c), and redesignated as paragraph 

(5) of subsection (z) by section 1201(1)(A) of HCERA, and redesignated as paragraph (3) and amended by section 1201(2)(C) of 

HCERA¿ A State is an expansion State if, on the date of the 

enactment of the Patient Protection and Affordable Care Act, 

the State offers health benefits coverage statewide to parents 

and nonpregnant, childless adults whose income is at least 100 

percent of the poverty line that includes inpatient hospital 

services, is not dependent on access to employer coverage, employer contribution, or employment and is not limited to premium assistance, hospital-only benefits, a high deductible 

health plan, or alternative benefits under a demonstration program authorized under section 1938. A State that offers health 

benefits coverage to only parents or only nonpregnant childless 

adults described in the preceding sentence shall not be considered to be an expansion State.’’; 

(5) øStruck and inserted language in subsection (aa)¿ 

(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 
Sec. 10201 PPACA (Consolidated) 842 

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) øAmended section 1108(g)(4)(B) of the Social Security Act 

(42 U.S.C. 1308(g)(4)(B)), as added by section 2005(b); should have 

been repealed by sec. 1204(b)(2)(A) of HCERA¿ 

(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 
843 Sec. 10201 PPACA (Consolidated) 

ø(B) in paragraph (7)—øAmendments superseded by 

amendment made by section 1203(w) of HCERA¿¿ 

ø(i) in subparagraph (A), in the matter preceding 

clause (i), by striking ‘‘subparagraph (E)’’ and inserting 

‘‘subparagraphs (E) and (G)’’;¿ 

ø(ii) in subparagraph (B)—¿ 

ø(I) in clause (i), by striking subclauses (I) and 

(II), and inserting the following:¿ 

ø‘‘(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;¿ 

ø‘‘(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;¿ 

ø‘‘(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¿ 

ø‘‘(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.’’;¿ 

ø(II) in clause (ii), by striking subclauses (I) and 

(II), and inserting the following:¿ 

ø‘‘(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;¿ 

ø‘‘(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;¿ 
Sec. 10201 PPACA (Consolidated) 844 

ø‘‘(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¿ 

ø‘‘(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.’’;¿ 

ø(III) in subparagraph (E), by striking ‘‘35 percent’’ and inserting ‘‘50 percent’’; and¿ 

ø(IV) by adding at the end the following:¿ 

ø‘‘(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) øStruck subsection (b) of section 2551¿ 

(g) øInserted sentence at the end of section 2105(d)(3)(B) of the 

Social Security Act, as added by section 2101(b)(1)¿ 

(h) øReplaced section 513(b)(2)(C)(i) of the Social Security Act, 

as added by section 2953¿ 

(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 
845 Sec. 10202 PPACA (Consolidated) 

‘‘(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) øAdded section 3512 to subtitle F of title III¿ 

SEC. 10202. ø42 U.S.C. 1396d note¿ INCENTIVES FOR STATES TO OFFER 

HOME AND COMMUNITY-BASED SERVICES AS A LONGTERM 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 estab-
Sec. 10202 PPACA (Consolidated) 846 

lishment 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 communitybased 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 
847 Sec. 10202 PPACA (Consolidated) 

portal, in accordance with such standards as the State 

shall establish and that shall provide information regarding the availability of such services, how to apply for such 

services, referral services for services and supports otherwise available in the community, and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial 

and functional eligibility. 

(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— 
Sec. 10202 PPACA (Consolidated) 848 

(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 noninstitutionally-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. 
849 Sec. 10203 PPACA (Consolidated) 

SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL 

YEAR 2015 AND OTHER CHIP-RELATED PROVISIONS. 

(a) øInserted subparagraph (I) at the end of section 1311(c)(1)¿ 

(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) øAmended subsections (b) and (d)(3) of section 2105 of the 

Social Security Act (42 U.S.C. 1397ee), as amended by section 

2101¿ 

(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 semiannual 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)— 
Sec. 10203 PPACA (Consolidated) 850 

(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 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 
851 Sec. 10203 PPACA (Consolidated) 

(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 
Sec. 10211 PPACA (Consolidated) 852 

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 2—SUPPORT FOR PREGNANT AND 

PARENTING TEENS AND WOMEN 

SEC. 10211. ø42 U.S.C. 18201¿ 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. 
853 Sec. 10213 PPACA (Consolidated) 

(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. ø42 U.S.C. 18202¿ 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. ø42 U.S.C. 18203¿ PERMISSIBLE USES OF FUND. 

(a) IN GENERAL.—A State shall use amounts received under a 

grant under section 10212 for the purposes described in this section 

to assist pregnant and parenting teens and women. 

(b) INSTITUTIONS OF HIGHER EDUCATION.— 

(1) IN GENERAL.—A State may use amounts received under 

a grant under section 10212 to make funding available to eligible institutions of higher education to enable the eligible institutions to establish, maintain, or operate pregnant and parenting student services. Such funding shall be used to supplement, not supplant, existing funding for such services. 

(2) APPLICATION.—An eligible institution of higher education that desires to receive funding under this subsection 

shall submit an application to the designated State agency at 

such time, in such manner, and containing such information as 

the State agency may require. 

(3) MATCHING REQUIREMENT.—An eligible institution of 

higher education that receives funding under this subsection 

shall contribute to the conduct of the pregnant and parenting 

student services office supported by the funding an amount 

from non-Federal funds equal to 25 percent of the amount of 

the funding provided. The non-Federal share may be in cash 

or in-kind, fairly evaluated, including services, facilities, supplies, or equipment. 
Sec. 10213 PPACA (Consolidated) 854 

(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. 
855 Sec. 10213 PPACA (Consolidated) 

(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. 
Sec. 10213 PPACA (Consolidated) 856 

(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. 
857 Sec. 10221 PPACA (Consolidated) 

SEC. 10214. ø42 U.S.C. 18204¿ 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 3—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. øThe bill, as enacted and amended by 

subsection (b), is shown in a separate compiled document.¿ 

(b) AMENDMENTS.—øAmendments below are incorporated into 

the separate compiled document.¿ 

(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: 
Sec. 10301 PPACA (Consolidated) 858 

‘‘(a) HHS APPROPRIATIONS.—Any limitation’’; and 

(B) by adding at the end the following: 

‘‘(b) LIMITATIONS PURSUANT TO OTHER FEDERAL LAW.—Any 

limitation pursuant to other Federal laws on the use of Federal 

funds appropriated to the Service shall apply with respect to the 

performance or coverage of abortions.’’. 

(4) The bill referred to in subsection (a) is amended by 

striking section 201. 

Subtitle C—Provisions Relating to Title III 

SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR 

AMBULATORY SURGICAL CENTERS øAMENDMENTS FULLY 

INCORPORATED ABOVE¿. 

(a) IN GENERAL.—øAdded subsection (f) in section 3006¿ 

(b) TECHNICAL.—øStruck clauses (i) and (ii) of section 

3006(a)(2)(A)¿ 

SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended 399HH9(a)(2)(B)(iii) of the Public Health Service 

Act, as added by section 3011¿ 

SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES. 

(a) DEVELOPMENT.—øAdded subsection (f) to section 931 of the 

Public Health Service Act, as added by section 3013(a)¿ 

(b) HOSPITAL-ACQUIRED CONDITIONS.—øAdded subsection (f) to 

section 1890A of the Social Security Act, as added by section 

3014(b) and as amended by section 3013(b)¿ 

(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 øAMENDMENTS 

FULLY INCORPORATED ABOVE¿. 

øAmended sections 1890(b)(7) and 1890A of the Social Security 

Act, as added by section 3014, by striking ‘‘quality’’ each place it appears and inserting ‘‘quality and efficiency’’.Because of different 

typefaces, uncertain if amended headings in those sections.¿ 
859 Sec. 10311 PPACA (Consolidated) 

SEC. 10305. DATA COLLECTION; PUBLIC REPORTING øAMENDMENTS 

FULLY INCORPORATED ABOVE¿. 

øReplaced section 399II(a) of the Public Health Service Act, as 

added by section 3015¿ 

SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND 

MEDICAID INNOVATION øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

Section 1115A of the Social Security Act, as added by section 

3021, is amended— 

(1) øInserted new paragraph at end of subsection (a)¿ 

(2) in subsection (b)(2)— 

(A) øAmended subparagraph (A)¿ 

(B) øAdded clauses (xix) and (xx) at end of subparagraph (B)¿ 

(C) øAdded clause (viii) at end of subparagraph (C)¿ 

(3) øAdded subparagraph (C) at the end of subsection 

(b)(4)¿ 

(4) øAmended paragraphs (1)(B) and (2) of subsection (c) 

and added paragraph (3) and sentence to subsection (c)¿ 

SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS 

PROGRAM øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAdded new subsections (i) - (k) to section 1899 of the Social 

Security Act, as added by section 3022¿ 

SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT 

BUNDLING øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) IN GENERAL.—Section 1866D of the Social Security Act, as 

added by section 3023, is amended— 

(1) øAmended paragraph (a)(2)(B)¿ 

(2) øReplaced subsection (c)(1)(B)¿ 

(3) øReplaced subsection (g)¿ 

(b) TECHNICAL AMENDMENTS.— 

(1) øAmended section 3023¿ 

(2) øRedesignated section 1866D of the Social Security Act, 

as added by section 3024, as section 1866E¿ 

SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION 

PROGRAM øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended section 1886(q)(1) of the Social Security Act, as 

added by section 3025¿ 

SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE øAMENDMENTS 

FULLY INCORPORATED ABOVE¿. 

øRepealed section 3101¿ 

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

øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 1834(l)(13)(A) of the Social Security Act, 

as amended by section 3105(a)¿ 

(b) øAmended section 146(b)(1) of the Medicare Improvements 

for Patients and Providers Act of 2008, as amended by section 

3105(b)¿ 

(c) øAmended section 1834(l)(12)(A) of the Social Security Act, 

as amended by section 3105(c)¿ 
Sec. 10312 PPACA (Consolidated) 860 

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

(a) øAmended section 114(c) of the Medicare, Medicaid, and 

SCHIP Extension Act of 2007, as amended by section 4302(a) of the 

American Recovery and Reinvestment Act and section 3106(a)¿ 

(b) øAmended section 114(d) of such Act, as amended by section 

3106(b)¿ 

SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL COMMUNITY HOSPITAL DEMONSTRATION PROGRAM øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øReplaced subsection (g) of section 410A of the Medicare 

Prescription Drug, Improvement, and Modernization Act of 2003, as 

added by section 3123(a)¿ 

(b) øAmended subsection (a)(5) of section 410A of the Medicare 

Prescription Drug, Improvement, and Modernization Act of 2003, as 

amended by section 3123(b)¿ 

SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION 

øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended subparagraphs (C)(i) and (D) of section 1886(d)(12) 

of the Social Security Act, as amended by section 3125¿ 

SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 1895(b)(3)(A)(iii) of the Social Security 

Act, as added by section 3131¿ 

(b) øReplaced section 3131(d)¿ 

SEC. 10316. MEDICARE DSH øAMENDMENTS FULLY INCORPORATED 

ABOVE¿. 

øAmended section 1886(r)(2)(B) of the Social Security Act, as 

added by section 3133¿ 

SEC. 10317. REVISIONS TO EXTENSION OF SECTION 508 HOSPITAL 

PROVISIONS øAMENDMENTS FULLY INCORPORATED 

ABOVE¿. 

øReplaced section 3137(a)¿ 

SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER 

MEDICARE ADVANTAGE øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended section 1853(p)(3)(A) of the Social Security Act, as 

added by section 3201(h); section 3201 and its amendments was 

subsequently repealed by section 1102(a) of HCERA¿ 

SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) INPATIENT ACUTE HOSPITALS.—øAmended section 

1886(b)(3)(B)(xii) of the Social Security Act, as added by section 

3401(a); subsequently amended by section 1105(a) of HCERA¿ 

(b) LONG-TERM CARE HOSPITALS.—øAmended section 

1886(m)(4) of the Social Security Act, as added by section 3401(c); 

subsequently amended by section 1105(b) of HCERA¿ 

(c) INPATIENT REHABILITATION FACILITIES.—øAmended section 

1886(j)(3)(D)(i) of SSA, as added by section 3401(d); subsequently 

amended by section 1105(c) of HCERA¿ 

(d) HOME HEALTH AGENCIES.—øAmended section 

1895(b)(3)(B)(vi)(II) of SSA, as added by section 3401(e)¿ 
861 Sec. 10322 PPACA (Consolidated) 

(e) PSYCHIATRIC HOSPITALS.—øAmended section 1886(s)(3)(A) of 

SSA, as added by section 3401(f); subsequently amended by section 

1105(d) of HCERA¿ 

(f) HOSPICE CARE.—øAmended section 1814(i)(1)(C) of the Social Security Act, as amended by section 3401(g)¿ 

(g) OUTPATIENT HOSPITALS.—øAmended section 1833(t)(3)(G)(i) 

of SSA, as added by section 3401(i); subsequently amended by section 1105(e) of HCERA¿ 

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) øAdded sentence at end of paragraph (1)(B)¿; 

(B) øAmended paragraph (2)(A) in clause (iv) and by 

adding new clause (vii)¿ 

(C) øAdded clause (vii) to paragraph (2)(B)¿ 

(D) øAmended paragraph (3), including striking subparagraph (A)(ii)(III)¿ 

(E) øAmended paragraph (4)¿ 

(F) øAmended paragraph (5)¿ 

(G) øAmended paragraph (6)(B)(i)¿ 

(2) øAmended subsection (d)¿ 

(3) in subsection (e)— 

(A) øAmended paragraph (1)¿ 

(B) øAmended paragraph (3), including adding a new 

subparagraph (B)¿ 

(4) øAmended subsection (f)(3)(B)¿ 

(5) øAdded subsections (n) and (o)¿ 

(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 øAMENDMENTS 

FULLY INCORPORATED ABOVE¿. 

øAmended section 3502(c)(2)(A)¿ 

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 Sec-
Sec. 10322 PPACA (Consolidated) 862 

retary 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.’’. 
863 Sec. 10323 PPACA (Consolidated) \1881A SSA 

(b) øAmended section 1890(b)(7)(B)(i)(I) of the Social Security 

Act, as added by section 3014¿ 

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. ø42 U.S.C. 1395rr–1¿ 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 
Sec. 10323\1881A SSA PPACA (Consolidated) 864 

‘‘(B) is an environmental exposure affected individual 

described in subsection (e)(3) who— 

‘‘(i) is deemed under subsection (a)(2); and 

‘‘(ii) meets such other criteria or conditions for 

participation in a pilot program under paragraph 

(1)(B) as the Secretary specifies. 

‘‘(3) FLEXIBLE BENEFITS AND SERVICES.—A pilot program 

under this subsection may provide for the furnishing of benefits, items, or services not otherwise covered or authorized 

under this title, if the Secretary determines that furnishing 

such benefits, items, or services will further the purposes of 

such pilot program (as described in paragraph (1)). 

‘‘(4) INNOVATIVE REIMBURSEMENT 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 
865 Sec. 10323 PPACA (Consolidated) \1881A SSA 

public health emergency under section 104(a) of the Comprehensive 

Environmental Response, Compensation, and Liability Act of 1980. 

‘‘(e) ENVIRONMENTAL EXPOSURE AFFECTED INDIVIDUAL DE- FINED.— ‘‘(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, 
Sec. 10323 PPACA (Consolidated) 866 

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 CON- DITIONS 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. ø42 U.S.C. 1397h¿ 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. 
867 Sec. 10323 PPACA (Consolidated) \2009 SSA 

‘‘(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 

‘‘(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 cri-
Sec. 10324 PPACA (Consolidated) 868 

teria 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. 
869 Sec. 10324 PPACA (Consolidated) 

‘‘(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 HOS- PITAL 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 
Sec. 10325 PPACA (Consolidated) 870 

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. ø42 U.S.C. 1395b–1 note¿ 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 
871 Sec. 10327 PPACA (Consolidated) 

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. 

‘‘(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. 
Sec. 10327 PPACA (Consolidated) 872 

‘‘(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). 
873 Sec. 10328 PPACA (Consolidated) 

‘‘(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) øAdded a paragraph (3) to section 3002(c)¿ 

(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 
Sec. 10329 PPACA (Consolidated) 874 

‘‘(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 OPTOUT.—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. 
875 Sec. 10331 PPACA (Consolidated) 

(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. ø42 U.S.C. 1395w–5 note¿ PUBLIC REPORTING OF PERFORMANCE INFORMATION. 

(a) IN GENERAL.— (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; 
Sec. 10331 PPACA (Consolidated) 876 

(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 
877 Sec. 10332 PPACA (Consolidated) 

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 valuebased 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— 
Sec. 10332 PPACA (Consolidated) 878 

‘‘(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). 
879 Sec. 10333 PPACA (Consolidated) \340H PHSA 

‘‘(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 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. ø42 U.S.C. 256i¿ 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 pro-
Sec. 10334 PPACA (Consolidated) 880 

vides 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— 
881 Sec. 10334 PPACA (Consolidated) 

(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 
Sec. 10334\1707A PHSA PPACA (Consolidated) 882 

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 SERV- ICES.— (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. ø42 U.S.C. 300u–6a¿ 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. 

(3) LIMITATION ON TERMINATION.—Notwithstanding any 

other provision of law, a Federal office of minority health or 
883 Sec. 10335 PPACA (Consolidated) 

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 VALUEBASED PURCHASING PROGRAM øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended section 1886(o)(2)A) of the Social Security Act, as 

added by section 3001¿ 
Sec. 10336 PPACA (Consolidated) 884 

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 nonoral 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 øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 4001(h)(4) and (5)¿ 

(b) øAmended section 4002(c)¿ 

(c) øAmended section 4004(a)(4)¿ 

SEC. 10402. AMENDMENTS TO SUBTITLE B øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 399Z–1(a)(1)(A) of the Public Health 

Service Act, as added by section 4101(b)¿ 

(b) øReplaced section 1861(hhh)(4)(G) of the Social Security Act, 

as added by section 4103(b)¿ 

SEC. 10403. AMENDMENTS TO SUBTITLE C øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended section 4201¿ 
885 Sec. 10407 PPACA (Consolidated) 

SEC. 10404. AMENDMENTS TO SUBTITLE D øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended section 399MM(2) of the Public Health Service Act, 

as added by section 4303¿ 

SEC. 10405. AMENDMENTS TO SUBTITLE E øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øStruck section 4401¿ 

SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR 

PREVENTIVE SERVICES øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øReplaced section 4104(b)¿ 

SEC. 10407. ø42 U.S.C. 247b–9a¿ 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.— (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. 
Sec. 10408 PPACA (Consolidated) 886 

(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. ø42 U.S.C. 280l note¿ 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 evidencebased 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). 
887 Sec. 10409 PPACA (Consolidated) \402C PHSA 

(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. ø42 U.S.C. 282d¿ 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 de-
Sec. 10409\402C PHSA PPACA (Consolidated) 888 

fined 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.— 
889 Sec. 10409 PPACA (Consolidated) \402C PHSA 

‘‘(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 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— 
Sec. 10409\402C PHSA PPACA (Consolidated) 890 

‘‘(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 mem-
891 Sec. 10409 PPACA (Consolidated) \402C PHSA 

bers, 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 United 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 orga-
Sec. 10409\402C PHSA PPACA (Consolidated) 892 

nization, 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 
893 Sec. 10409 PPACA (Consolidated) \402C PHSA 

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. 

‘‘(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 PPACA (Consolidated) 894 

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. ø42 U.S.C. 290bb–33¿ 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 
895 Sec. 10410 PPACA (Consolidated) \520B PHSA 

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 
Sec. 10410\520B PHSA PPACA (Consolidated) 896 

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 inkind, 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— 
897 Sec. 10410 PPACA (Consolidated) \520B PHSA 

‘‘(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; 

‘‘(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. 
Sec. 10411 PPACA (Consolidated) 898 

‘‘(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. ø42 U.S.C. 280g–13¿ 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. 
899 Sec. 10411 PPACA (Consolidated) \425 PHSA 

‘‘(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. ø42 U.S.C. 285b–8¿ 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 
Sec. 10411 PPACA (Consolidated) 900 

‘‘(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. ø42 U.S.C. 280m¿ 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; 
901 Sec. 10413 PPACA (Consolidated) \399NN PHSA 

‘‘(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). 

‘‘(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 
Sec. 10413\399NN PHSA PPACA (Consolidated) 902 

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, spe-
903 Sec. 10501 PPACA (Consolidated) \399V–3 PHSA 

cific 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) øAmended subsection (c)(2)(B)(i)(II)¿ 

(2) øAmended subsection (d)(4)(A)¿ 

(3) in subsection (i)(2)(B), by inserting ‘‘optometrists, ophthalmologists,’’ after ‘‘occupational therapists,’’. øNote: ‘‘occupational therapists,’’ does not appear in subparagraph (B) of subsection (i)(2), but does appear in subparagraphs (A) and (C) of 

subsection (i)(2).¿ 

(b) øAdded section 5104 at the end of subtitle B of title V¿ 

(c) øAmended section 399V of the Public Health Service Act, as 

added by section 5313¿ 

(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) øAdded section 5316 at the end of subtitle D of title V¿ 

(f) øRedesignated section 399W of the Public Health Service Act, 

added by section 5405, as section 399V–1 and amended subsection 

(b)(2)(A) of that section and conformed cross-references to that section in sections 934 & 935(b) of the PHSA, as added by sections 

3501 & 3503¿ 

(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. ø42 U.S.C. 280g–14¿ 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 
Sec. 10501 PPACA (Consolidated) 904 

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 nonprofits 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) øRepealed section 5501(c)¿ 

(i)(1) øRepealed section 5502¿ 

(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 Sec-
905 Sec. 10501 PPACA (Consolidated) 

retary 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. 

‘‘(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 
Sec. 10501\749B PHSA PPACA (Consolidated) 906 

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) øAdded new subsection at the end of section 5505¿ 

(k) øAdded section 5606 at the end of subtitle G of title V¿ 

(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. ø42 U.S.C. 293m¿ 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— 
907 Sec. 10501 PPACA (Consolidated) \749B PHSA 

‘‘(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, main-
Sec. 10501 PPACA (Consolidated) 908 

tain, 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. ø42 U.S.C. 295c¿ 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; 

‘‘(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 
909 Sec. 10501 PPACA (Consolidated) 

‘‘(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.’’. 
Sec. 10502 PPACA (Consolidated) 910 

(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) øAmended subsection (a) of section 338C of the Public 

Health Service Act, as amended by section 5508¿ 

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. ø42 U.S.C. 254b–2¿ 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—øAs revised by section 2303 of HCERA¿ 

(A) $1,000,000,000 for fiscal year 2011; 
911 Sec. 10601 PPACA (Consolidated) 

(B) $1,200,000,000 for fiscal year 2012; 

(C) $1,500,000,000 for fiscal year 2013; 

(D) $2,200,000,000 for fiscal year 2014; and 

(E) $3,600,000,000 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. ø42 U.S.C. 256 note¿ 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 øAMENDMENTS FULLY INCORPORATED 

ABOVE¿. 

(a) Section 1877(i) of the Social Security Act, as added by section 6001(a), is amended— 
Sec. 10602 PPACA (Consolidated) 912 

(1) in paragraph (1)(A)(i), by striking ‘‘February 1, 2010’’ 

and inserting ‘‘August 1, 2010’’; and øNote: paragraph (1)(A)(i) 

says ‘‘December 31, 2010’’, not ‘‘February’’ or ‘‘August’’, so 

amendment could not be executed¿ 

(2) øAmended paragraph (3)(A)¿ 

(b) øAmended section 6001(b)(2)¿ 

SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES RESEARCH øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

øAmended section 1181 of the Social Security Act (as added by 

section 6301)¿ 

SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL PROVIDER APPLICATION FEES øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 1866(j)(2)(C) of the Social Security Act, as 

added by section 6401(a)¿ 

(b) øReplaced section 6401(a)(2)¿ 

SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405 øAMENDMENTS 

FULLY INCORPORATED ABOVE¿. 

øReplaced paragraphs (1) and (2) of section 6405(b)¿ 

SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT 

FACE TO FACE ENCOUNTER FOR HOME HEALTH SERVICES øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øAmended section 1814(a)(2)(C) of the Social Security Act, 

as amended by section 6407(a)(1)¿ 

(b) øAmended section 1835(a)(2)(A)(iv) of the Social Security 

Act, as amended by section 6407(a)(2)¿ 

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; 
913 Sec. 10606 PPACA (Consolidated) 

(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 
Sec. 10606\3A CRIPA. PPACA (Consolidated) 914 

(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. ø42 U.S.C. 1997a–1¿ 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— 

‘‘(1) may not be used for any purpose other than to protect 

the rights, privileges, or immunities secured or protected by 
915 Sec. 10607 PPACA (Consolidated) \399V–4 PHSA 

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. ø42 U.S.C. 280g–15¿ 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 
Sec. 10607\399V–4 PHSA PPACA (Consolidated) 916 

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. 
917 Sec. 10607 PPACA (Consolidated) \399V–4 PHSA 

‘‘(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.— 
Sec. 10607\399V–4 PHSA PPACA (Consolidated) 918 

‘‘(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); 

‘‘(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 
919 Sec. 10607 PPACA (Consolidated) \399V–4 PHSA 

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 
Sec. 10608 PPACA (Consolidated) 920 

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 
921 Sec. 10902 PPACA (Consolidated) 

(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 øAMENDMENTS 

FULLY INCORPORATED ABOVE¿. 

(a) øAmended sections 3203 and 3204 of the Public Health 

Service Act, as added by section 8002(a)(1)¿ 

(b) øAmended heading for subsection (d) of section 8002¿ 

(c) øAmended section 6021(d)(2)(A)(iv) of the Deficit Reduction 

Act of 2005, as added by section 8002(d)¿ 

Subtitle H—Provisions Relating to Title IX 

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

FULLY INCORPORATED ABOVE¿. 

(a) øAmended paragraph (3) of section 4980I(f) of the Internal 

Revenue Code of 1986, as added by section 9001¿ 

(b) øAmended clause (i) of section 4980I(d)(1)(B) of the Internal 

Revenue Code of 1986, as added by section 9001¿ 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2017. 

øAs revised by section 1401(b)(2) of HCERA¿ 

SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH 

FLEXIBLE SPENDING ARRANGEMENTS UNDER CAFETERIA PLANS øAMENDMENTS FULLY INCORPORATED 

ABOVE¿. 

(a) øReplaced subsection (i) of section 125 of the Internal Revenue Code of 1986, as added by section 9005 and is further amended by section 1403(b) of HCERA¿ 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall apply to taxable years beginning after December 31, 2012. 

øAs revised by section 1403(a) of HCERA¿ 
Sec. 10903 PPACA (Consolidated) 922 

SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY CHARITABLE HOSPITALS øAMENDMENTS FULLY INCORPORATED 

ABOVE¿. 

(a) øAmended subparagraph (A) of section 501(r)(5) of the Internal Revenue Code of 1986, as added by section 9007¿ 

(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 øAMENDMENTS FULLY 

INCORPORATED ABOVE¿. 

(a) øAmended section 9009, which was subsequently repealed by 

section 1404(d) of HCERA¿ 

(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 øAMENDMENTS FULLY INCORPORATED ABOVE¿. 

(a) øReplaced section 9010(b)¿ 

(b) øReplaced section 9101(e); subsequently superseded by 

amendment made by section 1406(a)(4) of HCERA¿ 

(c) øAmended section 9010(c)(2) by adding new subparagraphs 

(C) through (E)¿ 

(d) øReplaced section 9010(h)(3)¿ 

(e) øAmended subsection (i) of section 9010¿ 

(f) CONFORMING AMENDMENTS.— 

(1) øAmended section 9010(a)(1)¿ 

(2) øAmended section 9010(c)(2)(B)¿ 

(3) Section 9010(c)(3) of this Act is amended by adding at 

the end the following new sentence: øsentence omitted; placement ‘‘at the end’’ is unclear and probably intended to be added 

at the end of subparagraph (A)¿ 

(4) øAmended section 9010(g)(1)¿ 

(5) Section 9010(j) of this Act is amended— 

(A) by striking ‘‘2008’’ and inserting ‘‘2009’’, and øNot 

executed as ‘‘2008’’ does not appear in provision; superseded 

by amendment made by section 1406(a)(6) of HCERA¿ 

(B) øStruck other language¿ 

(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 øAMENDMENTS FULLY 

INCORPORATED ABOVE¿. 

(a) øAmended section 3101(b)(2) of the Internal Revenue Code 

of 1986, as added by section 9015(a)(1)¿ 

(b) øAmended section 1401(b)(2)(A) of the Internal Revenue 

Code of 1986, as added by section 9015(b)(1)¿ 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply with respect to remuneration received, and taxable 

years beginning, after December 31, 2012. 
923 Sec. 10908 PPACA (Consolidated) 

SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF 

ELECTIVE COSMETIC MEDICAL PROCEDURES øSUBSTITUTES FOR SECTION 9017 OF PPACA¿. 

(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: 
Sec. 10909 PPACA (Consolidated) 924 

‘‘(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. 
925 Sec. 10909 PPACA (Consolidated) 

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.— 
Sec. 10909 PPACA (Consolidated) 926 

(A) Section 24(b)(3)(B) of such Code is amended by 

striking ‘‘23,’’. 

(B) Section 25(e)(1)(C) of such Code is amended by 

striking ‘‘23,’’ both places it appears. 

(C) Section 25A(i)(5)(B) of such Code is amended by 

striking ‘‘23, 25D,’’ and inserting ‘‘25D’’. 

(D) Section 25B(g)(2) of such Code is amended by 

striking ‘‘23,’’. 

(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. 
927 

øThis is the text of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152) shown, in a manner similar 

to that of title X of PPACA above. Subtitle A of title II (relating to 

education) is not shown.¿ 

SEC. 1. SHORT TITLE; TABLE OF CONTENTS. 

(a) SHORT TITLE.—This Act may be cited as the ‘‘Health Care 

and Education Reconciliation Act of 2010’’. 

(b) TABLE OF CONTENTS.—The table of contents of this Act is 

as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—COVERAGE, MEDICARE, MEDICAID, AND REVENUES 

Subtitle A—Coverage 

Sec. 1001. Tax credits øamendments fully incorporated into PPACA¿. 

Sec. 1002. Individual responsibility øamendments fully incorporated into PPACA¿. 

Sec. 1003. Employer responsibility øamendments fully incorporated into PPACA¿. 

Sec. 1004. Income definitions. 

Sec. 1005. Implementation funding. 

Subtitle B—Medicare 

Sec. 1101. Closing the medicare prescription drug ‘‘donut hole’’øsubstitutes for section 3315 of PPACA¿. 

Sec. 1102. Medicare Advantage payments øsubstitutes for sections 3201 & 3203 of 

PPACA¿. 

Sec. 1103. Savings from limits on MA plan administrative costs. 

Sec. 1104. Disproportionate share hospital (DSH) payments øamendment fully incorporated into PPACA¿. 

Sec. 1105. Market basket updates øamendments fully incorporated into PPACA¿. 

Sec. 1106. Physician ownership-referral øamendments fully incorporated into 

PPACA¿. 

Sec. 1107. Payment for imaging services øamendments fully incorporated into 

PPACA¿. 

Sec. 1108. PE GPCI adjustment for 2010 øamendment fully incorporated into 

PPACA¿. 

Sec. 1109. Payment for qualifying hospitals. 

Subtitle C—Medicaid 

Sec. 1201. Federal funding for States øamendments fully incorporated into 

PPACA¿. 

Sec. 1202. Payments to primary care physicians. 

Sec. 1203. Disproportionate share hospital payments. 

Sec. 1204. Funding for the territories. 

Sec. 1205. Delay in Community First Choice option øamendment fully incorporated 

into PPACA¿. 

Sec. 1206. Drug rebates for new formulations of existing drugs øamendment fully 

incorporated into PPACA¿. 

Subtitle D—Reducing Fraud, Waste, and Abuse 

Sec. 1301. Community mental health centers. 

Sec. 1302. Medicare prepayment medical review limitations. 

Sec. 1303. Funding to fight fraud, waste, and abuse. 

Sec. 1304. 90-day period of enhanced oversight for initial claims of DME suppliers 

øamendment fully incorporated into PPACA¿. 
Sec. 1001 HEALTH RECONCILIATION 928 

Subtitle E—Provisions Relating to Revenue 

Sec. 1401. High-cost plan excise tax øamendments fully incorporated into PPACA¿. 

Sec. 1402. Unearned income Medicare contribution. 

Sec. 1403. Delay of limitation on health flexible spending arrangements under cafeteria plans øamendments fully incorporated into PPACA¿. 

Sec. 1404. Brand name pharmaceuticals øamendments fully incorporated into 

PPACA¿. 

Sec. 1405. Excise tax on medical device manufacturers øsubstitutes for section 9009 

of PPACA¿. 

Sec. 1406. Health insurance providers øamendment fully incorporated into 

PPACA¿. 

Sec. 1407. Delay of elimination of deduction for expenses allocable to medicare part 

D subsidy øamendment fully incorporated in PPACA¿. 

Sec. 1408. Elimination of unintended application of cellulosic biofuel producer credit. 

Sec. 1409. Codification of economic substance doctrine and penalties. 

Sec. 1410. Time for payment of corporate estimated taxes. 

Subtitle F—Other Provisions 

Sec. 1501. Community college and career training grant program. 

TITLE II—EDUCATION AND HEALTH 

Subtitle A—Education øOmitted From This Compilation¿ 

Subtitle B—Health 

Sec. 2301. Insurance reforms øamendment fully incorporated into PPACA¿. 

Sec. 2302. Drugs purchased by covered entities. 

Sec. 2303. Community health centers øamendment fully incorporated into PPACA¿. 

TITLE I—COVERAGE, MEDICARE, 

MEDICAID, AND REVENUES 

Subtitle A—Coverage 

SEC. 1001. TAX CREDITS øAMENDMENTS FULLY INCORPORATED INTO 

PPACA¿. 

(a) PREMIUM TAX CREDITS.—øAmended section 36B of the IRC, 

as added by section 1401 (and amended by section 10105) of 

PPACA¿— 

(1) in subsection (b)(3)(A)— 

(A) øAmended clause (i) by inserting new matter, including a table¿ 

(B) øStruck clauses (ii) and (iii) and inserted a new 

clause (ii)¿ 

(2) in subsection (c)(2)(C)— 

(A) øAmended percentages in clauses (i)(II) and (iv)¿ 

(B) øAmended clause (iv)¿. (b) COST SHARING.—Section 1402(c) of the Patient Protection 

and Affordable Care Act is amended— 

(1) in paragraph (1)(B)(i)— 

(A) øAmended percentage in subclause (I)¿; 

(B) øAmended percentage in subclause (II)¿ 

(C) øStruck subclause (III) and inserted new subclauses (III) and (IV)¿ 

(2) in paragraph (2)— 

(A) øAmended percentage in subparagraph (A)¿ 

(B) øAmended percentage in subparagraph (B)¿ 
929 Sec. 1004 HEALTH RECONCILIATION 

(C) øInserted a subparagraph (C)¿’’. 

SEC. 1002. INDIVIDUAL RESPONSIBILITY øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

(a) AMOUNTS.—Section 5000A(c) of the Internal Revenue Code 

of 1986, as added by section 1501(b) of the Patient Protection and 

Affordable Care Act and amended by section 10106 of such Act, is 

amended— 

(1) in paragraph (2)(B)— 

(A) øAmended matter before clause (i)¿ 

(B) øAmended percentage in clause (i)¿ 

(C) øAmended percentage in clause (ii)¿ 

(D) øAmended percentage in clause (iii)¿ 

(2) øAmended dollar amounts in subparagraphs (A), (B), 

and (D) of paragraph (3)¿ 

(b) THRESHOLD.—Section 5000A of such Code, as so added and 

amended, is amended— 

(1) øStruck subsection (c)(4)(D)¿ 

(2) øAmended subsection (e)(2)¿ 

SEC. 1003. EMPLOYER RESPONSIBILITY øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

(a) PAYMENT CALCULATION.—øReplaced section 4980H(d)(2)(D) 

of the IRC, as added by section 1513 (and amended by section 

10106) of PPACA, before redesignation by subsection (d)¿ 

(b) APPLICABLE PAYMENT AMOUNT.—Section 4980H of such 

Code, as so added and amended, is amended— 

(1) øAmended flush text in subsection (c)(1), before redesignation by subsection (d)¿ 

(2) øAmended amount in subsection (d)(1), before redesignation by subsection (d)¿ 

(3) øAmended subsection (d)(5)(A), before redesignation by 

subsection (d)¿ 

(c) COUNTING PART-TIME WORKERS IN SETTING THE THRESHOLD

FOR EMPLOYER RESPONSIBILITY.—øAdded a subparagraph (E) at 

the end of section 4980H(d)(2) of the IRC, as so added, before redesignation by subsection (d)¿ 

(d) ELIMINATING WAITING PERIOD ASSESSMENT.—øStruck subsection (b) of section 4980H of the IRC and redesignated succeeding 

subsections accordingly¿ 

SEC. 1004. INCOME DEFINITIONS. 

(a) MODIFIED ADJUSTED GROSS INCOME.— 

(1) IN GENERAL.—øAmended section 36B(d)(2)(A)(i) & (ii) of 

the IRC, added by section 1401 of PPACA, 6103(l)(21)(A)(iv) of 

IRC, added by section 1414 of PPACA, and 5000A(c)(4)ƒsic≈(i) 

& (ii) of IRC, added by section 1501(b) of PPACA—executed as 

if referenced 5000A(c)(4)(B)¿ 

(2) DEFINITION.— 

(A) øReplaced section 36(d)(2)(B) of IRC¿ 

(B) øReplaced section 5000A(c)(4)(C) of the IRC¿ 

(b) MODIFIED ADJUSTED GROSS INCOME DEFINITION.— 

(1) MEDICAID.—øAmended section 1902(e)(14) of the Social 

Security Act, added by section 2002(a) of PPACA, and 

1902(gg)(4)(A) of the SSA, added by section 2001(b) of PPACA¿ 

(2) CHIP.— 
Sec. 1004 HEALTH RECONCILIATION 930 

(A) STATE PLAN REQUIREMENTS.—øAmended section 

2102(b)(1)(B)(v) of the Social Security Act, added by section 

2101(d)(1) of PPACA¿. 

(B) PLAN ADMINISTRATION.—øAmended section 

2107(e)(1)(E) of the SSA, added by section 2101(d)(2) of 

PPACA, which was redesignated by section 6401(c)(1) of 

PPACA; effected to reflect probable intent¿ 

(c) NO EXCESS PAYMENTS.—øAdded paragraph (3) to section 

36B(f) of the IRC, added by section 1401(a) of PPACA¿ 

(d) ADULT DEPENDENTS.— 

(1) EXCLUSION OF AMOUNTS EXPENDED FOR MEDICAL

CARE.—The first sentence of section 105(b) of the Internal Revenue Code of 1986 (relating to amounts expended for medical 

care) is amended— 

(A) by striking ‘‘and his dependents’’ and inserting ‘‘his 

dependents’’; and 

(B) by inserting before the period the following: ‘‘, and 

any child (as defined in section 152(f)(1)) of the taxpayer 

who as of the end of the taxable year has not attained age 

27’’. 

(2) SELF-EMPLOYED HEALTH INSURANCE DEDUCTION.—Section 162(l)(1) of such Code is amended to read as follows: 

‘‘(1) ALLOWANCE OF DEDUCTION.—In the case of a taxpayer 

who is an employee within the meaning of section 401(c)(1), 

there shall be allowed as a deduction under this section an 

amount equal to the amount paid during the taxable year for 

insurance which constitutes medical care for— 

‘‘(A) the taxpayer, 

‘‘(B) the taxpayer’s spouse, 

‘‘(C) the taxpayer’s dependents, and 

‘‘(D) any child (as defined in section 152(f)(1)) of the 

taxpayer who as of the end of the taxable year has not attained age 27.’’. 

(3) COVERAGE UNDER SELF-EMPLOYED DEDUCTION.—Section 

162(l)(2)(B) of such Code is amended by inserting ‘‘, or any dependent, or individual described in subparagraph (D) of paragraph (1) with respect to,’’ after ‘‘spouse of’’. 

(4) SICK AND ACCIDENT BENEFITS PROVIDED TO MEMBERS OF

A VOLUNTARY EMPLOYEES’ BENEFICIARY ASSOCIATION AND THEIR

DEPENDENTS.—Section 501(c)(9) of such Code is amended by 

adding at the end the following new sentence: ‘‘For purposes of 

providing for the payment of sick and accident benefits to 

members of such an association and their dependents, the term 

‘dependent’ shall include any individual who is a child (as defined in section 152(f)(1)) of a member who as of the end of the 

calendar year has not attained age 27.’’. 

(5) MEDICAL AND OTHER BENEFITS FOR RETIRED EMPLOYEES.—Section 401(h) of such Code is amended by adding at the 

end the following: ‘‘For purposes of this subsection, the term 

‘dependent’ shall include any individual who is a child (as defined in section 152(f)(1)) of a retired employee who as of the 

end of the calendar year has not attained age 27.’’. 
931 Sec. 1101 HEALTH RECONCILIATION 

(e) FIVE PERCENT INCOME DISREGARD FOR CERTAIN INDIVIDUALS.—øAmended section 1902(e)(14) of the SSA, added by section 

2002(a) of PPACA, including adding a subparagraph (I)¿ 

SEC. 1005. IMPLEMENTATION FUNDING. 

(a) IN GENERAL.—There is hereby established a Health Insurance Reform Implementation Fund (referred to in this section as 

the ‘‘Fund’’) within the Department of Health and Human Services 

to carry out the Patient Protection and Affordable Care Act and 

this Act (and the amendments made by such Acts øsic; should be 

‘‘Act’’¿). 

(b) FUNDING.—There is appropriated to the Fund, out of any 

funds in the Treasury not otherwise appropriated, $1,000,000,000 

for Federal administrative expenses to carry out such Act (and the 

amendments made by such Acts). 

Subtitle B—Medicare 

SEC. 1101. CLOSING THE MEDICARE PRESCRIPTION DRUG ‘‘DONUT 

HOLE’’øSUBSTITUTES FOR SECTION 3315 OF PPACA¿. 

(a) COVERAGE GAP REBATE FOR 2010.— 

(1) IN GENERAL.—Section 1860D–42 of the Social Security 

Act (42 U.S.C. 1395w–152) is amended by adding at the end 

the following new subsection: 

‘‘(c) COVERAGE GAP REBATE FOR 2010.— 

‘‘(1) IN GENERAL.—In the case of an individual described in 

subparagraphs (A) through (D) of section 1860D–14A(g)(1) who 

as of the last day of a calendar quarter in 2010 has incurred 

costs for covered part D drugs so that the individual has exceeded the initial coverage limit under section 1860D–2(b)(3) 

for 2010, the Secretary shall provide for payment from the 

Medicare Prescription Drug Account of $250 to the individual 

by not later than the 15th day of the third month following the 

end of such quarter. 

‘‘(2) LIMITATION.—The Secretary shall provide only 1 payment under this subsection with respect to any individual.’’. 

(2) REPEAL OF PROVISION.—øRepealed section 3315 of 

PPACA¿ 

(b) CLOSING THE DONUT HOLE.—Part D of title XVIII of the Social Security Act (42 U.S.C. 1395w–101 et seq.), as amended by section 3301 of the Patient Protection and Affordable Care Act, is further amended— 

(1) øAmended dates in section 1860D-43; error in omitting 

‘‘ending on’’ before ‘‘December 31, 2011’’¿ 

(2) øAmended dates in section 1860D–14A; error in failing 

to reference clause (i) of subsection (b)(1)(C) and in duplicate insertion of ‘‘not later than’’¿ 

(3) in section 1860D–2(b)— 

(A) in paragraph (2)(A), by striking ‘‘The coverage’’ 

and inserting ‘‘Subject to subparagraphs (C) and (D), the 

coverage’’; 

(B) in paragraph (2)(B), by striking ‘‘subparagraph 

(A)(ii)’’ and inserting ‘‘subparagraphs (A)(ii), (C), and (D)’’; 
Sec. 1101 HEALTH RECONCILIATION 932 

(C) by adding at the end of paragraph (2) the following 

new subparagraphs: 

‘‘(C) COVERAGE FOR GENERIC DRUGS IN COVERAGE

GAP.— ‘‘(i) IN GENERAL.—Except as provided in paragraph (4), the coverage for an applicable beneficiary 

(as defined in section 1860D–14A(g)(1)) has coinsurance (for costs above the initial coverage limit under 

paragraph (3) and below the out-of-pocket threshold) 

for covered part D drugs that are not applicable drugs 

under section 1860D–14A(g)(2) that is— 

‘‘(I) equal to the generic-gap coinsurance percentage (specified in clause (ii)) for the year; or 

‘‘(II) actuarially equivalent (using processes 

and methods established under section 1860D– 

11(c)) to an average expected payment of such percentage of such costs for covered part D drugs 

that are not applicable drugs under section 

1860D–14A(g)(2). 

‘‘(ii) GENERIC-GAP COINSURANCE PERCENTAGE.— The generic-gap coinsurance percentage specified in 

this clause for— 

‘‘(I) 2011 is 93 percent; 

‘‘(II) 2012 and each succeeding year before 

2020 is the generic-gap coinsurance percentage 

under this clause for the previous year decreased 

by 7 percentage points; and 

‘‘(III) 2020 and each subsequent year is 25 

percent. 

‘‘(D) COVERAGE FOR APPLICABLE DRUGS IN COVERAGE

GAP.— 

‘‘(i) IN GENERAL.—Except as provided in paragraph (4), the coverage for an applicable beneficiary 

(as defined in section 1860D–14A(g)(1)) has coinsurance (for costs above the initial coverage limit under 

paragraph (3) and below the out-of-pocket threshold) 

for the negotiated price (as defined in section 1860D– 

14A(g)(6)) of covered part D drugs that are applicable 

drugs under section 1860D–14A(g)(2) that is— 

‘‘(I) equal to the difference between the applicable gap percentage (specified in clause (ii) for 

the year) and the discount percentage specified in 

section 1860D–14A(g)(4)(A) for such applicable 

drugs; or 

‘‘(II) actuarially equivalent (using processes 

and methods established under section 1860D– 

11(c)) to an average expected payment of such percentage of such costs, for covered part D drugs 

that are applicable drugs under section 1860D– 

14A(g)(2). 

‘‘(ii) APPLICABLE GAP PERCENTAGE.—The applicable gap percentage specified in this clause for— 

‘‘(I) 2013 and 2014 is 97.5 percent; 

‘‘(II) 2015 and 2016 is 95 percent; 
933 Sec. 1101 HEALTH RECONCILIATION 

‘‘(III) 2017 is 90 percent; 

‘‘(IV) 2018 is 85 percent; 

‘‘(V) 2019 is 80 percent; and 

‘‘(VI) 2020 and each subsequent year is 75 

percent.’’; 

(D) in paragraph (3)(A), as restored under subsection 

(a)(2), by striking ‘‘paragraph (4)’’ and inserting ‘‘paragraphs (2)(C), (2)(D), and (4)’’; and 

(E) øAmends paragraph (4)(E)¿ 

(4) in section 1860D–22(a)(2)(A), by inserting before the 

period at the end the following: ‘‘, not taking into account the 

value of any discount or coverage provided during the gap in 

prescription drug coverage that occurs between the initial coverage limit under section 1860D–2(b)(3) during the year and 

the out-of-pocket threshold specified in section 1860D– 

2(b)(4)(B)’’. 

(c) CONFORMING AMENDMENT TO AMP UNDER MEDICAID.— øAdds new subclause (V) to section 1927(k)(1)(B)(i) of the Social Security Act , as amended by section 2503(a)(2)(B) of PPACA; error in 

subclause (IV) by only striking period and not inserting ‘‘; and’’¿ 

(d) REDUCING GROWTH RATE OF OUT-OF-POCKET COST THRESH- OLD.—Section 1860D–2(b) of the Social Security Act (42 U.S.C. 

1395w–102(b)) is amended— 

(1) in paragraph (4)(B)(i)— 

(A) in subclause (I), by striking ‘‘or’’ at the end; 

(B) by redesignating subclause (II) as subclause (VI); 

and 

(C) by inserting after subclause (I) the following new 

subclauses: 

‘‘(II) for each of years 2007 through 2013, is 

equal to the amount specified in this subparagraph for the previous year, increased by the annual percentage increase described in paragraph 

(6) for the year involved; 

‘‘(III) for 2014 and 2015, is equal to the 

amount specified in this subparagraph for the previous year, increased by the annual percentage increase described in paragraph (6) for the year involved, minus 0.25 percentage point; 

‘‘(IV) for each of years 2016 through 2019, is 

equal to the amount specified in this subparagraph for the previous year, increased by the lesser of— 

‘‘(aa) the annual percentage increase described in paragraph (7) for the year involved, 

plus 2 percentage points; or 

‘‘(bb) the annual percentage increase described in paragraph (6) for the year; 

‘‘(V) for 2020, is equal to the amount that 

would have been applied under this subparagraph 

for 2020 if the amendments made by section 

1101(d)(1) of the Health Care and Education Reconciliation Act of 2010 had not been enacted; or’’; 

and 
Sec. 1102 HEALTH RECONCILIATION 934 

(2) by adding at the end the following new paragraph: 

‘‘(7) ADDITIONAL ANNUAL PERCENTAGE INCREASE.—The annual percentage increase specified in this paragraph for a year 

is equal to the annual percentage increase in the consumer 

price index for all urban consumers (United States city average) for the 12-month period ending in July of the previous 

year.’’. 

SEC. 1102. MEDICARE ADVANTAGE PAYMENTS øSUBSTITUTES FOR SECTION 3201 & 3203 OF PPACA¿. 

(a) REPEAL.—øRepealed sections 3201 and 3203 of PPACA; additional conforming repeals should probably have been made to sections 3202(b)(2) and 10318¿ 

(b) PHASE-IN OF MODIFIED BENCHMARKS.—Section 1853 of the 

Social Security Act (42 U.S.C. 1395w–23) is amended— 

(1) in subsection (j)(1)(A), by striking ‘‘(or, beginning with 

2007, 1⁄12 of the applicable amount determined under subsection (k)(1)) for the area for the year’’ and inserting ‘‘for the 

area for the year (or, for 2007, 2008, 2009, and 2010, 1⁄12 of the 

applicable amount determined under subsection (k)(1) for the 

area for the year; for 2011, 1⁄12 of the applicable amount determined under subsection (k)(1) for the area for 2010; and, beginning with 2012, 1⁄12 of the blended benchmark amount determined under subsection (n)(1) for the area for the year)’’; and 

(2) by adding at the end the following new subsection: 

‘‘(n) DETERMINATION OF BLENDED BENCHMARK AMOUNT.— 

‘‘(1) IN GENERAL.—For purposes of subsection (j), subject to 

paragraphs (3), (4), and (5), the term ‘blended benchmark 

amount’ means for an area— 

‘‘(A) for 2012 the sum of— 

‘‘(i) 1⁄2 of the applicable amount for the area and 

year; and 

‘‘(ii) 1⁄2 of the amount specified in paragraph (2)(A) 

for the area and year; and 

‘‘(B) for a subsequent year the amount specified in 

paragraph (2)(A) for the area and year. 

‘‘(2) SPECIFIED AMOUNT.— 

‘‘(A) IN GENERAL.—The amount specified in this subparagraph for an area and year is the product of— 

‘‘(i) the base payment amount specified in subparagraph (E) for the area and year adjusted to take 

into account the phase-out in the indirect costs of medical education from capitation rates described in subsection (k)(4); and 

‘‘(ii) the applicable percentage for the area for the 

year specified under subparagraph (B). 

‘‘(B) APPLICABLE PERCENTAGE.—Subject to subparagraph (D) øsec. 1102(c)(2) of HCERA attempts to insert ‘‘, 

subject to subsection (o)’’ after ‘‘as follows’’ in this subparagraph but could not be executed¿ , the applicable percentage specified in this subparagraph for an area for a year 

in the case of an area that is ranked— 

‘‘(i) in the highest quartile under subparagraph 

(C) for the previous year is 95 percent; 
935 Sec. 1102 HEALTH RECONCILIATION 

‘‘(ii) in the second highest quartile under such 

subparagraph for the previous year is 100 percent; 

‘‘(iii) in the third highest quartile under such subparagraph for the previous year is 107.5 percent; or 

‘‘(iv) in the lowest quartile under such subparagraph for the previous year is 115 percent. 

‘‘(C) PERIODIC RANKING.—For purposes of this paragraph in the case of an area located— 

‘‘(i) in 1 of the 50 States or the District of Columbia, the Secretary shall rank such area in each year 

specified under subsection (c)(1)(D)(ii) based upon the 

level of the amount specified in subparagraph (A)(i) for 

such areas; or 

‘‘(ii) in a territory, the Secretary shall rank such 

areas in each such year based upon the level of the 

amount specified in subparagraph (A)(i) for such area 

relative to quartile rankings computed under clause 

(i). 

‘‘(D) 1-YEAR TRANSITION FOR CHANGES IN APPLICABLE

PERCENTAGE.—If, for a year after 2012, there is a change 

in the quartile in which an area is ranked compared to the 

previous year, the applicable percentage for the area in the 

year shall be the average of— 

‘‘(i) the applicable percentage for the area for the 

previous year; and 

‘‘(ii) the applicable percentage that would otherwise apply for the area for the year. 

‘‘(E) BASE PAYMENT AMOUNT.—Subject to subparagraph (F), the base payment amount specified in this subparagraph— 

‘‘(i) for 2012 is the amount specified in subsection 

(c)(1)(D) for the area for the year; or 

‘‘(ii) for a subsequent year that— 

‘‘(I) is not specified under subsection 

(c)(1)(D)(ii), is the base amount specified in this 

subparagraph for the area for the previous year, 

increased by the national per capita MA growth 

percentage, described in subsection (c)(6) for that 

succeeding year, but not taking into account any 

adjustment under subparagraph (C) of such subsection for a year before 2004; and 

‘‘(II) is specified under subsection (c)(1)(D)(ii), 

is the amount specified in subsection (c)(1)(D) for 

the area for the year. 

‘‘(F) APPLICATION OF INDIRECT MEDICAL EDUCATION

PHASE-OUT.—The base payment amount specified in subparagraph (E) for a year shall be adjusted in the same 

manner under paragraph (4) of subsection (k) as the applicable amount is adjusted under such subsection. 

‘‘(3) ALTERNATIVE PHASE-INS.— 

‘‘(A) 4-YEAR PHASE-IN FOR CERTAIN AREAS.—If the difference between the applicable amount (as defined in subsection (k)) for an area for 2010 and the projected 2010 

benchmark amount (as defined in subparagraph (C)) for 
Sec. 1102 HEALTH RECONCILIATION 936 

the area is at least $30 but less than $50, the blended 

benchmark amount for the area is— 

‘‘(i) for 2012 the sum of— 

‘‘(I) 3⁄4 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄4 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(ii) for 2013 the sum of— 

‘‘(I) 1⁄2 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄2 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(iii) for 2014 the sum of— 

‘‘(I) 1⁄4 of the applicable amount for the area 

and year; and 

‘‘(II) 3⁄4 of the amount specified in paragraph 

(2)(A) for the area and year; and 

‘‘(iv) for a subsequent year the amount specified in 

paragraph (2)(A) for the area and year. 

‘‘(B) 6-YEAR PHASE-IN FOR CERTAIN AREAS.—If the difference between the applicable amount (as defined in subsection (k)) for an area for 2010 and the projected 2010 

benchmark amount (as defined in subparagraph (C)) for 

the area is at least $50, the blended benchmark amount 

for the area is— 

‘‘(i) for 2012 the sum of— 

‘‘(I) 5⁄6 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄6 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(ii) for 2013 the sum of— 

‘‘(I) 2⁄3 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄3 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(iii) for 2014 the sum of— 

‘‘(I) 1⁄2 of the applicable amount for the area 

and year; and 

‘‘(II) 1⁄2 of the amount specified in paragraph 

(2)(A) for the area and year; 

‘‘(iv) for 2015 the sum of— 

‘‘(I) 1⁄3 of the applicable amount for the area 

and year; and 

‘‘(II) 2⁄3 of the amount specified in paragraph 

(2)(A) for the area and year; and 

‘‘(v) for 2016 the sum of— 

‘‘(I) 1⁄6 of the applicable amount for the area 

and year; and 

‘‘(II) 5⁄6 of the amount specified in paragraph 

(2)(A) for the area and year; and 

‘‘(vi) for a subsequent year the amount specified in 

paragraph (2)(A) for the area and year. 
937 Sec. 1102 HEALTH RECONCILIATION 

‘‘(C) PROJECTED 2010 BENCHMARK AMOUNT.—The projected 2010 benchmark amount described in this subparagraph for an area is equal to the sum of— 

‘‘(i) 1⁄2 of the applicable amount (as defined in subsection (k)) for the area for 2010; and 

‘‘(ii) 1⁄2 of the amount specified in paragraph (2)(A) 

for the area for 2010 but determined as if there were 

substituted for the applicable percentage specified in 

clause (ii) of such paragraph the sum of— 

‘‘(I) the applicable percent that would be specified under subparagraph (B) of paragraph (2) (determined without regard to subparagraph (D) of 

such paragraph) for the area for 2010 if any reference in such paragraph to ‘the previous year’ 

were deemed a reference to 2010; and 

‘‘(II) the applicable percentage increase that 

would apply to a qualifying plan in the area under 

subsection (o) as if any reference in such subsection to 2012 were deemed a reference to 2010 

and as if the determination of a qualifying county 

under paragraph (3)(B) of such subsection were 

made for 2010. 

‘‘(4) CAP ON BENCHMARK AMOUNT.—In no case shall the 

blended benchmark amount for an area for a year (determined 

taking into account subsection (o)) be greater than the applicable amount that would (but for the application of this subsection) be determined under subsection (k)(1) for the area for 

the year. 

‘‘(5) NON-APPLICATION TO PACE PLANS.—This subsection 

shall not apply to payments to a PACE program under section 

1894.’’. 

(c) APPLICABLE PERCENTAGE QUALITY INCREASES.—Section 

1853 of such Act (42 U.S.C. 1395w–23), as amended by subsection 

(b), is amended— 

(1) in subsection (j), by inserting ‘‘subject to subsection (o),’’ 

after ‘‘For purposes of this part,’’; 

(2) øsic. amendment could not be executed because ‘‘as follows’’ does not appear¿ in subsection (n)(2)(B), as added by subsection (b), by inserting ‘‘, subject to subsection (o)’’ after ‘‘as 

follows’’; and 

(3) by adding at the end the following new subsection: 

‘‘(o) APPLICABLE PERCENTAGE QUALITY INCREASES.— 

‘‘(1) IN GENERAL.—Subject to the succeeding paragraphs, in 

the case of a qualifying plan with respect to a year beginning 

with 2012, the applicable percentage under subsection (n)(2)(B) 

shall be increased on a plan or contract level, as determined 

by the Secretary— 

‘‘(A) for 2012, by 1.5 percentage points; 

‘‘(B) for 2013, by 3.0 percentage points; and 

‘‘(C) for 2014 or a subsequent year, by 5.0 percentage 

points. 

‘‘(2) INCREASE FOR QUALIFYING PLANS IN QUALIFYING COUNTIES.—The increase applied under paragraph (1) for a quali-
Sec. 1102 HEALTH RECONCILIATION 938 

fying plan located in a qualifying county for a year shall be 

doubled. 

‘‘(3) QUALIFYING PLANS AND QUALIFYING COUNTY DEFINED; 

APPLICATION OF INCREASES TO LOW ENROLLMENT AND NEW

PLANS.—For purposes of this subsection: 

‘‘(A) QUALIFYING PLAN.— 

‘‘(i) IN GENERAL.—The term ‘qualifying plan’ 

means, for a year and subject to paragraph (4), a plan 

that had a quality rating under paragraph (4) of 4 

stars or higher based on the most recent data available for such year. 

‘‘(ii) APPLICATION OF INCREASES TO LOW ENROLLMENT PLANS.— 

‘‘(I) 2012.—For 2012, the term ‘qualifying 

plan’ includes an MA plan that the Secretary determines is not able to have a quality rating 

under paragraph (4) because of low enrollment. 

‘‘(II) 2013 AND SUBSEQUENT YEARS.—For 2013 

and subsequent years, for purposes of determining 

whether an MA plan with low enrollment (as defined by the Secretary) is included as a qualifying 

plan, the Secretary shall establish a method to 

apply to MA plans with low enrollment (as defined 

by the Secretary) the computation of quality rating and the rating system under paragraph (4). 

‘‘(iii) APPLICATION OF INCREASES TO NEW PLANS.— 

‘‘(I) IN GENERAL.—A new MA plan that meets 

criteria specified by the Secretary shall be treated 

as a qualifying plan, except that in applying paragraph (1), the applicable percentage under subsection (n)(2)(B) shall be increased— 

‘‘(aa) for 2012, by 1.5 percentage points; 

‘‘(bb) for 2013, by 2.5 percentage points; 

and 

‘‘(cc) for 2014 or a subsequent year, by 3.5 

percentage points. 

‘‘(II) NEW MA PLAN DEFINED.—The term ‘new 

MA plan’ means, with respect to a year, a plan offered by an organization or sponsor that has not 

had a contract as a Medicare Advantage organization in the preceding 3-year period. 

‘‘(B) QUALIFYING COUNTY.—The term ‘qualifying county’ means, for a year, a county— 

‘‘(i) that has an MA capitation rate that, in 2004, 

was based on the amount specified in subsection 

(c)(1)(B) for a Metropolitan Statistical Area with a 

population of more than 250,000; 

‘‘(ii) for which, as of December 2009, of the Medicare Advantage eligible individuals residing in the 

county at least 25 percent of such individuals were enrolled in Medicare Advantage plans; and 

‘‘(iii) that has per capita fee-for-service spending 

that is lower than the national monthly per capita cost 
939 Sec. 1102 HEALTH RECONCILIATION 

for expenditures for individuals enrolled under the 

original medicare fee-for-service program for the year. 

‘‘(4) QUALITY DETERMINATIONS FOR APPLICATION OF IN- CREASE.— 

‘‘(A) QUALITY DETERMINATION.—The quality rating for 

a plan shall be determined according to a 5-star rating system (based on the data collected under section 1852(e)). 

‘‘(B) PLANS THAT FAILED TO REPORT.—An MA plan 

which does not report data that enables the Secretary to 

rate the plan for purposes of this paragraph shall be 

counted as having a rating of fewer than 3.5 stars. 

‘‘(5) EXCEPTION FOR PACE PLANS.—This subsection shall not 

apply to payments to a PACE program under section 1894.’’. 

(4) DETERMINATION OF MEDICARE PART D LOW-INCOME

BENCHMARK PREMIUM.—øAmended section 1860D– 

14(b)(2)(B)(iii) of SSA, as amended by section 3302 of PPACA¿ 

(d) BENEFICIARY REBATES.—Section 1854(b)(1)(C) of such Act 

(42 U.S.C. 1395w–24(b)(1)(C)), as amended by section 3202(b) of 

the Patient Protection and Affordable Care Act, is further amended— 

(1) in clause (i), by inserting ‘‘(or the applicable rebate percentage specified in clause (iii) in the case of plan years beginning on or after January 1, 2012)’’ after ‘‘75 percent’’; and 

(2) øStruck clause (iii), redesignated clauses (iv) and (v) as 

clauses (vii) and (viii), respectively, and inserted in new clauses 

(iii) through (vi)¿’’. 

(e) CODING INTENSITY ADJUSTMENT.—Section 1853(a)(1)(C)(ii) 

of such Act (42 U.S.C. 1395w–23(a)(1)(C)(ii)) is amended— 

(1) in the heading, by striking ‘‘DURING PHASEOUT OF

BUDGET NEUTRALITY FACTOR’’ and inserting ‘‘OF CODING ADJUSTMENT’’; 

(2) in the matter before subclause (I), by striking ‘‘through 

2010’’ and inserting ‘‘and each subsequent year’’; and 

(3) in subclause (II)— 

(A) in the first sentence, by inserting ‘‘annually’’ before 

‘‘conduct an analysis’’; 

(B) in the second sentence— 

(i) by inserting ‘‘on a timely basis’’ after ‘‘are incorporated’’; and 

(ii) by striking ‘‘only for 2008, 2009, and 2010’’ and 

inserting ‘‘for 2008 and subsequent years’’; 

(C) in the third sentence, by inserting ‘‘and updated as 

appropriate’’ before the period at the end; and 

(D) by adding at the end the following new subclauses: 

‘‘(III) In calculating each year’s adjustment, 

the adjustment factor shall be for 2014, not less 

than the adjustment factor applied for 2010, plus 

1.3 percentage points; for each of years 2015 

through 2018, not less than the adjustment factor 

applied for the previous year, plus 0.25 percentage 

point; and for 2019 and each subsequent year, not 

less than 5.7 percent. 

‘‘(IV) Such adjustment shall be applied to risk 

scores until the Secretary implements risk adjust-
Sec. 1103 HEALTH RECONCILIATION 940 

ment using Medicare Advantage diagnostic, cost, 

and use data.’’. 

(f) REPEAL OF COMPARATIVE COST ADJUSTMENT 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. 1103. SAVINGS FROM LIMITS ON MA PLAN ADMINISTRATIVE 

COSTS. 

Section 1857(e) of the Social Security Act (42 U.S.C. 1395w– 

27(e)) is amended by adding at the end the following new paragraph: 

‘‘(4) REQUIREMENT FOR MINIMUM MEDICAL LOSS RATIO.—If 

the Secretary determines for a contract year (beginning with 

2014) that an MA plan has failed to have a medical loss ratio 

of at least .85— 

‘‘(A) the MA plan shall remit to the Secretary an 

amount equal to the product of— 

‘‘(i) the total revenue of the MA plan under this 

part for the contract year; and 

‘‘(ii) the difference between .85 and the medical 

loss ratio; 

‘‘(B) for 3 consecutive contract years, the Secretary 

shall not permit the enrollment of new enrollees under the 

plan for coverage during the second succeeding contract 

year; and 

‘‘(C) the Secretary shall terminate the plan contract if 

the plan fails to have such a medical loss ratio for 5 consecutive contract years.’’. 

SEC. 1104. DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS 

øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

øAmended section 1886(r) of the SSA, as added by section 3133 

(and amended by section 10316) of PPACA)¿ 

SEC. 1105. MARKET BASKET UPDATES øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

(a) IPPS.—øAmended section 1886(b)(3)(B) of the Social Security Act, as amended by sections 3401(a)(4) and 10319(a) of PPACA, 

by substituting subclauses (III)-(V) of clause (xii) for previous subclause (III) and striking clause (xiii)¿ 

(b) LONG-TERM CARE HOSPITALS.—øAmended section 

1886(m)(4) of the Social Security Act, as added by section 3401(c) 

(and amended by section 10319(b)) of PPACA, by striking subparagraph (B), redesignating clauses in subparagraph (A), and by substituting subparagraphs (C)-(E) for clauses (iii)-(v) of previous subparagraph (A)¿ 

(c) INPATIENT REHABILITATION FACILITIES.—øAmended section 

1886(j)(3)(D) of the Social Security Act, as added by section 

3401(d)(2) (and amended by section 10319(c)) of PPACA, by striking 

clause (ii), redesignating subclauses in clause (i), and by substituting clauses (iii)-(v) for subclauses (III)(-(V) of previous clause 

(i)¿ 

(d) PSYCHIATRIC HOSPITALS.—øAmended section 1886(s)(3) of 

the Social Security Act, as added by section 3401(f) (and amended 
941 Sec. 1109 HEALTH RECONCILIATION 

by section 10319(e)) of PPACA, by striking subparagraph (B), redesignating clauses in subparagraph (A), and by substituting subparagraphs (C)-(E) for clauses (iii)-(v) of previous subparagraph (A)¿ 

(e) OUTPATIENT HOSPITALS.—øAmended section 1833(t)(3)(G) of 

the Social Security Act, as added by section 3401(i)(2) (and amended by section 10319(g)) of PPACA, by striking clause (ii), redesignating subclauses in clause (i), and by substituting clauses (iii)-(v) 

for subclauses (III)-(V) of previous clause (i)¿ 

SEC. 1106. PHYSICIAN OWNERSHIP-REFERRAL øAMENDMENTS FULLY 

INCORPORATED INTO PPACA¿. 

Section 1877(i) of the Social Security Act (42 U.S.C. 1395nn(i)), 

as added by section 6001(a)(3) of the Patient Protection and Affordable Care Act and as amended by section 10601(a) of such Act, is 

amended— 

(1) øAmended paragraph (1)(A)(i)¿ 

(2) øAmended paragraph (2) in subparagraphs (A)(i), 

(C)(iii), redesignated subparagraphs, and inserted new subparagraph (F)¿ 

SEC. 1107. PAYMENT FOR IMAGING SERVICES øAMENDMENTS FULLY 

INCORPORATED INTO PPACA¿. 

Section 1848 of the Social Security Act (42 U.S.C. 1395w–4), as 

amended by section 3135(a) of the Patient Protection and Affordable Care Act, is amended— 

(1) øAmended subsection (b)(4) by amending subparagraph 

(B) and replacing subparagraph (C)¿ 

(2) øAmended subsection (c)(2)(B)(v) by substituting a new 

subclause (III) for subclauses (III), (IV), and (V)¿ 

SEC. 1108. PE GPCI ADJUSTMENT FOR 2010 øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

øAmended section 1848(e)(1)(H)(i) of the Social Security Act, as 

added by section 3102(b)(2) of PPACA¿ 

SEC. 1109. ø42 U.S.C. 1395ww note¿ PAYMENT FOR QUALIFYING HOSPITALS. 

(a) IN GENERAL.—From the amount available under subsection 

(b), the Secretary of Health and Human Services shall provide for 

a payment to qualifying hospitals (as defined in subsection (d)) for 

fiscal years 2011 and 2012 of the amount determined under subsection (c). 

(b) AMOUNTS AVAILABLE.—There shall be available from the 

Federal Hospital Insurance Trust Fund $400,000,000 for payments 

under this section for fiscal years 2011 and 2012. 

(c) PAYMENT AMOUNT.—The amount of payment under this section for a qualifying hospital shall be determined, in a manner consistent with the amount available under subsection (b), in proportion to the portion of the amount of the aggregate payments under 

section 1886(d) of the Social Security Act to the hospital for fiscal 

year 2009 bears to the sum of all such payments to all qualifying 

hospitals for such fiscal year. 

(d) QUALIFYING HOSPITAL DEFINED.—In this section, the term 

‘‘qualifying hospital’’ means a subsection (d) hospital (as defined for 

purposes of section 1886(d) of the Social Security Act) that is located in a county that ranks, based upon its ranking in age, sex, 

and race adjusted spending for benefits under parts A and B under 
Sec. 1201 HEALTH RECONCILIATION 942 

title XVIII of such Act per enrollee, within the lowest quartile of 

such counties in the United States. 

Subtitle C—Medicaid 

SEC. 1201. FEDERAL FUNDING FOR STATES øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

Section 1905 of the Social Security Act (42 U.S.C. 1396d), as 

amended by sections 2001(a)(3) and 10201(c) of the Patient Protection and Affordable Care Act, is amended— 

(1) in subsection (y)— 

(A) by redesignating subclause (II) of paragraph 

(1)(B)(ii) as paragraph (5) of subsection (z) and realigning 

the left margins accordingly øsee subsection (z) in section 

10201(c), p. 840¿; and 

(B) øReplaced paragraph (1)¿ 

(2) in subsection (z)— 

(A) øAmended paragraph (1)¿ 

(B) øStruck paragraphs (2) through (4) and inserted a 

new paragraph (2)¿ 

(C) by redesignating paragraph (5) (as added by paragraph (1)(A) of this section) as paragraph (3), realigning 

the left margins to align with paragraph (2), and striking 

the heading and all that follows through ‘‘a State is’’ and 

inserting ‘‘A State is’’. 

SEC. 1202. PAYMENTS TO PRIMARY CARE PHYSICIANS. 

(a) IN GENERAL.— (1) FEE-FOR-SERVICE PAYMENTS.—Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended by section 

2303(a)(2) of the Patient Protection and Affordable Care Act, is 

amended— 

(A) in subsection (a)(13)— 

(i) by striking ‘‘and’’ at the end of subparagraph 

(A); 

(ii) by adding ‘‘and’’ at the end of subparagraph 

(B); and 

(iii) by adding at the end the following new subparagraph: 

‘‘(C) payment for primary care services (as defined in 

subsection (jj)) furnished in 2013 and 2014 by a physician 

with a primary specialty designation of family medicine, 

general internal medicine, or pediatric medicine at a rate 

not less than 100 percent of the payment rate that applies 

to such services and physician under part B of title XVIII 

(or, if greater, the payment rate that would be applicable 

under such part if the conversion factor under section 

1848(d) for the year involved were the conversion factor 

under such section for 2009);’’; and 

(B) by adding at the end the following new subsection: 

‘‘(jj) PRIMARY CARE SERVICES DEFINED.—For purposes of subsection (a)(13)(C), the term ‘primary care services’ means— 

‘‘(1) evaluation and management services that are procedure codes (for services covered under title XVIII) for services 
943 Sec. 1203 HEALTH RECONCILIATION 

in the category designated Evaluation and Management in the 

Healthcare Common Procedure Coding System (established by 

the Secretary under section 1848(c)(5) as of December 31, 2009, 

and as subsequently modified); and 

‘‘(2) services related to immunization administration for 

vaccines and toxoids for which CPT codes 90465, 90466, 90467, 

90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such System.’’. 

(2) UNDER MEDICAID MANAGED CARE PLANS.—Section 

1932(f) of such Act (42 U.S.C. 1396u–2(f)) is amended— 

(A) in the heading, by adding at the end the following: 

‘‘; ADEQUACY OF PAYMENT FOR PRIMARY CARE SERVICES’’; 

and 

(B) by inserting before the period at the end the following: ‘‘and, in the case of primary care services described 

in section 1902(a)(13)(C), consistent with the minimum 

payment rates specified in such section (regardless of the 

manner in which such payments are made, including in 

the form of capitation or partial capitation)’’. 

(b) INCREASE IN PAYMENT USING INCREASED FMAP.—Section 

1905 of the Social Security Act, as amended by section 1004(b) of 

this Act and section 10201(c)(6) of the Patient Protection and Affordable Care Act, is amended by adding at the end the following 

new subsection: 

‘‘(dd) INCREASED FMAP FOR ADDITIONAL EXPENDITURES FOR

PRIMARY CARE SERVICES.—Notwithstanding subsection (b), with respect to the portion of the amounts expended for medical assistance 

for services described in section 1902(a)(13)(C) furnished on or after 

January 1, 2013, and before January 1, 2015, that is attributable 

to the amount by which the minimum payment rate required under 

such section (or, by application, section 1932(f)) exceeds the payment rate applicable to such services under the State plan as of 

July 1, 2009, the Federal medical assistance percentage for a State 

that is one of the 50 States or the District of Columbia shall be 

equal to 100 percent. The preceding sentence does not prohibit the 

payment of Federal financial participation based on the Federal 

medical assistance percentage for amounts in excess of those specified in such sentence.’’. 

SEC. 1203. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS. 

(a) IN GENERAL.—Section 1923(f) of the Social Security Act (42 

U.S.C. 1396r–4(f)), as amended by sections 2551(a)(4) and 

10201(e)(1) of the Patient Protection and Affordable Care Act, is 

amended— 

(1) in paragraph (6)(B)(iii), in the matter preceding subclause (I), by striking ‘‘or paragraph (7)’’; and 

(2) øReplaced paragraph (7)¿ 

(b) EXTENSION OF DSH ALLOTMENT.—Section 1923(f)(6)(A) of 

the Social Security Act (42 U.S.C. 1396r–4(f)(6)(A)) is amended by 

adding at the end the following: 

‘‘(v) ALLOTMENT FOR 2D, 3RD, AND 4TH QUARTERS

OF FISCAL YEAR 2012 AND FOR FISCAL YEAR 2013.—Notwithstanding the table set forth in paragraph (2): 
Sec. 1204 HEALTH RECONCILIATION 944 

‘‘(I) 2D, 3RD, AND 4TH QUARTERS OF FISCAL

YEAR 2012.—In the case of a State that has a DSH 

allotment of $0 for the 2d, 3rd, and 4th quarters 

of fiscal year 2012, the DSH allotment shall be 

$47,200,000 for such quarters. 

‘‘(II) FISCAL YEAR 2013.—In the case of a State 

that has a DSH allotment of $0 for fiscal year 

2013, the DSH allotment shall be $53,100,000 for 

such fiscal year.’’. 

SEC. 1204. FUNDING FOR THE TERRITORIES. 

(a) IN GENERAL.—øInserted a new section 1323 relating to 

funding for the territories¿ 

(b) MEDICAID FUNDING.— 

(1) INCREASE IN FUNDING CAPS.—Section 1108(g) of the Social Security Act (42 U.S.C. 1308(g)), as amended by section 

2005(a) of the Patient Protection and Affordable Care Act, is 

amended— 

(A) in paragraph (2), by inserting ‘‘and section 

1323(a)(2) of the Patient Protection and Affordable Care 

Act’’ after ‘‘subject to’’ øprobably should have inserted after 

‘‘paragraphs (3) and (5)’’¿; and 

(B) øReplaced paragraph (5)¿ 

(2) DISREGARD OF PAYMENTS; INCREASED FMAP.—Section 

2005 of the Patient Protection and Affordable Care Act is 

amended— 

(A) by repealing subsection (b) (and the amendments 

made by that subsection) øsec. 10201(d) should also probably have been repealed¿ and section 1108(g)(4) of the Social Security Act shall be applied as if such amendments 

had never been enacted; and 

(B) øAmended subsection (c)(2)¿ 

SEC. 1205. DELAY IN COMMUNITY FIRST CHOICE OPTION øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

øAmended section 1915(k)(1) of the Social Security Act, as 

added by section 2401 of PPACA¿ 

SEC. 1206. DRUG REBATES FOR NEW FORMULATIONS OF EXISTING 

DRUGS øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

(a) TREATMENT OF NEW FORMULATIONS.—øReplaced subparagraph (C) of section 1927(c)(2) of the Social Security Act, as added 

by section 2501(d)(1) of PPACA¿ 

(b) EFFECTIVE DATE.—The amendment made by subsection (a) 

shall take effect as if included in the enactment of the Patient Protection and Affordable Care Act. 

Subtitle D—Reducing Fraud, Waste, and 

Abuse 

SEC. 1301. COMMUNITY MENTAL HEALTH CENTERS. 

(a) IN GENERAL.—Section 1861(ff)(3)(B) of the Social Security 

Act (42 U.S.C. 1395x(ff)(3)(B)) is amended— 

(1) in clause (ii), by striking ‘‘and’’ at the end; 

(2) by redesignating clause (iii) as clause (iv); and 
945 Sec. 1303 HEALTH RECONCILIATION 

(3) by inserting after clause (ii) the following: 

‘‘(iii) provides at least 40 percent of its services to individuals who are not eligible for benefits under this title; and’’. 

(b) RESTRICTION.—Section 1861(ff)(3)(A) of such Act (42 U.S.C. 

1395x(ff)(3)(A)) is amended by inserting ‘‘other than in an individual’s home or in an inpatient or residential setting’’ before the period. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to items and services furnished on or after the first day 

of the first calendar quarter that begins at least 12 months after 

the date of the enactment of this Act. 

SEC. 1302. MEDICARE PREPAYMENT MEDICAL REVIEW LIMITATIONS. 

Section 1874A(h) of the Social Security Act (42 U.S.C. 1395w– 

3a(h) øUSC citation should have been to section 1395kk–1a(h)≈) is 

repealed. 

SEC. 1303. FUNDING TO FIGHT FRAUD, WASTE, AND ABUSE. 

(a) FUNDING TO FIGHT FRAUD, WASTE, AND ABUSE.— 

(1) IN GENERAL.—Section 1817(k) of the Social Security Act 

(42 U.S.C. 1395i(k)), as amended by section 6402(i) of the Patient Protection and Affordable Care Act, is further amended— 

(A) by adding at the end the following new paragraph: 

‘‘(8) ADDITIONAL FUNDING.— ‘‘(A) IN GENERAL.—In addition to the funds otherwise 

appropriated to the Account from the Trust Fund under 

paragraphs (3)(C) and (4)(A) and for purposes described in 

paragraphs (3)(C) and (4)(A), there are hereby appropriated to such Account from such Trust Fund the following additional amounts: 

‘‘(i) For fiscal year 2011, $95,000,000. 

‘‘(ii) For fiscal year 2012, $55,000,000. 

‘‘(iii) For each of fiscal years 2013 and 2014, 

$30,000,000. 

‘‘(iv) For each of fiscal years 2015 and 2016, 

$20,000,000. 

‘‘(B) ALLOCATION.—The funds appropriated under this 

paragraph shall be allocated in the same proportion as the 

total funding appropriated with respect to paragraphs 

(3)(A) and (4)(A) was allocated with respect to fiscal year 

2010, and shall be available without further appropriation 

until expended.’’; and 

(B) in paragraph (4)(A), by inserting ‘‘for activities described in paragraph (3)(C) and’’ after ‘‘necessary’’. 

(b) MEDICAID INTEGRITY PROGRAM.—Section 1936(e)(1) of such 

Act (42 U.S.C. 1396–u6(e)(1)) is amended— 

(1) in subparagraph (B), by striking at the end ‘‘and’’; 

(2) in subparagraph (C)— 

(A) by striking ‘‘for each fiscal year thereafter’’ and inserting ‘‘for each of fiscal years 2009 and 2010’’; and 

(B) by striking the period and inserting ‘‘; and’’; and 

(3) by adding at the end the following new subparagraph: 

‘‘(D) for each fiscal year after fiscal year 2010, the 

amount appropriated under this paragraph for the previous fiscal year, increased by the percentage increase in 
Sec. 1304 HEALTH RECONCILIATION 946 

the consumer price index for all urban consumers (all 

items; United States city average) over the previous year.’’. 

SEC. 1304. 90-DAY PERIOD OF ENHANCED OVERSIGHT FOR INITIAL 

CLAIMS OF DME SUPPLIERS øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

øInserted new paragraph (4) in section 1866(j) of the Social Security Act, as amended by section 6401¿ 

Subtitle E—Provisions Relating to 

Revenue 

SEC. 1401. HIGH-COST PLAN EXCISE TAX øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

(a) IN GENERAL.—Section 4980I of the Internal Revenue Code 

of 1986, as added by section 9001 of the Patient Protection and Affordable Care Act and amended by section 10901 of such Act, is 

amended— 

(1) øAdded a clause (ii) to subsection (b)(3)(B)¿ 

(2) øAmended subsection (b)(3)(C), including insertion of 

new clauses (ii) and (iii)¿ 

(3) øStruck subparagraph (D) of subsection (b)(3)¿ 

(4) øInserted new clause (ii) in subsection (d)(1)(B)¿ 

(5) øAdded a paragraph (3) at end of subsection (d)¿ 

(b) EFFECTIVE DATES.— (1) øAmended section 9001(c) of PPACA¿ 

(2) øAmended section 10901(c) of PPACA¿ 

SEC. 1402. UNEARNED INCOME MEDICARE CONTRIBUTION. 

(a) INVESTMENT INCOME.— (1) IN GENERAL.—Subtitle A of the Internal Revenue Code 

of 1986 is amended by inserting after chapter 2 the following 

new chapter: 

‘‘CHAPTER 2A—UNEARNED INCOME MEDICARE 

CONTRIBUTION 

‘‘Sec. 1411. Imposition of tax. 

‘‘SEC. 1411. IMPOSITION OF TAX. 

‘‘(a) IN GENERAL.—Except as provided in subsection (e)— 

‘‘(1) APPLICATION TO INDIVIDUALS.—In the case of an individual, there is hereby imposed (in addition to any other tax 

imposed by this subtitle) for each taxable year a tax equal to 

3.8 percent of the lesser of— 

‘‘(A) net investment income for such taxable year, or 

‘‘(B) the excess (if any) of— 

‘‘(i) the modified adjusted gross income for such 

taxable year, over 

‘‘(ii) the threshold amount. 

‘‘(2) APPLICATION TO ESTATES AND TRUSTS.—In the case of 

an estate or trust, there is hereby imposed (in addition to any 

other tax imposed by this subtitle) for each taxable year a tax 

of 3.8 percent of the lesser of— 

‘‘(A) the undistributed net investment income for such 

taxable year, or 
947 Sec. 1402 HEALTH RECONCILIATION \1411 IRC 

‘‘(B) the excess (if any) of— 

‘‘(i) the adjusted gross income (as defined in section 67(e)) for such taxable year, over 

‘‘(ii) the dollar amount at which the highest tax 

bracket in section 1(e) begins for such taxable year. 

‘‘(b) THRESHOLD AMOUNT.—For purposes of this chapter, the 

term ‘threshold amount’ means— 

‘‘(1) in the case of a taxpayer making a joint return under 

section 6013 or a surviving spouse (as defined in section 2(a)), 

$250,000, 

‘‘(2) in the case of a married taxpayer (as defined in section 

7703) filing a separate return, 1⁄2 of the dollar amount determined under paragraph (1), and 

‘‘(3) in any other case, $200,000. 

‘‘(c) NET INVESTMENT INCOME.—For purposes of this chapter— 

‘‘(1) IN GENERAL.—The term ‘net investment income’ means 

the excess (if any) of— 

‘‘(A) the sum of— 

‘‘(i) gross income from interest, dividends, annuities, royalties, and rents, other than such income 

which is derived in the ordinary course of a trade or 

business not described in paragraph (2), 

‘‘(ii) other gross income derived from a trade or 

business described in paragraph (2), and 

‘‘(iii) net gain (to the extent taken into account in 

computing taxable income) attributable to the disposition of property other than property held in a trade or 

business not described in paragraph (2), over 

‘‘(B) the deductions allowed by this subtitle which are 

properly allocable to such gross income or net gain. 

‘‘(2) TRADES AND BUSINESSES TO WHICH TAX APPLIES.—A 

trade or business is described in this paragraph if such trade 

or business is— 

‘‘(A) a passive activity (within the meaning of section 

469) with respect to the taxpayer, or 

‘‘(B) a trade or business of trading in financial instruments or commodities (as defined in section 475(e)(2)). 

‘‘(3) INCOME ON INVESTMENT OF WORKING CAPITAL SUBJECT

TO TAX.—A rule similar to the rule of section 469(e)(1)(B) shall 

apply for purposes of this subsection. 

‘‘(4) EXCEPTION FOR CERTAIN ACTIVE INTERESTS IN PARTNERSHIPS AND S CORPORATIONS.—In the case of a disposition of 

an interest in a partnership or S corporation— 

‘‘(A) gain from such disposition shall be taken into account under clause (iii) of paragraph (1)(A) only to the extent of the net gain which would be so taken into account 

by the transferor if all property of the partnership or S 

corporation were sold for fair market value immediately 

before the disposition of such interest, and 

‘‘(B) a rule similar to the rule of subparagraph (A) 

shall apply to a loss from such disposition. 

‘‘(5) EXCEPTION FOR DISTRIBUTIONS FROM QUALIFIED

PLANS.—The term ‘net investment income’ shall not include 
Sec. 1402 HEALTH RECONCILIATION 948 

any distribution from a plan or arrangement described in section 401(a), 403(a), 403(b), 408, 408A, or 457(b). 

‘‘(6) SPECIAL RULE.—Net investment income shall not include any item taken into account in determining self-employment income for such taxable year on which a tax is imposed 

by section 1401(b). 

‘‘(d) MODIFIED ADJUSTED GROSS INCOME.—For purposes of this 

chapter, the term ‘modified adjusted gross income’ means adjusted 

gross income increased by the excess of— 

‘‘(1) the amount excluded from gross income under section 

911(a)(1), over 

‘‘(2) the amount of any deductions (taken into account in 

computing adjusted gross income) or exclusions disallowed 

under section 911(d)(6) with respect to the amounts described 

in paragraph (1). 

‘‘(e) NONAPPLICATION OF SECTION.—This section shall not apply 

to— 

‘‘(1) a nonresident alien, or 

‘‘(2) a trust all of the unexpired interests in which are devoted to one or more of the purposes described in section 

170(c)(2)(B).’’. 

(2) ESTIMATED TAXES.—Section 6654 of the Internal Revenue Code of 1986 is amended— 

(A) in subsection (a), by striking ‘‘and the tax under 

chapter 2’’ and inserting ‘‘the tax under chapter 2, and the 

tax under chapter 2A’’; and 

(B) in subsection (f)— 

(i) by striking ‘‘minus’’ at the end of paragraph (2) 

and inserting ‘‘plus’’; and 

(ii) by redesignating paragraph (3) as paragraph 

(4) and inserting after paragraph (2) the following new 

paragraph: 

‘‘(3) the taxes imposed by chapter 2A, minus’’. 

(3) CLERICAL AMENDMENT.—The table of chapters for subtitle A of chapter 1 øsic; ‘‘of chapter 1’’ should have been omitted¿ of the Internal Revenue Code of 1986 is amended by inserting after the item relating to chapter 2 the following new 

item: 

‘‘CHAPTER 2A—UNEARNED INCOME MEDICARE CONTRIBUTION’’. 

(4) EFFECTIVE DATES.—The amendments made by this subsection shall apply to taxable years beginning after December 

31, 2012. 

(b) EARNED INCOME.— 

(1) THRESHOLD.— 

(A) FICA.—øAmended section 3101(b)(2) of the IRC, as 

added by section 9015 (and amended by section 10906) of 

PPACA, including inserting a new subparagraph (B)¿ 

(B) SECA.—øAmended section 1401(b)(2) of the IRC, 

as added by section 9015 (and amended by section 10906) 

of PPACA, including inserting a new clause (ii) in subparagraph (A)¿ 

(2) ESTIMATED TAXES.—Section 6654 of the Internal Revenue Code of 1986 is amended by redesignating subsection (m) 
949 Sec. 1405 HEALTH RECONCILIATION \4191 IRC 

as subsection (n) and by inserting after subsection (l) the following new subsection: 

‘‘(m) SPECIAL RULE FOR MEDICARE TAX.—For purposes of this 

section, the tax imposed under section 3101(b)(2) (to the extent not 

withheld) shall be treated as a tax imposed under chapter 2.’’. 

(3) EFFECTIVE DATE.—The amendments made by this subsection shall apply with respect to remuneration received, and 

taxable years beginning after, øsic; comma should be after ‘‘beginning’’¿ December 31, 2012. 

SEC. 1403. DELAY OF LIMITATION ON HEALTH FLEXIBLE SPENDING 

ARRANGEMENTS UNDER CAFETERIA PLANS øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

(a) IN GENERAL.—øAmended section 10902(b) of PPACA¿ 

(b) INFLATION ADJUSTMENT.—øAmended section 125(i)(2) of the 

Internal Revenue Code of 1986, as added by section 9005 (and 

amended by section 10902) of PPACA¿ 

SEC. 1404. BRAND NAME PHARMACEUTICALS øAMENDMENTS FULLY INCORPORATED INTO PPACA¿. 

(a) IN GENERAL.—Section 9008 of the Patient Protection and 

Affordable Care Act is amended— 

(1) øAmended subsection (a)(1)¿ 

(2) øAmended subsection (r)(1) and added paragraph (4) to 

subsection (b)¿ 

(3) øAdded a paragraph (3) to subsection (d)¿ 

(4) øReplaced subsection (j)¿ 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall take effect as if included in section 9008 of the Patient Protection and Affordable Care Act. 

SEC. 1405. EXCISE TAX ON MEDICAL DEVICE MANUFACTURERS øSUBSTITUTES FOR SECTION 9009 OF PPACA¿. 

øThis section effectively substituted for section 9009 of PPACA, 

and is copied above.¿ 

(a) IN GENERAL.—Chapter 32 of the Internal Revenue Code of 

1986 is amended— 

(1) by inserting after subchapter D the following new subchapter: 

‘‘Subchapter E—Medical Devices 

‘‘Sec. 4191. Medical devices. 

‘‘SEC. 4191. MEDICAL DEVICES. 

‘‘(a) IN GENERAL.—There is hereby imposed on the sale of any 

taxable medical device by the manufacturer, producer, or importer 

a tax equal to 2.3 percent of the price for which so sold. 

‘‘(b) TAXABLE MEDICAL DEVICE.—For purposes of this section— 

‘‘(1) IN GENERAL.—The term ‘taxable medical device’ means 

any device (as defined in section 201(h) of the Federal Food, 

Drug, and Cosmetic Act) intended for humans. 

‘‘(2) EXEMPTIONS.—Such term shall not include— 

‘‘(A) eyeglasses, 

‘‘(B) contact lenses, 

‘‘(C) hearing aids, and 
Sec. 1405 HEALTH RECONCILIATION 950 

‘‘(D) any other medical device determined by the Secretary to be of a type which is generally purchased by the 

general public at retail for individual use.’’, and 

(2) by inserting after the item relating to subchapter D in 

the table of subchapters for such chapter the following new 

item: 

‘‘SUBCHAPTER E. MEDICAL DEVICES’’. 

(b) CERTAIN EXEMPTIONS NOT TO APPLY.— 

(1) Section 4221(a) of the Internal Revenue Code of 1986 

is amended by adding at the end the following new sentence: 

‘‘In the case of the tax imposed by section 4191, paragraphs (3), 

(4), (5), and (6) shall not apply.’’. 

(2) Section 6416(b)(2) of such Code is amended by adding 

at the end the following: ‘‘In the case of the tax imposed by section 4191, subparagraphs (B), (C), (D), and (E) shall not 

apply.’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to sales after December 31, 2012. 

(d) REPEAL OF SECTION 9009 OF THE PATIENT PROTECTION AND

AFFORDABLE CARE ACT.—øRepealed section 9009 of PPACA¿ . 

SEC. 1406. HEALTH INSURANCE PROVIDERS øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

(a) IN GENERAL.—Section 9010 of the Patient Protection and 

Affordable Care Act, as amended by section 10905 of such Act, is 

amended— 

(1) øAmended subsection (a)(1)¿ 

(2) øAmended subsection (b)(2), including adding subparagraph (B)¿ 

(3) in subsection (c)— 

(A) øInserted language¿ 

(B) øAmended paragraph (2) by substitute new subparagraphs (C) and (D) for subparagraphs (C) through 

(E)¿ 

(C) øExecuted as if intended to amend sentence added 

by section added by section 10905(f)(3)¿ 

(D) øAdded new paragraph (4)¿ 

(4) øReplaced subsection (e)¿ 

(5) øAdded paragraphs (3) and (4) to subsection (g)¿ 

(6) øReplaced subsection (j)¿ 

(b) EFFECTIVE DATE.—The amendments made by this section 

shall take effect as if included in section 9010 of the Patient Protection and Affordable Care Act. 

SEC. 1407. DELAY OF ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE TO MEDICARE PART D SUBSIDY øAMENDMENT 

FULLY INCORPORATED INTO PPACA¿. 

øAmended section 9012(b) of PPACA¿ 

SEC. 1408. ELIMINATION OF UNINTENDED APPLICATION OF CELLULOSIC BIOFUEL PRODUCER CREDIT. 

(a) IN GENERAL.—Section 40(b)(6)(E) of the Internal Revenue 

Code of 1986 is amended by adding at the end the following new 

clause: 
951 Sec. 1409 HEALTH RECONCILIATION 

‘‘(iii) EXCLUSION OF UNPROCESSED FUELS.—The 

term ‘cellulosic biofuel’ shall not include any fuel if— 

‘‘(I) more than 4 percent of such fuel (determined by weight) is any combination of water and 

sediment, or 

‘‘(II) the ash content of such fuel is more than 

1 percent (determined by weight).’’. 

(b) EFFECTIVE DATE.—The amendment made by this section 

shall apply to fuels sold or used on or after January 1, 2010. 

SEC. 1409. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE AND 

PENALTIES. 

(a) IN GENERAL.—Section 7701 of the Internal Revenue Code 

of 1986 is amended by redesignating subsection (o) as subsection 

(p) and by inserting after subsection (n) the following new subsection: 

‘‘(o) CLARIFICATION OF ECONOMIC SUBSTANCE DOCTRINE.— 

‘‘(1) APPLICATION OF DOCTRINE.—In the case of any transaction to which the economic substance doctrine is relevant, 

such transaction shall be treated as having economic substance 

only if— 

‘‘(A) the transaction changes in a meaningful way 

(apart from Federal income tax effects) the taxpayer’s economic position, and 

‘‘(B) the taxpayer has a substantial purpose (apart 

from Federal income tax effects) for entering into such 

transaction. 

‘‘(2) SPECIAL RULE WHERE TAXPAYER RELIES ON PROFIT POTENTIAL.— 

‘‘(A) IN GENERAL.—The potential for profit of a transaction shall be taken into account in determining whether 

the requirements of subparagraphs (A) and (B) of paragraph (1) are met with respect to the transaction only if 

the present value of the reasonably expected pre-tax profit 

from the transaction is substantial in relation to the 

present value of the expected net tax benefits that would 

be allowed if the transaction were respected. 

‘‘(B) TREATMENT OF FEES AND FOREIGN TAXES.—Fees 

and other transaction expenses shall be taken into account 

as expenses in determining pre-tax profit under subparagraph (A). The Secretary shall issue regulations requiring 

foreign taxes to be treated as expenses in determining pretax profit in appropriate cases. 

‘‘(3) STATE AND LOCAL TAX BENEFITS.—For purposes of 

paragraph (1), any State or local income tax effect which is related to a Federal income tax effect shall be treated in the 

same manner as a Federal income tax effect. 

‘‘(4) FINANCIAL ACCOUNTING BENEFITS.—For purposes of 

paragraph (1)(B), achieving a financial accounting benefit shall 

not be taken into account as a purpose for entering into a 

transaction if the origin of such financial accounting benefit is 

a reduction of Federal income tax. 

‘‘(5) DEFINITIONS AND SPECIAL RULES.—For purposes of this 

subsection— 
Sec. 1409 HEALTH RECONCILIATION 952 

‘‘(A) ECONOMIC SUBSTANCE DOCTRINE.—The term ‘economic substance doctrine’ means the common law doctrine 

under which tax benefits under subtitle A with respect to 

a transaction are not allowable if the transaction does not 

have economic substance or lacks a business purpose. 

‘‘(B) EXCEPTION FOR PERSONAL TRANSACTIONS OF INDIVIDUALS.—In the case of an individual, paragraph (1) shall 

apply only to transactions entered into in connection with 

a trade or business or an activity engaged in for the production of income. 

‘‘(C) DETERMINATION OF APPLICATION OF DOCTRINE NOT

AFFECTED.—The determination of whether the economic 

substance doctrine is relevant to a transaction shall be 

made in the same manner as if this subsection had never 

been enacted. 

‘‘(D) TRANSACTION.—The term ‘transaction’ includes a 

series of transactions.’’. 

(b) PENALTY FOR UNDERPAYMENTS ATTRIBUTABLE TO TRANSACTIONS LACKING ECONOMIC SUBSTANCE.— 

(1) IN GENERAL.—Subsection (b) of section 6662 øpresumably ‘‘of such Code’’≈ is amended by inserting after paragraph 

(5) the following new paragraph: 

‘‘(6) Any disallowance of claimed tax benefits by reason of 

a transaction lacking economic substance (within the meaning 

of section 7701(o)) or failing to meet the requirements of any 

similar rule of law.’’. 

(2) INCREASED PENALTY FOR NONDISCLOSED TRANSACTIONS.—Section 6662 øpresumably ‘‘of such Code’’≈ is 

amended by adding at the end ƒprobably should have been inserted after subsection (h) and before subsection (j), added by 

sec. 512(a) of Public Law 111–147¿ the following new subsection: 

‘‘(i) INCREASE IN PENALTY IN CASE OF NONDISCLOSED NONECONOMIC SUBSTANCE TRANSACTIONS.— 

‘‘(1) IN GENERAL.—In the case of any portion of an underpayment which is attributable to one or more nondisclosed 

noneconomic substance transactions, subsection (a) shall be applied with respect to such portion by substituting ‘40 percent’ 

for ‘20 percent’. 

‘‘(2) NONDISCLOSED NONECONOMIC SUBSTANCE TRANSACTIONS.—For purposes of this subsection, the term ‘nondisclosed noneconomic substance transaction’ means any portion 

of a transaction described in subsection (b)(6) with respect to 

which the relevant facts affecting the tax treatment are not 

adequately disclosed in the return nor in a statement attached 

to the return. 

‘‘(3) SPECIAL RULE FOR AMENDED RETURNS.—In no event 

shall any amendment or supplement to a return of tax be 

taken into account for purposes of this subsection if the amendment or supplement is filed after the earlier of the date the 

taxpayer is first contacted by the Secretary regarding the examination of the return or such other date as is specified by 

the Secretary.’’. 
953 Sec. 1409 HEALTH RECONCILIATION 

(3) CONFORMING AMENDMENT.—Subparagraph (B) of section 6662A(e)(2) øpresumably ‘‘of such Code’’≈ is amended— 

(A) by striking ‘‘section 6662(h)’’ and inserting ‘‘subsections (h) or (i) of section 6662’’; and 

(B) by striking ‘‘GROSS VALUATION MISSTATEMENT PENALTY’’ in the heading and inserting ‘‘CERTAIN INCREASED

UNDERPAYMENT PENALTIES’’. 

(c) REASONABLE CAUSE EXCEPTION NOT APPLICABLE TO NONECONOMIC SUBSTANCE TRANSACTIONS.— 

(1) REASONABLE CAUSE EXCEPTION FOR UNDERPAYMENTS.— 

Subsection (c) of section 6664 øpresumably ‘‘of such Code’’≈ is 

amended— 

(A) by redesignating paragraphs (2) and (3) as paragraphs (3) and (4), respectively; 

(B) by striking ‘‘paragraph (2)’’ in paragraph (4)(A), as 

so redesignated, and inserting ‘‘paragraph (3)’’; and 

(C) by inserting after paragraph (1) the following new 

paragraph: 

‘‘(2) EXCEPTION.—Paragraph (1) shall not apply to any portion of an underpayment which is attributable to one or more 

transactions described in section 6662(b)(6).’’. 

(2) REASONABLE CAUSE EXCEPTION FOR REPORTABLE TRANSACTION UNDERSTATEMENTS.—Subsection (d) of section 6664 

øpresumably ‘‘of such Code’’≈ is amended— 

(A) by redesignating paragraphs (2) and (3) as paragraphs (3) and (4), respectively; 

(B) by striking ‘‘paragraph (2)(C)’’ in paragraph (4), as 

so redesignated, and inserting ‘‘paragraph (3)(C)’’; and 

(C) by inserting after paragraph (1) the following new 

paragraph: 

‘‘(2) EXCEPTION.—Paragraph (1) shall not apply to any portion of a reportable transaction understatement which is attributable to one or more transactions described in section 

6662(b)(6).’’. 

(d) APPLICATION OF PENALTY FOR ERRONEOUS CLAIM FOR REFUND OR CREDIT TO NONECONOMIC SUBSTANCE TRANSACTIONS.— 

Section 6676 øpresumably ‘‘of such Code’’≈ is amended by redesignating subsection (c) as subsection (d) and inserting after subsection 

(b) the following new subsection: 

‘‘(c) NONECONOMIC SUBSTANCE TRANSACTIONS TREATED AS

LACKING REASONABLE BASIS.—For purposes of this section, any excessive amount which is attributable to any transaction described 

in section 6662(b)(6) shall not be treated as having a reasonable 

basis.’’. 

(e) EFFECTIVE DATE.— 

(1) IN GENERAL.—Except as otherwise provided in this subsection, the amendments made by this section shall apply to 

transactions entered into after the date of the enactment of 

this Act. 

(2) UNDERPAYMENTS.—The amendments made by subsections (b) and (c)(1) shall apply to underpayments attributable to transactions entered into after the date of the enactment of this Act. 
Sec. 1410 HEALTH RECONCILIATION 954 

(3) UNDERSTATEMENTS.—The amendments made by subsection (c)(2) shall apply to understatements attributable to 

transactions entered into after the date of the enactment of 

this Act. 

(4) REFUNDS AND CREDITS.—The amendment made by subsection (d) shall apply to refunds and credits attributable to 

transactions entered into after the date of the enactment of 

this Act. 

SEC. 1410. TIME FOR PAYMENT OF CORPORATE ESTIMATED TAXES. 

The percentage under paragraph (1) of section 202(b) of the 

Corporate Estimated Tax Shift Act of 2009 in effect on the date of 

the enactment of this Act is increased by 15.75 percentage points. 

Subtitle F—Other Provisions 

SEC. 1501. COMMUNITY COLLEGE AND CAREER TRAINING GRANT PROGRAM. 

Section 279(b) of the Trade Act of 1974 (19 U.S.C. 2372a(b)) is 

amended by striking ‘‘SUPPLEMENT’’ and all that follows through 

‘‘Funds’’ and inserting ‘‘There are’’ and by striking ‘‘pursuant’’ and 

all that follows and inserting ‘‘$500,000,000 for each of fiscal years 

2011, 2012, 2013, and 2014 to carry out this subchapter, except 

that the limitations contained in section 278(a)(2) shall not apply 

to such funds and each State shall receive not less than 0.5 percent 

of the amount appropriated pursuant to this subsection for each 

such fiscal year.’’. 

TITLE II—EDUCATION AND HEALTH 

Subtitle A—Education øOmitted From This 

Compilation¿ 

Subtitle B—Health 

SEC. 2301. INSURANCE REFORMS øAMENDMENTS FULLY INCORPORATED 

INTO PPACA¿. 

(a) EXTENDING CERTAIN INSURANCE REFORMS TO GRANDFATHERED PLANS.—øAdds a paragraph (4) to section 1251(a) of 

PPACA, as amended by section 101013(d) of PPACA¿ 

(b) CLARIFICATION REGARDING DEPENDENT COVERAGE.— 

øAmends section 2714(a) of the Public Health Service Act, as added 

by section 1001(5) of PPACA¿ 

SEC. 2302. DRUGS PURCHASED BY COVERED ENTITIES. 

Section 340B of the Public Health Service Act (42 U.S.C. 256b), 

as amended by sections 7101 and 7102 of the Patient Protection 

and Affordable Care Act, is amended— 

(1) in subsection (a)— 

(A) in paragraphs (1), (2), (5), (7), and (9), by striking 

the terms ‘‘covered drug’’ and ‘‘covered drugs’’ each place 

either term appears and inserting ‘‘covered outpatient 

drug’’ or ‘‘covered outpatient drugs’’, respectively; 
955 Sec. 2303 HEALTH RECONCILIATION 

(B) in paragraph (4)(L)— 

(i) in clause (i), by striking ‘‘and’’ at the end; 

(ii) in clause (ii), by striking the period and inserting ‘‘; and’’; and 

(iii) by inserting after clause (ii), the following: 

‘‘(iii) does not obtain covered outpatient drugs 

through a group purchasing organization or other 

group purchasing arrangement.’’; and 

(C) in paragraph (5)— 

(i) by striking subparagraph (C); 

(ii) by redesignating subparagraphs (D) and (E) as 

subparagraphs (C) and (D), respectively; and 

(iii) in subparagraph (D), as so redesignated, by 

striking ‘‘subparagraph (D)’’ and inserting ‘‘subparagraph (C)’’; 

(2) by striking subsection (c); 

(3) in subsection (d)— 

(A) by striking ‘‘covered drugs’’ each place it appears 

and inserting ‘‘covered outpatient drugs’’; 

(B) by striking ‘‘(a)(5)(D)’’ each place it appears and inserting ‘‘(a)(5)(C)’’; and 

(C) by striking ‘‘(a)(5)(E)’’ each place it appears and inserting ‘‘(a)(5)(D)’’; and 

(4) by inserting after subsection (d) the following: 

‘‘(e) EXCLUSION OF ORPHAN DRUGS FOR CERTAIN COVERED ENTITIES.—For covered entities described in subparagraph (M), (N), or 

(O) of subsection (a)(4), the term ‘covered outpatient drug’ shall not 

include a drug designated by the Secretary under section 526 of the 

Federal Food, Drug, and Cosmetic Act for a rare disease or condition.’’. 

SEC. 2303. COMMUNITY HEALTH CENTERS øAMENDMENT FULLY INCORPORATED INTO PPACA¿. 

øAmended dollar amounts in section 10503(b)(1) of PPACA¿