II 

111TH CONGRESS 

1ST SESSION S. 1262 

To amend title VII of the Public Health Service Act and titles XVIII and 

XIX of the Social Security Act to provide additional resources for primary care services, to create new payment models for services under 

Medicare, to expand provision of non-institutionally-based long-term services, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 15, 2009 

Ms. CANTWELL introduced the following bill; which was read twice and 

referred to the Committee on Finance 

A BILL 

To amend title VII of the Public Health Service Act and 

titles XVIII and XIX of the Social Security Act to provide additional resources for primary care services, to 

create new payment models for services under Medicare, 

to expand provision of non-institutionally-based long-term 

services, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medical Efficiency and 

5 Delivery Improvement of Care Act (MEDIC) of 2009’’. 


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1 SEC. 2. TABLE OF CONTENTS. 

2 The table of contents for this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

TITLE I—LOAN PROGRAM PROVISIONS 

Sec. 1001. Short title. 

Sec. 1002. Hospital residency loan program. 

TITLE II—PRIMARY CARE PROVISIONS 

Sec. 2001. Short title. 

Sec. 2002. Findings. 

Sec. 2003. Definitions. 

Subtitle A—Medical Education 

Sec. 2101. Recruitment incentives. 

Sec. 2102. Debt forgiveness, scholarships, and service obligations. 

Sec. 2103. Deferment of loans during residency and internships. 

Sec. 2104. Educating medical students about primary care careers. 

Sec. 2105. Training in family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistant education, general 

dentistry, and pediatric dentistry. 

Sec. 2106. Increased funding for National Health Service Corps Scholarship 

and loan repayment programs. 

Subtitle B—Medicaid Related Provisions 

Sec. 2201. Transformation grants to support patient-centered medical homes 

under Medicaid and CHIP. 

Subtitle C—Medicare Provisions 

PART I—PRIMARY CARE

Sec. 2301. Reforming payment systems under Medicare to support primary 

care. 

Sec. 2302. Coverage of patient-centered medical home services. 

Sec. 2303. Medicare primary care payment equity and access provision. 

Sec. 2304. Additional incentive payment program for primary care services furnished in health professional shortage areas. 

Sec. 2305. Permanent extension of Medicare incentive payment program for 

physician scarcity areas. 

Sec. 2306. HHS study and report on the process for determining relative value 

under the Medicare physician fee schedule. 

PART II—PREVENTIVE SERVICES

Sec. 2311. Eliminating time restriction for initial preventive physical examination. 

Sec. 2312. Elimination of cost-sharing for preventive benefits under the Medicare program. 

Sec. 2313. HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries. 


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PART III—OTHER PROVISIONS

Sec. 2321. HHS study and report on improving the ability of physicians and 

primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D. 

Sec. 2322. HHS study and report on improved patient care through increased 

caregiver and physician interaction. 

Sec. 2323. Improved patient care through expanded support for limited English 

proficiency (LEP) services. 

Sec. 2324. HHS study and report on use of real-time Medicare claims adjudication. 

Sec. 2325. Ongoing assessment by MedPAC of the impact of Medicare payments on primary care access and equity. 

Sec. 2326. Distribution of additional residency positions. 

Sec. 2327. Counting resident time in outpatient settings. 

Sec. 2328. Rules for counting resident time for didactic and scholarly activities 

and other activities. 

Sec. 2329. Preservation of resident cap positions from closed and acquired hospitals. 

Sec. 2330. Quality improvement organization assistance for physician practices 

seeking to be patient-centered medical home practices. 

Subtitle D—Studies 

Sec. 2401. Study concerning the designation of primary care as a shortage profession. 

Sec. 2402. Study concerning the education debt of medical school graduates. 

Sec. 2403. Study on minority representation in primary care. 

TITLE III—MEDICARE PAYMENT PROVISIONS 

Sec. 3001. Short title. 

Sec. 3002. Findings. 

Sec. 3003. Value index under the Medicare physician fee schedule. 

TITLE IV—LONG-TERM SERVICES PROVISIONS 

Sec. 4001. Short title. 

Subtitle A—Balancing Incentives 

Sec. 4101. Enhanced FMAP for expanding the provision of non-institutionallybased long-term services and supports. 

Subtitle B—Strengthening the Medicaid Home and Community-Based State 

Plan Amendment Option 

Sec. 4201. Removal of barriers to providing home and community-based services under State plan amendment option for individuals in 

need. 

Sec. 4202. Mandatory application of spousal impoverishment protections to recipients of home and community-based services. 

Sec. 4203. State authority to elect to exclude up to 6 months of average cost 

of nursing facility services from assets or resources for purposes of eligibility for home and community-based services. 

Subtitle C—Coordination of Home and Community-Based Waivers 


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Sec. 4301. Streamlined process for combined waivers under subsections (b) and 

(c) of section 1915. 

TITLE V—HOME AND COMMUNITY-BASED SERVICES PROVISIONS 

Sec. 5001. Short title. 

Sec. 5002. Long-term services and supports. 

1 TITLE I—LOAN PROGRAM 

2 PROVISIONS 

3 SEC. 1001. SHORT TITLE. 

4 This title may be cited as the ‘‘Physician Workforce 

5 Enhancement Act of 2009’’. 

6 SEC. 1002. HOSPITAL RESIDENCY LOAN PROGRAM. 

7 Subpart 2 of part E of title VII of the Public Health 

8 Service Act is amended by adding at the end the following 

9 new section: 

10 ‘‘SEC. 771. HOSPITAL RESIDENCY LOAN PROGRAM. 

11 ‘‘(a) ESTABLISHMENT.—Not later than January 1, 

12 2010, the Secretary, acting through the Administrator of 

13 the Health Resources and Services Administration, shall 

14 establish a loan program that provides loans to eligible 

15 hospitals to establish residency training programs. 

16 ‘‘(b) APPLICATION.—No loan may be provided under 

17 this section to an eligible hospital except pursuant to an 

18 application that is submitted and approved in a time, man19 ner, and form specified by the Administrator of the Health 

20 Resources and Services Administration. A loan under this 

21 section shall be on such terms and conditions and meet 


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1 such requirements as the Administrator determines appro2 priate, in accordance with the provisions of this section. 

3 ‘‘(c) ELIGIBILITY; PREFERENCE FOR RURAL AND

4 SMALL URBAN AREAS.— 

5 ‘‘(1) ELIGIBLE HOSPITAL DEFINED.—For pur6 poses of this section, an ‘eligible hospital’ means, 

7 with respect to a loan under this section, a hospital 

8 that, as of the date of the submission of an applica9 tion under subsection (b), meets, to the satisfaction 

10 of the Administrator of the Health Resources and 

11 Services Administration, each of the following cri12 teria: 

13 ‘‘(A) The hospital does not operate a resi14 dency training program, has not previously op15 erated such a program, and has not taken any 

16 significant action, such as the expenditure of a 

17 material amount of funds, before July 1, 2009, 

18 to establish such a program. 

19 ‘‘(B) The hospital has secured initial ac20 creditation by the American Council for Grad21 uate Medical Education or the American Osteo22 pathic Association. 

23 ‘‘(C) The hospital provides assurances to 

24 the satisfaction of the Administrator of the 

25 Health Resources and Services Administration 


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1 that such loan shall be used, consistent with 

2 subsection (d), only for the purposes of estab3 lishing and conducting an allopathic or osteo4 pathic physician residency training program in 

5 at least one of the following medical specialties, 

6 or a combination of the following: 

7 ‘‘(i) Family medicine. 

8 ‘‘(ii) Internal medicine. 

9 ‘‘(iii) Emergency medicine. 

10 ‘‘(iv) Obstetrics or gynecology. 

11 ‘‘(v) General surgery. 

12 ‘‘(vi) Preventive Medicine. 

13 ‘‘(vii) Pediatrics. 

14 ‘‘(viii) Behavioral and Mental Health. 

15 ‘‘(D) The hospital enters into an agree16 ment with the Administrator that certifies the 

17 hospital will provide for the repayment of the 

18 loan in accordance with subsection (e). 

19 ‘‘(2) PREFERENCE FOR RURAL AND SMALL

20 AREAS.—In making loans under this section, the Ad21 ministrator of the Health Resources and Services 

22 Administration shall give preference to any applicant 

23 for such a loan that is a hospital located in a rural 

24 areas (as such term is defined in section 

25 1886(d)(2)(D) of the Social Security Act) or an 


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1 urban area that is not a large urban area (as such 

2 terms are respectively defined in such section). 

3 ‘‘(d) PERMISSIBLE USES OF LOAN FUNDS.—A loan 

4 provided under this section shall be used, with respect to 

5 a residency training program, only for costs directly at6 tributable to the residency training program, except as 

7 otherwise provided by the Administrator of the Health Re8 sources and Services Administration. 

9 ‘‘(e) REPAYMENT OF LOANS.— 

10 ‘‘(1) REPAYMENT PLANS.—For purposes of 

11 subsection (c)(1)(D), a repayment plan for an eligi12 ble hospital is in accordance with this subsection if 

13 it provides for the repayment of the loan amount in 

14 installments, in accordance with a schedule that is 

15 agreed to by the Administrator of the Health Re16 sources and Services Administration and the hospital 

17 and that is in accordance with this subsection. 

18 ‘‘(2) COMMENCEMENT OF REPAYMENT.—Re19 payment by an eligible hospital of a loan under this 

20 section shall commence not later than the date that 

21 is 18 months after the date on which the loan 

22 amount is disbursed to such hospital. 

23 ‘‘(3) REPAYMENT PERIOD.—A loan made under 

24 this section shall be fully repaid not later than the 


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1 date that is 24 months after the date on which the 

2 repayment is required to commence. 

3 ‘‘(4) LOAN PAYABLE IN FULL IF RESIDENCY

4 TRAINING PROGRAM CANCELED.—In the case that 

5 an eligible hospital borrows a loan under this sec6 tion, with respect to a residency training program, 

7 and terminates such program before the date on 

8 which such loan has been fully repaid in accordance 

9 with a plan under paragraph (1), such loan shall be 

10 payable by the hospital not later than 45 days after 

11 the date of such termination. 

12 ‘‘(f) NO INTEREST CHARGED.—The Administrator of 

13 the Health Resources and Services Administration may 

14 not charge or collect interest on any loan made under this 

15 section. 

16 ‘‘(g) LIMITATION ON TOTAL AMOUNT OF LOAN.— 

17 The cumulative dollar amount of a loan made to an eligible 

18 hospital under this section may not exceed $1,000,000. 

19 ‘‘(h) PENALTIES.—The Administrator of the Health 

20 Resources and Services Administration shall establish pen21 alties to which an eligible hospital receiving a loan under 

22 this section would be subject if such hospital is in violation 

23 of any of the criteria described in subsection (c)(1). 

24 ‘‘(i) REPORTS.—Not later than January 1, 2014, and 

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1 istrator of the Health Resources and Services Administra2 tion shall submit to Congress a report on the efficacy of 

3 the program under this section in increasing the number 

4 of residents practicing in each medical specialty described 

5 in subsection (c)(1)(C) during such year and the extent 

6 to which the program resulted in an increase in the num7 ber of available practitioners in each of such medical spe8 cialties that serve medically underserved populations. 

9 ‘‘(j) FUNDING.—— 

10 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

11 For the purpose of providing amounts for loans 

12 under this section, there are authorized to be appro13 priated $25,000,000 for the period of fiscal years 

14 2010 through 2020. 

15 ‘‘(2) AVAILABILITY.—Amounts appropriated 

16 under paragraph (1) shall remain available until ex17 pended. 

18 ‘‘(3) REPAID LOAN AMOUNTS.—Any amount re19 paid by, or recovered from, an eligible hospital under 

20 this section on or before the date of termination de21 scribed in subsection (k) shall be credited to the ap22 propriation account from which the loan amount in23 volved was originally paid. Any amount repaid by, or 

24 recovered from, such a hospital under this section 


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1 after such date shall be credited to the general fund 

2 in the Treasury. 

3 ‘‘(k) TERMINATION OF PROGRAM.—No loan may be 

4 made under this section after December 31, 2019.’’. 

5 TITLE II—PRIMARY CARE 

6 PROVISIONS 

7 SEC. 2001. SHORT TITLE. 

8 This title may be cited as the ‘‘Preserving Patient 

9 Access to Primary Care Act of 2009’’. 

10 SEC. 2002. FINDINGS. 

11 Congress makes the following findings: 

12 (1) Approximately 21 percent of physicians who 

13 were board certified in general internal medicine 

14 during the early 1990s have left internal medicine, 

15 compared to a 5 percent departure rate for those 

16 who were certified in subspecialties of internal medi17 cine. 

18 (2) The number of United States medical grad19 uates going into family medicine has fallen by more 

20 than 50 percent from 1997 to 2005. 

21 (3) In 2007, only 88 percent of the available 

22 medicine residency positions were filled and only 42 

23 percent of those were filled by United States medical 

24 school graduates. 


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1 (4) In 2006, only 24 percent of third-year inter2 nal medicine resident intended to pursue careers in 

3 general internal medicine, down from 54 percent in 

4 1998. 

5 (5) Primary care physicians serve as the point 

6 of first contact for most patients and are able to co7 ordinate the care of the whole person, reducing un8 necessary care and duplicative testing. 

9 (6) Primary care physicians and primary care 

10 providers practicing preventive care, including 

11 screening for illness and treating diseases, can help 

12 prevent complications that result in more costly 

13 care. 

14 (7) Patients with primary care physicians or 

15 primary care providers have lower health care ex16 penditures and primary care is correlated with better 

17 health status, lower overall mortality, and longer life 

18 expectancy. 

19 (8) Higher proportions of primary care physi20 cians are associated with significantly reduced utili21 zation. 

22 (9) The United States has a higher ratio of spe23 cialists to primary care physicians than other indus24 trialized nations and the population of the United 


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1 States is growing faster than the expected rate of 

2 growth in the supply of primary care physicians. 

3 (10) The number of Americans age 65 and 

4 older, those eligible for Medicare and who use far 

5 more ambulatory care visits per person as those 

6 under age 65, is expected to double from 2000 to 

7 2030. 

8 (11) A decrease in Federal spending to carry 

9 out programs authorized by title VII of the Public 

10 Health Service Act threatens the viability of one of 

11 the programs used to solve the problem of inad12 equate access to primary care. 

13 (12) The National Health Service Corps pro14 gram has a proven record of supplying physicians to 

15 underserved areas, and has played an important role 

16 in expanding access for underserved populations in 

17 rural and inner city communities. 

18 (13) Individuals in many geographic areas, es19 pecially rural areas, lack adequate access to high 

20 quality preventive, primary health care, contributing 

21 to significant health disparities that impair Amer22 ica’s public health and economic productivity. 

23 (14) About 20 percent of the population of the 

24 United States resides in primary medical care 

25 Health Professional Shortage Areas. 


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1 SEC. 2003. DEFINITIONS. 

2 (a) GENERAL DEFINITIONS.—In this title: 

3 (1) CHRONIC CARE COORDINATION.—The term 

4 ‘‘chronic care coordination’’ means the coordination 

5 of services that is based on the Chronic Care Model 

6 that provides on-going health care to patients with 

7 chronic diseases that may include any of the fol8 lowing services: 

9 (A) The development of an initial plan of 

10 care, and subsequent appropriate revisions to 

11 such plan of care. 

12 (B) The management of, and referral for, 

13 medical and other health services, including 

14 interdisciplinary care conferences and manage15 ment with other providers. 

16 (C) The monitoring and management of 

17 medications. 

18 (D) Patient education and counseling serv19 ices. 

20 (E) Family caregiver education and coun21 seling services. 

22 (F) Self-management services, including 

23 health education and risk appraisal to identify 

24 behavioral risk factors through self-assessment. 

25 (G) Providing access by telephone with 

26 physicians and other appropriate health care 


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1 professionals, including 24-hour availability of 

2 such professionals for emergencies. 

3 (H) Management with the principal non4 professional caregiver in the home. 

5 (I) Managing and facilitating transitions 

6 among health care professionals and across set7 tings of care, including the following: 

8 (i) Pursuing the treatment option 

9 elected by the individual. 

10 (ii) Including any advance directive 

11 executed by the individual in the medical 

12 file of the individual. 

13 (J) Information about, and referral to, 

14 hospice care, including patient and family care15 giver education and counseling about hospice 

16 care, and facilitating transition to hospice care 

17 when elected. 

18 (K) Information about, referral to, and 

19 management with, community services. 

20 (2) CRITICAL SHORTAGE HEALTH FACILITY.— 

21 The term ‘‘critical shortage health facility’’ means a 

22 public or private nonprofit health facility that does 

23 not serve a health professional shortage area (as 

24 designated under section 332 of the Public Health 

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1 sicians (as determined by the Secretary) in a pri2 mary care field. 

3 (3) PHYSICIAN.—The term physician has the 

4 meaning given such term in section 1861(r)(1) of 

5 the Social Security Act. 

6 (4) PRIMARY CARE.—The term ‘‘primary care’’ 

7 means the provision of integrated, high-quality, ac8 cessible health care services by health care providers 

9 who are accountable for addressing a full range of 

10 personal health and health care needs, developing a 

11 sustained partnership with patients, practicing in 

12 the context of family and community, and working 

13 to minimize disparities across population subgroups. 

14 (5) PRIMARY CARE FIELD.—The term ‘‘primary 

15 care field’’ means any of the following fields: 

16 (A) The field of family medicine. 

17 (B) The field of general internal medicine. 

18 (C) The field of geriatric medicine. 

19 (D) The field of pediatric medicine 

20 (6) PRIMARY CARE PHYSICIAN.—The term ‘‘pri21 mary care physician’’ means a physician who is 

22 trained in a primary care field who provides first 

23 contact, continuous, and comprehensive care to pa24 tients. 


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1 (7) PRIMARY CARE PROVIDER.—The term ‘‘pri2 mary care provider’’ means— 

3 (A) a nurse practitioner; or 

4 (B) a physician assistant practicing as a 

5 member of a physician-directed team; 

6 who provides first contact, continuous, and com7 prehensive care to patients. 

8 (8) PRINCIPAL CARE.—The term ‘‘principal 

9 care’’ means integrated, accessible health care that 

10 is provided by a physician who is a medical sub11 specialist that addresses the majority of the personal 

12 health care needs of patients with chronic conditions 

13 requiring the subspecialist’s expertise, and for whom 

14 the subspecialist assumes care management, devel15 oping a sustained physician-patient partnership and 

16 practicing within the context of family and commu17 nity. 

18 (9) SECRETARY.—The term ‘‘Secretary’’ means 

19 the Secretary of Health and Human Services. 

20 (b) PRIMARY MEDICAL CARE SHORTAGE AREA.— 

21 (1) IN GENERAL.—In this title, the term ‘‘pri22 mary medical care shortage area’’ or ‘‘PMCSA’’ 

23 means a geographic area with a shortage of physi24 cians (as designated by the Secretary) in a primary 


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1 care field, as designated in accordance with para2 graph (2). 

3 (2) DESIGNATION.—To be designated by the 

4 Secretary as a PMCSA, the Secretary must find 

5 that the geographic area involved has an established 

6 shortage of primary care physicians for the popu7 lation served. The Secretary shall make such a des8 ignation with respect to an urban or rural geo9 graphic area if the following criteria are met: 

10 (A) The area is a rational area for the de11 livery of primary care services. 

12 (B) One of the following conditions pre13 vails within the area: 

14 (i) The area has a population to full15 time-equivalent primary care physician 

16 ratio of at least 3,500 to 1. 

17 (ii) The area has a population to full18 time-equivalent primary care physician 

19 ratio of less than 3,500 to 1 and has un20 usually high needs for primary care serv21 ices or insufficient capacity of existing pri22 mary care providers. 

23 (C) Primary care providers in contiguous 

24 geographic areas are overutilized. 

25 (c) MEDICALLY UNDERSERVED AREA.— 


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1 (1) IN GENERAL.—In this title, the term ‘‘medi2 cally underserved area’’ or ‘‘MUA’’ means a rational 

3 service area with a demonstrable shortage of pri4 mary healthcare resources relative to the needs of 

5 the entire population within the service area as de6 termined in accordance with paragraph (2) through 

7 the use of the Index of Medical Underservice (re8 ferred to in this subsection as the ‘‘IMU’’) with re9 spect to data on a service area. 

10 (2) DETERMINATIONS.—Under criteria to be 

11 established by the Secretary with respect to the 

12 IMU, if a service area is determined by the Sec13 retary to have a score of 62.0 or less, such area shall 

14 be eligible to be designated as a MUA. 

15 (3) IMU VARIABLES.—In establishing criteria 

16 under paragraph (2), the Secretary shall ensure that 

17 the following variables are utilized: 

18 (A) The ratio of primary medical care phy19 sicians per 1,000 individuals in the population 

20 of the area involved. 

21 (B) The infant mortality rate in the area 

22 involved. 

23 (C) The percentage of the population in24 volved with incomes below the poverty level. 


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1 (D) The percentage of the population in2 volved age 65 or over. 

3 The value of each of such variables for the service 

4 area involved shall be converted by the Secretary to 

5 a weighted value, according to established criteria, 

6 and added together to obtain the area’s IMU score. 

7 (d) PATIENT-CENTERED MEDICAL HOME.— 

8 (1) IN GENERAL.—In this title, the term ‘‘pa9 tient-centered medical home’’ means a physician-di10 rected practice (or a nurse practitioner directed 

11 practice in those States in which such functions are 

12 included in the scope of practice of licensed nurse 

13 practitioners) that has been certified by an organiza14 tion under paragraph (3) as meeting the following 

15 standards: 

16 (A) The practice provides patients who 

17 elect to obtain care through a patient-centered 

18 medical home (referred to as ‘‘participating pa19 tients’’) with direct and ongoing access to a pri20 mary or principal care physician or a primary 

21 care provider who accepts responsibility for pro22 viding first contact, continuous, and comprehen23 sive care to the whole person, in collaboration 

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1 ing nurses and specialist physicians, as needed 

2 and appropriate. 

3 (B) The practice applies standards for ac4 cess to care and communication with partici5 pating beneficiaries. 

6 (C) The practice has readily accessible, 

7 clinically useful information on participating pa8 tients that enables the practice to treat such 

9 patients comprehensively and systematically. 

10 (D) The practice maintains continuous re11 lationships with participating patients by imple12 menting evidence-based guidelines and applying 

13 such guidelines to the identified needs of indi14 vidual beneficiaries over time and with the in15 tensity needed by such beneficiaries. 

16 (2) RECOGNITION OF NCQA APPROVAL.—Such 

17 term also includes a physician-directed (or nurse18 practitioner-directed) practice that has been recog19 nized as a medical home through the Physician 

20 Practice Connections—patient-centered Medical 

21 Home (‘‘PPC–PCMH’’) voluntary recognition proc22 ess of the National Committee for Quality Assur23 ance. 

24 (3) STANDARD SETTING AND QUALIFICATION

25 PROCESS FOR MEDICAL HOMES.—The Secretary 


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1 shall establish a process for the selection of a quali2 fied standard setting and certification organiza3 tion— 

4 (A) to establish standards, consistent with 

5 this subsection, to enable medical practices to 

6 qualify as patient-centered medical homes; and 

7 (B) to provide for the review and certifi8 cation of medical practices as meeting such 

9 standards. 

10 (4) TREATMENT OF CERTAIN PRACTICES.— 

11 Nothing in this section shall be construed as pre12 venting a nurse practitioner from leading a patient13 centered medical home so long as— 

14 (A) all of the requirements of this section 

15 are met; and 

16 (B) the nurse practitioner is acting con17 sistently with State law. 

18 (e) APPLICATION UNDER MEDICARE, MEDICAID, 

19 PHSA, ETC.—Unless otherwise provided, the provisions of 

20 the previous subsections shall apply for purposes of provi21 sions of the Social Security Act, the Public Health Service 

22 Act, and any other Act amended by this title. 


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1 Subtitle A—Medical Education 

2 SEC. 2101. RECRUITMENT INCENTIVES. 

3 Title VII of the Higher Education Act of 1965 (20 

4 U.S.C. 1133 et seq.) is amended by adding at the end 

5 the following: 

6 ‘‘PART VI—MEDICAL EDUCATION RECRUITMENT 

7 INCENTIVES 

8 ‘‘SEC. 786. MEDICAL EDUCATION RECRUITMENT INCEN9 TIVES. 

10 ‘‘(a) IN GENERAL.—The Secretary is authorized to 

11 award grants or contracts to institutions of higher edu12 cation that are graduate medical schools, to enable the 

13 graduate medical schools to improve primary care edu14 cation and training for medical students. 

15 ‘‘(b) APPLICATION.—A graduate medical school that 

16 desires to receive a grant under this section shall submit 

17 to the Secretary an application at such time, in such man18 ner, and containing such information as the Secretary may 

19 require. 

20 ‘‘(c) USES OF FUNDS.—A graduate medical school 

21 that receives a grant under this section shall use such 

22 grant funds to carry out 1 or more of the following: 

23 ‘‘(1) The creation of primary care mentorship 

24 programs. 


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1 ‘‘(2) Curriculum development for population2 based primary care models of care, such as the pa3 tient-centered medical home. 

4 ‘‘(3) Increased opportunities for ambulatory, 

5 community-based training. 

6 ‘‘(4) Development of generalist curriculum to 

7 enhance care for rural and underserved populations 

8 in primary care or general surgery. 

9 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

10 is authorized to be appropriated to carry out this section 

11 $50,000,000 for each of the fiscal years 2010 through 

12 2012.’’. 

13 SEC. 2102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERV14 ICE OBLIGATIONS. 

15 (a) PURPOSE.—It is the purpose of this section to 

16 encourage individuals to enter and continue in primary 

17 care physician careers. 

18 (b) AMENDMENT TO THE PUBLIC HEALTH SERVICE

19 ACT.—Part D of title III of the Public Health Service Act 

20 (42 U.S.C. 254b et seq.) is amended by adding at the end 

21 the following: 

22 ‘‘Subpart XX—Primary Care Medical Education 

23 ‘‘SEC. 340A. SCHOLARSHIPS. 

24 ‘‘(a) IN GENERAL.—The Secretary, acting through 

25 the Administrator of the Health Resources and Services 


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1 Administration, shall award grants to critical shortage 

2 health facilities to enable such facilities to provide scholar3 ships to individuals who agree to serve as physicians at 

4 such facilities after completing a residency in a primary 

5 care field (as defined in section 3(a)(5) of the Preserving 

6 Patient Access to Primary Care Act of 2009). 

7 ‘‘(b) SCHOLARSHIPS.—A health facility shall use 

8 amounts received under a grant under this section to enter 

9 into contracts with eligible individuals under which— 

10 ‘‘(1) the facility agrees to provide the individual 

11 with a scholarship for each school year (not to ex12 ceed 4 school years) in which the individual is en13 rolled as a full-time student in a school of medicine 

14 or a school of osteopathic medicine; and 

15 ‘‘(2) the individual agrees— 

16 ‘‘(A) to maintain an acceptable level of 

17 academic standing; 

18 ‘‘(B) to complete a residency in a primary 

19 care field; and 

20 ‘‘(C) after completing the residency, to 

21 serve as a primary care physician at such facil22 ity in such field for a time period equal to the 

23 greater of— 


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1 ‘‘(i) one year for each school year for 

2 which the individual was provided a schol3 arship under this section; or 

4 ‘‘(ii) two years. 

5 ‘‘(c) AMOUNT.— 

6 ‘‘(1) IN GENERAL.—The amount paid by a 

7 health facility to an individual under a scholarship 

8 under this section shall not exceed $35,000 for any 

9 school year. 

10 ‘‘(2) CONSIDERATIONS.—In determining the 

11 amount of a scholarship to be provided to an indi12 vidual under this section, a health facility may take 

13 into consideration the individual’s financial need, ge14 ographic differences, and educational costs. 

15 ‘‘(3) EXCLUSION FROM GROSS INCOME.—For 

16 purposes of the Internal Revenue Code of 1986, 

17 gross income shall not include any amount received 

18 as a scholarship under this section. 

19 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

20 provisions of subpart III of part D shall, except as incon21 sistent with this section, apply to the program established 

22 in subsection (a) in the same manner and to the same 

23 extent as such provisions apply to the National Health 

24 Service Corps Scholarship Program established in such 

25 subpart. 


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1 ‘‘(e) DEFINITIONS.—In this section: 

2 ‘‘(1) CRITICAL SHORTAGE HEALTH FACILITY.— 

3 The term ‘critical shortage health facility’ means a 

4 public or private nonprofit health facility that does 

5 not serve a health professional shortage area (as 

6 designated under section 332), but has a critical 

7 shortage of physicians (as determined by the Sec8 retary) in a primary care field. 

9 ‘‘(2) ELIGIBLE INDIVIDUAL.—The term ‘eligible 

10 individual’ means an individual who is enrolled, or 

11 accepted for enrollment, as a full-time student in an 

12 accredited school of medicine or school of osteo13 pathic medicine. 

14 ‘‘SEC. 340B. LOAN REPAYMENT PROGRAM. 

15 ‘‘(a) PURPOSE.—It is the purpose of this section to 

16 alleviate critical shortages of primary care physicians and 

17 primary care providers. 

18 ‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 

19 through the Administrator of the Health Resources and 

20 Services Administration, shall establish a program of en21 tering into contracts with eligible individuals under 

22 which— 

23 ‘‘(1) the individual agrees to serve— 

24 ‘‘(A) as a primary care physician or pri25 mary care provider in a primary care field; and 


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1 ‘‘(B) in an area that is not a health profes2 sional shortage area (as designated under sec3 tion 332), but has a critical shortage of primary 

4 care physicians and primary care providers (as 

5 determined by the Secretary) in such field; and 

6 ‘‘(2) the Secretary agrees to pay, for each year 

7 of such service, not more than $35,000 of the prin8 cipal and interest of the undergraduate or graduate 

9 educational loans of the individual. 

10 ‘‘(c) SERVICE REQUIREMENT.—A contract entered 

11 into under this section shall allow the individual receiving 

12 the loan repayment to satisfy the service requirement de13 scribed in subsection (a)(1) through employment in a solo 

14 or group practice, a clinic, a public or private nonprofit 

15 hospital, or any other appropriate health care entity. 

16 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

17 provisions of subpart III of part D shall, except as incon18 sistent with this section, apply to the program established 

19 in subsection (a) in the same manner and to the same 

20 extent as such provisions apply to the National Health 

21 Service Corps Scholarship Program established in such 

22 subpart. 

23 ‘‘(e) DEFINITION.—In this section, the term ‘eligible 

24 individual’ means— 


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1 ‘‘(1) an individual with a degree in medicine or 

2 osteopathic medicine; or 

3 ‘‘(2) a primary care provider (as defined in sec4 tion 3(a)(7) of the Preserving Patient Access to Pri5 mary Care Act of 2009). 

6 ‘‘SEC. 340C. LOAN REPAYMENTS FOR PHYSICIANS IN THE 

7 FIELDS OF OBSTETRICS AND GYNECOLOGY 

8 AND CERTIFIED NURSE MIDWIVES. 

9 ‘‘(a) PURPOSE.—It is the purpose of this section to 

10 alleviate critical shortages of physicians in the fields of 

11 obstetrics and gynecology and certified nurse midwives. 

12 ‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 

13 through the Administrator of the Health Resources and 

14 Services Administration, shall establish a program of en15 tering into contracts with eligible individuals under 

16 which— 

17 ‘‘(1) the individual agrees to serve— 

18 ‘‘(A) as a physician in the field of obstet19 rics and gynecology or as a certified nurse mid20 wife; and 

21 ‘‘(B) in an area that is not a health profes22 sional shortage area (as designated under sec23 tion 332), but has a critical shortage of physi24 cians in the fields of obstetrics and gynecology 


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1 or certified nurse midwives (as determined by 

2 the Secretary), respectively; and 

3 ‘‘(2) the Secretary agrees to pay, for each year 

4 of such service, not more than $35,000 of the prin5 cipal and interest of the undergraduate or graduate 

6 educational loans of the individual. 

7 ‘‘(c) SERVICE REQUIREMENT.—A contract entered 

8 into under this section shall allow the individual receiving 

9 the loan repayment to satisfy the service requirement de10 scribed in subsection (a)(1) through employment in a solo 

11 or group practice, a clinic, a public or private nonprofit 

12 hospital, or any other appropriate health care entity. 

13 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

14 provisions of subpart III of part D shall, except as incon15 sistent with this section, apply to the program established 

16 in subsection (a) in the same manner and to the same 

17 extent as such provisions apply to the National Health 

18 Service Corps Scholarship Program established in such 

19 subpart. 

20 ‘‘(e) DEFINITION.—In this section, the term ‘eligible 

21 individual’ means— 

22 ‘‘(1) a physician in the field of obstetrics and 

23 gynecology; or 

24 ‘‘(2) a certified nurse midwife. 


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1 ‘‘SEC. 340D. REPORTS. 

2 ‘‘Not later than 18 months after the date of enact3 ment of this section, and annually thereafter, the Sec4 retary shall submit to Congress a report that describes 

5 the programs carried out under this subpart, including 

6 statements concerning— 

7 ‘‘(1) the number of enrollees, scholarships, loan 

8 repayments, and grant recipients; 

9 ‘‘(2) the number of graduates; 

10 ‘‘(3) the amount of scholarship payments and 

11 loan repayments made; 

12 ‘‘(4) which educational institution the recipients 

13 attended; 

14 ‘‘(5) the number and placement location of the 

15 scholarship and loan repayment recipients at health 

16 care facilities with a critical shortage of primary 

17 care physicians; 

18 ‘‘(6) the default rate and actions required; 

19 ‘‘(7) the amount of outstanding default funds of 

20 both the scholarship and loan repayment programs; 

21 ‘‘(8) to the extent that it can be determined, 

22 the reason for the default; 

23 ‘‘(9) the demographics of the individuals par24 ticipating in the scholarship and loan repayment 

25 programs; 


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1 ‘‘(10) the justification for the allocation of 

2 funds between the scholarship and loan repayment 

3 programs; and 

4 ‘‘(11) an evaluation of the overall costs and 

5 benefits of the programs. 

6 ‘‘SEC. 340E. AUTHORIZATION OF APPROPRIATIONS. 

7 ‘‘To carry out sections 340I, 340J, and 340K there 

8 are authorized to be appropriated $55,000,000 for fiscal 

9 year 2010, $90,000,000 for fiscal year 2011, and 

10 $125,000,000 for fiscal year 2012, to be used solely for 

11 scholarships and loan repayment awards for primary care 

12 physicians and primary care providers.’’. 

13 SEC. 2103. DEFERMENT OF LOANS DURING RESIDENCY AND 

14 INTERNSHIPS. 

15 (a) LOAN REQUIREMENTS.—Section 427(a)(2)(C)(i) 

16 of the Higher Education Act of 1965 (20 U.S.C. 

17 1077(a)(2)(C)(i)) is amended by inserting ‘‘unless the 

18 medical internship or residency program is in a primary 

19 care field (as defined in section 3(a)(5) of the Preserving 

20 Patient Access to Primary Care Act of 2009)’’ after ‘‘resi21 dency program’’. 

22 (b) FFEL LOANS.—Section 428(b)(1)(M)(i) of the 

23 Higher Education Act of 1965 (20 U.S.C. 

24 1078(b)(1)(M)(i)) is amended by inserting ‘‘unless the 

25 medical internship or residency program is in a primary 


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1 care field (as defined in section 3(a)(5) of the Preserving 

2 Patient Access to Primary Care Act of 2009)’’ after ‘‘resi3 dency program’’. 

4 (c) FEDERAL DIRECT LOANS.—Section 455(f)(2)(A) 

5 of the Higher Education Act of 1965 (20 U.S.C. 

6 1087e(f)(2)(A)) is amended by inserting ‘‘unless the med7 ical internship or residency program is in a primary care 

8 field (as defined in section 3(a)(5) of the Preserving Pa9 tient Access to Primary Care Act of 2009)’’ after ‘‘resi10 dency program’’. 

11 (d) FEDERAL PERKINS LOANS.—Section 

12 464(c)(2)(A)(i) of the Higher Education Act of 1965 (20 

13 U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting ‘‘un14 less the medical internship or residency program is in a 

15 primary care field (as defined in section 3(a)(5) of the 

16 Preserving Patient Access to Primary Care Act of 2009)’’ 

17 after ‘‘residency program’’. 

18 SEC. 2104. EDUCATING MEDICAL STUDENTS ABOUT PRI19 MARY CARE CAREERS. 

20 Part C of title VII of the Public Health Service Act 

21 (42 U.S.C. 293k) is amended by adding at the end the 

22 following: 


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1 ‘‘SEC. 749. EDUCATING MEDICAL STUDENTS ABOUT PRI2 MARY CARE CAREERS. 

3 ‘‘(a) IN GENERAL.—The Secretary shall award 

4 grants to eligible State and local government entities for 

5 the development of informational materials that promote 

6 careers in primary care by highlighting the advantages 

7 and rewards of primary care, and that encourage medical 

8 students, particularly students from disadvantaged back9 grounds, to become primary care physicians. 

10 ‘‘(b) ANNOUNCEMENT.—The grants described in sub11 section (a) shall be announced through a publication in 

12 the Federal Register and through appropriate media out13 lets in a manner intended to reach medical education insti14 tutions, associations, physician groups, and others who 

15 communicate with medical students. 

16 ‘‘(c) ELIGIBILITY.—To be eligible to receive a grant 

17 under this section an entity shall— 

18 ‘‘(1) be a State or local entity; and 

19 ‘‘(2) submit to the Secretary an application at 

20 such time, in such manner, and containing such in21 formation as the Secretary may require. 

22 ‘‘(d) USE OF FUNDS.— 

23 ‘‘(1) IN GENERAL.—An entity shall use 

24 amounts received under a grant under this section to 

25 support State and local campaigns through appro26 priate media outlets to promote careers in primary 


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1 care and to encourage individuals from disadvan2 taged backgrounds to enter and pursue careers in 

3 primary care. 

4 ‘‘(2) SPECIFIC USES.—In carrying out activities 

5 under paragraph (1), an entity shall use grants 

6 funds to develop informational materials in a man7 ner intended to reach as wide and diverse an audi8 ence of medical students as possible, in order to— 

9 ‘‘(A) advertise and promote careers in pri10 mary care; 

11 ‘‘(B) promote primary care medical edu12 cation programs; 

13 ‘‘(C) inform the public of financial assist14 ance regarding such education programs; 

15 ‘‘(D) highlight individuals in the commu16 nity who are practicing primary care physicians; 

17 or 

18 ‘‘(E) provide any other information to re19 cruit individuals for careers in primary care. 

20 ‘‘(e) LIMITATION.—An entity shall not use amounts 

21 received under a grant under this section to advertise par22 ticular employment opportunities. 

23 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

24 is authorized to be appropriated to carry out this section, 


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1 such sums as may be necessary for each of fiscal years 

2 2010 through 2013.’’. 

3 SEC. 2105. TRAINING IN FAMILY MEDICINE, GENERAL IN4 TERNAL MEDICINE, GENERAL GERIATRICS, 

5 GENERAL PEDIATRICS, PHYSICIAN ASSIST6 ANT EDUCATION, GENERAL DENTISTRY, AND 

7 PEDIATRIC DENTISTRY. 

8 Section 747(e) of the Public Health Service Act (42 

9 U.S.C. 293k) is amended by striking paragraph (1) and 

10 inserting the following: 

11 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

12 For the purpose of carrying out this section, there 

13 is authorized to be appropriated $198,000,000 for 

14 each of fiscal years 2010 through 2012.’’. 

15 SEC. 2106. INCREASED FUNDING FOR NATIONAL HEALTH 

16 SERVICE CORPS SCHOLARSHIP AND LOAN 

17 REPAYMENT PROGRAMS. 

18 (a) IN GENERAL.—There is authorized to be appro19 priated $332,000,000 for the period of fiscal years 2010 

20 through 2012 for the purpose of carrying out subpart III 

21 of part D of title III of the Public Health Service Act 

22 (42 U.S.C. 254l et seq.). Such authorization of appropria23 tions is in addition to the authorization of appropriations 

24 in section 338H of such Act (42 U.S.C. 254q) and any 

25 other authorization of appropriations for such purpose. 


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1 (b) ALLOCATION.—Of the amounts appropriated 

2 under subsection (a) for the period of fiscal years 2010 

3 through 2012, the Secretary shall obligate $96,000,000 

4 for the purpose of providing contracts for scholarships and 

5 loan repayments to individuals who— 

6 (1) are primary care physicians or primary care 

7 providers; and 

8 (2) have not previously received a scholarship or 

9 loan repayment under subpart III of part D of title 

10 III of the Public Health Service Act (42 U.S.C. 254l 

11 et seq.). 

12 Subtitle B—Medicaid Related 

13 Provisions 

14 SEC. 2201. TRANSFORMATION GRANTS TO SUPPORT PA15 TIENT-CENTERED MEDICAL HOMES UNDER 

16 MEDICAID AND CHIP. 

17 (a) IN GENERAL.—Section 1903(z) of the Social Se18 curity Act (42 U.S.C. 1396b(z)) is amended— 

19 (1) in paragraph (2), by adding at the end the 

20 following new subparagraph: 

21 ‘‘(G) Methods for improving the effective22 ness and efficiency of medical assistance pro23 vided under this title and child health assist24 ance provided under title XXI by encouraging 

25 the adoption of medical practices that satisfy 


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1 the standards established by the Secretary 

2 under paragraph (2) of section 3(d) of the Pre3 serving Patient Access to Primary Care Act of 

4 2009 for medical practices to qualify as patient5 centered medical homes (as defined in para6 graph (1) of such section).’’; and 

7 (2) in paragraph (4)— 

8 (A) in subparagraph (A)— 

9 (i) in clause (i), by striking ‘‘and’’ at 

10 the end; 

11 (ii) in clause (ii), by striking the pe12 riod at the end and inserting ‘‘; and’’; and 

13 (iii) by inserting after clause (ii), the 

14 following new clause: 

15 ‘‘(iii) $25,000,000 for each of fiscal 

16 years 2010, 2011, and 2012.’’; and 

17 (B) in subparagraph (B), by striking the 

18 second and third sentences and inserting the 

19 following: ‘‘Such method shall provide that 100 

20 percent of such funds for each of fiscal years 

21 2010, 2011, and 2012 shall be allocated among 

22 States that design programs to adopt the inno23 vative methods described in paragraph (2)(G), 

24 with preference given to States that design pro25 grams involving multipayers (including under 


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1 title XVIII and private health plans) test 

2 projects for implementation of the elements nec3 essary to be recognized as a patient-centered 

4 medical home practice under the National Com5 mittee for Quality Assurance Physicians Prac6 tice Connection—PCMH module (or any other 

7 equivalent process, as determined by the Sec8 retary).’’. 

9 (b) EFFECTIVE DATE.—The amendments made by 

10 this section take effect on October 1, 2010. 

11 Subtitle C—Medicare Provisions 

12 PART I—PRIMARY CARE 

13 SEC. 2301. REFORMING PAYMENT SYSTEMS UNDER MEDI14 CARE TO SUPPORT PRIMARY CARE. 

15 (a) INCREASING BUDGET NEUTRALITY LIMITS

16 UNDER THE PHYSICIAN FEE SCHEDULE TO ACCOUNT

17 FOR ANTICIPATED SAVINGS RESULTING FROM PAYMENTS

18 FOR CERTAIN SERVICES AND THE COORDINATION OF

19 BENEFICIARY CARE.—Section 1848(c)(2)(B) of the Social 

20 Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended— 

21 (1) in clause (ii)(II), by striking ‘‘(iv) and (v)’’ 

22 and inserting ‘‘(iv), (v), and (vii)’’; and 

23 (2) by adding at the end the following new 

24 clause: 


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1 ‘‘(vii) INCREASE IN LIMITATION TO

2 ACCOUNT FOR CERTAIN ANTICIPATED SAV3 INGS.— 

4 ‘‘(I) IN GENERAL.—Effective for 

5 fee schedules established beginning 

6 with 2010, the Secretary shall in7 crease the limitation on annual ad8 justments under clause (ii)(II) by an 

9 amount equal to the anticipated sav10 ings under parts A, B, and D (includ11 ing any savings with respect to items 

12 and services for which payment is not 

13 made under this section) which are a 

14 result of payments for designated pri15 mary care services and comprehensive 

16 care coordination services under sec17 tion 1834(m) and the coverage of pa18 tient-centered medical home services 

19 under section 1861(s)(2)(FF) (as de20 termined by the Secretary). 

21 ‘‘(II) MECHANISM TO DETER22 MINE APPLICATION OF INCREASE.— 

23 The Secretary shall establish a mecha24 nism for determining which relative 

25 value units established under this 


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1 paragraph for physicians’ services 

2 shall be subject to an adjustment 

3 under clause (ii)(I) as a result of the 

4 increase under subclause (I). 

5 ‘‘(III) ADDITIONAL FUNDING AS

6 DETERMINED NECESSARY BY THE

7 SECRETARY.—In addition to any 

8 funding that may be made available 

9 as a result of an increase in the limi10 tation on annual adjustments under 

11 subclause (I), there shall also be avail12 able to the Secretary, for purposes of 

13 making payments under this title for 

14 new services and capabilities to im15 prove care provided to individuals 

16 under this title and to generate effi17 ciencies under this title, such addi18 tional funds as the Secretary deter19 mines are necessary.’’. 

20 (b) SEPARATE MEDICARE PAYMENT FOR DES21 IGNATED PRIMARY CARE SERVICES AND COMPREHENSIVE

22 CARE COORDINATION SERVICES.— 

23 (1) IN GENERAL.—Section 1834 of the Social 

24 Security Act (42 U.S.C. 1395m) is amended by add25 ing at the end the following new subsection: 


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1 ‘‘(n) PAYMENT FOR DESIGNATED PRIMARY CARE

2 SERVICES AND COMPREHENSIVE CARE COORDINATION

3 SERVICES.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall pay for 

5 designated primary care services and comprehensive 

6 care coordination services furnished to an individual 

7 enrolled under this part. 

8 ‘‘(2) PAYMENT AMOUNT.—The Secretary shall 

9 determine the amount of payment for designated 

10 primary care services and comprehensive care co11 ordination services under this subsection. 

12 ‘‘(3) DOCUMENTATION REQUIREMENTS.—The 

13 Secretary shall propose appropriate documentation 

14 requirements to justify payments for designated pri15 mary care services and comprehensive care coordina16 tion services under this subsection. 

17 ‘‘(4) DEFINITIONS.— 

18 ‘‘(A) COMPREHENSIVE CARE COORDINA19 TION SERVICES.—The term ‘comprehensive care 

20 coordination services’ means care coordination 

21 services with procedure codes established by the 

22 Secretary (as appropriate) which are furnished 

23 to an individual enrolled under this part by a 

24 primary care provider or principal care physi25 cian. 


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1 ‘‘(B) DESIGNATED PRIMARY CARE SERV2 ICES.—The term ‘designated primary care serv3 ice’ means a service which the Secretary deter4 mines has a procedure code which involves a 

5 clinical interaction with an individual enrolled 

6 under this part that is inherent to care coordi7 nation, including interactions outside of a face8 to-face encounter. Such term includes the fol9 lowing: 

10 ‘‘(i) Care plan oversight. 

11 ‘‘(ii) Evaluation and management pro12 vided by phone. 

13 ‘‘(iii) Evaluation and management 

14 provided using internet resources. 

15 ‘‘(iv) Collection and review of physio16 logic data, such as from a remote moni17 toring device. 

18 ‘‘(v) Education and training for pa19 tient self management. 

20 ‘‘(vi) Anticoagulation management 

21 services. 

22 ‘‘(vii) Any other service determined 

23 appropriate by the Secretary.’’. 


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1 (2) EFFECTIVE DATE.—The amendment made 

2 by this section shall apply to items and services fur3 nished on or after January 1, 2010. 

4 SEC. 2302. COVERAGE OF PATIENT-CENTERED MEDICAL 

5 HOME SERVICES. 

6 (a) IN GENERAL.—Section 1861(s)(2) of the Social 

7 Security Act (42 U.S.C. 1395x(s)(2)) is amended— 

8 (1) in subparagraph (DD), by striking ‘‘and’’ at 

9 the end; 

10 (2) in subparagraph (EE), by inserting ‘‘and’’ 

11 at the end; and 

12 (3) by adding at the end the following new sub13 paragraph: 

14 ‘‘(FF) patient-centered medical home services 

15 (as defined in subsection (hhh)(1));’’. 

16 (b) DEFINITION OF PATIENT-CENTERED MEDICAL

17 HOME SERVICES.—Section 1861 of the Social Security 

18 Act (42 U.S.C. 1395x) is amended by adding at the end 

19 the following new subsection: 

20 ‘‘Patient-Centered Medical Home Services 

21 ‘‘(hhh)(1) The term ‘patient-centered medical home 

22 services’ means care coordination services furnished by a 

23 qualified patient-centered medical home. 

24 ‘‘(2) The term ‘qualified patient-centered medical 

25 home’ means a patient-centered medical home (as defined 


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1 in section 3(d) of the Preserving Patient Access to Pri2 mary Care Act of 2009).’’. 

3 (c) MONTHLY FEE FOR PATIENT-CENTERED MED4 ICAL HOME SERVICES.—Section 1848 of the Social Secu5 rity Act (42 U.S.C. 1395w–4) is amended by adding at 

6 the end the following new subsection: 

7 ‘‘(p) MONTHLY FEE FOR PATIENT-CENTERED MED8 ICAL HOME SERVICES.— 

9 ‘‘(1) MONTHLY FEE.— 

10 ‘‘(A) IN GENERAL.—Not later than Janu11 ary 1, 2012, the Secretary shall establish a pay12 ment methodology for patient-centered medical 

13 home services (as defined in paragraph (1) of 

14 section 1861(hhh)). Under such payment meth15 odology, the Secretary shall pay qualified pa16 tient-centered medical homes (as defined in 

17 paragraph (2) of such section) a monthly fee 

18 for each individual who elects to receive patient19 centered medical home services at that medical 

20 home. Such fee shall be paid on a prospective 

21 basis. 

22 ‘‘(B) CONSIDERATIONS.—The Secretary 

23 shall take into account the results of the Medi24 care medical home demonstration project under 

25 section 204 of the Medicare Improvement and 


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1 Extension Act of 2006 (42 U.S.C. 1395b–1 

2 note; division B of Public Law 109–432) in es3 tablishing the payment methodology under sub4 paragraph (A). 

5 ‘‘(2) AMOUNT OF PAYMENT.— 

6 ‘‘(A) CONSIDERATIONS.—In determining 

7 the amount of such fee, subject to paragraph 

8 (3), the Secretary shall consider the following: 

9 ‘‘(i) The clinical work and practice ex10 penses involved in providing care coordina11 tion services consistent with the patient12 centered medical home model (such as pro13 viding increased access, care coordination, 

14 disease population management, and edu15 cation) for which payment is not made 

16 under this section as of the date of enact17 ment of this subsection. 

18 ‘‘(ii) Ensuring that the amount of 

19 payment is sufficient to support the acqui20 sition, use, and maintenance of clinical in21 formation systems which— 

22 ‘‘(I) are needed by a qualified pa23 tient-centered medical home; and 


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1 ‘‘(II) have been shown to facili2 tate improved outcomes through care 

3 coordination. 

4 ‘‘(iii) The establishment of a tiered 

5 monthly care management fee that pro6 vides for a range of payment depending on 

7 how advanced the capabilities of a qualified 

8 patient-centered medical home are in hav9 ing the information systems needed to sup10 port care coordination. 

11 ‘‘(B) RISK-ADJUSTMENT.—The Secretary 

12 shall use appropriate risk-adjustment in deter13 mining the amount of the monthly fee under 

14 this paragraph. 

15 ‘‘(3) FUNDING.— 

16 ‘‘(A) IN GENERAL.—The Secretary shall 

17 determine the aggregate estimated savings for a 

18 calendar year as a result of the implementation 

19 of this subsection on reducing preventable hos20 pital admissions, duplicate testing, medication 

21 errors and drug interactions, and other savings 

22 under this part and part A (including any sav23 ings with respect to items and services for 

24 which payment is not made under this section). 


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1 ‘‘(B) FUNDING.—Subject to subparagraph 

2 (C), the aggregate amount available for pay3 ment of the monthly fee under this subsection 

4 during a calendar year shall be equal to the ag5 gregate estimated savings (as determined under 

6 subparagraph (A)) for the calendar year (as de7 termined by the Secretary). 

8 ‘‘(C) ADDITIONAL FUNDING.—In the case 

9 where the amount of the aggregate actual sav10 ings during the preceding 3 years exceeds the 

11 amount of the aggregate estimated savings (as 

12 determined under subparagraph (A)) during 

13 such period, the aggregate amount available for 

14 payment of the monthly fee under this sub15 section during the calendar year (as determined 

16 under subparagraph (B)) shall be increased by 

17 the amount of such excess. 

18 ‘‘(D) ADDITIONAL FUNDING AS DETER19 MINED NECESSARY BY THE SECRETARY.—In 

20 addition to any funding made available under 

21 subparagraphs (B) and (C), there shall also be 

22 available to the Secretary, for purposes of effec23 tively implementing this subsection, such addi24 tional funds as the Secretary determines are 

25 necessary. 


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1 ‘‘(4) PERFORMANCE-BASED BONUS PAY2 MENTS.—The Secretary shall establish a process for 

3 paying a performance-based bonus to qualified pa4 tient-centered medical homes which meet or achieve 

5 substantial improvements in performance (as speci6 fied under clinical, patient satisfaction, and effi7 ciency benchmarks established by the Secretary). 

8 Such bonus shall be in an amount determined appro9 priate by the Secretary. 

10 ‘‘(5) NO EFFECT ON PAYMENTS FOR EVALUA11 TION AND MANAGEMENT SERVICES.—The monthly 

12 fee under this subsection shall have no effect on the 

13 amount of payment for evaluation and management 

14 services under this title.’’. 

15 (d) COINSURANCE.—Section 1833(a)(1) of the Social 

16 Security Act (42 U.S.C. 1395l(a)(1)) is amended— 

17 (1) by striking ‘‘and’’ before ‘‘(W)’’; and 

18 (2) by inserting before the semicolon at the end 

19 the following: ‘‘, and (X) with respect to patient-cen20 tered medical home services (as defined in section 

21 1861(hhh)(1)), the amount paid shall be (i) in the 

22 case of such services which are physicians’ services, 

23 the amount determined under subparagraph (N), 

24 and (ii) in the case of all other such services, 80 per25 cent of the lesser of the actual charge for the service 


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1 or the amount determined under a fee schedule es2 tablished by the Secretary for purposes of this sub3 paragraph’’. 

4 (e) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to services furnished on or after 

6 January 1, 2012. 

7 SEC. 2303. MEDICARE PRIMARY CARE PAYMENT EQUITY 

8 AND ACCESS PROVISION. 

9 (a) IN GENERAL.—Section 1848 of the Social Secu10 rity Act (42 U.S.C. 1395w–4), as amended by section 

11 2302(c), is amended by adding at the end the following 

12 new subsection: 

13 ‘‘(q) PRIMARY CARE PAYMENT EQUITY AND AC14 CESS.— 

15 ‘‘(1) IN GENERAL.—Not later than January 1, 

16 2010, the Secretary shall develop a methodology, in 

17 consultation with primary care physician organiza18 tions and primary care provider organizations, the 

19 Medicare Payment Advisory Commission, and other 

20 experts, to increase payments under this section for 

21 designated evaluation and management services pro22 vided by primary care physicians, primary care pro23 viders, and principal care providers through 1 or 

24 more of the following: 


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1 ‘‘(A) A service-specific modifier to the rel2 ative value units established for such services. 

3 ‘‘(B) Service-specific bonus payments. 

4 ‘‘(C) Any other methodology determined 

5 appropriate by the Secretary. 

6 ‘‘(2) INCLUSION OF PROPOSED CRITERIA.—The 

7 methodology developed under paragraph (1) shall in8 clude proposed criteria for providers to qualify for 

9 such increased payments, including consideration 

10 of— 

11 ‘‘(A) the type of service being rendered; 

12 ‘‘(B) the specialty of the provider providing 

13 the service; and 

14 ‘‘(C) demonstration by the provider of vol15 untary participation in programs to improve 

16 quality, such as participation in the Physician 

17 Quality Reporting Initiative (as determined by 

18 the Secretary) or practice-level qualification as 

19 a patient-centered medical home. 

20 ‘‘(3) FUNDING.— 

21 ‘‘(A) DETERMINATION.—The Secretary 

22 shall determine the aggregate estimated savings 

23 for a calendar year as a result of such increased 

24 payments on reducing preventable hospital ad25 missions, duplicate testing, medication errors 


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1 and drug interactions, Intensive Care Unit ad2 missions, per capita health care expenditures, 

3 and other savings under this part and part A 

4 (including any savings with respect to items 

5 and services for which payment is not made 

6 under this section). 

7 ‘‘(B) FUNDING.—The aggregate amount 

8 available for such increased payments during a 

9 calendar year shall be equal to the aggregate 

10 estimated savings (as determined under sub11 paragraph (A)) for the calendar year (as deter12 mined by the Secretary). 

13 ‘‘(C) ADDITIONAL FUNDING AS DETER14 MINED NECESSARY BY THE SECRETARY.—In 

15 addition to any funding made available under 

16 subparagraph (B), there shall also be available 

17 to the Secretary, for purposes of effectively im18 plementing this subsection, such additional 

19 funds as the Secretary determines are nec20 essary.’’. 

21 (b) EFFECTIVE DATE.—The amendment made by 

22 this section shall apply to services furnished on or after 

23 January 1, 2010. 


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1 SEC. 2304. ADDITIONAL INCENTIVE PAYMENT PROGRAM 

2 FOR PRIMARY CARE SERVICES FURNISHED 

3 IN HEALTH PROFESSIONAL SHORTAGE 

4 AREAS. 

5 (a) IN GENERAL.—Section 1833 of the Social Secu6 rity Act (42 U.S.C. 1395l) is amended by adding at the 

7 end the following new subsection: 

8 ‘‘(x) ADDITIONAL INCENTIVE PAYMENTS FOR PRI9 MARY CARE SERVICES FURNISHED IN HEALTH PROFES10 SIONAL SHORTAGE AREAS.— 

11 ‘‘(1) IN GENERAL.—In the case of primary care 

12 services furnished on or after January 1, 2010, by 

13 a primary care physician or primary care provider in 

14 an area that is designated (under section 

15 332(a)(1)(A) of the Public Health Service Act) as a 

16 health professional shortage area as identified by the 

17 Secretary prior to the beginning of the year involved, 

18 in addition to the amount of payment that would 

19 otherwise be made for such services under this part, 

20 there also shall be paid (on a monthly or quarterly 

21 basis) an amount equal to 10 percent of the pay22 ment amount for the service under this part. 

23 ‘‘(2) DEFINITIONS.—In this subsection: 

24 ‘‘(A) PRIMARY CARE PHYSICIAN; PRIMARY

25 CARE PROVIDER.—The terms ‘primary care 

26 physician’ and ‘primary care provider’ have the 


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1 meaning given such terms in paragraphs (6) 

2 and (7), respectively, of section 3(a) of the Pre3 serving Patient Access to Primary Care Act of 

4 2009. 

5 ‘‘(B) PRIMARY CARE SERVICES.—The term 

6 ‘primary care services’ means procedure codes 

7 for services in the category of the Healthcare 

8 Common Procedure Coding System, as estab9 lished by the Secretary under section 

10 1848(c)(5) (as of December 31, 2008, and as 

11 subsequently modified by the Secretary) con12 sisting of evaluation and management services, 

13 but limited to such procedure codes in the cat14 egory of office or other outpatient services, and 

15 consisting of subcategories of such procedure 

16 codes for services for both new and established 

17 patients. 

18 ‘‘(3) JUDICIAL REVIEW.—There shall be no ad19 ministrative or judicial review under section 1869, 

20 1878, or otherwise, respecting the identification of 

21 primary care physicians, primary care providers, or 

22 primary care services under this subsection.’’. 

23 (b) CONFORMING AMENDMENT.—Section 

24 1834(g)(2)(B) of the Social Security Act (42 U.S.C. 

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1 lowing sentence: ‘‘Section 1833(x) shall not be taken into 

2 account in determining the amounts that would otherwise 

3 be paid pursuant to the preceding sentence.’’. 

4 SEC. 2305. PERMANENT EXTENSION OF MEDICARE INCEN5 TIVE PAYMENT PROGRAM FOR PHYSICIAN 

6 SCARCITY AREAS. 

7 Section 1833(u) of the Social Security Act (42 U.S.C. 

8 1395l(u)) is amended— 

9 (1) in paragraph (1)— 

10 (A) by inserting ‘‘or on or after July 1, 

11 2009’’ after ‘‘before July 1, 2008’’; and 

12 (B) by inserting ‘‘(or, in the case of serv13 ices furnished on or after July 1, 2009, 10 per14 cent)’’ after ‘‘5 percent’’; and 

15 (2) in paragraph (4)(D), by striking ‘‘before 

16 July 1, 2008’’ and inserting ‘‘before January 1, 

17 2010’’. 

18 SEC. 2306. HHS STUDY AND REPORT ON THE PROCESS FOR 

19 DETERMINING RELATIVE VALUE UNDER THE 

20 MEDICARE PHYSICIAN FEE SCHEDULE. 

21 (a) STUDY.—The Secretary shall conduct a study on 

22 the process used by the Secretary for determining relative 

23 value under the Medicare physician fee schedule under 

24 section 1848(c) of the Social Security Act (42 U.S.C. 


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1 1395w–4(c)). Such study shall include an analysis of the 

2 following: 

3 (1)(A) Whether the existing process includes 

4 equitable representation of primary care physicians 

5 (as defined in section 2003(a)(6)); and 

6 (B) any changes that may be necessary to en7 sure such equitable representation. 

8 (2)(A) Whether the existing process provides 

9 the Secretary with expert and impartial input from 

10 physicians in medical specialties that provide pri11 mary care to patients with multiple chronic diseases, 

12 the fastest growing part of the Medicare population; 

13 and 

14 (B) any changes that may be necessary to en15 sure such input. 

16 (3)(A) Whether the existing process includes 

17 equitable representation of physician medical special18 ties in proportion to their relative contributions to19 ward caring for Medicare beneficiaries, as deter20 mined by the percentage of Medicare billings per 

21 specialty, percentage of Medicare encounters by spe22 cialty, or such other measures of relative contribu23 tions to patient care as determined by the Secretary; 

24 and 


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1 (B) any changes that may be necessary to re2 flect such equitable representation. 

3 (4)(A) Whether the existing process, including 

4 the application of budget neutrality rules, unfairly 

5 disadvantages primary care physicians, primary care 

6 providers, or other physicians who principally pro7 vide evaluation and management services; and 

8 (B) any changes that may be necessary to 

9 eliminate such disadvantages. 

10 (b) REPORT.—Not later than 12 months after the 

11 date of enactment of this Act, the Secretary shall submit 

12 to Congress a report containing the results of the study 

13 conducted under subsection (a), together with rec14 ommendations for such legislation and administrative ac15 tion as the Secretary determines appropriate. 

16 PART II—PREVENTIVE SERVICES 

17 SEC. 2311. ELIMINATING TIME RESTRICTION FOR INITIAL 

18 PREVENTIVE PHYSICAL EXAMINATION. 

19 (a) IN GENERAL.—Section 1862(a)(1)(K) of the So20 cial Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended 

21 by striking ‘‘more than’’ and all that follows before the 

22 comma at the end and inserting ‘‘more than one time dur23 ing the lifetime of the individual’’. 


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1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to services furnished on or after 

3 January 1, 2010. 

4 SEC. 2312. ELIMINATION OF COST-SHARING FOR PREVEN5 TIVE BENEFITS UNDER THE MEDICARE PRO6 GRAM. 

7 (a) DEFINITION OF PREVENTIVE SERVICES.—Sec8 tion 1861(ddd) of the Social Security Act (42 U.S.C. 

9 1395w(dd)) is amended— 

10 (1) in the heading, by inserting ‘‘; Preventive 

11 Services’’ after ‘‘Services’’; 

12 (2) in paragraph (1), by striking ‘‘not otherwise 

13 described in this title’’ and inserting ‘‘not described 

14 in subparagraphs (A) through (N) of paragraph 

15 (3)’’; and 

16 (3) by adding at the end the following new 

17 paragraph: 

18 ‘‘(3) The term ‘preventive services’ means the fol19 lowing: 

20 ‘‘(A) Prostate cancer screening tests (as defined 

21 in subsection (oo)). 

22 ‘‘(B) Colorectal cancer screening tests (as de23 fined in subsection (pp)). 

24 ‘‘(C) Diabetes outpatient self-management 

25 training services (as defined in subsection (qq)). 


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1 ‘‘(D) Screening for glaucoma for certain indi2 viduals (as described in subsection (s)(2)(U)). 

3 ‘‘(E) Medical nutrition therapy services for cer4 tain individuals (as described in subsection 

5 (s)(2)(V)). 

6 ‘‘(F) An initial preventive physical examination 

7 (as defined in subsection (ww)). 

8 ‘‘(G) Cardiovascular screening blood tests (as 

9 defined in subsection (xx)(1)). 

10 ‘‘(H) Diabetes screening tests (as defined in 

11 subsection (yy)). 

12 ‘‘(I) Ultrasound screening for abdominal aortic 

13 aneurysm for certain individuals (as described in 

14 subsection (s)(2)(AA)). 

15 ‘‘(J) Pneumococcal and influenza vaccine and 

16 their administration (as described in subsection 

17 (s)(10)(A)). 

18 ‘‘(K) Hepatitis B vaccine and its administration 

19 for certain individuals (as described in subsection 

20 (s)(10)(B)). 

21 ‘‘(L) Screening mammography (as defined in 

22 subsection (jj)). 

23 ‘‘(M) Screening pap smear and screening pelvic 

24 exam (as described in subsection (s)(14)). 


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1 ‘‘(N) Bone mass measurement (as defined in 

2 subsection (rr)). 

3 ‘‘(O) Additional preventive services (as deter4 mined under paragraph (1)).’’. 

5 (b) COINSURANCE.— 

6 (1) GENERAL APPLICATION.— 

7 (A) IN GENERAL.—Section 1833(a)(1) of 

8 the Social Security Act (42 U.S.C. 

9 1395l(a)(1)), as amended by section 2302, is 

10 amended— 

11 (i) in subparagraph (T), by striking 

12 ‘‘80 percent’’ and inserting ‘‘100 percent’’; 

13 (ii) in subparagraph (W), by striking 

14 ‘‘80 percent’’ and inserting ‘‘100 percent’’; 

15 (iii) by striking ‘‘and’’ before ‘‘(X)’’; 

16 and 

17 (iv) by inserting before the semicolon 

18 at the end the following: ‘‘, and (Y) with 

19 respect to preventive services described in 

20 subparagraphs (A) through (O) of section 

21 1861(ddd)(3), the amount paid shall be 

22 100 percent of the lesser of the actual 

23 charge for the services or the amount de24 termined under the fee schedule that ap25 plies to such services under this part’’. 


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1 (2) ELIMINATION OF COINSURANCE FOR

2 SCREENING SIGMOIDOSCOPIES AND

3 COLONOSCOPIES.—Section 1834(d) of the Social Se4 curity Act (42 U.S.C. 1395m(d)) is amended— 

5 (A) in paragraph (2)— 

6 (i) in subparagraph (A), by inserting 

7 ‘‘, except that payment for such tests 

8 under such section shall be 100 percent of 

9 the payment determined under such sec10 tion for such tests’’ before the period at 

11 the end; and 

12 (ii) in subparagraph (C)— 

13 (I) by striking clause (ii); and 

14 (II) in clause (i)— 

15 (aa) by striking ‘‘(i) IN GEN16 ERAL.—Notwithstanding’’ and 

17 inserting ‘‘Notwithstanding’’; 

18 (bb) by redesignating sub19 clauses (I) and (II) as clauses (i) 

20 and (ii), respectively, and moving 

21 such clauses 2 ems to the left; 

22 and 

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1 nated, by inserting ‘‘100 percent 

2 of’’ after ‘‘based on’’; and 

3 (B) in paragraph (3)— 

4 (i) in subparagraph (A), by inserting 

5 ‘‘, except that payment for such tests 

6 under such section shall be 100 percent of 

7 the payment determined under such sec8 tion for such tests’’ before the period at 

9 the end; and 

10 (ii) in subparagraph (C)— 

11 (I) by striking clause (ii); and 

12 (II) in clause (i)— 

13 (aa) by striking ‘‘(i) IN GEN14 ERAL.—Notwithstanding’’ and 

15 inserting ‘‘Notwithstanding’’; and 

16 (bb) by inserting ‘‘100 per17 cent of’’ after ‘‘based on’’. 

18 (3) ELIMINATION OF COINSURANCE IN OUT19 PATIENT HOSPITAL SETTINGS.— 

20 (A) EXCLUSION FROM OPD FEE SCHED21 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

22 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 

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1 raphy, and preventive services (as defined in 

2 section 1861(ddd)(3))’’. 

3 (B) CONFORMING AMENDMENTS.—Section 

4 1833(a)(2) of the Social Security Act (42 

5 U.S.C. 1395l(a)(2)) is amended— 

6 (i) in subparagraph (F), by striking 

7 ‘‘and’’ after the semicolon at the end; 

8 (ii) in subparagraph (G)(ii), by adding 

9 ‘‘and’’ at the end; and 

10 (iii) by adding at the end the fol11 lowing new subparagraph: 

12 ‘‘(H) with respect to preventive services (as 

13 defined in section 1861(ddd)(3)) furnished by 

14 an outpatient department of a hospital, the 

15 amount determined under paragraph (1)(W) or 

16 (1)(X), as applicable;’’. 

17 (c) WAIVER OF APPLICATION OF DEDUCTIBLE.—The 

18 first sentence of section 1833(b) of the Social Security Act 

19 (42 U.S.C. 1395l(b)) is amended— 

20 (1) in clause (1), by striking ‘‘items and serv21 ices described in section 1861(s)(10)(A)’’ and insert22 ing ‘‘preventive services (as defined in section 

23 1861(ddd)(3))’’; 

24 (2) by inserting ‘‘and’’ before ‘‘(4)’’; and 


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1 (3) by striking ‘‘, (5)’’ and all that follows up 

2 to the period at the end. 

3 SEC. 2313. HHS STUDY AND REPORT ON FACILITATING THE 

4 RECEIPT OF MEDICARE PREVENTIVE SERV5 ICES BY MEDICARE BENEFICIARIES. 

6 (a) STUDY.—The Secretary, in consultation with pro7 vider organizations and other appropriate stakeholders, 

8 shall conduct a study on— 

9 (1) ways to assist primary care physicians and 

10 primary care providers (as defined in section 

11 2003(a)) in— 

12 (A) furnishing appropriate preventive serv13 ices (as defined in section 1861(ddd)(3) of the 

14 Social Security Act, as added by section 2312) 

15 to individuals enrolled under part B of title 

16 XVIII of such Act; and 

17 (B) referring such individuals for other 

18 items and services furnished by other physicians 

19 and health care providers; and 

20 (2) the advisability and feasability of making 

21 additional payments under the Medicare program to 

22 physicians and primary care providers for— 

23 (A) the work involved in ensuring that 

24 such individuals receive appropriate preventive 


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1 services furnished by other physicians and 

2 health care providers; and 

3 (B) incorporating the resulting clinical in4 formation into the treatment plan for the indi5 vidual. 

6 (b) REPORT.—Not later than 12 months after the 

7 date of enactment of this Act, the Secretary shall submit 

8 to Congress a report containing the results of the study 

9 conducted under subsection (a), together with rec10 ommendations for such legislation and administrative ac11 tion as the Secretary determines appropriate. 

12 PART III—OTHER PROVISIONS 

13 SEC. 2321. HHS STUDY AND REPORT ON IMPROVING THE 

14 ABILITY OF PHYSICIANS AND PRIMARY CARE 

15 PROVIDERS TO ASSIST MEDICARE BENE16 FICIARIES IN OBTAINING NEEDED PRESCRIP17 TIONS UNDER MEDICARE PART D. 

18 (a) STUDY.—The Secretary, in consultation with phy19 sician organizations and other appropriate stakeholders, 

20 shall conduct a study on the development and implementa21 tion of mechanisms to facilitate increased efficiency relat22 ing to the role of physicians and primary care providers 

23 in Medicare beneficiaries obtaining needed prescription 

24 drugs under the Medicare prescription drug program 


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1 under part D of title XVIII of the Social Security Act. 

2 Such study shall include an analysis of ways to— 

3 (1) improve the accessibility of formulary infor4 mation; 

5 (2) streamline the prior authorization, excep6 tion, and appeals processes, through, at a minimum, 

7 standardizing formats and allowing electronic ex8 change of information; and 

9 (3) recognize the work of the physician and pri10 mary care provider involved in the prescribing proc11 ess, especially work that may extend beyond the 

12 amount considered to be bundled into payment for 

13 evaluation and management services. 

14 (b) REPORT.—Not later than 12 months after the 

15 date of enactment of this Act, the Secretary shall submit 

16 to Congress a report containing the results of the study 

17 conducted under subsection (a), together with rec18 ommendations for such legislation and administrative ac19 tion as the Secretary determines appropriate. 

20 SEC. 2322. HHS STUDY AND REPORT ON IMPROVED PA21 TIENT CARE THROUGH INCREASED CARE22 GIVER AND PHYSICIAN INTERACTION. 

23 (a) STUDY.—The Secretary, in consultation with ap24 propriate stakeholders, shall conduct a study on the devel25 opment and implementation of mechanisms to promote 


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1 and increase interaction between physicians or primary 

2 care providers and the families of Medicare beneficiaries, 

3 as well as other caregivers who support such beneficiaries, 

4 for the purpose of improving patient care under the Medi5 care program. Such study shall include an analysis of— 

6 (1) ways to recognize the work of physicians 

7 and primary care providers involved in discussing 

8 clinical issues with caregivers that relate to the care 

9 of the beneficiary; and 

10 (2) regulations under the Medicare program 

11 that are barriers to interactions between caregivers 

12 and physicians or primary care providers and how 

13 such regulations should be revised to eliminate such 

14 barriers. 

15 (b) REPORT.—Not later than 12 months after the 

16 date of enactment of this Act, the Secretary shall submit 

17 to Congress a report containing the results of the study 

18 conducted under subsection (a), together with rec19 ommendations for such legislation and administrative ac20 tion as the Secretary determines appropriate. 

21 SEC. 2323. IMPROVED PATIENT CARE THROUGH EXPANDED 

22 SUPPORT FOR LIMITED ENGLISH PRO23 FICIENCY (LEP) SERVICES. 

24 (a) ADDITIONAL PAYMENTS FOR PRIMARY CARE

25 PHYSICIANS AND PRIMARY CARE PROVIDERS.—Section 


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1 1833 of the Social Security Act (42 U.S.C. 1395l), as 

2 amended by section 2304, is amended by adding at the 

3 end the following new subsection: 

4 ‘‘(y) ADDITIONAL PAYMENTS FOR PROVIDING SERV5 ICES TO INDIVIDUALS WITH LIMITED ENGLISH PRO6 FICIENCY.— 

7 ‘‘(1) IN GENERAL.—In the case of primary care 

8 providers’ services furnished on or after January 1, 

9 2010, to an individual with limited English pro10 ficiency by a provider, in addition to the amount of 

11 payment that would otherwise be made for such 

12 services under this part, there shall also be paid an 

13 appropriate amount (as determined by the Sec14 retary) in order to recognize the additional time in15 volved in furnishing the service to such individual. 

16 ‘‘(2) JUDICIAL REVIEW.—There shall be no ad17 ministrative or judicial review under section 1869, 

18 1878, or otherwise, respecting the determination of 

19 the amount of additional payment under this sub20 section.’’. 

21 (b) NATIONAL CLEARINGHOUSE.—Not later than 

22 180 days after the date of enactment of this Act, the Sec23 retary shall establish a national clearinghouse to make 

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1 ing patient care and education under the Medicare pro2 gram, the Medicaid program, and the State Children’s 

3 Health Insurance Program under titles XVIII, XIX, and 

4 XXI, respectively, of the Social Security Act. 

5 (c) GRANTS TO SUPPORT LANGUAGE TRANSLATION

6 SERVICES IN UNDERSERVED COMMUNITIES.— 

7 (1) AUTHORITY TO AWARD GRANTS.—The Sec8 retary shall award grants to support language trans9 lation services for primary care physicians and pri10 mary care providers in medically underserved areas 

11 (as defined in section 2003(c)). 

12 (2) AUTHORIZATION OF APPROPRIATIONS.— 

13 There are authorized to be appropriated to the Sec14 retary to award grants under this subsection, such 

15 sums as are necessary for fiscal years beginning with 

16 fiscal year 2010. 

17 SEC. 2324. HHS STUDY AND REPORT ON USE OF REAL-TIME 

18 MEDICARE CLAIMS ADJUDICATION. 

19 (a) STUDY.—The Secretary shall conduct a study to 

20 assess the ability of the Medicare program under title 

21 XVIII of the Social Security Act to engage in real-time 

22 claims adjudication for items and services furnished to 

23 Medicare beneficiaries. 

24 (b) CONSULTATION.—In conducting the study under 

25 subsection (a), the Secretary consult with stakeholders in 


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1 the private sector, including stakeholders who are using 

2 or are testing real-time claims adjudication systems. 

3 (c) REPORT.—Not later than January 1, 2011, the 

4 Secretary shall submit to Congress a report containing the 

5 results of the study conducted under subsection (a), to6 gether with recommendations for such legislation and ad7 ministrative action as the Secretary determines appro8 priate. 

9 SEC. 2325. ONGOING ASSESSMENT BY MEDPAC OF THE IM10 PACT OF MEDICARE PAYMENTS ON PRIMARY 

11 CARE ACCESS AND EQUITY. 

12 The Medicare Payment Advisory Commission, begin13 ning in 2010 and in each of its subsequent annual reports 

14 to Congress on Medicare physician payment policies, shall 

15 provide an assessment of the impact of changes in Medi16 care payment policies in improving access to and equity 

17 of payments to primary care physicians and primary care 

18 providers. Such assessment shall include an assessment of 

19 the effectiveness, once implemented, of the Medicare pay20 ment-related reforms required by this Act to support pri21 mary care as well as any other payment changes that may 

22 be required by Congress to improve access to and equity 

23 of payments to primary care physicians and primary care 

24 providers. 


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1 SEC. 2326. DISTRIBUTION OF ADDITIONAL RESIDENCY PO2 SITIONS. 

3 (a) IN GENERAL.—Section 1886(h) of the Social Se4 curity Act (42 U.S.C. 1395ww(h)) is amended— 

5 (1) in paragraph (4)(F)(i), by striking ‘‘para6 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

7 (2) in paragraph (4)(H)(i), by striking ‘‘para8 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

9 and 

10 (3) by adding at the end the following new 

11 paragraph: 

12 ‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY

13 POSITIONS.— 

14 ‘‘(A) ADDITIONAL RESIDENCY POSI15 TIONS.— 

16 ‘‘(i) REDUCTION IN LIMIT BASED ON

17 UNUSED POSITIONS.— 

18 ‘‘(I) IN GENERAL.—The Sec19 retary shall reduce the otherwise ap20 plicable resident limit for a hospital 

21 that the Secretary determines had 

22 residency positions that were unused 

23 for all 5 of the most recent cost re24 porting periods ending prior to the 

25 date of enactment of this paragraph 

26 by an amount that is equal to the 


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1 number of such unused residency po2 sitions. 

3 ‘‘(II) EXCEPTION FOR RURAL

4 HOSPITALS AND CERTAIN OTHER HOS5 PITALS.—This subparagraph shall not 

6 apply to a hospital— 

7 ‘‘(aa) located in a rural area 

8 (as defined in subsection 

9 (d)(2)(D)(ii)); 

10 ‘‘(bb) that has participated 

11 in a voluntary reduction plan 

12 under paragraph (6); or 

13 ‘‘(cc) that has participated 

14 in a demonstration project ap15 proved as of October 31, 2003, 

16 under the authority of section 

17 402 of Public Law 90–248. 

18 ‘‘(ii) NUMBER AVAILABLE FOR DIS19 TRIBUTION.—The number of additional 

20 residency positions available for distribu21 tion under subparagraph (B) shall be an 

22 amount that the Secretary determines 

23 would result in a 15 percent increase in 

24 the aggregate number of full-time equiva25 lent residents in approved medical training 


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1 programs (as determined based on the 

2 most recent cost reports available at the 

3 time of distribution). One-third of such 

4 number shall only be available for distribu5 tion to hospitals described in subclause (I) 

6 of subparagraph (B)(ii) under such sub7 paragraph. 

8 ‘‘(B) DISTRIBUTION.— 

9 ‘‘(i) IN GENERAL.—The Secretary 

10 shall increase the otherwise applicable resi11 dent limit for each qualifying hospital that 

12 submits an application under this subpara13 graph by such number as the Secretary 

14 may approve for portions of cost reporting 

15 periods occurring on or after the date of 

16 enactment of this paragraph. The aggre17 gate number of increases in the otherwise 

18 applicable resident limit under this sub19 paragraph shall be equal to the number of 

20 additional residency positions available for 

21 distribution under subparagraph (A)(ii). 

22 ‘‘(ii) DISTRIBUTION TO HOSPITALS

23 ALREADY OPERATING OVER RESIDENT

24 LIMIT.— 


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1 ‘‘(I) IN GENERAL.—Subject to 

2 subclause (II), in the case of a hos3 pital in which the reference resident 

4 level of the hospital (as defined in 

5 clause (ii)) is greater than the other6 wise applicable resident limit, the in7 crease in the otherwise applicable resi8 dent limit under this subparagraph 

9 shall be an amount equal to the prod10 uct of the total number of additional 

11 residency positions available for dis12 tribution under subparagraph (A)(ii) 

13 and the quotient of— 

14 ‘‘(aa) the number of resident 

15 positions by which the reference 

16 resident level of the hospital ex17 ceeds the otherwise applicable 

18 resident limit for the hospital; 

19 and 

20 ‘‘(bb) the number of resident 

21 positions by which the reference 

22 resident level of all such hospitals 

23 with respect to which an applica24 tion is approved under this sub25 paragraph exceeds the otherwise 


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1 applicable resident limit for such 

2 hospitals. 

3 ‘‘(II) REQUIREMENTS.—A hos4 pital described in subclause (I)— 

5 ‘‘(aa) is not eligible for an 

6 increase in the otherwise applica7 ble resident limit under this sub8 paragraph unless the amount by 

9 which the reference resident level 

10 of the hospital exceeds the other11 wise applicable resident limit is 

12 not less than 10 and the hospital 

13 trains at least 25 percent of the 

14 full-time equivalent residents of 

15 the hospital in primary care and 

16 general surgery (as of the date of 

17 enactment of this paragraph); 

18 and 

19 ‘‘(bb) shall continue to train 

20 at least 25 percent of the full21 time equivalent residents of the 

22 hospital in primary care and gen23 eral surgery for the 10-year pe24 riod beginning on such date. 


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1 In the case where the Secretary deter2 mines that a hospital no longer meets 

3 the requirement of item (bb), the Sec4 retary may reduce the otherwise appli5 cable resident limit of the hospital by 

6 the amount by which such limit was 

7 increased under this clause. 

8 ‘‘(III) CLARIFICATION REGARD9 ING ELIGIBILITY FOR OTHER ADDI10 TIONAL RESIDENCY POSITIONS.— 

11 Nothing in this clause shall be con12 strued as preventing a hospital de13 scribed in subclause (I) from applying 

14 for additional residency positions 

15 under this paragraph that are not re16 served for distribution under this 

17 clause. 

18 ‘‘(iii) REFERENCE RESIDENT

19 LEVEL.— 

20 ‘‘(I) IN GENERAL.—Except as 

21 otherwise provided in subclause (II), 

22 the reference resident level specified in 

23 this clause for a hospital is the resi24 dent level for the most recent cost re25 porting period of the hospital ending 


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1 on or before the date of enactment of 

2 this paragraph, for which a cost re3 port has been settled (or, if not, sub4 mitted (subject to audit)), as deter5 mined by the Secretary. 

6 ‘‘(II) USE OF MOST RECENT AC7 COUNTING PERIOD TO RECOGNIZE EX8 PANSION OF EXISTING PROGRAM OR

9 ESTABLISHMENT OF NEW PRO10 GRAM.—If a hospital submits a timely 

11 request to increase its resident level 

12 due to an expansion of an existing 

13 residency training program or the es14 tablishment of a new residency train15 ing program that is not reflected on 

16 the most recent cost report that has 

17 been settled (or, if not, submitted 

18 (subject to audit)), after audit and 

19 subject to the discretion of the Sec20 retary, the reference resident level for 

21 such hospital is the resident level for 

22 the cost reporting period that includes 

23 the additional residents attributable to 

24 such expansion or establishment, as 

25 determined by the Secretary. 


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1 ‘‘(C) CONSIDERATIONS IN REDISTRIBU2 TION.—In determining for which hospitals the 

3 increase in the otherwise applicable resident 

4 limit is provided under subparagraph (B) (other 

5 than an increase under subparagraph (B)(ii)), 

6 the Secretary shall take into account the dem7 onstrated likelihood of the hospital filling the 

8 positions within the first 3 cost reporting peri9 ods beginning on or after July 1, 2010, made 

10 available under this paragraph, as determined 

11 by the Secretary. 

12 ‘‘(D) PRIORITY FOR CERTAIN AREAS.—In 

13 determining for which hospitals the increase in 

14 the otherwise applicable resident limit is pro15 vided under subparagraph (B) (other than an 

16 increase under subparagraph (B)(ii)), the Sec17 retary shall distribute the increase to hospitals 

18 based on the following criteria: 

19 ‘‘(i) The Secretary shall give pref20 erence to hospitals that submit applica21 tions for new primary care and general 

22 surgery residency positions. In the case of 

23 any increase based on such preference, a 

24 hospital shall ensure that— 


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1 ‘‘(I) the position made available 

2 as a result of such increase remains a 

3 primary care or general surgery resi4 dency position for not less than 10 

5 years after the date on which the posi6 tion is filled; and 

7 ‘‘(II) the total number of primary 

8 care and general surgery residency po9 sitions in the hospital (determined 

10 based on the number of such positions 

11 as of the date of such increase, includ12 ing any position added as a result of 

13 such increase) is not decreased during 

14 such 10-year period. 

15 In the case where the Secretary determines 

16 that a hospital no longer meets the re17 quirement of subclause (II), the Secretary 

18 may reduce the otherwise applicable resi19 dent limit of the hospital by the amount by 

20 which such limit was increased under this 

21 paragraph. 

22 ‘‘(ii) The Secretary shall give pref23 erence to hospitals that emphasizes train24 ing in community health centers and other 

25 community-based clinical settings. 


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1 ‘‘(iii) The Secretary shall give pref2 erence to hospitals in States that have 

3 more medical students than residency posi4 tions available (including a greater pref5 erence for those States with smaller resi6 dent-to-medical-student ratios). In deter7 mining the number of medical students in 

8 a State for purposes of the preceding sen9 tence, the Secretary shall include planned 

10 students at medical schools which have 

11 provisional accreditation by the Liaison 

12 Committee on Medical Education or the 

13 American Osteopathic Association. 

14 ‘‘(iv) The Secretary shall give pref15 erence to hospitals in States that have low 

16 resident-to-population ratios (including a 

17 greater preference for those States with 

18 lower resident-to-population ratios). 

19 ‘‘(E) LIMITATION.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), in no case may a hos22 pital (other than a hospital described in 

23 subparagraph (B)(ii)(I), subject to the lim24 itation under subparagraph (B)(ii)(III)) 

25 apply for more than 50 full-time equivalent 


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1 additional residency positions under this 

2 paragraph. 

3 ‘‘(ii) INCREASE IN NUMBER OF ADDI4 TIONAL POSITIONS AVAILABLE FOR DIS5 TRIBUTION.—The Secretary shall increase 

6 the number of full-time equivalent addi7 tional residency positions a hospital may 

8 apply for under this paragraph if the Sec9 retary determines that the number of addi10 tional residency positions available for dis11 tribution under subparagraph (A)(ii) ex12 ceeds the number of such applications ap13 proved. 

14 ‘‘(F) APPLICATION OF PER RESIDENT

15 AMOUNTS FOR PRIMARY CARE AND NONPRI16 MARY CARE.—With respect to additional resi17 dency positions in a hospital attributable to the 

18 increase provided under this paragraph, the ap19 proved FTE resident amounts are deemed to be 

20 equal to the hospital per resident amounts for 

21 primary care and nonprimary care computed 

22 under paragraph (2)(D) for that hospital. 

23 ‘‘(G) DISTRIBUTION.—The Secretary shall 

24 distribute the increase to hospitals under this 


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1 paragraph not later than 2 years after the date 

2 of enactment of this paragraph.’’. 

3 (b) IME.— 

4 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of 

5 the Social Security Act (42 U.S.C. 

6 1395ww(d)(5)(B)(v)), in the second sentence, is 

7 amended— 

8 (A) by striking ‘‘subsection (h)(7)’’ and in9 serting ‘‘subsections (h)(7) and (h)(8)’’; and 

10 (B) by striking ‘‘it applies’’ and inserting 

11 ‘‘they apply’’. 

12 (2) CONFORMING PROVISION.—Section 

13 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

14 1395ww(d)(5)(B)) is amended by adding at the end 

15 the following clause: 

16 ‘‘(x) For discharges occurring on or after the 

17 date of enactment of this clause, insofar as an addi18 tional payment amount under this subparagraph is 

19 attributable to resident positions distributed to a 

20 hospital under subsection (h)(8)(B), the indirect 

21 teaching adjustment factor shall be computed in the 

22 same manner as provided under clause (ii) with re23 spect to such resident positions.’’. 


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1 SEC. 2327. COUNTING RESIDENT TIME IN OUTPATIENT SET2 TINGS. 

3 (a) D–GME.—Section 1886(h)(4)(E) of the Social 

4 Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amended— 

5 (1) by striking ‘‘under an approved medical 

6 residency training program’’; and 

7 (2) by striking ‘‘if the hospital incurs all, or 

8 substantially all, of the costs for the training pro9 gram in that setting’’ and inserting ‘‘if the hospital 

10 continues to incur the costs of the stipends and 

11 fringe benefits of the resident during the time the 

12 resident spends in that setting’’. 

13 (b) IME.—Section 1886(d)(5)(B)(iv) of the Social 

14 Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend15 ed— 

16 (1) by striking ‘‘under an approved medical 

17 residency training program’’; and 

18 (2) by striking ‘‘if the hospital incurs all, or 

19 substantially all, of the costs for the training pro20 gram in that setting’’ and inserting ‘‘if the hospital 

21 continues to incur the costs of the stipends and 

22 fringe benefits of the intern or resident during the 

23 time the intern or resident spends in that setting’’. 

24 (c) EFFECTIVE DATES; APPLICATION.— 

25 (1) IN GENERAL.—Effective for cost reporting 

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1 retary of Health and Human Services shall imple2 ment the amendments made by this section in a 

3 manner so as to apply to cost reporting periods be4 ginning on or after July 1, 2009. 

5 (2) APPLICATION.—The amendments made by 

6 this section shall not be applied in a manner that re7 quires reopening of any settled hospital cost reports 

8 as to which there is not a jurisdictionally proper ap9 peal pending as of the date of the enactment of this 

10 Act on the issue of payment for indirect costs of 

11 medical education under section 1886(d)(5)(B) of 

12 the Social Security Act (42 U.S.C. 

13 1395ww(d)(5)(B)) or for direct graduate medical 

14 education costs under section 1886(h) of such Act 

15 (42 U.S.C. 1395ww(h)). 

16 SEC. 2328. RULES FOR COUNTING RESIDENT TIME FOR DI17 DACTIC AND SCHOLARLY ACTIVITIES AND 

18 OTHER ACTIVITIES. 

19 (a) GME.—Section 1886(h) of the Social Security 

20 Act (42 U.S.C. 1395ww(h)), as amended by section 

21 2327(a), is amended— 

22 (1) in paragraph (4)(E)— 

23 (A) by designating the first sentence as a 

24 clause (i) with the heading ‘‘IN GENERAL’’ and 

25 appropriate indentation and by striking ‘‘Such 


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1 rules’’ and inserting ‘‘Subject to clause (ii), 

2 such rules’’; and 

3 (B) by adding at the end the following new 

4 clause: 

5 ‘‘(ii) TREATMENT OF CERTAIN NON6 HOSPITAL AND DIDACTIC ACTIVITIES.— 

7 Such rules shall provide that all time spent 

8 by an intern or resident in an approved 

9 medical residency training program in a 

10 nonhospital setting that is primarily en11 gaged in furnishing patient care (as de12 fined in paragraph (5)(K)) in non-patient 

13 care activities, such as didactic conferences 

14 and seminars, but not including research 

15 not associated with the treatment or diag16 nosis of a particular patient, as such time 

17 and activities are defined by the Secretary, 

18 shall be counted toward the determination 

19 of full-time equivalency.’’; 

20 (2) in paragraph (4), by adding at the end the 

21 following new subparagraph: 

22 ‘‘(I) In determining the hospital’s number 

23 of full-time equivalent residents for purposes of 

24 this subsection, all the time that is spent by an 

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1 dency training program on vacation, sick leave, 

2 or other approved leave, as such time is defined 

3 by the Secretary, and that does not prolong the 

4 total time the resident is participating in the 

5 approved program beyond the normal duration 

6 of the program shall be counted toward the de7 termination of full-time equivalency.’’; and 

8 (3) in paragraph (5), by adding at the end the 

9 following new subparagraph: 

10 ‘‘(M) NONHOSPITAL SETTING THAT IS PRI11 MARILY ENGAGED IN FURNISHING PATIENT

12 CARE.—The term ‘nonhospital setting that is 

13 primarily engaged in furnishing patient care’ 

14 means a nonhospital setting in which the pri15 mary activity is the care and treatment of pa16 tients, as defined by the Secretary.’’. 

17 (b) IME DETERMINATIONS.—Section 1886(d)(5)(B) 

18 of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by 

19 section 2326(b), is amended by adding at the end the fol20 lowing new clause: 

21 ‘‘(xi)(I) The provisions of subparagraph (I) of 

22 subsection (h)(4) shall apply under this subpara23 graph in the same manner as they apply under such 

24 subsection. 


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1 ‘‘(II) In determining the hospital’s number of 

2 full-time equivalent residents for purposes of this 

3 subparagraph, all the time spent by an intern or 

4 resident in an approved medical residency training 

5 program in non-patient care activities, such as di6 dactic conferences and seminars, as such time and 

7 activities are defined by the Secretary, that occurs in 

8 the hospital shall be counted toward the determina9 tion of full-time equivalency if the hospital— 

10 ‘‘(aa) is recognized as a subsection (d) hos11 pital; 

12 ‘‘(bb) is recognized as a subsection (d) 

13 Puerto Rico hospital; 

14 ‘‘(cc) is reimbursed under a reimbursement 

15 system authorized under section 1814(b)(3); or 

16 ‘‘(dd) is a provider-based hospital out17 patient department. 

18 ‘‘(III) In determining the hospital’s number of 

19 full-time equivalent residents for purposes of this 

20 subparagraph, all the time spent by an intern or 

21 resident in an approved medical residency training 

22 program in research activities that are not associ23 ated with the treatment or diagnosis of a particular 

24 patient, as such time and activities are defined by 


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1 the Secretary, shall not be counted toward the deter2 mination of full-time equivalency.’’. 

3 (c) EFFECTIVE DATES; APPLICATION.— 

4 (1) IN GENERAL.—Except as otherwise pro5 vided, the Secretary of Health and Human Services 

6 shall implement the amendments made by this sec7 tion in a manner so as to apply to cost reporting pe8 riods beginning on or after January 1, 1983. 

9 (2) DIRECT GME.—Section 1886(h)(4)(E)(ii) of 

10 the Social Security Act, as added by subsection 

11 (a)(1)(B), shall apply to cost reporting periods be12 ginning on or after July 1, 2009. 

13 (3) IME.—Section 1886(d)(5)(B)(xi)(III) of 

14 the Social Security Act, as added by subsection (b), 

15 shall apply to cost reporting periods beginning on or 

16 after October 1, 2001. Such section, as so added, 

17 shall not give rise to any inference on how the law 

18 in effect prior to such date should be interpreted. 

19 (4) APPLICATION.—The amendments made by 

20 this section shall not be applied in a manner that re21 quires reopening of any settled hospital cost reports 

22 as to which there is not a jurisdictionally proper ap23 peal pending as of the date of the enactment of this 

24 Act on the issue of payment for indirect costs of 

25 medical education under section 1886(d)(5)(B) of 


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1 the Social Security Act or for direct graduate med2 ical education costs under section 1886(h) of such 

3 Act. 

4 SEC. 2329. PRESERVATION OF RESIDENT CAP POSITIONS 

5 FROM CLOSED AND ACQUIRED HOSPITALS. 

6 (a) GME.—Section 1886(h)(4)(H) of the Social Se7 curity Act (42 U.S.C. 1395ww(h)(4)(H)) is amended by 

8 adding at the end the following new clauses: 

9 ‘‘(vi) REDISTRIBUTION OF RESIDENCY

10 SLOTS AFTER A HOSPITAL CLOSES.— 

11 ‘‘(I) IN GENERAL.—Subject to 

12 the succeeding provisions of this 

13 clause, the Secretary shall, by regula14 tion, establish a process under which, 

15 in the case where a hospital with an 

16 approved medical residency program 

17 closes on or after the date of enact18 ment of the Balanced Budget Act of 

19 1997, the Secretary shall increase the 

20 otherwise applicable resident limit 

21 under this paragraph for other hos22 pitals in accordance with this clause. 

23 ‘‘(II) PRIORITY FOR HOSPITALS

24 IN CERTAIN AREAS.—Subject to the 

25 succeeding provisions of this clause, in 


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1 determining for which hospitals the 

2 increase in the otherwise applicable 

3 resident limit is provided under such 

4 process, the Secretary shall distribute 

5 the increase to hospitals located in the 

6 following priority order (with pref7 erence given within each category to 

8 hospitals that are members of the 

9 same affiliated group (as defined by 

10 the Secretary under clause (ii)) as the 

11 closed hospital): 

12 ‘‘(aa) First, to hospitals lo13 cated in the same core-based sta14 tistical area as, or a core-based 

15 statistical area contiguous to, the 

16 hospital that closed. 

17 ‘‘(bb) Second, to hospitals 

18 located in the same State as the 

19 hospital that closed. 

20 ‘‘(cc) Third, to hospitals lo21 cated in the same region of the 

22 country as the hospital that 

23 closed. 

24 ‘‘(dd) Fourth, to all other 

25 hospitals. 


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1 ‘‘(III) REQUIREMENT HOSPITAL

2 LIKELY TO FILL POSITION WITHIN

3 CERTAIN TIME PERIOD.—The Sec4 retary may only increase the otherwise 

5 applicable resident limit of a hospital 

6 under such process if the Secretary 

7 determines the hospital has dem8 onstrated a likelihood of filling the po9 sitions made available under this 

10 clause within 3 years. 

11 ‘‘(IV) LIMITATION.—The aggre12 gate number of increases in the other13 wise applicable resident limits for hos14 pitals under this clause shall be equal 

15 to the number of resident positions in 

16 the approved medical residency pro17 grams that closed on or after the date 

18 described in subclause (I). 

19 ‘‘(vii) SPECIAL RULE FOR ACQUIRED

20 HOSPITALS.— 

21 ‘‘(I) IN GENERAL.—In the case 

22 of a hospital that is acquired (through 

23 any mechanism) by another entity 

24 with the approval of a bankruptcy 

25 court, during a period determined by 


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1 the Secretary (but not less than 3 

2 years), the applicable resident limit of 

3 the acquired hospital shall, except as 

4 provided in subclause (II), be the ap5 plicable resident limit of the hospital 

6 that was acquired (as of the date im7 mediately before the acquisition), 

8 without regard to whether the acquir9 ing entity accepts assignment of the 

10 Medicare provider agreement of the 

11 hospital that was acquired, so long as 

12 the acquiring entity continues to oper13 ate the hospital that was acquired and 

14 to furnish services, medical residency 

15 programs, and volume of patients 

16 similar to the services, medical resi17 dency programs, and volume of pa18 tients of the hospital that was ac19 quired (as determined by the Sec20 retary) during such period. 

21 ‘‘(II) LIMITATION.—Subclause 

22 (I) shall only apply in the case where 

23 an acquiring entity waives the right as 

24 a new provider under the program 

25 under this title to have the otherwise 


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1 applicable resident limit of the ac2 quired hospital re-established or in3 creased.’’. 

4 (b) IME.—Section 1886(d)(5)(B)(v) of the Social Se5 curity Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 

6 sentence, as amended by section 2326(b), is amended by 

7 striking ‘‘subsections (h)(7) and (h)(8)’’ and inserting 

8 ‘‘subsections (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and 

9 (h)(8)’’. 

10 (c) APPLICATION.—The amendments made by this 

11 section shall not be applied in a manner that requires re12 opening of any settled hospital cost reports as to which 

13 there is not a jurisdictionally proper appeal pending as 

14 of the date of the enactment of this Act on the issue of 

15 payment for indirect costs of medical education under sec16 tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

17 1395ww(d)(5)(B)) or for direct graduate medical edu18 cation costs under section 1886(h) of such Act (42 U.S.C. 

19 1395ww(h)). 

20 (d) NO AFFECT ON TEMPORARY FTE CAP ADJUST21 MENTS.—The amendments made by this section shall not 

22 affect any temporary adjustment to a hospital’s FTE cap 

23 under section 413.79(h) of title 42, Code of Federal Regu24 lations (as in effect on the date of enactment of this Act). 


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1 SEC. 2330. QUALITY IMPROVEMENT ORGANIZATION ASSIST2 ANCE FOR PHYSICIAN PRACTICES SEEKING 

3 TO BE PATIENT-CENTERED MEDICAL HOME 

4 PRACTICES. 

5 Not later than 90 days after the date of enactment 

6 of this Act, the Secretary of Health and Human Services 

7 shall revise the 9th Statement of Work under the Quality 

8 Improvement Program under part B of title XI of the So9 cial Security Act to include a requirement that, in order 

10 to be an eligible Quality Improvement Organization (in 

11 this section referred to as a ‘‘QIO’’) for the 9th Statement 

12 of Work contract cycle, a QIO shall provide assistance, 

13 including technical assistance, to physicians under the 

14 Medicare program under title XVIII of the Social Security 

15 Act that seek to acquire the elements necessary to be rec16 ognized as a patient-centered medical home practice under 

17 the National Committee for Quality Assurance’s Physician 

18 Practice Connections—PCMH module (or any successor 

19 module issued by such Committee). 

20 Subtitle D—Studies 

21 SEC. 2401. STUDY CONCERNING THE DESIGNATION OF PRI22 MARY CARE AS A SHORTAGE PROFESSION. 

23 (a) IN GENERAL.—Not later than June 30, 2010, the 

24 Secretary of Labor shall conduct a study and submit to 

25 the Committee on Education and Labor of the House of 


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1 Representatives and the Committee on Health, Education, 

2 Labor, and Pensions a report that contains— 

3 (1) a description of the criteria for the designa4 tion of primary care physicians as professions in 

5 shortage as defined by the Secretary under section 

6 212(a)(5)(A) of the Immigration and Nationality 

7 Act; 

8 (2) the findings of the Secretary on whether 

9 primary care physician professions will, on the date 

10 on which the report is submitted, or within the 5- 

11 year period beginning on such date, satisfy the cri12 teria referred to in paragraph (1); and 

13 (3) if the Secretary finds that such professions 

14 will not satisfy such criteria, recommendations for 

15 modifications to such criteria to enable primary care 

16 physicians to be so designated as a profession in 

17 shortage. 

18 (b) REQUIREMENTS.—In conducting the study under 

19 subsection (a), the Secretary of Labor shall consider work20 force data from the Health Resources and Services Admin21 istration, the Council on Graduate Medical Education, the 

22 Association of American Medical Colleges, and input from 

23 physician membership organizations that represent pri24 mary care physicians. 


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1 SEC. 2402. STUDY CONCERNING THE EDUCATION DEBT OF 

2 MEDICAL SCHOOL GRADUATES. 

3 (a) STUDY.—The Comptroller General of the United 

4 States shall conduct a study to evaluate the higher edu5 cation-related indebtedness of medical school graduates in 

6 the United States at the time of graduation from medical 

7 school, and the impact of such indebtedness on specialty 

8 choice, including the impact on the field of primary care. 

9 (b) REPORT.— 

10 (1) SUBMISSION AND DISSEMINATION OF RE11 PORT.—Not later than 1 year after the date of en12 actment of this Act, the Comptroller General shall 

13 submit a report on the study required by subsection 

14 (a) to the Committee on Health, Education, Labor, 

15 and Pensions of the Senate and the Committee on 

16 Education and Labor of the House of Representa17 tives, and shall make such report widely available to 

18 the public. 

19 (2) ADDITIONAL REPORTS.—The Comptroller 

20 General may periodically prepare and release as nec21 essary additional reports on the topic described in 

22 subsection (a). 

23 SEC. 2403. STUDY ON MINORITY REPRESENTATION IN PRI24 MARY CARE. 

25 (a) STUDY.—The Secretary of Health and Human 

26 Services, acting through the Administrator of the Health 


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1 Resources and Services Administration, shall conduct a 

2 study of minority representation in training, and in prac3 tice, in primary care specialties. 

4 (b) REPORT.—Not later than 1 year after the date 

5 of enactment of this Act, the Secretary of Health and 

6 Human Services, acting through the Administrator of the 

7 Health Resources and Services Administration, shall sub8 mit to the appropriate committees of Congress a report 

9 concerning the study conducted under subsection (a), in10 cluding recommendations for achieving a primary care 

11 workforce that is more representative of the population of 

12 the United States. 

13 TITLE III—MEDICARE PAYMENT 

14 PROVISIONS 

15 SEC. 3001. SHORT TITLE. 

16 This title may be cited as the ‘‘Medicare Payment 

17 Improvement Act of 2009’’. 

18 SEC. 3002. FINDINGS. 

19 Congress makes the following findings: 

20 (1) The health care delivery system must be re21 aligned to provide better clinical outcomes, safety, 

22 and patient satisfaction at lower cost. This should be 

23 a common goal for all health care professionals, hos24 pitals, and other groups. Today’s reimbursement 

25 system pays the most to those who perform the most 


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1 services, and therefore can provide disincentives to 

2 efficient and high-quality providers. 

3 (2) The regional inequities in Medicare reim4 bursement penalize areas that have cost-effective 

5 health care delivery systems and reward those States 

6 that have high utilization rates and provide ineffi7 cient care. 

8 (3) According to the Dartmouth Health Atlas, 

9 over the past 10 years, a number of studies have ex10 plored the relationship between higher spending and 

11 the quality and outcomes of care. The findings are 

12 remarkably consistent, concluding that higher spend13 ing does not result in better quality of care. 

14 (4) New payment models should be developed to 

15 move away from paying for quantity and instead 

16 paying for improving health and truly rewarding ef17 fective and efficient care. 

18 SEC. 3003. VALUE INDEX UNDER THE MEDICARE PHYSI19 CIAN FEE SCHEDULE. 

20 (a) IN GENERAL.—Section 1848(e)(5) of the Social 

21 Security Act (42 U.S.C. 1395w–4(e)) is amended by add22 ing at the end the following new paragraph: 

23 ‘‘(6) VALUE INDEX.— 

24 ‘‘(A) IN GENERAL.—The Secretary shall 

25 determine a value index for each fee schedule 


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1 area. The value index shall be the ratio of the 

2 quality component under subparagraph (B) to 

3 the cost component under subparagraph (C) for 

4 that fee schedule area. 

5 ‘‘(B) QUALITY COMPONENT.— 

6 ‘‘(i) IN GENERAL.—The quality com7 ponent shall be based on a composite score 

8 that reflects quality measures available on 

9 a State or fee schedule area basis. The 

10 measures shall reflect health outcomes and 

11 health status for the Medicare population, 

12 patient safety, and patient satisfaction. 

13 The Secretary shall use the best data 

14 available, after consultation with the Agen15 cy for Healthcare Research and Quality 

16 and with private entities that compile qual17 ity data. 

18 ‘‘(ii) ADVISORY GROUP.— 

19 ‘‘(I) IN GENERAL.—Not later 

20 than 60 days after the date of enact21 ment of the Medicare Payment Im22 provement Act of 2009, the Secretary 

23 shall establish a group of experts and 

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1 garding development of the quality 

2 component. The membership of the 

3 advisory group shall at least reflect 

4 providers, purchasers, health plans, 

5 researchers, relevant Federal agencies, 

6 and individuals with technical exper7 tise on health care quality. 

8 ‘‘(II) DUTIES.—In the develop9 ment of recommendations with respect 

10 to the quality component, the group 

11 established under subclause (I) shall 

12 consider at least the following areas: 

13 ‘‘(aa) High cost procedures 

14 as determined by data under this 

15 title. 

16 ‘‘(bb) Health outcomes and 

17 functional status of patients. 

18 ‘‘(cc) The continuity, man19 agement, and coordination of 

20 health care and care transitions, 

21 including episodes of care, for pa22 tients across the continuum of 

23 providers, health care settings, 

24 and health plans. 


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1 ‘‘(dd) Patient, caregiver, and 

2 authorized representative experi3 ence, quality and relevance of in4 formation provided to patients, 

5 caregivers, and authorized rep6 resentatives, and use of informa7 tion by patients, caregivers, and 

8 authorized representatives to in9 form decision making. 

10 ‘‘(ee) The safety, effective11 ness, and timeliness of care. 

12 ‘‘(ff) The appropriate use of 

13 health care resources and serv14 ices. 

15 ‘‘(gg) Other items deter16 mined appropriate by the Sec17 retary. 

18 ‘‘(iii) REQUIREMENT.—In establishing 

19 the quality component under this subpara20 graph, the Secretary shall— 

21 ‘‘(I) take into account the rec22 ommendations of the group estab23 lished under clause (ii)(I); and 

24 ‘‘(II) provide for an open and 

25 transparent process for the activities 


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1 conducted pursuant to the convening 

2 of such group with respect to the de3 velopment of the quality component. 

4 ‘‘(iv) ESTABLISHMENT.—The quality 

5 component for each fee schedule area shall 

6 be the ratio of the quality score for such 

7 area to the national average quality score. 

8 ‘‘(v) QUALITY BASELINE.—If the 

9 quality component for a fee schedule area 

10 does not rank in the top 25th percentile as 

11 compared to the national average (as de12 termined by the Secretary) and the amount 

13 of reimbursement for services under this 

14 section is greater than the amount of reim15 bursement for such services that would 

16 have applied under this section if the 

17 amendments made by section 2 of the 

18 Medicare Payment Improvement Act of 

19 2009 had not been enacted, this section 

20 shall be applied as if such amendments 

21 had not been enacted. 

22 ‘‘(vi) APPLICATION.—In the case of a 

23 fee schedule area that is less than an en24 tire State, if available quality data is not 

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1 State level, the quality component for a 

2 sub-State fee schedule area shall be the 

3 quality component for the entire State. 

4 ‘‘(C) COST COMPONENT.— 

5 ‘‘(i) IN GENERAL.—The cost compo6 nent shall be total annual per beneficiary 

7 Medicare expenditures under part A and 

8 this part for the fee schedule area. The 

9 Secretary may use total per beneficiary ex10 penditures under such parts in the last two 

11 years of life as an alternative measure if 

12 the Secretary determines that such meas13 ure better takes into account severity dif14 ferences among fee schedule areas. 

15 ‘‘(ii) ESTABLISHMENT.—The cost 

16 component for a fee schedule area shall be 

17 the ratio of the cost per beneficiary for 

18 such area to the national average cost per 

19 beneficiary.’’. 

20 (b) CONFORMING AMENDMENTS.—Section 1848 of 

21 the Social Security Act (42 U.S.C. 1395w–4) is amend22 ed— 

23 (1) in subsection (b)(1)(C), by striking ‘‘geo24 graphic’’ and inserting ‘‘geographic and value’’; and 

25 (2) in subsection (e)— 


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1 (A) in paragraph (1)— 

2 (i) in the heading, by inserting ‘‘AND

3 VALUE’’ after ‘‘GEOGRAPHIC’’; 

4 (ii) in subparagraph (A), by striking 

5 clause (iii) and inserting the following new 

6 clause: 

7 ‘‘(iii) a value index (as defined in 

8 paragraph (6)) applicable to physician 

9 work.’’; 

10 (iii) in subparagraph (C), by inserting 

11 ‘‘and value’’ after ‘‘geographic’’ in the first 

12 sentence; 

13 (iv) in subparagraph (D), by striking 

14 ‘‘physician work effort’’ and inserting 

15 ‘‘value’’; 

16 (v) by striking subparagraph (E); and 

17 (vi) by striking subparagraph (G); 

18 (B) by striking paragraph (2) and insert19 ing the following new paragraph: 

20 ‘‘(2) COMPUTATION OF GEOGRAPHIC AND

21 VALUE ADJUSTMENT FACTOR.—For purposes of sub22 section (b)(1)(C), for all physicians’ services for each 

23 fee schedule area the Secretary shall establish a geo24 graphic and value adjustment factor equal to the 

25 sum of the geographic cost-of-practice adjustment 


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1 factor (specified in paragraph (3)), the geographic 

2 malpractice adjustment factor (specified in para3 graph (4)), and the value adjustment factor (speci4 fied in paragraph (5)) for the service and the area.’’; 

5 and 

6 (C) by striking paragraph (5) and insert7 ing the following new paragraph: 

8 ‘‘(5) PHYSICIAN WORK VALUE ADJUSTMENT

9 FACTOR.—For purposes of paragraph (2), the ‘phy10 sician work value adjustment factor’ for a service for 

11 a fee schedule area, is the product of— 

12 ‘‘(A) the proportion of the total relative 

13 value for the service that reflects the relative 

14 value units for the work component; and 

15 ‘‘(B) the value index score for the area, 

16 based on the value index established under 

17 paragraph (6).’’. 

18 (c) AVAILABILITY OF QUALITY COMPONENT PRIOR

19 TO IMPLEMENTATION.—The Secretary of Health and 

20 Human Services shall make the quality component de21 scribed in section 1848(c)(6)(B) of the Social Security 

22 Act, as added by subsection (a), for each fee schedule area 

23 available to the public by not later than July 1, 2011. 

24 (d) EFFECTIVE DATE.—Subject to subsection (e), 

25 the amendments made by this section shall apply to the 


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1 Medicare physician fee schedule for 2012 and each subse2 quent year. 

3 (e) TRANSITION.—Notwithstanding the amendments 

4 made by the preceding provisions of this section, the Sec5 retary of Health and Human Services shall provide for an 

6 appropriate transition to the amendments made by this 

7 section. Under such transition, in the case of payments 

8 under such fee schedule for services furnished during— 

9 (1) 2012, 25 percent of such payments shall be 

10 based on the amount of payment that would have 

11 applied to the services if such amendments had not 

12 been enacted and 75 percent of such payment shall 

13 be based on the amount of payment that would have 

14 applied to the services if such amendments had been 

15 fully implemented; 

16 (2) 2013, 50 percent of such payment shall be 

17 based on the amount of payment that would have 

18 applied to the services if such amendments had not 

19 been enacted and 50 percent of such payment shall 

20 be based on the amount of payment that would have 

21 applied to the services if such amendments had been 

22 fully implemented; and 

23 (3) 2014 and subsequent years, 100 percent of 

24 such payment shall be based on the amount of pay25 ment that is applicable under such amendments. 


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1 TITLE IV—LONG-TERM 

2 SERVICES PROVISIONS 

3 SEC. 4001. SHORT TITLE. 

4 This title may be cited as the ‘‘Home and Community 

5 Balanced Incentives Act of 2009’’. 

6 Subtitle A—Balancing Incentives 

7 SEC. 4101. ENHANCED FMAP FOR EXPANDING THE PROVI8 SION OF NON-INSTITUTIONALLY-BASED 

9 LONG-TERM SERVICES AND SUPPORTS. 

10 (a) ENHANCED FMAP TO ENCOURAGE EXPAN11 SION.—Section 1905 of the Social Security Act (42 U.S.C. 

12 1396d) is amended— 

13 (1) in the first sentence of subsection (b)— 

14 (A) by striking ‘‘, and (4)’’ and inserting 

15 ‘‘, (4)’’; and 

16 (B) by inserting before the period the fol17 lowing: ‘‘, and (5) in the case of a balancing in18 centive payment State, as defined in subsection 

19 (y)(1), that meets the conditions described in 

20 subsection (y)(2), the Federal medical assist21 ance percentage shall be increased by the appli22 cable number of percentage points determined 

23 under subsection (y)(3) for the State with re24 spect to medical assistance described in sub25 section (y)(4)’’; and 


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1 (2) by adding at the end the following new sub2 section: 

3 ‘‘(y) STATE BALANCING INCENTIVE PAYMENTS PRO4 GRAM.—For purposes of clause (5) of the first sentence 

5 of subsection (b): 

6 ‘‘(1) BALANCING INCENTIVE PAYMENT

7 STATE.—A balancing incentive payment State is a 

8 State— 

9 ‘‘(A) in which less than 50 percent of the 

10 total expenditures for medical assistance for fis11 cal year 2009 for long-term services and sup12 ports (as defined by the Secretary, subject to 

13 paragraph (5)) are for non-institutionally-based 

14 long-term services and supports described in 

15 paragraph (5)(B); 

16 ‘‘(B) that submits an application and 

17 meets the conditions described in paragraph 

18 (2); and 

19 ‘‘(C) that is selected by the Secretary to 

20 participate in the State balancing incentive pay21 ment program established under this sub22 section. 

23 ‘‘(2) CONDITIONS.—The conditions described in 

24 this paragraph are the following: 


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1 ‘‘(A) APPLICATION.—The State submits an 

2 application to the Secretary that includes the 

3 following: 

4 ‘‘(i) A description of the availability of 

5 non-institutionally-based long-term services 

6 and supports described in paragraph 

7 (5)(B) available (for fiscal years beginning 

8 with fiscal year 2009). 

9 ‘‘(ii) A description of eligibility re10 quirements for receipt of such services. 

11 ‘‘(iii) A projection of the number of 

12 additional individuals that the State ex13 pects to provide with such services to dur14 ing the 5-fiscal-year period that begins 

15 with fiscal year 2011. 

16 ‘‘(iv) An assurance of the State’s com17 mitment to a consumer-directed long-term 

18 services and supports system that values 

19 quality of life in addition to quality of care 

20 and in which beneficiaries are empowered 

21 to choose providers and direct their own 

22 care as much as possible. 

23 ‘‘(v) A proposed budget that details 

24 the State’s plan to expand and diversify 

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1 based long-term services and supports de2 scribed in paragraph (5)(B) during such 5- 

3 fiscal-year period, and that includes— 

4 ‘‘(I) a description of the new or 

5 expanded offerings of such services 

6 that the State will provide; and 

7 ‘‘(II) the projected costs of the 

8 services identified in subclause (I). 

9 ‘‘(vi) A description of how the State 

10 intends to achieve the target spending per11 centage applicable to the State under sub12 paragraph (B). 

13 ‘‘(vii) An assurance that the State will 

14 not use Federal funds, revenues described 

15 in section 1903(w)(1), or revenues ob16 tained through the imposition of bene17 ficiary cost-sharing for medical assistance 

18 for non-institutionally-based long-term 

19 services and supports described in para20 graph (5)(B) for the non-Federal share of 

21 expenditures for medical assistance de22 scribed in paragraph (4). 

23 ‘‘(B) TARGET SPENDING PERCENTAGES.— 

24 ‘‘(i) In the case of a balancing incen25 tive payment State in which less than 25 


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1 percent of the total expenditures for home 

2 and community-based services under the 

3 State plan and the various waiver authori4 ties for fiscal year 2009 are for such serv5 ices, the target spending percentage for the 

6 State to achieve by not later than October 

7 1, 2015, is that 25 percent of the total ex8 penditures for home and community-based 

9 services under the State plan and the var10 ious waiver authorities are for such serv11 ices. 

12 ‘‘(ii) In the case of any other bal13 ancing incentive payment State, the target 

14 spending percentage for the State to 

15 achieve by not later than October 1, 2015, 

16 is that 50 percent of the total expenditures 

17 for home and community-based services 

18 under the State plan and the various waiv19 er authorities are for such services. 

20 ‘‘(C) MAINTENANCE OF ELIGIBILITY RE21 QUIREMENTS.—The State does not apply eligi22 bility standards, methodologies, or procedures 

23 for determining eligibility for medical assistance 

24 for non-institutionally-based long-term services 

25 and supports described in paragraph (5)(B)) 


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1 that are more restrictive than the eligibility 

2 standards, methodologies, or procedures in ef3 fect for such purposes on December 31, 2010. 

4 ‘‘(D) USE OF ADDITIONAL FUNDS.—The 

5 State agrees to use the additional Federal funds 

6 paid to the State as a result of this subsection 

7 only for purposes of providing new or expanded 

8 offerings of non-institutionally-based long-term 

9 services and supports described in paragraph 

10 (5)(B) (including expansion through offering 

11 such services to increased numbers of bene12 ficiaries of medical assistance under this title). 

13 ‘‘(E) STRUCTURAL CHANGES.—The State 

14 agrees to make, not later than the end of the 

15 6-month period that begins on the date the 

16 State submits and application under this para17 graph, such changes to the administration of 

18 the State plan (and, if applicable, to waivers ap19 proved for the State that involve the provision 

20 of long-term care services and supports) as the 

21 Secretary determines, by regulation or other22 wise, are essential to achieving an improved bal23 ance between the provision of non-institution24 ally-based long-term services and supports de25 scribed in paragraph (5)(B) and other longVerDate Nov 24 2008 02:10 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00111 Fmt 6652 Sfmt 6201 E:\BILLS\S1262.IS S1262

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1 term services and supports, and which shall in2 clude the following: 

3 ‘‘(i) ‘NO WRONG DOOR’—SINGLE

4 ENTRY POINT SYSTEM.—Development of a 

5 statewide system to enable consumers to 

6 access all long-term services and supports 

7 through an agency, organization, coordi8 nated network, or portal, in accordance 

9 with such standards as the State shall es10 tablish and that— 

11 ‘‘(I) shall require such agency, 

12 organization, network, or portal to 

13 provide— 

14 ‘‘(aa) consumers with infor15 mation regarding the availability 

16 of such services, how to apply for 

17 such services, and other referral 

18 services; and 

19 ‘‘(bb) information regarding, 

20 and make recommendations for, 

21 providers of such services; and 

22 ‘‘(II) may, at State option, per23 mit such agency, organization, net24 work, or portal to— 


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1 ‘‘(aa) determine financial 

2 and functional eligibility for such 

3 services and supports; and 

4 ‘‘(bb) provide or refer eligi5 ble individuals to services and 

6 supports otherwise available in 

7 the community (under programs 

8 other than the State program 

9 under this title), such as housing, 

10 job training, and transportation. 

11 ‘‘(ii) PRESUMPTIVE ELIGIBILITY.—At 

12 the option of the State, provision of a 60- 

13 day period of presumptive eligibility for 

14 medical assistance for non-institutionally15 based long-term services and supports de16 scribed in paragraph (5)(B) for any indi17 vidual whom the State has reason to be18 lieve will qualify for such medical assist19 ance (provided that any expenditures for 

20 such medical assistance during such period 

21 are disregarded for purposes of deter22 mining the rate of erroneous excess pay23 ments for medical assistance under section 

24 1903(u)(1)(D)). 


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1 ‘‘(iii) CASE MANAGEMENT.—Develop2 ment, in accordance with guidance from 

3 the Secretary, of conflict-free case manage4 ment services to— 

5 ‘‘(I) address transitioning from 

6 receipt of institutionally-based long7 term services and supports described 

8 in paragraph (5)(A) to receipt of non9 institutionally-based long-term serv10 ices and supports described in para11 graph (5)(B); and 

12 ‘‘(II) in conjunction with the ben13 eficiary, assess the beneficiary’s needs 

14 and , if appropriate, the needs of fam15 ily caregivers for the beneficiary, and 

16 develop a service plan, arrange for 

17 services and supports, support the 

18 beneficiary (and, if appropriate, the 

19 caregivers) in directing the provision 

20 of services and supports, for the bene21 ficiary, and conduct ongoing moni22 toring to assure that services and sup23 ports are delivered to meet the bene24 ficiary’s needs and achieve intended 

25 outcomes. 


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1 ‘‘(iv) CORE STANDARDIZED ASSESS2 MENT INSTRUMENTS.—Development of 

3 core standardized assessment instruments 

4 for determining eligibility for non-institu5 tionally-based long-term services and sup6 ports described in paragraph (5)(B), which 

7 shall be used in a uniform manner 

8 throughout the State, to— 

9 ‘‘(I) assess a beneficiary’s eligi10 bility and functional level in terms of 

11 relevant areas that may include med12 ical, cognitive, and behavioral status, 

13 as well as daily living skills, and voca14 tional and communication skills; 

15 ‘‘(II) based on the assessment 

16 conducted under subclause (I), deter17 mine a beneficiary’s needs for train18 ing, support services, medical care, 

19 transportation, and other services, 

20 and develop an individual service plan 

21 to address such needs; 

22 ‘‘(III) conduct ongoing moni23 toring based on the service plan; and 


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1 ‘‘(IV) require reporting of collect 

2 data for purposes of comparison 

3 among different service models. 

4 ‘‘(F) DATA COLLECTION.—Collecting from 

5 providers of services and through such other 

6 means as the State determines appropriate the 

7 following data: 

8 ‘‘(i) SERVICES DATA.—Services data 

9 from providers of non-institutionally-based 

10 long-term services and supports described 

11 in paragraph (5)(B) on a per-beneficiary 

12 basis and in accordance with such stand13 ardized coding procedures as the State 

14 shall establish in consultation with the Sec15 retary. 

16 ‘‘(ii) QUALITY DATA.—Quality data 

17 on a selected set of core quality measures 

18 agreed upon by the Secretary and the 

19 State that are linked to population-specific 

20 outcomes measures and accessible to pro21 viders. 

22 ‘‘(iii) OUTCOMES MEASURES.—Out23 comes measures data on a selected set of 

24 core population-specific outcomes measures 

25 agreed upon by the Secretary and the 


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1 State that are accessible to providers and 

2 include— 

3 ‘‘(I) measures of beneficiary and 

4 family caregiver experience with pro5 viders; 

6 ‘‘(II) measures of beneficiary and 

7 family caregiver satisfaction with serv8 ices; and 

9 ‘‘(III) measures for achieving de10 sired outcomes appropriate to a spe11 cific beneficiary, including employ12 ment, participation in community life, 

13 health stability, and prevention of loss 

14 in function. 

15 ‘‘(3) APPLICABLE NUMBER OF PERCENTAGE

16 POINTS INCREASE IN FMAP.—The applicable number 

17 of percentage points are— 

18 ‘‘(A) in the case of a balancing incentive 

19 payment State subject to the target spending 

20 percentage described in paragraph (2)(B)(i), 5 

21 percentage points; and 

22 ‘‘(B) in the case of any other balancing in23 centive payment State, 2 percentage points. 

24 ‘‘(4) ELIGIBLE MEDICAL ASSISTANCE EXPENDI25 TURES.— 


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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), medical assistance described in this 

3 paragraph is medical assistance for non-institu4 tionally-based long-term services and supports 

5 described in paragraph (5)(B) that is provided 

6 during the period that begins on October 1, 

7 2011, and ends on September 30, 2015. 

8 ‘‘(B) LIMITATION ON PAYMENTS.—In no 

9 case may the aggregate amount of payments 

10 made by the Secretary to balancing incentive 

11 payment States under this subsection during 

12 the period described in subparagraph (A), or to 

13 a State to which paragraph (6) of the first sen14 tence of subsection (b) applies, exceed 

15 $3,000,000,000. 

16 ‘‘(5) LONG-TERM SERVICES AND SUPPORTS DE17 FINED.—In this subsection, the term ‘long-term 

18 services and supports’ has the meaning given that 

19 term by Secretary and shall include the following: 

20 ‘‘(A) INSTITUTIONALLY-BASED LONG-TERM

21 SERVICES AND SUPPORTS.—Services provided 

22 in an institution, including the following: 

23 ‘‘(i) Nursing facility services. 


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1 ‘‘(ii) Services in an intermediate care 

2 facility for the mentally retarded described 

3 in subsection (a)(15). 

4 ‘‘(B) NON-INSTITUTIONALLY-BASED LONG5 TERM SERVICES AND SUPPORTS.—Services not 

6 provided in an institution, including the fol7 lowing: 

8 ‘‘(i) Home and community-based serv9 ices provided under subsection (c), (d), or 

10 (i), of section 1915 or under a waiver 

11 under section 1115. 

12 ‘‘(ii) Home health care services. 

13 ‘‘(iii) Personal care services. 

14 ‘‘(iv) Services described in subsection 

15 (a)(26) (relating to PACE program serv16 ices). 

17 ‘‘(v) Self-directed personal assistance 

18 services described in section 1915(j)’’. 

19 (b) ENHANCED FMAP FOR CERTAIN STATES TO

20 MAINTAIN THE PROVISION OF HOME AND COMMUNITY21 BASED SERVICES.—The first sentence of section 1905(b) 

22 of such Act (42 U.S.C. 1396d(b)), as amended by sub23 section (a), is amended— 

24 (1) by striking ‘‘, and (5)’’ and inserting ‘‘, 

25 (5)’’; and 


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1 (2) by inserting before the period the following: 

2 ‘‘, and (6) in the case of a State in which at least 

3 50 percent of the total expenditures for medical as4 sistance for fiscal year 2009 for long-term services 

5 and supports (as defined by the Secretary for pur6 poses of subsection (y)) are for non-institutionally7 based long-term services and supports described in 

8 subsection (y)(5)(B), and which satisfies the require9 ments of subparagraphs (A) (other than clauses (iii), 

10 (v), and (vi)), (C), and (F) of subsection (y)(2), and 

11 has implemented the structural changes described in 

12 each clause of subparagraph (E) of that subsection, 

13 the Federal medical assistance percentage shall be 

14 increased by 1 percentage point with respect to med15 ical assistance described in subparagraph (A) of sub16 section (y)(4) (but subject to the limitation described 

17 in subparagraph (B) of that subsection)’’. 

18 (c) GRANTS TO SUPPORT STRUCTURAL CHANGES.— 

19 (1) IN GENERAL.—The Secretary of Health and 

20 Human Services shall award grants to States for the 

21 following purposes: 

22 (A) To support the development of com23 mon national set of coding methodologies and 

24 databases related to the provision of non-insti25 tutionally-based long-term services and supports 


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1 described in paragraph (5)(B) of section 

2 1905(y) of the Social Security Act (as added by 

3 subsection (a)). 

4 (B) To make structural changes described 

5 in paragraph (2)(E) of section 1905(y) to the 

6 State Medicaid program. 

7 (2) PRIORITY.—In awarding grants for the pur8 pose described in paragraph (1)(A), the Secretary of 

9 Health and Human Services shall give priority to 

10 States in which at least 50 percent of the total ex11 penditures for medical assistance under the State 

12 Medicaid program for fiscal year 2009 for long-term 

13 services and supports, as defined by the Secretary 

14 for purposes of section 1905(y) of the Social Secu15 rity Act, are for non-institutionally-based long-term 

16 services and supports described in paragraph (5)(B) 

17 of such section. 

18 (3) COLLABORATION.—States awarded a grant 

19 for the purpose described in paragraph (1)(A) shall 

20 collaborate with other States, the National Gov21 ernor’s Association, the National Conference of 

22 State Legislatures, the National Association of State 

23 Medicaid Directors, the National Association of 

24 State Directors of Developmental Disabilities, and 

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1 fications for a common national set of coding meth2 odologies and databases. 

3 (4) AUTHORIZATION OF APPROPRIATIONS.— 

4 There are authorized to be appropriated to carry out 

5 this subsection, such sums as may be necessary for 

6 each of fiscal years 2010 through 2012. 

7 (d) AUTHORITY FOR INDIVIDUALIZED BUDGETS

8 UNDER WAIVERS TO PROVIDE HOME AND COMMUNITY9 BASED SERVICES.—In the case of any waiver to provide 

10 home and community-based services under subsection (c) 

11 or (d) of section 1915 of the Social Security Act (42 

12 U.S.C. 1396n) or section 1115 of such Act (42 U.S.C. 

13 1315), that is approved or renewed after the date of enact14 ment of this Act, the Secretary of Health and Human 

15 Services shall permit a State to establish individualized 

16 budgets that identify the dollar value of the services and 

17 supports to be provided to an individual under the waiver. 

18 (e) OVERSIGHT AND ASSESSMENT.— 

19 (1) DEVELOPMENT OF STANDARDIZED REPORT20 ING REQUIREMENTS.— 

21 (A) STANDARDIZATION OF DATA AND OUT22 COME MEASURES.—The Secretary of Health 

23 and Human Services shall consult with States 

24 and the National Governor’s Association, the 

25 National Conference of State Legislatures, the 


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1 National Association of State Medicaid Direc2 tors, the National Association of State Direc3 tors of Developmental Disabilities, and other 

4 appropriate organizations to develop specifica5 tions for standardization of— 

6 (i) reporting of assessment data for 

7 long-term services and supports (as defined 

8 by the Secretary for purposes of section 

9 1905(y)(5) of the Social Security Act) for 

10 each population served, including informa11 tion standardized for purposes of certified 

12 EHR technology (as defined in section 

13 1903(t)(3)(A) of the Social Security Act 

14 (42 U.S.C. 1396b(t)(3)(A)) and under 

15 other electronic medical records initiatives; 

16 and 

17 (ii) outcomes measures that track as18 sessment processes for long-term services 

19 and supports (as so defined) for each such 

20 population that maintain and enhance indi21 vidual function, independence, and sta22 bility. 

23 (2) ADMINISTRATION OF HOME AND COMMU24 NITY SERVICES.—The Secretary of Health and 

25 Human Services shall promulgate regulations to enVerDate Nov 24 2008 02:10 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00123 Fmt 6652 Sfmt 6201 E:\BILLS\S1262.IS S1262

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1 sure that all States develop service systems that are 

2 designed to— 

3 (A) allocate resources for services in a 

4 manner that is responsive to the changing 

5 needs and choices of beneficiaries receiving non6 institutionally-based long-term services and sup7 ports described in paragraph (5)(B) of section 

8 1905(y) of the Social Security Act (as added by 

9 subsection (a)) (including such services and 

10 supports that are provided under programs 

11 other the State Medicaid program), and that 

12 provides strategies for beneficiaries receiving 

13 such services to maximize their independence; 

14 (B) provide the support and coordination 

15 needed for a beneficiary in need of such services 

16 (and their family caregivers or representative, if 

17 applicable) to design an individualized, self-di18 rected, community-supported life; and 

19 (C) improve coordination among all pro20 viders of such services under federally and 

21 State-funded programs in order to— 

22 (i) achieve a more consistent adminis23 tration of policies and procedures across 

24 programs in relation to the provision of 

25 such services; and 


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1 (ii) oversee and monitor all service 

2 system functions to assure— 

3 (I) coordination of, and effective4 ness of, eligibility determinations and 

5 individual assessments; and 

6 (II) development and service 

7 monitoring of a complaint system, a 

8 management system, a system to 

9 qualify and monitor providers, and 

10 systems for role-setting and individual 

11 budget determinations. 

12 (3) MONITORING.—The Secretary of Health 

13 and Human Services shall assess on an ongoing 

14 basis and based on measures specified by the Agency 

15 for Healthcare Research and Quality, the safety and 

16 quality of non-institutionally-based long-term serv17 ices and supports described in paragraph (5)(B) of 

18 section 1905(y) of that Act provided to beneficiaries 

19 of such services and supports and the outcomes with 

20 regard to such beneficiaries’ experiences with such 

21 services. Such oversight shall include examination 

22 of— 

23 (A) the consistency, or lack thereof, of 

24 such services in care plans as compared to 

25 those services that were actually delivered; and 


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1 (B) the length of time between when a 

2 beneficiary was assessed for such services, when 

3 the care plan was completed, and when the ben4 eficiary started receiving such services. 

5 (4) GAO STUDY AND REPORT.—The Comp6 troller General of the United States shall study the 

7 longitudinal costs of Medicaid beneficiaries receiving 

8 long-term services and supports (as defined by the 

9 Secretary for purposes of section 1905(y)(5) of the 

10 Social Security Act) over 5-year periods across var11 ious programs, including the non-institutionally12 based long-term services and supports described in 

13 paragraph (5)(B) of such section, PACE program 

14 services under section 1894 of the Social Security 

15 Act (42 U.S.C. 1395eee, 1396u–4), and services pro16 vided under specialized MA plans for special needs 

17 individuals under part C of title XVIII of the Social 

18 Security Act. 


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1 Subtitle B—Strengthening the 

2 Medicaid Home and Commu3 nity-Based State Plan Amend4 ment Option 

5 SEC. 4201. REMOVAL OF BARRIERS TO PROVIDING HOME 

6 AND COMMUNITY-BASED SERVICES UNDER 

7 STATE PLAN AMENDMENT OPTION FOR INDI8 VIDUALS IN NEED. 

9 (a) PARITY WITH INCOME ELIGIBILITY STANDARD

10 FOR INSTITUTIONALIZED INDIVIDUALS.—Paragraph (1) 

11 of section 1915(i) of the Social Security Act (42 U.S.C. 

12 1396n(i)) is amended by striking ‘‘150 percent of the pov13 erty line (as defined in section 2110(c)(5))’’ and inserting 

14 ‘‘300 percent of the supplemental security income benefit 

15 rate established by section 1611(b)(1)’’. 

16 (b) ADDITIONAL STATE OPTIONS.—Section 1915(i) 

17 of the Social Security Act (42 U.S.C. 1396n(i)) is amend18 ed by adding at the end the following new paragraphs: 

19 ‘‘(6) STATE OPTION TO PROVIDE HOME AND

20 COMMUNITY-BASED SERVICES TO INDIVIDUALS ELI21 GIBLE FOR SERVICES UNDER A WAIVER.— 

22 ‘‘(A) IN GENERAL.—A State that provides 

23 home and community-based services in accord24 ance with this subsection to individuals who 

25 satisfy the needs-based criteria for the receipt 


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1 of such services established under paragraph 

2 (1)(A) may, in addition to continuing to provide 

3 such services to such individuals, elect to pro4 vide home and community-based services in ac5 cordance with the requirements of this para6 graph to individuals who are eligible for home 

7 and community-based services under a waiver 

8 approved for the State under subsection (c), 

9 (d), or (e) or under section 1115 to provide 

10 such services, but only for those individuals 

11 whose income does not exceed 300 percent of 

12 the supplemental security income benefit rate 

13 established by section 1611(b)(1). 

14 ‘‘(B) APPLICATION OF SAME REQUIRE15 MENTS FOR INDIVIDUALS SATISFYING NEEDS16 BASED CRITERIA.—Subject to subparagraph 

17 (C), a State shall provide home and community18 based services to individuals under this para19 graph in the same manner and subject to the 

20 same requirements as apply under the other 

21 paragraphs of this subsection to the provision 

22 of home and community-based services to indi23 viduals who satisfy the needs-based criteria es24 tablished under paragraph (1)(A). 


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1 ‘‘(C) AUTHORITY TO OFFER DIFFERENT

2 TYPE, AMOUNT, DURATION, OR SCOPE OF HOME

3 AND COMMUNITY-BASED SERVICES.—A State 

4 may offer home and community-based services 

5 to individuals under this paragraph that differ 

6 in type, amount, duration, or scope from the 

7 home and community-based services offered for 

8 individuals who satisfy the needs-based criteria 

9 established under paragraph (1)(A), so long as 

10 such services are within the scope of services 

11 described in paragraph (4)(B) of subsection (c) 

12 for which the Secretary has the authority to ap13 prove a waiver and do not include room or 

14 board. 

15 ‘‘(7) STATE OPTION TO OFFER HOME AND COM16 MUNITY-BASED SERVICES TO SPECIFIC, TARGETED

17 POPULATIONS.— 

18 ‘‘(A) IN GENERAL.—A State may elect in 

19 a State plan amendment under this subsection 

20 to target the provision of home and community21 based services under this subsection to specific 

22 populations and to differ the type, amount, du23 ration, or scope of such services to such specific 

24 populations. 

25 ‘‘(B) 5-YEAR TERM.— 


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1 ‘‘(i) IN GENERAL.—An election by a 

2 State under this paragraph shall be for a 

3 period of 5 years. 

4 ‘‘(ii) PHASE-IN OF SERVICES AND ELI5 GIBILITY PERMITTED DURING INITIAL 5- 

6 YEAR PERIOD.—A State making an elec7 tion under this paragraph may, during the 

8 first 5-year period for which the election is 

9 made, phase-in the enrollment of eligible 

10 individuals, or the provision of services to 

11 such individuals, or both, so long as all eli12 gible individuals in the State for such serv13 ices are enrolled, and all such services are 

14 provided, before the end of the initial 5- 

15 year period. 

16 ‘‘(C) RENEWAL.—An election by a State 

17 under this paragraph may be renewed for addi18 tional 5-year terms if the Secretary determines, 

19 prior to beginning of each such renewal period, 

20 that the State has— 

21 ‘‘(i) adhered to the requirements of 

22 this subsection and paragraph in providing 

23 services under such an election; and 


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1 ‘‘(ii) met the State’s objectives with 

2 respect to quality improvement and bene3 ficiary outcomes.’’. 

4 (c) REMOVAL OF LIMITATION ON SCOPE OF SERV5 ICES.—Paragraph (1) of section 1915(i) of the Social Se6 curity Act (42 U.S.C. 1396n(i)), as amended by sub7 section (a), is amended by striking ‘‘or such other services 

8 requested by the State as the Secretary may approve’’. 

9 (d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE

10 FULL MEDICAID BENEFITS TO INDIVIDUALS RECEIVING

11 HOME AND COMMUNITY-BASED SERVICES UNDER A

12 STATE PLAN AMENDMENT.— 

13 (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) 

14 of the Social Security Act (42 U.S.C. 

15 1396a(a)(10)(A)(ii)) is amended— 

16 (A) in subclause (XVIII), by striking ‘‘or’’ 

17 at the end; 

18 (B) in subclause (XIX), by adding ‘‘or’’ at 

19 the end; and 

20 (C) by inserting after subclause (XIX), the 

21 following new subclause: 

22 ‘‘(XX) who are eligible for home 

23 and community-based services under 

24 needs-based criteria established under 

25 paragraph (1)(A) of section 1915(i), 


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1 or who are eligible for home and com2 munity-based services under para3 graph (6) of such section, and who 

4 will receive home and community5 based services pursuant to a State 

6 plan amendment under such sub7 section;’’. 

8 (2) CONFORMING AMENDMENTS.— 

9 (A) Section 1903(f)(4) of the Social Secu10 rity Act (42 U.S.C. 1396b(f)(4)) is amended in 

11 the matter preceding subparagraph (A), by in12 serting ‘‘1902(a)(10)(A)(ii)(XX),’’ after 

13 ‘‘1902(a)(10)(A)(ii)(XIX),’’. 

14 (B) Section 1905(a) of the Social Security 

15 Act (42 U.S.C. 1396d(a)) is amended in the 

16 matter preceding paragraph (1)— 

17 (i) in clause (xii), by striking ‘‘or’’ at 

18 the end; 

19 (ii) in clause (xiii), by adding ‘‘or’’ at 

20 the end; and 

21 (iii) by inserting after clause (xiii) the 

22 following new clause: 

23 ‘‘(xiv) individuals who are eligible for home and 

24 community-based services under needs-based criteria 

25 established under paragraph (1)(A) of section 


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1 1915(i), or who are eligible for home and commu2 nity-based services under paragraph (6) of such sec3 tion, and who will receive home and community4 based services pursuant to a State plan amendment 

5 under such subsection,’’. 

6 (e) ELIMINATION OF OPTION TO LIMIT NUMBER OF

7 ELIGIBLE INDIVIDUALS OR LENGTH OF PERIOD FOR

8 GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA

9 IS MODIFIED.—Paragraph (1) of section 1915(i) of such 

10 Act (42 U.S.C. 1396n(i)) is amended— 

11 (1) by striking subparagraph (C) and inserting 

12 the following: 

13 ‘‘(C) PROJECTION OF NUMBER OF INDI14 VIDUALS TO BE PROVIDED HOME AND COMMU15 NITY-BASED SERVICES.—The State submits to 

16 the Secretary, in such form and manner, and 

17 upon such frequency as the Secretary shall 

18 specify, the projected number of individuals to 

19 be provided home and community-based serv20 ices.’’; and 

21 (2) in subclause (II) of subparagraph (D)(ii), 

22 by striking ‘‘to be eligible for such services for a pe23 riod of at least 12 months beginning on the date the 

24 individual first received medical assistance for such 

25 services’’ and inserting ‘‘to continue to be eligible for 


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1 such services after the effective date of the modifica2 tion and until such time as the individual no longer 

3 meets the standard for receipt of such services under 

4 such pre-modified criteria’’. 

5 (f) ELIMINATION OF OPTION TO WAIVE

6 STATEWIDENESS; ADDITION OF OPTION TO WAIVE COM7 PARABILITY.—Paragraph (3) of section 1915(i) of such 

8 Act (42 U.S.C. 1396n(3)) is amended by striking 

9 ‘‘1902(a)(1) (relating to statewideness)’’ and inserting 

10 ‘‘1902(a)(10)(B) (relating to comparability)’’. 

11 (g) EFFECTIVE DATE.—The amendments made by 

12 this section take effect on the first day of the first fiscal 

13 year quarter that begins after the date of enactment of 

14 this Act. 

15 SEC. 4202. MANDATORY APPLICATION OF SPOUSAL IMPOV16 ERISHMENT PROTECTIONS TO RECIPIENTS 

17 OF HOME AND COMMUNITY-BASED SERVICES. 

18 (a) IN GENERAL.—Section 1924(h)(1)(A) of the So19 cial Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amend20 ed by striking ‘‘(at the option of the State) is described 

21 in section 1902(a)(10)(A)(ii)(VI)’’ and inserting ‘‘is eligi22 ble for medical assistance for home and community-based 

23 services under subsection (c), (d), (e), or (i) of section 

24 1915’’. 


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1 (b) EFFECTIVE DATE.—The amendment made by 

2 subsection (a) takes effect on October 1, 2009. 

3 SEC. 4203. STATE AUTHORITY TO ELECT TO EXCLUDE UP 

4 TO 6 MONTHS OF AVERAGE COST OF NURS5 ING FACILITY SERVICES FROM ASSETS OR 

6 RESOURCES FOR PURPOSES OF ELIGIBILITY 

7 FOR HOME AND COMMUNITY-BASED SERV8 ICES. 

9 (a) IN GENERAL.—Section 1917 of the Social Secu10 rity Act (42 U.S.C. 1396p) is amended by adding at the 

11 end the following new subsection: 

12 ‘‘(i) STATE AUTHORITY TO EXCLUDE UP TO 6 

13 MONTHS OF AVERAGE COST OF NURSING FACILITY

14 SERVICES FROM HOME AND COMMUNITY-BASED SERV15 ICES ELIGIBILITY DETERMINATIONS.—Nothing in this 

16 section or any other provision of this title, shall be con17 strued as prohibiting a State from excluding from any de18 termination of an individual’s assets or resources for pur19 poses of determining the eligibility of the individual for 

20 medical assistance for home and community-based services 

21 under subsection (c), (d), (e), or (i) of section 1915 (if 

22 a State imposes an limitation on assets or resources for 

23 purposes of eligibility for such services), an amount equal 

24 to the product of the amount applicable under subsection 

25 (c)(1)(E)(ii)(II) (at the time such determination is made) 


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1 and such number, not to exceed 6, as the State may 

2 elect.’’. 

3 (b) RULE OF CONSTRUCTION.—Nothing in the 

4 amendment made by subsection (a) shall be construed as 

5 affecting a State’s option to apply less restrictive meth6 odologies under section 1902(r)(2) for purposes of deter7 mining income and resource eligibility for individuals spec8 ified in that section. 

9 Subtitle C—Coordination of Home 

10 and Community-Based Waivers 

11 SEC. 4301. STREAMLINED PROCESS FOR COMBINED WAIV12 ERS UNDER SUBSECTIONS (B) AND (C) OF 

13 SECTION 1915. 

14 Not later than 90 days after the date of enactment 

15 of this Act, the Secretary of Health and Human Services 

16 shall create a template to streamline the process of ap17 proving, monitoring, evaluating, and renewing State pro18 posals to conduct a program that combines the waiver au19 thority provided under subsections (b) and (c) of section 

20 1915 of the Social Security Act (42 U.S.C. 1396n) into 

21 a single program under which the State provides home and 

22 community-based services to individuals based on individ23 ualized assessments and care plans (in this section re24 ferred to as the ‘‘combined waivers program’’). The temVerDate Nov 24 2008 02:10 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00136 Fmt 6652 Sfmt 6201 E:\BILLS\S1262.IS S1262

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1 plate required under this section shall provide for the fol2 lowing: 

3 (1) A standard 5-year term for conducting a 

4 combined waivers program. 

5 (2) Harmonization of any requirements under 

6 subsections (b) and (c) of such section that overlap. 

7 (3) An option for States to elect, during the 

8 first 5-year term for which the combined waivers 

9 program is approved to phase-in the enrollment of 

10 eligible individuals, or the provision of services to 

11 such individuals, or both, so long as all eligible indi12 viduals in the State for such services are enrolled, 

13 and all such services are provided, before the end of 

14 the initial 5-year period. 

15 (4) Examination by the Secretary, prior to each 

16 renewal of a combined waivers program, of how well 

17 the State has— 

18 (A) adhered to the combined waivers pro19 gram requirements; and 

20 (B) performed in meeting the State’s ob21 jectives for the combined waivers program, in22 cluding with respect to quality improvement 

23 and beneficiary outcomes. 


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1 TITLE V—HOME AND COMMU2 NITY-BASED SERVICES PROVI3 SIONS 

4 SEC. 5001. SHORT TITLE. 

5 This Act may be cited as the ‘‘Project 2020: Building 

6 on the Promise of Home and Community-Based Services 

7 Act of 2009’’. 

8 SEC. 5002. LONG-TERM SERVICES AND SUPPORTS. 

9 The Social Security Act (42 U.S.C. 301 et seq.) is 

10 amended by adding at the end the following: 

11 ‘‘TITLE XXII—LONG-TERM 

12 SERVICES AND SUPPORTS 

13 ‘‘SEC. 2201. DEFINITIONS. 

14 ‘‘Except as otherwise provided, the terms used in this 

15 title have the meanings given the terms in section 102 of 

16 the Older Americans Act of 1965 (42 U.S.C. 3002). 

17 ‘‘Subtitle A—Single-Entry Point 

18 System Program 

19 ‘‘SEC. 2211. STATE SINGLE-ENTRY POINT SYSTEMS. 

20 ‘‘(a) DEFINITIONS.—In this title: 

21 ‘‘(1) LONG-TERM SERVICES AND SUPPORTS.— 

22 The term ‘long-term services and supports’ means 

23 any service (including a disease prevention and 

24 health promotion service, an in-home service, or a 


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1 case management service), care, or item (including 

2 an assistive device) that is— 

3 ‘‘(A) intended to assist individuals in cop4 ing with, and, to the extent practicable, com5 pensating for, functional impairment in car6 rying out activities of daily living; 

7 ‘‘(B) furnished at home, in a community 

8 care setting, including a small community care 

9 setting (as defined in section 1929(g)(1)) and a 

10 large community care setting (as defined in sec11 tion 1929(h)(1)), or in a long-term care facility; 

12 and 

13 ‘‘(C) not furnished to diagnose, treat, or 

14 cure a medical disease or condition. 

15 ‘‘(2) SINGLE-ENTRY POINT SYSTEM.—The term 

16 ‘single-entry point system’ means any coordinated 

17 system for providing— 

18 ‘‘(A) comprehensive information to con19 sumers and caregivers on the full range of 

20 available public and private long-term services 

21 and supports, options, service providers, and re22 sources, including information on the avail23 ability of integrated long-term care, including 

24 consumer directed care options; 


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1 ‘‘(B) personal counseling to assist individ2 uals in assessing their existing or anticipated 

3 long-term care needs, and developing and imple4 menting a plan for long-term care designed to 

5 meet their specific needs and circumstances; 

6 and 

7 ‘‘(C) consumers and caregivers access to 

8 the range of publicly supported and privately 

9 supported long-term services and supports that 

10 are available. 

11 ‘‘(b) PROGRAM.—The Secretary shall establish and 

12 carry out a single-entry point system program. In carrying 

13 out the program, the Secretary shall make grants to 

14 States, from allotments described in subsection (c), to pay 

15 for the Federal share of the cost of establishing State sin16 gle-entry point systems. 

17 ‘‘(c) ALLOTMENTS.— 

18 ‘‘(1) ALLOTMENTS TO INDIAN TRIBES AND

19 TERRITORIES.— 

20 ‘‘(A) RESERVATION.—The Secretary shall 

21 reserve from the funds made available under 

22 subsection (g)— 

23 ‘‘(i) for fiscal year 2010, $1,962,456; 

24 and 


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1 ‘‘(ii) for each subsequent fiscal year, 

2 $1,962,456, increased by the percentage 

3 increase in the Consumer Price Index for 

4 All Urban Consumers, between October of 

5 the fiscal year preceding the subsequent 

6 fiscal year and October 2007. 

7 ‘‘(B) ALLOTMENTS.—The Secretary shall 

8 use the funds reserved under subparagraph (A) 

9 to make allotments to— 

10 ‘‘(i) Indian tribes; and 

11 ‘‘(ii) Guam, American Samoa, the 

12 Commonwealth of the Northern Mariana 

13 Islands, the Commonwealth of Puerto 

14 Rico, and the United States Virgin Islands. 

15 ‘‘(2) ALLOTMENTS TO STATES.— 

16 ‘‘(A) IN GENERAL.— 

17 ‘‘(i) AMOUNT.—The Secretary shall 

18 allot to each eligible State for a fiscal year 

19 the sum of the fixed amount determined 

20 under subparagraph (B), and the alloca21 tion determined under subparagraph (C), 

22 for the State. 

23 ‘‘(ii) SUBGRANTS TO AREA AGENCIES

24 ON AGING.— 


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1 ‘‘(I) IN GENERAL.—Each State 

2 agency receiving an allotment under 

3 clause (i) shall use such allotment to 

4 make subgrants to area agencies on 

5 aging that can demonstrate perform6 ance capacity to carry out activities 

7 described in this section whether such 

8 area agency on aging carries out the 

9 activities directly or through contract 

10 with an aging network or disability 

11 entity. 

12 ‘‘(II) SUBGRANTS TO OTHER EN13 TITIES.—A State agency may make 

14 subgrants described in subclause (I) 

15 to other qualified aging network or 

16 disability entities only if the area 

17 agency on aging chooses not to apply 

18 for a subgrant or is not able to dem19 onstrate performance capacity to 

20 carry out the activities described in 

21 this section. 

22 ‘‘(III) SUBGRANTEE RECIPIENT

23 SUBGRANTS.—An administrator of a 

24 single-entry point system established 

25 by a State receiving an allotment 


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1 under clause (i) shall make any nec2 essary subgrants to key partners in3 volved in developing, planning, or im4 plementing the single-entry point sys5 tem. Such partners may include cen6 ters for independent living (as defined 

7 in section 702 of the Rehabilitation 

8 Act of 1973 (29 U.S.C. 796a)). 

9 ‘‘(B) FIXED AMOUNTS FOR STATES.— 

10 ‘‘(i) RESERVATION.—The Secretary 

11 shall reserve from the funds made available 

12 under subsection (g)— 

13 ‘‘(I) for fiscal year 2010, 

14 $15,759,000; and 

15 ‘‘(II) for each subsequent fiscal 

16 year, $15,759,000, increased by the 

17 percentage increase in the Consumer 

18 Price Index for All Urban Consumers, 

19 between October of the fiscal year 

20 preceding the subsequent fiscal year 

21 and October 2007. 

22 ‘‘(ii) FIXED AMOUNTS.—The Sec23 retary shall use the funds reserved under 

24 clause (i) to provide equal fixed amounts to 

25 the States. 


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1 ‘‘(C) ALLOCATION FOR STATES.—The Sec2 retary shall allocate to each eligible State for a 

3 fiscal year an amount that bears the same rela4 tionship to the funds made available under sub5 section (g) (and not reserved under paragraph 

6 (1) or subparagraph (B)) for that fiscal year as 

7 the number of persons who are either older in8 dividuals or individuals with disabilities in that 

9 State bears to the number of such persons or 

10 individuals in all the States. 

11 ‘‘(D) DETERMINATION OF NUMBER OF

12 PERSONS.— 

13 ‘‘(i) OLDER INDIVIDUALS.—The num14 ber of older individuals in any State and in 

15 all States shall be determined by the Sec16 retary on the basis of the most recent data 

17 available from the Bureau of the Census, 

18 and other reliable demographic data satis19 factory to the Secretary. 

20 ‘‘(ii) INDIVIDUALS WITH DISABIL21 ITIES.—The number of individuals with 

22 disabilities in any State and in all States 

23 shall be determined by the Secretary on 

24 the basis of the most recent data available 

25 from the American Community Survey, 


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1 and other reliable demographic data satis2 factory to the Secretary, on individuals 

3 who have a sensory disability, physical dis4 ability, mental disability, self-care dis5 ability, go-outside-home disability, or em6 ployment disability. 

7 ‘‘(3) ELIGIBILITY.—In addition to the States 

8 determined by the Secretary to be eligible for a 

9 grant under this section, a State that receives a 

10 Federal grant for an aging and disability resource 

11 center is eligible for a grant under this section. 

12 ‘‘(4) DEFINITION.—In this subsection, the term 

13 ‘State’ shall not include any jurisdiction described in 

14 paragraph (1)(B)(ii). 

15 ‘‘(d) APPLICATIONS.— 

16 ‘‘(1) IN GENERAL.—To be eligible to receive an 

17 initial grant under this section, a State agency shall, 

18 after consulting and coordinating with consumers, 

19 other stakeholders, and area agencies on aging in 

20 the State, if any, submit an application to the Sec21 retary at such time, in such manner, and containing 

22 the following information: 

23 ‘‘(A) Evidence of substantial involvement 

24 of stakeholders and agencies in the State that 


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1 are administering programs that will be the 

2 subject of referrals. 

3 ‘‘(B) The applicant shall establish or des4 ignate a collaborative board to ensure meaning5 ful involvement of stakeholders in the develop6 ment, planning, implementation, and evaluation 

7 of a single-entry point system consistent with 

8 the following: 

9 ‘‘(i) The collaborative board shall be 

10 composed of— 

11 ‘‘(I) individuals representing all 

12 populations served by the applicant’s 

13 single-entry point system, including 

14 older adults and individuals from di15 verse backgrounds who have a dis16 ability or a chronic condition requiring 

17 long-term support; 

18 ‘‘(II) a representative from the 

19 local center for independent living (as 

20 defined in section 702 of the Rehabili21 tation Act of 1973 (29 U.S.C. 796a)), 

22 and representatives from other organi23 zations that provide services to the in24 dividuals served by the system and 


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1 those who advocate on behalf of such 

2 individuals; and 

3 ‘‘(III) representatives of the gov4 ernment and non-governmental agen5 cies that are affected by the system. 

6 ‘‘(ii) The applicant shall work in con7 junction with the collaborative board on— 

8 ‘‘(I) the design and operations of 

9 the single-entry point system; 

10 ‘‘(II) stakeholder input; and 

11 ‘‘(III) other program and policy 

12 development issues related to the sin13 gle-entry point system. 

14 ‘‘(iii) An advisory board established 

15 under the Real Choice Systems Change 

16 Program or for an existing single-entry 

17 point system may be used to carry out the 

18 activities of a collaborative board under 

19 this subparagraph if such advisory board 

20 meets the requirements under clause (i). 

21 ‘‘(C) The applicant’s plan for providing— 

22 ‘‘(i) comprehensive information on the 

23 full range of available public and private 

24 long-term services and supports options, 

25 providers, and resources, including building 


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1 awareness of the single-entry point system 

2 as a resource; 

3 ‘‘(ii) objective, neutral, and personal 

4 information, counseling, and assistance to 

5 individuals and their caregivers in assess6 ing their existing or anticipated long-term 

7 care needs, and developing and imple8 menting a plan for long-term care to meet 

9 their needs; 

10 ‘‘(iii) for eligibility screening and re11 ferral for services; 

12 ‘‘(iv) for stakeholder input; 

13 ‘‘(v) for a management information 

14 system; and 

15 ‘‘(vi) for an evaluation of the effective16 ness of the single-entry point system. 

17 ‘‘(D) A specification of the period of the 

18 grant request, which shall include not less than 

19 3 consecutive fiscal years in the 5-fiscal-year 

20 period beginning with fiscal year 2010. 

21 ‘‘(E) Such other information as the Sec22 retary determines appropriate. 

23 ‘‘(2) APPLICATION FOR CONTINUATION.— 

24 ‘‘(A) IN GENERAL.—A State that receives 

25 an initial grant under this section shall apply, 


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1 after consulting and coordinating with the area 

2 agencies on aging, for a continuation of the ini3 tial grant, which includes a description of any 

4 significant changes to the information provided 

5 in the initial application and such data con6 cerning performance measures related to the re7 quirements in the initial application as the Sec8 retary shall require. 

9 ‘‘(B) EFFECT.—The requirement under 

10 subparagraph (A) shall be in effect through fis11 cal year 2020. 

12 ‘‘(e) USE OF FUNDS.— 

13 ‘‘(1) IN GENERAL.—A State that receives a 

14 grant under this section shall use the funds made 

15 available through the grant to— 

16 ‘‘(A) establish a State single-entry point 

17 system, to enable older individuals and individ18 uals with disabilities and their caregivers to ob19 tain resources concerning long-term services 

20 and supports options; and 

21 ‘‘(B) provide information on, access to, 

22 and assistance regarding long-term services and 

23 supports. 


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1 ‘‘(2) SERVICES.—In particular, the State sin2 gle-entry point system shall be the referral source 

3 to— 

4 ‘‘(A) provide information about long-term 

5 care planning and available long-term services 

6 and supports through a variety of media (such 

7 as websites, seminars, and pamphlets); 

8 ‘‘(B) provide assistance with making deci9 sions about long-term services and supports and 

10 determining the most appropriate services 

11 through options counseling, future financial 

12 planning, and case management; 

13 ‘‘(C) provide streamlined access to and as14 sistance with applying for federally funded long15 term care benefits (including medical assistance 

16 under title XIX, Medicare skilled nursing facil17 ity services, services under title III of the Older 

18 Americans Act of 1965 (42 U.S.C. 3021 et 

19 seq.), the services of Aging and Disability Re20 source Centers), and State-funded and privately 

21 funded long-term care benefits, through efforts 

22 to shorten and simplify the eligibility processes 

23 for older individuals and individuals with dis24 abilities; 


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1 ‘‘(D) provide referrals to the State evi2 dence-based disease prevention and health pro3 motion programs under subtitle B; 

4 ‘‘(E) allocate the State funds available 

5 under subtitle C and carry out the State en6 hanced nursing home diversion program under 

7 subtitle C; and 

8 ‘‘(F) and provide information about, other 

9 services available in the State that may assist 

10 an individual to remain in the community, in11 cluding the Medicare and Medicaid programs, 

12 the State health insurance assistance program, 

13 the supplemental nutrition assistance program 

14 established under the Food and Nutrition Act 

15 of 2008 (7 U.S.C. 2011 et seq.), and the Low16 Income Home Energy Assistance Program 

17 under the Low-Income Home Energy Assist18 ance Act of 1981 (42 U.S.C. 8621 et seq.), and 

19 such other services, as the State shall include. 

20 ‘‘(3) COLLABORATIVE ARRANGEMENTS.— 

21 ‘‘(A) CENTER FOR INDEPENDENT LIV22 ING.—Each entity receiving an allotment under 

23 subsection (c) shall involve in the planning and 

24 implementation of the single-entry point system 

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1 fined in section 702 of the Rehabilitation Act of 

2 1973 (29 U.S.C. 796a)), which provides infor3 mation, referral, assistance, or services to indi4 viduals with disabilities. 

5 ‘‘(B) OTHER ENTITIES.—To the extent 

6 practicable, the State single-entry point system 

7 is encouraged to enter into collaborative ar8 rangements with aging and disability programs, 

9 service providers, agencies, the direct care work 

10 force, and other entities in order to ensure that 

11 information about such services may be made 

12 available to individuals accessing the State sin13 gle-entry point system. 

14 ‘‘(f) FEDERAL SHARE.— 

15 ‘‘(1) IN GENERAL.—The Federal share of the 

16 cost described in subsection (b) shall be 75 percent. 

17 ‘‘(2) NON-FEDERAL SHARE.—The State may 

18 provide the non-Federal share of the cost in cash or 

19 in-kind, fairly evaluated, including plant, equipment, 

20 or services. The State may provide the non-Federal 

21 share from State, local, or private sources. 

22 ‘‘(g) FUNDING.— 

23 ‘‘(1) IN GENERAL.—The Secretary shall use 

24 amounts made available under paragraph (2) to 

25 make the grants described in subsection (b). 


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1 ‘‘(2) FUNDING.—There are authorized to be ap2 propriated to carry out this section— 

3 ‘‘(A) $30,900,000 for fiscal year 2010; 

4 ‘‘(B) $38,264,000 for fiscal year 2011; 

5 ‘‘(C) $48,410,000 for fiscal year 2012; 

6 ‘‘(D) $53,560,000 for fiscal year 2013; 

7 ‘‘(E) $63,860,000 for fiscal year 2014; 

8 ‘‘(F) $69,010,000 for fiscal year 2015; 

9 ‘‘(G) $74,160,000 for fiscal year 2016; 

10 ‘‘(H) $79,310,000 for fiscal year 2017; 

11 ‘‘(I) $84,460,000 for fiscal year 2018; 

12 ‘‘(J) $89,610,000 for fiscal year 2019; and 

13 ‘‘(K) $95,790,000 for fiscal year 2020. 

14 ‘‘(3) AVAILABILITY.—Funds appropriated 

15 under paragraph (2) shall remain available until ex16 pended. 

17 ‘‘Subtitle B—Healthy Living 

18 Program 

19 ‘‘SEC. 2221. EVIDENCE-BASED DISEASE PREVENTION AND 

20 HEALTH PROMOTION PROGRAMS. 

21 ‘‘(a) PROGRAM.—The Secretary shall establish and 

22 carry out a healthy living program. In carrying out the 

23 program, the Secretary shall make grants to State agen24 cies, from allotments described in subsection (b), to pay 


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1 for the Federal share of the cost of carrying out evidence2 based disease prevention and health promotion programs. 

3 ‘‘(b) ALLOTMENTS.— 

4 ‘‘(1) ALLOTMENTS TO INDIAN TRIBES AND

5 TERRITORIES.— 

6 ‘‘(A) RESERVATION.—The Secretary shall 

7 reserve from the funds made available under 

8 subsection (g)— 

9 ‘‘(i) for fiscal year 2010, $1,500,952; 

10 and 

11 ‘‘(ii) for each subsequent fiscal year, 

12 $1,500,952, increased by the percentage 

13 increase in the Consumer Price Index for 

14 All Urban Consumers, between October of 

15 the fiscal year preceding the subsequent 

16 fiscal year and October 2007. 

17 ‘‘(B) ALLOTMENTS.—The Secretary shall 

18 use the reserved funds under subparagraph (A) 

19 to make allotments to— 

20 ‘‘(i) Indian tribes; and 

21 ‘‘(ii) Guam, American Samoa, the 

22 Commonwealth of the Northern Mariana 

23 Islands, the Commonwealth of Puerto 

24 Rico, and the United States Virgin Islands. 

25 ‘‘(2) IN GENERAL.— 


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1 ‘‘(A) AMOUNTS.— 

2 ‘‘(i) IN GENERAL.—Except as pro3 vided in paragraph (3), the Secretary shall 

4 allot to each eligible State for a fiscal year 

5 an amount that bears the same relation6 ship to the funds made available under this 

7 section and not reserved under paragraph 

8 (1) for that fiscal year as the number of 

9 older individuals in the State bears to the 

10 number of older individuals in all the 

11 States. 

12 ‘‘(ii) OLDER INDIVIDUALS.—The 

13 number of older individuals in any State 

14 and in all States shall be determined by 

15 the Secretary on the basis of the most re16 cent data available from the Bureau of the 

17 Census, and other reliable demographic 

18 data satisfactory to the Secretary. 

19 ‘‘(B) SUBGRANTS.— 

20 ‘‘(i) IN GENERAL.—Each State agency 

21 that receives an amount under subpara22 graph (A) shall award subgrants to area 

23 agencies on aging that can demonstrate 

24 performance capacity to carry out activities 

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1 cy on aging carries out the activities di2 rectly or through contract with an aging 

3 network entity. 

4 ‘‘(ii) SUBGRANTS TO OTHER ENTI5 TIES.—A State agency may make sub6 grants described in clause (i) to other 

7 qualified aging network entities only if the 

8 area agency on aging chooses not to apply 

9 for a subgrant or is not able to dem10 onstrate performance capacity to carry out 

11 the activities described in this section. 

12 ‘‘(3) MINIMUM ALLOTMENT.—No State shall 

13 receive an allotment under this section for a fiscal 

14 year that is less than 0.5 percent of the funds made 

15 available to carry out this section for that fiscal year 

16 and not reserved under paragraph (1). 

17 ‘‘(4) ELIGIBILITY.—In addition to the States 

18 determined by the Secretary to be eligible for a 

19 grant under this section, a State that receives a 

20 Federal grant for evidence-based disease prevention 

21 is eligible for a grant under this section. 

22 ‘‘(c) APPLICATIONS.—To be eligible to receive a grant 

23 under this section, a State agency shall, after consulting 

24 and coordinating with consumers, other stakeholders, and 

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1 plication to the Secretary at such time, in such manner, 

2 and containing the following information: 

3 ‘‘(1) A description of the evidence-based disease 

4 prevention and health promotion program. 

5 ‘‘(2) Sufficient information to demonstrate that 

6 the infrastructure exists to support the program. 

7 ‘‘(3) A specification of the period of the grant 

8 request, which shall include not less than 3 consecu9 tive fiscal years in the 5-fiscal-year period beginning 

10 with fiscal year 2010. 

11 ‘‘(4) Such other information as the Secretary 

12 determines appropriate. 

13 ‘‘(d) APPLICATION FOR CONTINUATION.— 

14 ‘‘(1) IN GENERAL.—A State that receives an 

15 initial grant under this section shall apply, after con16 sulting and coordinating with the area agencies on 

17 aging, for a continuation of the initial grant, which 

18 application shall include— 

19 ‘‘(A) a description of any significant 

20 changes to the information provided in the ini21 tial application; and 

22 ‘‘(B) such data concerning performance 

23 measures related to the requirements in the ini24 tial application as the Secretary shall require. 


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1 ‘‘(2) EFFECT.—The requirement under para2 graph (1) shall be in effect through fiscal year 2020. 

3 ‘‘(e) USE OF FUNDS.—A State that receives a grant 

4 under this section shall use the funds made available 

5 through the grant to carry out— 

6 ‘‘(1) an evidence-based chronic disease self7 management program; 

8 ‘‘(2) an evidence-based falls prevention pro9 gram; or 

10 ‘‘(3) another evidence-based disease prevention 

11 and health promotion program. 

12 ‘‘(f) FEDERAL SHARE.— 

13 ‘‘(1) IN GENERAL.—The Federal share of the 

14 cost described in subsection (a) shall be 85 percent. 

15 ‘‘(2) NON-FEDERAL SHARE.—The State may 

16 provide the non-Federal share of the cost in cash or 

17 in-kind, fairly evaluated, including plant, equipment, 

18 or services. The State may provide the non-Federal 

19 share from State, local, or private sources. 

20 ‘‘(g) FUNDING.— 

21 ‘‘(1) IN GENERAL.—The Secretary shall use 

22 amounts made available under paragraph (2) to 

23 make the grants described in subsection (a). 

24 ‘‘(2) FUNDING.—There are authorized to be ap25 propriated to carry out this section— 


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1 ‘‘(A) $36,050,000 for fiscal year 2010; 

2 ‘‘(B) $41,200,000 for fiscal year 2011; 

3 ‘‘(C) $56,650,000 for fiscal year 2012; 

4 ‘‘(D) $77,250,000 for fiscal year 2013; 

5 ‘‘(E) $92,700,000 for fiscal year 2014; 

6 ‘‘(F) $103,000,000 for fiscal year 2015; 

7 ‘‘(G) $118,450,000 for fiscal year 2016; 

8 ‘‘(H) $133,900,000 for fiscal year 2017; 

9 ‘‘(I) $149,350,000 for fiscal year 2018; 

10 ‘‘(J) $157,590,000 for fiscal year 2019; 

11 and 

12 ‘‘(K) $173,040,000 for fiscal year 2020. 

13 ‘‘(3) AVAILABILITY.—Funds appropriated 

14 under paragraph (2) shall remain available until ex15 pended. 

16 ‘‘Subtitle C—Diversion Programs 

17 ‘‘SEC. 2231. ENHANCED NURSING HOME DIVERSION PRO18 GRAMS. 

19 ‘‘(a) DEFINITION.—In this section: 

20 ‘‘(1) LOW-INCOME SENIOR.—The term ‘low-in21 come senior’ means an individual who— 

22 ‘‘(A) is age 75 or older; and 

23 ‘‘(B) is from a household with a household 

24 income that is not less than 150 percent, and 

25 not more than 300 percent, of the poverty line. 


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1 ‘‘(2) NURSING HOME.—The term ‘nursing 

2 home’ means— 

3 ‘‘(A) a skilled nursing facility, as defined 

4 in section 1819(a); or 

5 ‘‘(B) a nursing facility, as defined in sec6 tion 1919(a). 

7 ‘‘(b) PROGRAM.— 

8 ‘‘(1) IN GENERAL.—The Secretary shall estab9 lish and carry out a diversion program. In carrying 

10 out the program, the Secretary shall make grants to 

11 States, from allotments described in subsection (c), 

12 to pay for the Federal share of the cost of carrying 

13 out enhanced nursing home diversion programs. 

14 ‘‘(2) COHORTS.—The Secretary shall make the 

15 grants to— 

16 ‘‘(A) a first year cohort consisting of one 

17 third of the States, for fiscal year 2010; 

18 ‘‘(B) a second year cohort consisting of the 

19 cohort described in subparagraph (A) and an 

20 additional one third of the States, for fiscal 

21 year 2011; and 

22 ‘‘(C) a third year cohort consisting of all 

23 the eligible States, for fiscal year 2012 and 

24 each subsequent fiscal year. 


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1 ‘‘(3) READINESS.—In determining whether to 

2 include an eligible State in the first year, second 

3 year, or third year and subsequent year cohort, the 

4 Secretary shall consider the readiness of the State to 

5 carry out an enhanced nursing home diversion pro6 gram under this section. Readiness shall be deter7 mined based on a consideration of the following fac8 tors: 

9 ‘‘(A) Availability of a comprehensive array 

10 of home and community-based services. 

11 ‘‘(B) Sufficient home and community12 based services provider capacity. 

13 ‘‘(C) Availability of housing. 

14 ‘‘(D) Availability of supports for consumer15 directed services, including whether a fiscal 

16 intermediary is in place. 

17 ‘‘(E) Ability to perform timely eligibility 

18 determinations and assessment for services. 

19 ‘‘(F) Existence of a quality assessment and 

20 improvement program for home and commu21 nity-based services. 

22 ‘‘(G) Such other factors as the Secretary 

23 determines appropriate. 

24 ‘‘(c) ALLOTMENTS.— 

25 ‘‘(1) IN GENERAL.— 


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1 ‘‘(A) AMOUNT.—The Secretary shall allot 

2 to an eligible State (within the applicable co3 hort) for a fiscal year an amount that bears the 

4 same relationship to the funds made available 

5 under subsection (i) for that fiscal year as the 

6 number of low-income seniors in the State bears 

7 to the number of low-income seniors within 

8 States in the applicable cohort for that fiscal 

9 year. 

10 ‘‘(B) LOW-INCOME SENIORS.—The number 

11 of low-income seniors in any State and in all 

12 States shall be determined by the Secretary on 

13 the basis of the most recent data available from 

14 the American Community Survey, and other re15 liable demographic data satisfactory to the Sec16 retary. 

17 ‘‘(2) ELIGIBILITY.—In addition to the States 

18 determined by the Secretary to be eligible for a 

19 grant under this section, a State that receives a 

20 Federal grant for a nursing home diversion is eligi21 ble for a grant under this section. 

22 ‘‘(d) APPLICATIONS.—To be eligible to receive a 

23 grant under this section, a State agency shall, after con24 sulting and coordinating with consumers, other stake25 holders, and area agencies on aging in the State, if any, 


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1 submit an application to the Secretary at such time, in 

2 such manner, and containing such information as the Sec3 retary may require, including a specification of the period 

4 of the grant request, which shall include not less than 3 

5 consecutive fiscal years in the 5-fiscal-year period begin6 ning with the fiscal year prior to the year of application. 

7 ‘‘(e) APPLICATION FOR CONTINUATION.— 

8 ‘‘(1) IN GENERAL.—A State that receives an 

9 initial grant under this section shall apply, after con10 sulting and coordinating with the area agencies on 

11 aging, for a continuation of the initial grant, which 

12 application shall include— 

13 ‘‘(A) a description of any significant 

14 changes to the information provided in the ini15 tial application; and 

16 ‘‘(B) such data concerning performance 

17 measures related to the requirements in the ini18 tial application as the Secretary shall require. 

19 ‘‘(2) EFFECT.—The requirement under para20 graph (1) shall be in effect through fiscal year 2020. 

21 ‘‘(f) USE OF FUNDS.— 

22 ‘‘(1) IN GENERAL.—A State that receives a 

23 grant under this section shall carry out the fol24 lowing: 


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1 ‘‘(A) Use the funds made available through 

2 the grant to carry out an enhanced nursing 

3 home diversion program that enables eligible in4 dividuals to avoid admission into nursing homes 

5 by enabling the individuals to obtain alternative 

6 long-term services and supports and remain in 

7 their communities. 

8 ‘‘(B) Award subgrants to area agencies on 

9 aging that can demonstrate performance capac10 ity to carry out activities under this section 

11 whether such area agency on aging carries out 

12 the activities directly or through contract with 

13 an aging network entity. A State may make 

14 subgrants to other qualified aging network enti15 ties only if the area agency on aging chooses 

16 not to apply for a subgrant or is not able to 

17 demonstrate performance capacity to carry out 

18 the activities described in this section. 

19 ‘‘(2) CASE MANAGEMENT.— 

20 ‘‘(A) IN GENERAL.—The State, through 

21 the State single-entry point system established 

22 under subtitle A, shall provide for case manage23 ment services to the eligible individuals. 

24 ‘‘(B) USE OF EXISTING SERVICES.—In 

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1 cy or area agency on aging may utilize existing 

2 case management services delivery networks 

3 if— 

4 ‘‘(i) the networks have adequate safe5 guards against potential conflicts of inter6 est; and 

7 ‘‘(ii) the State agency or area agency 

8 on aging includes a description of such 

9 safeguards in the grant application. 

10 ‘‘(C) CARE PLAN.—The State shall provide 

11 for development of a care plan for each eligible 

12 individual served, in consultation with the eligi13 ble individual and their caregiver, as appro14 priate. In developing the care plan, the State 

15 shall explain the option of consumer directed 

16 care and assist an individual, who so requests, 

17 with developing a consumer-directed care plan 

18 that shall include arranging for support services 

19 and funding. Such assistance shall include pro20 viding information and outreach to individuals 

21 in the hospital, in a nursing home for post22 acute care, or undergoing changes in their 

23 health status or caregiver situation. 

24 ‘‘(g) ELIGIBLE INDIVIDUALS.—In this section, the 

25 term ‘eligible individual’ means an individual— 


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1 ‘‘(1) who has been determined by the State to 

2 be at high functional risk of nursing home place3 ment, as defined by the State agency in the State 

4 agency’s grant application; 

5 ‘‘(2) who is not eligible for medical assistance 

6 under title XIX; and 

7 ‘‘(3) who meets the income and asset eligibility 

8 requirements established by the State and included 

9 in such State’s grant application for approval by the 

10 Secretary. 

11 ‘‘(h) FEDERAL SHARE.— 

12 ‘‘(1) IN GENERAL.—The Federal share of the 

13 cost described in subsection (b) shall be, for a State 

14 and for a fiscal year, the sum of— 

15 ‘‘(A) the Federal medical assistance per16 centage applicable to the State for the year 

17 under section 1905(b); and 

18 ‘‘(B) 5 percentage points. 

19 ‘‘(2) NON-FEDERAL SHARE.—The State may 

20 provide the non-Federal share of the cost in cash or 

21 in-kind, fairly evaluated, including plant, equipment, 

22 or services. The State may provide the non-Federal 

23 share from State, local, or private sources. 

24 ‘‘(i) FUNDING.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall use 

2 amounts made available under paragraph (2) to 

3 make the grants described in subsection (b). 

4 ‘‘(2) FUNDING.—There are authorized to be ap5 propriated to carry out this section— 

6 ‘‘(A) $111,825,137 for fiscal year 2010; 

7 ‘‘(B) $337,525,753 for fiscal year 2011; 

8 ‘‘(C) $650,098,349 for fiscal year 2012; 

9 ‘‘(D) $865,801,631 for fiscal year 2013; 

10 ‘‘(E) $988,504,887 for fiscal year 2014; 

11 ‘‘(F) $1,124,547,250 for fiscal year 2015; 

12 ‘‘(G) $1,276,750,865 for fiscal year 2016; 

13 ‘‘(H) $1,364,488,901 for fiscal year 2017; 

14 ‘‘(I) $1,466,769,052 for fiscal year 2018; 

15 ‘‘(J) $1,712,755,702 for fiscal year 2019; 

16 and 

17 ‘‘(K) $1,712,755,702 for fiscal year 2020. 

18 ‘‘(3) AVAILABILITY.—Funds appropriated 

19 under paragraph (2) shall remain available until ex20 pended. 


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1 ‘‘Subtitle D—Administration, Eval2 uation, and Technical Assist3 ance 

4 ‘‘SEC. 2241. ADMINISTRATION, EVALUATION, AND TECH5 NICAL ASSISTANCE. 

6 ‘‘(a) ADMINISTRATION AND EXPENSES.—For pur7 poses of carrying out this title, there are authorized to 

8 be appropriated for administration and expenses— 

9 ‘‘(1) of the area agencies on aging— 

10 ‘‘(A) $16,825,895 for fiscal year 2010; 

11 ‘‘(B) $39,246,141 for fiscal year 2011; 

12 ‘‘(C) $50,766,948 for fiscal year 2012; 

13 ‘‘(D) $66,999,101 for fiscal year 2013; 

14 ‘‘(E) $76,979,152 for fiscal year 2014; 

15 ‘‘(F) $87,163,513 for fiscal year 2015; 

16 ‘‘(G) $98,780,562 for fiscal year 2016; 

17 ‘‘(H) $106,063,792 for fiscal year 2017; 

18 ‘‘(I) $114,324,642 for fiscal year 2018; 

19 ‘‘(J) $123,312,948 for fiscal year 2019; 

20 and 

21 ‘‘(K) $133,215,845 for fiscal year 2020; 

22 ‘‘(2) of the State agencies— 

23 ‘‘(A) $8,412,948 for fiscal year 2010; 

24 ‘‘(B) $19,623,071 for fiscal year 2011; 

25 ‘‘(C) $25,383,474 for fiscal year 2012; 


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1 ‘‘(D) $33,499,551 for fiscal year 2013; 

2 ‘‘(E) $38,489,576 for fiscal year 2014; 

3 ‘‘(F) $43,581,756 for fiscal year 2015; 

4 ‘‘(G) $49,390,281 for fiscal year 2016; 

5 ‘‘(H) $53,031,896 for fiscal year 2017; 

6 ‘‘(I) $57,162,321 for fiscal year 2018; 

7 ‘‘(J) $61,656,474 for fiscal year 2019; and 

8 ‘‘(K) $66,607,923 for fiscal year 2020; 

9 and 

10 ‘‘(3) of the Administration— 

11 ‘‘(A) $2,103,237 for fiscal year 2010; 

12 ‘‘(B) $4,905,768 for fiscal year 2011; 

13 ‘‘(C) $6,345,868 for fiscal year 2012; 

14 ‘‘(D) $8,374,888 for fiscal year 2013; 

15 ‘‘(E) $9,622,394 for fiscal year 2014; 

16 ‘‘(F) $10,895,439 for fiscal year 2015; 

17 ‘‘(G) $12,347,570 for fiscal year 2016; 

18 ‘‘(H) $13,257,974 for fiscal year 2017; 

19 ‘‘(I) $14,290,580 for fiscal year 2018; 

20 ‘‘(J) $15,414,118 for fiscal year 2019; and 

21 ‘‘(K) $16,651,981 for fiscal year 2020. 

22 ‘‘(b) EVALUATION AND TECHNICAL ASSISTANCE.— 

23 ‘‘(1) CONDITIONS TO RECEIPT OF GRANT.—In 

24 awarding grants under this title, the Secretary shall 

25 condition receipt of the grant for the second and 


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1 subsequent grant years on a satisfactory determina2 tion that the State agency is meeting benchmarks 

3 specified in the grant agreement for each grant 

4 awarded under this title. 

5 ‘‘(2) EVALUATIONS.—The Secretary shall meas6 ure and evaluate, either directly or through grants 

7 or contracts, the impact of the programs authorized 

8 under this title. Not later than June 1 of the year 

9 that is 6 years after the year of the date of enact10 ment of the Project 2020: Building on the Promise 

11 of Home and Community-Based Services Act of 

12 2009 and every 2 years thereafter, the Secretary 

13 shall— 

14 ‘‘(A) compile the reports of the measures 

15 and evaluations of the grantees; 

16 ‘‘(B) establish benchmarks to show 

17 progress toward savings; and 

18 ‘‘(C) present a compilation of the informa19 tion under this paragraph to Congress. 

20 ‘‘(3) TECHNICAL ASSISTANCE GRANTS.—The 

21 Secretary shall award technical assistance grants, in22 cluding State-specific grants whenever practicable, to 

23 carry out the programs authorized under this title. 


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1 ‘‘(4) TRANSFER.—There are authorized to be 

2 appropriated for such evaluation and technical as3 sistance under this subsection— 

4 ‘‘(A) $4,206,474 for fiscal year 2010; 

5 ‘‘(B) $9,811,535 for fiscal year 2011; 

6 ‘‘(C) $8,461,158 for fiscal year 2012; 

7 ‘‘(D) $11,166,517 for fiscal year 2013; 

8 ‘‘(E) $12,829,859 for fiscal year 2014; 

9 ‘‘(F) $14,527,252 for fiscal year 2015; 

10 ‘‘(G) $16,463,427 for fiscal year 2016; 

11 ‘‘(H) $17,677,299 for fiscal year 2017; 

12 ‘‘(I) $19,054,107 for fiscal year 2018; 

13 ‘‘(J) $20,552,158 for fiscal year 2019; and 

14 ‘‘(K) $22,202,641 for fiscal year 2020. 

15 ‘‘(c) AVAILABILITY.—Funds appropriated under this 

16 section shall remain available until expended.’’. 

Æ 


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